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Clinical reasoning: Deduction, induction, and abduction, part 2 (#5/31)

Submitted by RST on Thu, 08/09/2012 - 03:45
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Rock climbing is a good metaphor for clinical reasoning and decision-making.

If you go climbing, you can plan a route from the bottom to the top in advance, but when you are actually in the process of ascending the rock face, you have to deal with the actual material physical reality you find in front of you. If that turns out to be different from your previous plan, then the plan gets adjusted to accommodate what you are really dealing with in the moment. If you try to privilege the theoretical plan over the actual facts, things can end very badly very fast.

To get from one place on the rock to the next place without falling, you make sure that you are in a stable position where you currently are, and you look for a way to get safely to the next place you want to be. You repeat this process over and over, and at the end--if all goes well--all those decisions in the moment about how to get from one place to the next lead you to reach the summit you were aiming for all along.

The reason that this is metaphorically like clinical decision-making and reasoning is that need to ensure that you are first in a stable place before you extend yourself to get to the next place.

Like climbing, reasoning is a process--the culmination of many smaller decisions along the way. If you take too many unwarranted risks along the way, you can lose control of the process.

Unlike in individual climbing, however, the one most harmed by a bad outcome in clinical decision-making is someone else: the client.

That's why we have an extra responsibility to do the best job in getting it right that we possibly can--our clients trust us as the experts.

Source: http://upload.wikimedia.org/wikipedia/commons/6/66/Free_solo.jpg accessed 9 August 2012

 

 

As we've seen in the previous post, deductive reasoning helps you to get from one point to the next--from the general to the specific--in a safe and valid way, but the kinds of questions it can support are rather limited in comparison to the situations we often encounter in clinical situations. It's a safe and easy line from one point to the next, and the valid results may be exactly what you need in particular situations.

Inductive reasoning is somewhat more powerful, as it can take you from the specific to making generalizations about how things work in the material physical universe--but, by the nature of taking on that task, it's possible to do every thing right--to begin with a valid starting point, to reason in a flawlessly valid way--and to still end up with invalid conclusions, such as "All swans are white". It's riskier than deduction, but--if it succeeds--it opens the door to more possibilities than deductive reasoning alone can provide.

Among other things, it's this recognition that you can do everything right and still end up with invalid conclusions that makes all of scientific knowledge provisional (it holds unless and until it is replaced with better evidence) and contingent (hanging together as part of an integrated whole with other knowledge).

The old joke about how scientists never say anything without including error bars (to show their level of confidence that the statement is correct) references this aspect of scientific knowledge.

Source: http://upload.wikimedia.org/wikipedia/commons/d/df/Confidenceinterval.png accessed 9 August 2012

 

You will, of course, hear statements made with absolute certainty, but that certainty comes from some place other than science.

 

 

The fact that scientific knowledge is contingent and provisional does not, however, mean that it is totally random--that anything goes, and therefore, you can just make up anything you want and it will be every bit as valid as anything scientists have spent centuries testing.

The idea that nothing has any meaning at all, so it doesn't really matter what you claim, is a kind of nihilism, and we're not going to indulge in nihilism here.

Scientific knowlege always has a confidence level of how much we are sure it is true attached to it. That confidence level is never 100%--we are never totally certain without any doubt at all--but in many cases, it does get pretty close. We have tested that knowledge, and reliably repeated it so much that, for all practical purposes, we can proceed to build on it as though it were actually 100% certain.

We can trust it as a safe enough platform in our climb to use it as a base for the next bit of knowledge, reasoning, or clinical decision-making.

This is why the more extravagant claims of energy healers don't hold up--they contradict what we have spent centuries rigorously testing about how energy actually does work in the material physical universe. Principles and laws such as the inverse-square law and the laws of thermodynamics have held up so well under independent repeated testing by independent observers that we are as close to certain about them as we ever reasonably can get about anything.

If energy really did work the way energy healers claim they operate, then the inverse-square law and the laws of thermodynamics would fail so spectacularly that the world around us would look very different from how it actually does. The fact that we can rely so reliably on these laws means that what the energy healers claim cannot be true--it is a clear decision point, where you have to make the decision whether you accept or deny material physical reality.

Here's a couple of examples of how the universe around us would be very different if energy healing claims were true. Many energy healers claim that it does not matter how far away they are from the person they have intent to heal--that it's the same whether they're in the same room, or half a world away.

Have you ever been to a bonfire on a cold night?

Source: http://upload.wikimedia.org/wikipedia/commons/a/ac/Christmas_bonfire.jpg accessed 9 August 2012

 

A fire, among other things, is heat energy and light energy.

Did you get close, so that it felt very, very hot? Did you get further away from the fire, far enough so that you could feel the cold night air? You didn't have to get very far away for that experience, did you? The heat and light energy from the fire drops off very quickly as you get further away.

Source: http://upload.wikimedia.org/wikipedia/commons/2/28/Inverse_square_law.svg accessed 9 August 2012

 

Would the effect of the fire be the same, whether it was in the same room, or half a world away?

What kind of reasoning are we practicing here?

Heat energy quickly gets less effective as we get further away from the source; light energy quickly gets less effective as we get further away from the source, therefore, if energy healing is really based on energy, we expect it to quickly get less effective as we get further away from the source.

 

We are going from different examples of energy to derive a universal principle applying to all energy, so what kind of reasoning is that?

Now that we have derived that universal principle, we apply it in the following way:

The effect of physical energy falls off quickly with increasing distance from the source of the energy.

Energy healers claim that what they practice is not affected by distance from them as the source.

Therefore, what energy healers practice is not physical energy.

 

In applying the general principle about energy to a particular example, what kind of reasoning are we practicing there?

So--since they can't both be true at the same time--which one is right?

Are the energy healers right, and every bit of physics knowledge multiple independent researchers have built up over centuries wrong?

Or is the physics knowledge right, and the energy healers' explanations wrong in some way?

Since you have to choose only one of them, which possibility is more plausible: more likely, more reliable, and more believable?

Understanding these ideas--that not everything can simultaneously be true, that you really do have to choose between what is true and what is false, that scientific knowledge is never 100% certain but can at times get very close to that ideal--lays the groundwork for understanding the next form of logical reasoning we'll discuss.

Abductive reasoning is sometimes called "reasoning to the best explanation", and we'll look at how that works.

 

 

Abductive reasoning is difficult to describe concisely, or to teach, because it depends so much on what went before it. To use abductive reasoning, you have to have a solid multidisciplinary knowledge base.

If you don't have that, then, from the outside, it looks like you're making things up, or changing the rules arbitrarily or unfairly.

That's not really what's happening, but you can feel compassion for people who think that, because they don't see the entire process going on. It's like watching a far-away rock climber--you see them going in progression from hold to hold, but you don't see all the information they have up close that they are basing their decisions on in the moment.

And you can't just teach it easily, because it's not like a vending machine, where you always put the exact information in, and you get exactly the same answer in return.

These aspects of abductive reasoning can make it challenging, both to observers outside the process, as well as to learners trying to come to grips with carrying it out. We can certainly sympathize with frustrations at that challenge, yet all we can do is to try to connect the dots, and be as transparent as possible about the process, to assist those who come along afterwards in understanding why decisions are made in the way they are.

 

 

If you don't care where you're going, it doesn't matter which way you set out.

If, on the other hand, you care about going to the "best" explanation, then you have to know what that means in order to plan your journey to get there.

It's a complex question, not one that we can just answer by rote. Let's work through it by examples, and try to get larger principles out of those examples for the next situation that comes along.

Just like we had the classic "Socrates is a mortal" and "All swans are white" examples for deductive and inductive reasoning, there is a classic example of abductive reasoning that we can share with generations of people who studied these questions before us.

"The lawn is wet, so it must have rained last night" is an example frequently used to show abductive reasoning.

We have an observable, empirical, tangible fact: the lawn is wet.

We don't know why the lawn is wet, so we try to draw a hypothesis to account for our observation. There are many possibilities that could become hypotheses:

  1. It could have rained last night.
  2. Someone could have poured water on the lawn, accidentally or on purpose.
  3. A passing water truck could have sprung a leak.

 

There are lots of other possibilities as well, limited only by our imaginations.

If all of those possibilities are equally good as explanations, then we are stuck--we remain unable to develop a causal explanation that we can then test to see whether or not that explanation is correct.

But not all possibilities are equally good as explanations--some are ruled out by patterns in our observation.

Others are ruled out, as we saw with the energy-healing claim, by centuries of shared human knowledge about the way the physical universe works--for those explanations to be true, our universe would have to look and act totally different than it does now. So we can rule out explanations like that as well, never with 100% certainty, but with enough certainty to operate on for now.

Starting out as a brand-new student in first grade at the age of 6, I was absolutely, madly, deeply in love with my teacher, Miss Kirby. I would have done anything at all to get her to think highly of me.

So I told her about my brand-new baby brother that my parents brought home from the hospital. She was very interested to hear that I was now the big girl in the family, and told me that I must be very proud.

I assured her that I was really a very good big sister.

I told her about how my baby brother escaped from his crib after my parents brought him home, and how he climbed a tree and got stuck up there, and how I had to go rescue him.

I told her I saved my little brother all by myself, and Miss Kirby reassured me that I was, indeed, a very good big sister.

Not long after that, my parents and I were at the grocery store, where we ran into her doing her own shopping. She asked my parents about the new addition to the family, and that's when the facts came out: there was no new little brother. I had just made the entire story up to impress her, and make her think I was strong and brave.

Which explanation more plausibly accounts for the facts of the matter?

  1. Unlike any other newborn in the history of the human race, my infant baby brother really had the cognitive skills to formulate an escape plan, and the motor skills to climb out of the crib, let himself out the door, and then climb a tree, or
  2. A little girl who doesn't know much about infant development tells a lie that makes herself look like a hero, in order to impress an adult whom she loves, and who she wants to think she is a very good girl.

 

(Just to complete the story, I'll mention that no punishment ensued from this either at school or at home. All of the grownups understood why I had told that lie, and dealt with it in constructive ways that supported me in not needing to tell lies anymore just to impress beloved adults.)

To figure out how plausible something is--not either a "true" or "false" answer, but values along a spectrum from "more plausible" to "less plausible"--you can't just look at it in isolation. You have to evaluate how well it fits into the integrated whole of everything else we know about.

Abductive reasoning, getting at the best explanations for facts, draws on that plausibility as one of the pillars that supports it.

To be able to evaluate that plausibility, we need to have a large, solid, and interdisciplinary knowledge base, and to know how the parts of that knowledge base integrate seamlessly with one another.

This is not an easy task, and it can't just be reduced to vending-machine science. That's why it can look to people who are not in on the process as if scientists are making arbitrary choices about what they accept and what they reject. The scientists are making choices among possibilities, but unless you are close up to the process, you can't see the details of how they're doing it.

The choices aren't arbitrary, but neither can they be easily summed up in a single concise one-size-fits-all formula, either.

Clinical reasoning: Deduction, induction, and abduction, part 1 (#4/31)

Submitted by RST on Wed, 08/08/2012 - 00:36
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You may have been introduced to logic and reasoning in your previous education--different schools vary on whether they include it, and at what grade level they include it, if they do.

If so, then some of this will look familiar to you--you've probably already encounted deduction and induction in school.

If you haven't seen this material before, don't worry--we'll go over it in more depth, to make sure that these foundational concepts get the coverage they merit.

And even if you have seen some of this before, I'm willing to venture that part of it is new to you as well. So we're all on a learning journey through this material together.

 

 

Logic is the study of how we reason about things in the world around us. We use principles of logic to try to ensure that our methods of reasoning lead us to correct answers, rather than falling into traps that give us wrong answers.

Deduction is a logical technique that takes us from general statements to specific ones, ensuring the correctness of our specific conclusion. The classic example of deductive reasoning taught in school is:

  1. All men are mortal.
  2. Socrates is a man.
  3. Therefore, Socrates is mortal.

 

For an example of deduction that is more relevant to massage, we could create the following:

  1. People who suffer from pain often benefit from massagea.
  2. Robertb has an upcoming surgical operation planned, and one of the side effects of the surgery will be post-operative pain.
  3. Therefore, Robert may benefit from massage after surgeryc.

 

a We know this generally from the cumulative body of massage research evidence.

b A specific client.

c A valid recommendation for a specific client, based on what we know generally.

 

So deductive reasoning is one way that we can take general principles from research evidence, and apply those principles for the benefit of specific clients.

One of the strengths of deductive reasoning is that--if the assumptions you start with are true--then you will definitely reach a correct, or valid, conclusion.

But deductive reasoning, as solid as it is, will only take us so far. It's a good start, but it's not going to be enough for real-life clinical decision-making.

We're going to need additional tools to help our processes get beyond the very first level.

 

 

Inductive reasoning, in a way, is the mirror image of deductive reasoning: it starts with specific knowledge, and aims to draw conclusions about general principles from that specific knowledge.

Induction is the process of observing many specific instances, and abstracting--making a generalization about what those instances have in common with each other.

For example, the sun has come up every day in the past since humans have begun observing it, so on that basis we reason, inductively, that it will rise tomorrow as well.

An famous example of inductive reasoning in clinical observation and decision-making in recent history took place in the early 1980s, when primary healthcare providers began noticing a dramatic increase in young gay male patients presenting in clinic with an unusual kind of tumor--Kaposi's sarcoma (KS), a relatively uncommon condition usually found in older men of Mediterranean heritage.

Sources: upper left: http://upload.wikimedia.org/wikipedia/commons/3/3c/Kaposi's_Sarcoma.jpg accessed 7 August 2012; upper right: http://upload.wikimedia.org/wikipedia/commons/d/d5/Kaposi’s_sarcoma_intraoral_AIDS_072_lores.jpg accessed 7 August 2012; lower center: http://upload.wikimedia.org/wikipedia/commons/c/c2/Kaposi's_sarcoma_before.jpg accessed 7 August 2012

 

At first, it seemed like it might be a coincidence, but at some point the number of cases reached critical mass for a real phenomenon, rather than just chance. Clinicians wrote up their observations in medical journal articles like the following, for other clinicians to compare their own observations against, and to share their own observations and knowledge.

Urmacher C, Myskowski P, Ochoa M Jr, Kris M, Safai B. Outbreak of Kaposi's sarcoma with cytomegalovirus infection in young homosexual men. Am J Med. 1982 Apr;72(4):569-75. PMID: 6280498

Kaposi's sarcoma, a multicentric malignant neoplasm, occurs in certain geographic areas in the world. It is most common in Equatorial Africa and Eastern Europe. The annual incidence of Kaposi's sarcoma in the United States is between 0.021 and 0.061 per 100,000 persons. The appearance of an outbreak of Kaposi's sarcoma in young homosexual men in New York and California is a new and unique phenomenon. Certain differences are already recognized between the disease in these young men and the ordinary Kaposi's sarcoma. Herein we report our observations of the first 10 cases of Kaposi's sarcoma in young homosexual men. In these patients, the disease follows an aggressive clinical course characterized by widespread skin lesions with early involvement of the lymph nodes. In some of these patients, the result was death in a short period of time after initial diagnosis. In addition, cytomegalovirus infections were seen in these patients, which suggests at least a possible association between this viral and the disease.

 

Myskowski PL, Romano JF, Safai B. Kaposi's sarcoma in young homosexual men. Cutis. 1982 Jan;29(1):31-4. PMID: 6276100

An outbreak of KS has been observed in young homosexual men. These patients are different from those with classical KS for the following reasons: 1. geographic distribution (clustering in New York and California); 2. age (younger, mean--39 years); 3. higher incidence; 4. sexual preference (homosexual); 5. distribution of skin lesions (face, upper extremities, trunk); 6. lymph node involvement; 7. visceral lesions; 8. associated opportunistic infections (Pneumocystis carinii, toxoplasmosis); 9. history of sexually-transmitted diseases (hepatitis, syphilis, gonorrhea); and 10. aggressive course of the disease. Awareness of these features of the new KS will enable the practitioner to better recognize this important, emerging disease.

 

Hymes KB, Cheung T, Greene JB, Prose NS, Marcus A, Ballard H, William DC, Laubenstein LJ. Kaposi's sarcoma in homosexual men-a report of eight cases. Lancet. 1981 Sep 19;2(8247):598-600. PMID: 6116083

The clinical findings in eight young homosexual men in New York with Kaposi's sarcoma showed some unusual features. Unlike the form usually seen in North America and Europe, it affected younger men (4th decade rather than 7th decade); the skin lesions were generalised rather than being predominantly in the lower limbs, and the disease was more aggressive (survival of less than 20 months rather 8-13 years). All eight had had a variety of sexually transmitted diseases. All those tested for cytomegalovirus antibodies and hepatitis B surface antigen of anti-hepatitis B antibody gave positive results. This unusual occurrence of Kaposi's sarcoma in a population much exposed to sexually transmissible diseases suggests that such exposure may play a role in its pathogenesis.

 

Borkovic SP, Schwartz RA. Kaposi's sarcoma presenting in the homosexual man -- a new and striking phenomenon! Ariz Med. 1981 Dec;38(12):902-4. PMID: 7332494

 

Gottlieb GJ, Ragaz A, Vogel JV, Friedman-Kien A, Rywlin AM, Weiner EA, Ackerman AB. A preliminary communication on extensively disseminated Kaposi's sarcoma in young homosexual men. Am J Dermatopathol. 1981 Summer;3(2):111-4. PMID: 7270808

 

Those observations pointed to what we later recognized as the beginning of the AIDS epidemic in the developed world. Inductive reasoning based on observations that young gay men were presenting with these unusual symptoms in clinic helped alert clinicians that other young gay men (and, later, other population groups at well) might be at particular risk from whatever was causing this new disease.

It is quite possible, with the efforts at case report repository-building going on here at POEM and elsewhere (like the Massage Therapy Foundation), that someday MTs will be able to put together observations made by multiple therapists in multiple distributed clinical locations, and--through a similar process of inductive reasoning--will be able to derive more general knowledge from those specific individual instances.

But unlike deductive reasoning, which--if the beginning assumptions are true--will lead to correct conclusions, there is a degree of uncertainty about the validity of conclusions arrived at through inductive reasoning.

Using inductive reasoning, it is possible to begin with true observations, follow the procedure correctly, and yet arrive at false conclusions anyway. This is just a risk we take when abstracting from specific instances to general principles.

The black-swan problem illustrates how this can happen.

"All swans are white" is a well-known example of a positive claim.

....................

Source: http://www.birdsofoklahoma.net/images/MuteSwan01.jpg accessed 8 August 2012

 

What does it take to disprove this claim? One black swan is all that is needed (but here are two, for good measure).

Source: http://upload.wikimedia.org/wikipedia/commons/6/60/Black_Swans.jpg accessed 8 August 2012

 

The claim that "All swans are white" is definitively disproved by the existence of one black swan.

That's easy enough. But what does it take to prove the claim that all swans are white?

One white swan is a good start.

 

Another white swan is also good.

 

Three white swans--so far, so good.

 

 

Have we proved that all swans are white? Three is not very many, after all.

 

How many white swans in a row do we need to find in order to prove that all swans are white?

 .....?

 

 

The problem is that no number of white swans will ever be enough for us to be 100% certain that the next swan won't be black. And it only takes one black swan to disprove the entire claim.

Let's use the white swan as a metaphor for something you might observe in clinic.

Let's say you provide pregnancy massage, and among your clients, you have noticed what seems to you to be a trend--the older the mother is in her first pregnancy, the worse her self-reported nausea and vomiting appears to be. In the same way, the younger the mother is, the less nausea and vomiting she reports.

Does that mean that you can accurately tell how much nausea and vomiting the next new pregnancy massage client you see will report having, based on her age?

Maybe you can, and maybe you can't--you could have yet another white swan in a row. Alternatively, this new client might be your first black swan, breaking the trend you had observed up until she arrived.

That's a problem for induction, as compared to deduction, which provides us much more certainty when reasoning from the general to specific instances. After all, induction, abstraction, and generalization led clinicians to reach out to other gay males at potential risk for the disease, but fallacies based on those generalizations also led to discrimination and blame against them for the disease, as well.

Deductive and inductive reasoning certainly have important purposes they can serve in clinical decision-making, yet, by themselves, they are not enough to provide us with all the validated information and support we need.

There is another form of reasoning that we can call on as well, one that goes some way toward meeting that need. But this post is already quite long, and this is a good place to end it for now.

We'll pick up with abductive reasoning in the next post (Part 2).

Finding your space: Anatomical reasoning and our relationship to realism

Submitted by RST on Thu, 07/26/2012 - 05:23
Posted in

There are at least three ways, maybe even many more, to approach the practice of massage--as healthcare profession, as self-expression, and as business.

Of course, no one approaches it exclusively one way or another--even healthcare professionals, mystics, and artists have to make a living, professional ethics in business are a thriving area of exploration, and the feeling of self-actualization can be the key to a long and fulfilling career no matter what other aspects of massage you pursue.

These aren't self-contained monocultural boxes you find yourself in, so much as they are tendencies, one way or another. The interactions among those tendencies, and the choices you prioritize, will influence where you find yourself in the space of massage practice.

In this illustration, practitioners A, B, and C all find themselves in different areas of massage practice space, because of the different blends of healthcare professional, self-expression, and business orientations they bring to their practice.

 

Meaning, too, has multiple aspects, including:

  • the ideas we have about the universe around us, and the feelings and reactions those ideas draw out of us;
  • the words, or terms, that we use to talk about those ideas; and
  • the material physical things in the universe that those ideas and words refer to.

 

Since all of these aspects interact with and influence each other, we can model them as a triangle, with the three connected corners representing concepts/ideas, words/terms, and material physical referents.

 

Looking at the relationships among components of the Semantic Triangle, it is easy to see how referents can influence concepts: for example, Wilma--a sun bear at Woodland Park Zoo in Seattle, who no one suspected was positively riddled with tumors, but who held on just long enough to wean her twin cubs onto solid food before suddenly dying from the cancer--is a real-life referent whose fortitude while suffering reinforces the concept of "bear as good mother".

Sometimes the referent’s behavior, in addition to influencing concepts associated with a term, can actually influence the chosen or constructed term itself: the Russian for bear, медведь (pronounced "myed-vyed"), comes from the linguistic roots for "honey-eater" (our word "mead" for honey wine, comes from the same root as "мед").

And, like in the English term "bruin" ("the brown one"), it's also an example of intentional misdirection, and an indication of the beliefs behind it--bears can be scary, especially way back in history at the time when we were first deciding on words to describe the world around us.

To the people who came up with these terms, it may well have seemed safer to use taboo avoidance, just to be sure. Taboo avoidance means, in this case, a kind of magical thinking where it seems more prudent to refer to bears by euphemistic terms like "honey-eater (Russian)", "honey-paw (mesikämmen: Finnish)", or "the brown one (English)", rather than to get this scary animal's attention by outright saying "bear" in one of those languages, and running the risk of summoning angry supernatural bears down upon the speaker.

It’s not immediately obvious how influence flows the other way—that is, how concepts and terms can affect real-world referents—but a little thinking about it provides some examples. If someone thinks of bears as dangerous predators, they may lobby for laws allowing bear hunts, with real consequences to the referent bears themselves. However, assigning the term "endangered species" puts bears under particular legal protections, which could prevent their being hunted, saving the lives of actual bears.

So words, concepts, and real material physical referents all influence each other in the meaning we make of this universe around us.

And that meaning that we make, and decisions based on that meaning, influence where in massage practice space we find ourselves.

 

 

Although we often think of anatomy as strictly scientific, that's not always how people use anatomical terms and concepts. Gil Hedley writes:

The superficial fascia is an organ: it is an organ of metabolism, an endocrine organ producing some 30 hormones and counting; a great lymphoid organ; a sensory organ; a sensual organ; an electrical insulator; a thermal insulator; a movement sleeve; and a great antennae... what else? Tell me!!

 

And people did tell him. Responses included:

"All is fascia."

Microtubulars of liquid light .....-:-

Information super-highway......pure communication.

It's a Gigantic "Soft Drive", information collection unit...completely unique to each host...only to exist for One Lifetime.

Non specific immune function, and groovy to to work:-)

And a information webcam

The "copper wire - like" conduction system for sub atomic vibration of photons and electrons in cell communication.

 

Hedley continues to engage in the comments, but he does not correct any of the factual errors that either he or his commenters make.

What, exactly, is this process? It's not anatomical science--most of the discussion is, at best, highly metaphorical and allegorical, and at worst, factually wrong.

Clearly, it's meeting a huge need among his commenters, though:

Yes!

Your fascia discoveries are inspiring :)

Thanks for continuing to inspire the bodywork field. Blessings!

We are amazing!

 

If it is not science that Hedley is carrying out, then what is he doing?

I think that, given the apparent unmotivated functions of self-expression evident in the original post, and the motivated functions, among others, of validation, reflected in the commenters' responses, it would be fair to say that Hedley is carrying out performance art, religious expression, or both--using terms and concepts from anatomy for those purposes.

I don't think he would object to this taxonomic classification, based on what he's said about his philosophy:

Science to me is another religion among many, whose dogmas I am attempting to shed.

 

He isn't particularly concerned about doing science for the sake of knowledge.

That's perfectly fine, as long as we're all clear about what the process is about. If it's validation, or self-expression, or performance art that you're looking for, that's exactly what you're getting, and there's nothing wrong with that. Consenting adults, caveat emptor, and all that.

If it's anatomical science you want, on the other hand, not only is this not what you're looking for, but taking it at face value will get in the way of your actual understanding of the structure and function of the body.

This is where he makes an actually misleading statement:

I can do a much better job ripping into my own stuff than that particular critic [Paul Ingraham], and recently did so in front of 600 colleagues at the fascia congress in Vancouver, and will gladly do so again to move the knowledge base forward!

 

Propagating ideas such as that the superficial fascia is an endocrine organ, or that cells communicate with each other by means of photons and electrons, without correcting those factual errors, doesn't move the knowledge base forward at all. Instead, it sends a loud message to potential colleagues in healthcare professions that we aren't interested in, or are even actively hostile to, knowledge and reality.

This matters very much on an individual level, and on a professional level as well. One of the biggest obstacles to MTs becoming part of an integrated healthcare team is our inability to distinguish pseudoscience from science, and metaphor from literal truth.

If we remedy those problems, we can share in the common knowledge base of healthcare professions, and we can participate in sending a unified message to the client/patient.

If we don't, then we can't.

It's a decision we all need to make at the individual level, and those individual decisions will determine the fate of MT as an integrative healthcare profession, a siloed alternative medicine industry, or something else altogether.

 

 

What would an examination of these questions look like from the viewpoint of anatomical science?

The first, and most inportant, distinction between science and other human activities is that--rather than just operating in the realms of words and concepts--science has to do the work of connecting claims back to actual referents in the material physical universe.

So, for our claims, we will do that work as we go along.

A commenter on a different forum asked:

Why is Gil's comment so far fetched?

 

She's quite correct--I have made the claim that Hedley's work is performance art or some other form of self-expression, rather than anatomical science, and now it's my job to connect the dots and show why my claim is correct.

For the sake of time, let's just examine one part of the statement; it's representative of the same problems in the rest of it.

"The superficial fascia is an organ: it is an organ of metabolism, an endocrine organ producing some 30 hormones and counting"

 

What is he referring to? He clarifies that later on in the comments to his post:

"Adipocytes are generally classed as connective tissue cells with endocrinal function."

 

Fair enough--he gets the details right the second time. But he doesn't go back and correct his first statement to make it right.

By saying "superficial fascia...is an endocrine organ" there, he is confusing:

  1. structure (connective tissue versus glandular epithelial tissue) with function (protein secretion), as well as structure (endocrine) with function (secretion), and
  2. identity with parts/wholes: equating all of the superficial fascia (adipose tissue + loose areolar connective tissue) with only that part of it that actually secretes proteins (adipose tissue).

 

So he's at the wrong level of abstraction when he says superficial fascia--he means adipose tissue. Sounds like a picky little detail, doesn't it? And yet, it's a symptom of a lack of true understanding about anatomy.

This lack of true understanding about anatomy is a mistake that propagates among the MT community like wildfire--the very first thing you learn on the very first day of the very first anatomy class is the four kinds of tissue, right?

Epithelial, connective, nervous, and muscle tissue, right?

And yet, all over the web, you see people selling the concept that "body tissue can carry emotional memory", and MTs buying it, as though they had never heard of the distinction between epithelial and muscle tissue and nervous tissue. Those MTs can recite the names of those tissues to pass a multiple-choice test, yet they can't put the very first thing taught in anatomy class into practice when it comes to evaluating anatomical knowledge claims.

Being careless about the distinctions between different kinds of connective tissue, and what they are structurally, versus how they function, is exactly the same kind of error.

It prevents scientific understanding and real anatomical reasoning. As I mentioned previously, Hedley has been widely quoted as saying in his video that science is just another belief system, whose dogmas he's trying to shed.

The way he talks about anatomy, it is clear that he is not approaching it as science, nor bothering to get the scientific details correct. As a direct result, it comes across more as art or another form of self-expression, which is fine, as long as people know that that's what it is, and not anatomical science.

But I don't get the sense that people actually realize it; I think they think that's anatomical science they're doing, and it's a long way from it.

The "tell"s are comments like this one:

The "copper wire - like" conduction system for sub atomic vibration of photons and electrons in cell communication.

 

The words come from science, but they way they are strung together makes no sense. This is not a scientist nor a scientifically-trained layperson talking, yet salting the sentence with sciency words is, for some reason, important to the writer.

That indicates that the writer thinks they're making scientific sense, and really has no idea what science is and isn't.

Another, shorter way, to look at it is like this: confusing connective tissue with superficial fascia with adipose tissue and saying that connective tissue is an endocrine organ is the same kind of error as saying that mammals fly.

It's true that one kind of mammal--bats--do fly. But despite that one corner case, if you say that mammals fly, you'll be wrong most of the time.

If he is saying that adipose tissue is an endocrine organ, then he's using the term wrong, because adipose tissue is not an organ.

Superficial fascia, on the other hand, is an organ, but only one of its components has an endocrine function, so again, he's using terminology wrong: it's not an endocrine organ, although one of its components has an endocrine function.

It's the part/whole confusion, "bats fly, therefore mammals fly", logical error that he is committing there.

The questioner continues:

I did miss Gil's larger comment section and I am very glad you spent the time to explain the error and confusion of superficial fascia vs endocrine function of adipose tissue, which Gil is confusing with superficial fascia. Thank you.

But I must ask.... The primary function of the heart is circulatory yet it does have an endocrine function. I understand from Anatomy Trains, Fascia is highly innervated. Could it be possible fascia has more of a role than just stabilization? Especially when it is dysfunctional?

I think the role of fascia has not been studied well enough. Just a few years ago, science told us once a brain cell dies, it is gone forever. Now we understand neurogenesis better.

 

The questioner raises excellent questions, and I am glad they did so, as it gives us an opportunity to explore these issues in more depth.

It is true that sometimes scientific knowledge changes--so what does that mean for us here and now?

We'll examine these questions one by one, to try to figure out what is going on here.

 

 

Wikipedia: Neurogenesis, occurence in adults accessed 26 July 2012

 

"Considered": meaning they had the concept of the nervous system as fixed and incapable of regeneration, and they spoke of it in those terms.

 

The first evidence of adult mammalian neurogenesis in the cerebral cortex was presented by Joseph Altman in 1962, Wikipedia: Neurogenesis, occurence in adults accessed 26 July 2012

 

Joseph Altman questioned these concepts and ways of speaking about the nervous system, and as evidence for his claims, he introduced a material physical referent: the tangible new neural cells in the actual cerebral cortex.

 

followed by a demonstration of adult neurogenesis in the dentate gyrus of the hippocampus in 1963. Wikipedia: Neurogenesis, occurence in adults accessed 26 July 2012

 

Another material physical referent presented as evidence to counter the previous concepts and words: tangible new neurons in the dentate gyrus of the hippocampus.

In 1969, Joseph Altman discovered and named the rostral migratory stream as the source of adult generated granule cell neurons in the olfactory bulb. Wikipedia: Neurogenesis, occurence in adults accessed 26 July 2012

 

Yet another material physical referent: tangible adult generated granule cell neurons in the olfactory bulb.

Up until the 1980s, the scientific community ignored these findings despite use of the most direct method of demonstrating cell proliferation in the early studies, i. e. 3H-thymidine autoradiography. Wikipedia: Neurogenesis, occurence in adults accessed 26 July 2012

 

However, Altman and others' actual evidence with its connection to a referent was ignored in favor of the prevailing concepts and words.

The neuroscience community screwed up--that's not how science is supposed to work. Eventually, it did self-correct to more represent reality, but it took too long to do so.

But it didn't totally overturn their theories--if you're quadriplegic, for example, we still don't know how to make those nerves regenerate. And there are parts of the brain where they have observed neurogenesis, and others where they didn't.

So they were partly right, and partly wrong, and they held onto their theories for too long--but like the connective tissue example, and like the flying mammals example, you need to be very clear about the details of what exactly you are talking about--exactly what kind of connective tissue, exactly what part of the superficial fascia, exactly which nerve cells, in exactly what part of the brain.

Otherwise, you fall into unsound--false--conclusions like the "mammals fly" one.

That's the error that Hedley falls into--he gives names to things, and makes up explanations, without making any attempt to validate the connection of those names and explanations to material physical referents in reality.

It's perfectly acceptable in art or other forms of self-expression to not be constrained by any connection to a material physical referent. But science requires that connection, and since Hedley doesn't supply it, it's not science that he's practicing. Nothing more and nothing less than that.

 

 

The primary function of the heart is circulatory yet it does have an endocrine function.

 

That's correct. Does that make it an endocrine organ?

To answer that, we would need to clarify what an endocrine organ (a gland) is.

An endocrine organ is composed of glandular epithelium. Are the cardiac myocytes that produce the hormones atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) made up of glandular epithelium?

What does the answer to those questions tell us about whether the heart is an endocrine organ?

When you answer that question, then you have stepped through the process of anatomical reasoning.

And you have generated a piece of new knowledge as well--the answer to the question "are glands (endocrine organs) the only anatomical structures that produce hormones?".

You were able to do that because you maintained the difference between structure and function, and between part and whole that is absolutely necessary if you are going to figure out correct answers about new anatomical questions that you do not already know the answer to beforehand.

Hedley's descriptions don't support anatomical reasoning to correct answers, because of the way he substitutes parts for wholes, and structure for function. He can make any statement he wants, but you cannot put those statements together and use them to reason with, in the way you did here.

And sound and complete logical reasoning is absolutely necessary in anatomy, because there are so many facts that you cannot memorize all of them by rote. You have to learn enough anatomy to form a basis, and then use that basis for drawing correct conclusions as you need them.

So how do I know my definitions are 100% right, and his aren't?

First, I don't ever know anything 100%. But the way I am using anatomy, I am not only drawing on centuries of actual anatomical history, and distinctions that we can empirically detect with microscopes and other instruments (referents), but I am drawing on an integrated whole with other sciences and logic as well.

The fact that it works so well in generating new knowledge through reasoning is an indicator that this way of dividing up hormone producers between endocrine glands and things that are not endocrine glands, is more likely to be 99% right--and thus, not to change abruptly out from under us--than it is to be 60% right, and we'll have to make massive adjustments someday.

 

 

I understand from Anatomy Trains, Fascia is highly innervated. Could it be possible fascia has more of a role than just stabilization? Especially when it is dysfunctional?

 

Yes, it could be possible. You could form a hypothesis with that question, and you could test it, and you could accumulate evidence that backed up that hypothesis. And you would be carrying out science when you did that.

And when you have done that, and you have shown that your hypothesis is backed up by the evidence, then we can consider that it's part of our knowledge--how certain we are about it will depend on the evidence, but at least we trust it to some degree.|

But that only counts after it's been done. Before it's actually been done, and repeated, and other explanations for what we see have been ruled out, then it's really just marketing hype.

That can change, if the work is done to back it up. But fascia research is very preliminary right now.

Have you ever driven really fast at night, so fast that your stopping distance got ahead of where your headlights could see? That's called "overdriving your headlights".

Metaphorically, to speak of things with certainty before the work has been done to back those things up with evidence is like overdriving your headlights. It's great for ginning up enthusiasm, but you can't really use it to base anatomical reasoning on.

But it's a good question, and maybe the evidence will back it up someday. We just can't act as though we're there already, because we've just started learning so much.

 

 

 

To finish my thought I must say, Instant Ice and Kinesio Tape boggle my mind neither works directly to effect the muscle, yet tissue responds positively to them. Why do these techniques work?

 

You're right that something happens that creates a response of some type, yet the muscles are too deep for them to be directly effected.

What kinds of anatomical structure communicate both with superficial layers of skin, and with muscles as well?

Fascia is one kind of structure; can you think of any others?

That would be a very good candidate to begin looking at for answers.

 

'"What kinds of anatomical structure communicate both with superficial layers of skin, and with muscles as well?"

Sensory / Motor nerves come to mind, capillaries... As well as fascia.'

 

Good answers.

We know, from centuries of anatomy, that sensory nerves can carry pain signals, and that nerves can be blocked in various ways from carrying them, while capillaries don't carry pain signals.

Hedley says that superficial fascia is "a sensory organ", but he doesn't offer any explanation of why he says that.

It is a poetic metaphor, but it is not a fact that anatomical reasoning can be based on.

It is a similar error to the part/whole of adipose tissue/superficial fascia--as you observed, fascia is highly innervated.

Why would fascia duplicate that function itself, when it already contains tons of nerves doing that same job?

"Okay, that can explain the instant ice, but kinesio tape? Primarily effects fascia, or others thoughts...?"

 

I would say that, since:

  1. those modalities are directly contacting nerves, while the epidermis stands completely between them and the superficial fascia, blocking it from them,
  2. we know that nerves have that functionality, while there is absolutely no evidence that connective tissue does, and
  3. fascia already contains lots and lots of nerves, and there is no anatomical need for fascia to duplicate that function,

that the evidence up till now, plus our anatomical reasoning about the anatomy we know, indicates that it is much more likely that the mechanism involves the nervous system to a much greater degree than it does the fascia.

Now that we have an idea that is consistent with the anatomical evidence, we could do a literature search to see if others have investigated this question, or we could design a study of our own to test it.

That doesn't mean that nobody will ever show any interesting properties of fascia. But from what we know now, to a very strong degree of certainty, it doesn't make sense to speculate about new properties that fascia might have, until and unless the research actually shows that that is true.

 

 

 

 

It's up to you where you locate yourself in massage practice space. If you find self-expression or business to be your more natural fits, there is absolutely nothing wrong with that fact.

If you find healthcare professional to be your more natural fit, then--for the sake ultimately of your clients--you have a higher obligation than others do to get the knowledge and the facts as close to correct as you possibly can.

Anatomical science is crucial to the core of massage as a healthcare profession. If you are seeking anatomical science, then make sure that that is what you are actually getting.

There is nothing wrong with seeking other things instead of anatomical science--you just want to make sure that you are very clear on what the difference is, and that you know yourself and what you are looking for, and know for sure what you are getting.

 

Learning, success, and learning success

Submitted by RST on Sat, 07/21/2012 - 08:23
Posted in

UPDATE, 22 July 2012, 8:53 AM PDT: This post has undergone major revisions to correct scientific inaccuracies since its original, in response to feedback from Christopher Moyer.

But the post (and the WSJ story it is based on) are not scientifically accurate. Normally that might not matter so much, but we're scientists and we like to understand things and get things right, so it matters to you and me.

 

This.

He has summed up POEM's very reason for being--helping stakeholders in the community of massage to figure out how to get things right--and he took the time to engage with my post and to spell out the problems with it, so that I could correct them.

cheers, Chris!

 

Do you want to learn more about massage and how it fits into foundational human knowledge about the material physical universe, but fear you can't, because bad educational experiences in your past have locked you into an inescapable path?

That's not an issue at POEM--you're not going to be judged on your past education here, nor on how other people may have criticized you in the course of that education.

I originally included a story from the Wall Street Journal to reinforce that point--which still stands--but Christopher Moyer pointed out that the article was problematic and scientifically inaccurate in how it discussed intelligence, and that I, too, had propagated those errors in my original post.

Since here, we're all about getting it right, I've reworked the post to address the issues he raised, but I still want to ultimately keep the focus on this point:

Don't worry about whether you liked school or not, or whether they told you that you'd never do well because you aren't smart, because here at POEM we think the most important thing is a commitment to learning and we will help anyone who is motivated to understand what we are doing.

 

 

Neil deGrasse Tyson, an astrophysicist and science educator, interviewed in a recent Wall Street Journal article about recovering from educational failure, describes his views on people's capacity to learn as related to their attitudes about learning itself.

His views align nicely with our approach here, but before we get into just how that's true, we need to clarify inaccuracies in the article's lead-in:

Where do helpless students get the notion that intelligence is fixed? In part from our culture, which bombards them with the idea that IQ tests measure how bright they are.

Many people think of intelligence as static: you are born with lots of brains, very few, or somewhere in between, and that quantum of intelligence largely determines how well you do in school and in life.

 

Moyer points out that:

In fact, general intelligence *is* quite static. It is also true that it largely (a vague word here, but I'll agree to it for now) does determine how well people do in school. It also determines, to a lesser degree, how well they succeed in other areas of life. We may not like that, but it's well supported by mountains of solid evidence. The opening of the post suggests that those are not true.

 

He's correct, but that does not undermine my larger point, because general intelligence is not the only criterion involved in learning. And it is learning that we are concerned with here, not just general intelligence.

But the article does need to make that point more clearly than it did--it fails to explicitly point out that we are changing the topic from general intelligence to other factors that support learning. And I need to make that clearer in this post as well.

From this point on, we are setting general intelligence aside, and focusing on those other factors supporting learning instead.

The article continues:

The astrophysicist Neil deGrasse Tyson has never liked this view. "I hardly ever use the word intelligence," says Mr. Tyson, who directs the Hayden Planetarium in New York. "I think of people as either wanting to learn, ambivalent about learning or rejecting learning."

 

There is a lot of implicit subtext here, and since it is not stated explicitly, it runs a large risk of promoting misunderstanding. We'll clarify those implicit assumptions, and then bring it back to how it relates to our educational philosophy.

As Moyer points out:

"The astrophysicist Neil deGrasse Tyson has never liked this view."

As noted previously by me and then also by you, who cares? I don't like it either, but it's a fact. The implication here, of course, is that NDT, whose claim to fame is that he is really smart, must be rejecting the importance of intelligence because it isn't very important. In this case, he's wrong, especially if the content (say, astrophysics, or physiology) is complicated.

 

"Who cares?" is shorthand for at least three implicit references that he knows, and that he knows I know, so he doesn't spell them out every time he uses them--he's referring to the naturalistic fallacy, the moralistic fallacy, and the is-ought confusion.

In this case, the naturalistic fallacy would be that since nature, genetics, and material physical reality, in combination, are the source of general intelligence, then they would always do what is good and right, and never do anything else--they would dependably ensure that everyone has equal opportunity and capacity in general intelligence. Unfortunately, it doesn't work that way.

 

The moralistic fallacy sounds a lot like the naturalistic fallacy, and it is, in fact the converse of the naturalistic fallacy: it's what you get if you reverse the direction of the relationship, either by changing the direction of the arrow, as in A, or by swapping the entities with each other, as in B.

In this case, the moralistic fallacy would be that since equal opportunity and capacity in general intelligence is good and right, then we can expect nature, genetics, and material physical reality to provide it.

A

B

 

The is-ought confusion results when people confuse how things ought to be with how things really are in fact. People ought to be equal in opportunity and capacity in general intelligence; in reality, people are not equal in opportunity and capacity in general intelligence.

If general intelligence were the be-all and end-all in learning, we'd find ourselves confronted with a quite insoluble problem

Fortunately, that's not the case--general intelligence is one factor among several others in learning; those others include:

  • abilities,
  • motivation,
  • interests, and
  • personality.

 

We can create a lot of positive change in those aspects, and those are what we focus on from here on out.

As Moyer points out, although the article does not make it sufficiently explicit, Neil deGrasse Tyson also switches the emphasis to those other factors:

Next: ""I hardly ever use the word intelligence," says Mr. Tyson, who directs the Hayden Planetarium in New York."

Well that's fine, and appropriate; in his role as a public educator, it is not his job or even a good idea to try to sort people according to aptitude. Rather, the task is to present the information as accurately and effectively as possible, which is also the job at POEM. So this part is cool, but opening with the implication that intelligence isn't stable and isn't that important is misleading. It's both of those things.

 

So we say it explicitly, in order not to be misleading: we are focusing on those factors other than general intelligence here.

deGrasse Tyson's words sum up our philosophy here at POEM very well--if your experiences have been so bad that, as a result, you totally reject learning, then--unfortunately--we have nothing to offer you here, other than the hope that you will encounter enough good experiences along the way to convince you to give it another look someday.

If you do actively want to learn, then that's an easy win for all of us--all the content here is intended to give you ideas to think about in your learning journey. You don't have to agree with everything presented--it would actually be most surprising if you did--but in pushing back, thinking about, organizing, and expressing your viewpoints, learning will certainly happen, and you'll share that learning with the rest of the community.

And if you're ambivalent about learning, please give us a chance to meet you halfway and to build bridges to where you are. I hope it works for you, but if you give it a try and it's really not for you, we at least appreciate your efforts and your willingness to try, and hope that someday you find what you're looking for.

From the same WSJ article, although we'll mentally substitute "learning capacity" for "intelligence" to avoid the previous confusion, and to keep the focus on where we work:

A growth mind-set can be learned. In a 2007 study by psychologists from Columbia and Stanford, nearly 100 seventh graders (most of them struggling in math) participated in an eight-week workshop on studying. The subjects were secretly divided into two large groups. Both groups received instruction on how to use their study time most effectively and how to organize and remember new material.

But then came the difference: One of the groups read aloud an article titled "You Can Grow Your Intelligence." It explained research on how nerve cells in the brain make stronger connections after we learn something new. Students in the other group spent that time reading an article about how memory works and learning new strategies for recalling material.

Most of the students went into the sessions generally believing that intelligence was fixed for life, but the group that read about the brain's growth emerged from the experience with much stronger notions about improving intelligence with effort. That group generally showed greater motivation to do well in math class in the weeks and months after the experience.

As the researchers noted, someone's theory about intelligence may not make much difference when times are easy. But when failures accumulate, those who believe that they can improve their basic abilities are far more likely to weather the storm.

 

If you believe that you can improve your basic abilities, wherever you find yourself along your learning journey, then your chances of being successful are higher than if you believe there is nothing you can do. Here at POEM, we are in the process of building tools to help you take charge of your learning and build that success.

Moyer agrees with that point, and so we end on the optimistic note he raises:

That's great and definitely true. Practice, dedication, and routine exposure can and do improve concentration, effective habits, interest, and so on. They may even have a small but real effect on intelligence with enough time. (It is stable but not entirely immutable.)

 

 

 

 

Metaphysical boundary collapse

Submitted by RST on Wed, 06/27/2012 - 14:01
Posted in

One of massage's biggest culture wars at present arises out of the dispute between monistic and dualistic philosophies. It has implications for how we practice with clients, and how we teach our students in our schools.

Although we're experiencing this culture war every day in our own field, this argument is centuries-old and is not limited to massage. Throughout human history, great minds have tried--and failed--to resolve it. I don't expect us to resolve it anytime soon, but we do need to resolve whether those of us on opposite sides of the philosophical divide can work together, or whether it divides us irreconcilably.

The argument goes back much further in history, but in the early 1800s, advances in the relatively new science of chemistry caused a seismic shift in the evolving field of medicine. As Siddhartha Mukherjee describes the experiment that shattered previous thought on dualism in health and medicine:

Early interactions between synthetic chemistry and medicine had largely been disappointing. Gideon Harvey, a seventeenth-century physician, had once called chemists the "most impudent, ignorant, flatulent, fleshy, and vainly boasting sort of mankind." The mutual scorn and animosity between the two disciplines had persisted. In 1849, August Hofmann, William Perkin's teacher at the Royal College, gloomily acknowledged the chasm between medicine and chemistry: "None of these compounds have, as yet, found their way into any of the appliances of life. We have not been able to use them...for curing disease."

But even Hofmann knew that the boundary between the synthetic world and the natural world was inevitably collapsing. In 1828, a Berlin scientist named Friedrich Wöhler had sparked a metaphysical storm in science by building ammonium cyanate, a plain, inorganic salt, and creating urea, a chemical typically produced by the kidneys.

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

This drawing shows a molecule of ammonium cyanate, a compound that doesn't come from living things. It's made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray (since this is a 2-D drawing of a 3-D molecule, one of the hydrogens is hidden behind a nitrogen, but it really is there, even though we can't see it in this arrangement);
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

Urea, a kind of waste product produced by the kidneys in many different species of living things, forms molecules that are made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray;
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

These two very different substances, one found in living organisms and one not found in them at all, have exactly the same atoms in exactly the same amounts. The only difference is the arrangement of those atoms in 3D space.

 

 

Source: http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

 

The Wöhler experiment--seemingly trivial--had enormous implications. Urea was a "natural" chemical, while its precursor was an inorganic salt. That a chemical produced by natural organisms could be derived so easily in a flask threatened to overturn the entire conception of living organisms: for centuries, the chemistry of living organisms was thought to be imbued with some mystical property, a vital essence that could not be duplicated in a laboratory--a theory called vitalism. Wöhler's experiment demolished vitalism. Organic and inorganic chemicals, he proved, were interchangeable. Biology was chemistry: perhaps even a human body was no different from a bag of busily reacting chemicals--a beaker with arms, legs, eyes, brain, and soul.

With vitalism dead, the extension of this logic to medicine was inevitable. If the chemicals of life could be synthesized in a laboratory, could they work on living systems? If biology and chemistry were so interchangeable, could a molecule concocted in a flask affect the inner workings of a biological organism?

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

In one way, Mukherjee is right--this experiment showed that the vitalistic claim that a distinction based on vital essence existed between living organisms and non-living things had no basis in material physical reality. By "dead", he means that its foundation was shown to be false, and that there was therefore no basis to continue to use it as a basis for explanations in medicine or science. His usage refers to the "referent" part of the Semantic Triangle--no referent means no vitalism.

But in another sense, he's prematurely pronouncing it dead. There are still many people who believe in vitalism and dualism, not only in their own personal belief systems, but also by bringing dualistic concepts such as "spirit" and "energy healing" into the therapeutic encounter. The fact that there is no material physical referent in support of the idea does not prevent them from operating in the "concept" and "terms" part of the Semantic Triangle.

Whoever wrote the Wikipedia article on vitalism correctly observed that vitalism didn't disappear just because of that one experiment:

The concept of vitalism in chemistry can be traced back to Jöns Jakob Berzelius who suggested that in the division of organic and inorganic that a mysterious vital force exists in organic compounds.

Vitalism played a pivotal role in the history of chemistry since it gave rise to the basic distinction between organic and inorganic substances, following Aristotle's distinction between the mineral kingdom and the animal and vegetative kingdoms. The basic premise was that organic materials differed from inorganic materials fundamentally; accordingly, vitalist chemists predicted that organic materials could not be synthesized from inorganic components. However, as chemical techniques advanced, Friedrich Wöhler synthesised urea from inorganic components in 1828.

Further discoveries continued to marginalise need for a "vital force" explanation as more and more life processes came to be described in chemical or physical terms. However, contemporary accounts do not support the common belief that vitalism died when Wöhler made urea. This Wöhler Myth, as historian of science Peter J. Ramberg called it, originated from a popular history of chemistry published in 1931, which, "ignoring all pretense of historical accuracy, turned Wöhler into a crusader who made attempt after attempt to synthesize a natural product that would refute vitalism and lift the veil of ignorance, until 'one afternoon the miracle happened'". However, in 1845, Adolph Kolbe succeeded in making acetic acid from inorganic compounds, and in the 1850s, Marcellin Berthelot repeated this feat for numerous organic compounds. In retrospect, Wöhler's work was the beginning of the end of Berzelius's vitalist hypothesis, but only in retrospect, as Ramberg had shown.

In fact, some of the greatest scientific minds of the time continued to investigate the possibility of vital properties. Louis Pasteur, shortly after his famous rebuttal of spontaneous generation, performed several experiments that he felt supported the vital concepts of life. According to Bechtel, Pasteur "fitted fermentation into a more general programme describing special reactions that only occur in living organisms. These are irreducibly vital phenomena." In 1858, Pasteur showed that fermentation only occurs when living cells are present and, that fermentation only occurs in the absence of oxygen; he was thus led to describe fermentation as 'life without air'. Rejecting the claims of Berzelius, Liebig, Traube and others that fermentation resulted from chemical agents or catalysts within cells, he concluded that fermentation was a "vital action".

 

but he/she ends the chemistry section rather abruptly with Pasteur, rather than following through continuously to the present. This, too, is premature--vitalistic thought persists to this day. The developments in chemistry and other sciences that--among people who are familiar with the subject--convinced them that vitalism is no longer a compelling alternative explanation.

I think this overlooks a great number of people who aspire to be healthcare professionals, but who have not had access to an in-depth scientific and biomedical ethics education.

The issue of vitalism/dualism in MT is a huge issue for us. To continue to insist on vitalistic mechanisms as explanations is an obstacle to integration with other members of the healthcare team in fields that have long ago accepted the scientific consensus that--as a source of explanation in the lab and in the clinic--vitalism is dead.

And it directly contradicts established consensus of what belongs in an MT body of knowledge. As we've seen, vitalism contradicts chemistry and pharmacology.

Yet MTs are expected to know basic principles of pharmacology in order to practice.

The Massage Therapy Body of Knowledge (MTBoK) calls for the following required knowledge:

Pharmacology

  • General classification and types of drugs, herbs, supplements, their effects and their side effects.
  • Massage therapy considerations and potential responses to general classes of drugs, herbs and supplements.
  • Use of authoritative, medically accepted drug reference to look up drugs, their effects and their side effects.

--MTBoK, p. 18

 

while the Massage and Bodywork Licensing Examination (MBLEX) states the following expectations:

PATHOLOGY, CONTRAINDICATIONS, AREAS OF CAUTION, SPECIAL POPULATIONS (13%)
...

E. Classes of medications

--Massage and Bodywork Licensing Examination Candidate Handbook, Content Outline, p. 15

 

and the National Certification Exam in Therapeutic Massage and Bodywork/National Certification Exam in Therapeutic Massage lists the following topics:

III. Pathology (13%)

...

L. Drug interactions with massage/bodywork
1. medications (e.g., prescription; over-thecounter)
2. recreational drugs (e.g., tobacco; alcohol)
3. herbs
4. natural supplements

--NCETMB/NCETM Candidate Handbook, pp. 21, 23

 

and yet, at the same time, they require vitalistic concepts on the very same test--concepts that directly contradict the science on which these learning expectations are based.

This puts our students in an impossible position for learning, when one set of expectations directly contradicts another, as well as putting the teachers and schools in the position of being required to teach mutually contradictory information, and to assess students on how well they perform the impossible task of integrating that knowledge.

We need to figure out what this means to us as a community and as a developing profession. As Mukherjee observes, the metaphysical boundary collapsed a century and a half ago, but not all of us have quite gotten word of the collapse yet.

We need to address, at the very least (there may be even more issues that I have overlooked here):

  • how do we balance ethical standards and best practices in the client's interests in the therapeutic encounter with the practitioner's freedom of conscience?
  • how do we--schools, teachers, mentors--provide an education to our MT students that prepares them to build bridges to integration with other members of the biomedical healthcare team?
  • what do we do about the sunk costs in the previous unsustainable path, and the tremendous investment that it will require for us to practice as an integrated healthcare profession?

 

Source: The 7 November 1940 collapse of the Tacoma Narrows suspension bridge, http://upload.wikimedia.org/wikipedia/en/5/5c/TacomaNarrowsBridgeCollapse_in_color.jpg accessed 27 June 2012

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