Introduction

In recent years, osteopathy has achieved an unprecedentedly high status within the health care system of the Federal Republic of Germany [4; 5]. This has been achieved both on the part of the patients thanks to a high level of utilisation and satisfaction [6], and on the part of the statutory health insurance funds by means of a voluntary subsidy for this service [7]. In addition, osteopathy has been academised and successfully established within the German university landscape [8]. However, all these positive aspects should not obscure a confused and fragmented self-understanding of osteopathy with regard to its essence. The Flexner Report of 1910 can certainly be seen as the initiation of this historical uprooting and obfuscation towards a fragmentation of this medical philosophy. Due to the accreditation of osteopathy in the medical system of the then United States of America, this report resulted in a modification or deletion of numerous education contents [9]. This compromise, which was necessary at that time for academisation and professionalisation, should now, however, after more than 100 years, be discussed again or modified and osteopathy should take a clear position with adequate conditions. However, this is not really possible because, based on the Flexner Report, a division has been made within osteopathy into Lesionists, the followers of the traditional teachings of

A. T. Still, and the Broadists, those osteopaths who turned to orthodox medicine [10]. The integration of osteopathy into the field of manual medicine in Europe also forced the distancing and detachment from the guiding ideas of its discoverer. Currently, this "osteopathic chaos" [1] due to the obscuring of historical contents and ideas is revealed by the following facts, among others: First of all, the discrepancy between current osteopathic literature and the classical works of Still, Littlejohn or Burns seems obvious with regard to content. With a few exceptions [11; 12; 13; 14], the current literature is primarily technique-oriented, whereas the authors mentioned above published in a more philosophical or research-oriented way. A.T. Still published at all only as a critical reaction to a previously published book on osteopathic techniques and principles [15]. This discrepancy also illustrates the difference between the current way of teaching and A.T. Still's teaching method in the early years in Kirksville. Today, in contrast to A.T. Still's walks in nature and the dissection units, techniques and "dry" anatomy are often on the teaching agenda in Europe. This, in turn, is of very limited benefit to A.T. Still's goal of "making the osteopath a philosopher and placing him on the rock of rational reasoning" [2]. Philosophy, as the foundation and main focus of A.T. Still's osteopathy, still exists for the most part as a marginal phenomenon in current osteopathic training, which is certainly also due to the fact that the works of A.T. Still were not accessible for a long time. Another fact is the primary location of osteopathy in the system of conventional medicine. In Germany there were also attempts to integrate osteopathy as a component in the training catalogue of physiotherapy. Due to the original idea of A.T. Still to revolutionise or renew the conventional medicine of that time [2], the two aspects mentioned are to be considered incorrect. In addition, osteopathy and chiropractic or manual medicine have been mixed for decades, which is not only reflected in the literature [16; 17; 18] but also in various training courses. Finally, reference should be made to the multiplicity of osteopathic (style) directions and the resulting problems of conformity, as perceived by the author from decades of practical and teaching experience. In addition to numerous other aspects, all this prevents a clear positioning of osteopathy within the German health system and thus in turn a desiderable professional genesis.

Question

Based on the field of tension opened up in the introduction and the problem definition, numerous questions arise. In the context of this paper, the focus is primarily on osteopathic techniques. The techniques thus serve as a vehicle for the overarching structuring and differentiation of osteopathy. For this purpose, a catalogue of criteria is required, which enables a systematisation of techniques in order to clearly locate them in osteopathy or other disciplines. The resulting research question is therefore as follows: What criteria should a meta-concept of osteopathic technique contain according to the works of A.T. Still?

Methods

The procedure of a hermeneutic-interpretative analysis was considered from many different points of view. The most opportune aspect is based on the fact that the only direct legacy of A.T. Still is his four books and several publications, which also serve as the literary basis for this contribution. As a comment on A.T. Still's texts, it should be mentioned that although excessive interpretation between the lines is often propagated [19], in this contribution, however, reference is made to statements by

A.T. Still that he uses simple understandable language. "I merely ask the reader to read what I have written." [2]. First to hermeneutics, which comes from the Greek compound hermeneutike (ἑρμηνευτική) from the words art ἑρμηνεύειν and technique τέχνη [20] and is defined as "theory or art of interpretation, or interpretation" [21]. In this, hermeneutics has been pluralistic from the beginning [22]. This parallels the current situation of osteopathy [1]. And in the context of this paper, hermeneutics, although scientifically debatable, is to be understood from the Greek messenger of the gods, Hermes [23]. For A.T. Still can also be interpreted as a messenger of the messages of the "great architect" [2] for the people, since he "stylised himself as the Moses of osteopathy" [24]. Moreover, the hermeneutic circle in all its interpretations [22; 25; 26] shows a great intersection with osteopathic intervention. The term interpretation, as a Latin compound of inter- for between and pres for uncertain, is commonly translated as interpretation [27]. And just as an uncertain entry and exit is inherent in every treatment and the entire diagnostic process alone, whether manual or apparatus- based, is pure interpretation, since the evaluation parameters were always defined by the human being beforehand and are thus per se limiting, the result of an interpretation is also uncertain and is subject to the interpretive sovereignty of the subject. Or in Becker's words, "As always, the problem remains of expressing what is in words and finding methods to make it part of our experience. It is just something that one learns only from within oneself." [28] Analysis (Greek ἀνάλυσις for resolution) is used because, as in osteopathic practice, the resolution of the lesion and thus the integration into the existing whole, referred to by A.T. Still as the "Triune Man" [2], which, like in the case of hermeneutic textual interpretation, is characterised by the resolution of the problem previously posed. And since this treatise is, in the sense of A.T. Still, a "practical philosophy" [2], there should also be a solution answer to the question posed. All in all, the reader should allow the following chapters to have an effect on him or her from the above-mentioned points of view, since the methodology used here is deeply subjective, as is immanent in every space of experience and perception. Or in the words of Becker: "When one learns the science of osteopathy, one is not given specific instructions. It is a way of experiencing, a way of developing." [28] And it is precisely this method that conditions a subjective experiencing and developing and allows the user to follow the words of A.T. Still: "Know thyself and live at peace with God!" [1] And what is every osteopathic intervention if not a hermeneutic- interpretative analysis?

Terms

The term metaconcept is to be interpreted as follows. The Greek prefix μετά is to be translated in this context with the adjective underlying. The term concept (Latin conceptum for that which is summarised) is to be understood as that which is essential. The metaconcept is therefore to be defined in the context of this paper, as the underlying essence. A singular approach to meaning is chosen for the term pair osteopathic technique. First of all, the term osteopathy. Osteopathy cannot really be clearly defined, not only because of its different origins [29], but also because of its multiple manifestations [1]. Most of the history of the term refers to the Greek words osteon for bone and pathie for suffering, as A.T. Still wrote: "I concluded that the bone, osteon, was the starting point from which to explore the cause of pathological conditions, and so I combined "osteo" with "-pathie" and got osteopathy." [2] Due to the historical obfuscation and rootlessness of osteopathy, the definitions currently in use, such as those of the WHO [30], among others, will not be considered for dealing with the question addressed in this article. Rather, A.T. Still will have his say with his simple language: "Osteopathy is discovered in nature. Osteopathy is based on nature. Osteopathy is nature." [2] and concluding from this, osteopaths are "masters of the laws of nature." [2]. In A.T. Still's texts, nature is a synonym for God and over 50 other terms [1], which are subsumed into the term perfection. Perfection in A.T. Still is at the same time an expression of love (God) and love in turn an expression of perfection (God), so that these two terms can also be synonymised, for "Osteopathy is the law of God."

[2] Another definition of osteopathy that is useful for this paper, because of the triangulation included, comes from Wright: "Osteopathy is at once philosophy, science and art all in one. Its philosophy includes the concept of the unity of structure and function of the organism in both healthy and diseased states. As a science, it encompasses branches of biology, chemistry and physics in the service of health and the prevention, cure and alleviation of disease. Its art consists in the application of this philosophy and science in practice and in all its subfields." [31] In this context, the art, i.e. the intervention of osteopathic techniques on the patient, forms the field of action [1] which is generated from the philosophy and science practised on human beings. Technique as the second word of the pair of terms is derived from the Greek word τέχνη for art, handicraft, artistry [32] and clarifies the ductus of osteopathy as artistry [14]. The osteopath in the quintessence of this interpretation is in the mentioned field of action ergo a master of perfection or love (of God). And thus, in the field of action of his discipline, the practising osteopath possesses, "after a conscientious examination" [2] by means of a "closing mind" [2], both an understanding of the materialised perfection (God) in his patient, and a skill for adjusting the body structures with the aim of autoregulating salutogenesis. It should be noted here that a differentiation of techniques into diagnostics and therapy only makes sense from a didactic point of view due to the processual character of an osteopathic intervention; for the practical implementation on the patient, however, it is to be regarded as obsolete. Ergo, the term technique in this article includes both aspects of treatment.

Osteopathic Technique - Quo vadis?

The following question may serve as a starting point: Is there a difference between direct manipulation of C3 in dysfunction rotation on the right from a manual medical perspective and from an osteopathic perspective? If the answer is No, then there is no need for further terminology and substantive concretisation of osteopathy, and it ekes out an existence as a historical appendix in manual medicine. If, however, the answer is Yes, then this answer must be clearly and argumentatively underlined and substantiated. In order to be able to conduct a well-founded argumentation and to gain the essence, the following supplementary question suggests itself: What is the connection between an osteopathic muscle energy technique of the biceps brachii muscle, a High Velocity Low Amplitude technique of L4, a General Osteopathic Treatment technique of the foot, a disengagement technique of the sagittal sutura or an inhibition technique of the ductus choledochus? A common feature of the techniques mentioned is that they are all taught and practised under the guise of an osteopathic technique. However, just because this is routinely done does not mean that it is acceptable from a scientific perspective. Some of the techniques listed are also used in physiotherapy [33], chiropractic [34; 35] or Traditional Chinese Medicine [36]. It would then have to be clarified on the basis of which concrete criteria a manual technique can then be specifically assigned to osteopathy. Under the provisional assumption that something like osteopathic techniques exist at all, the objective-quantitative parameters such as starting position, angle of adjustment, direction of treatment etc. would be out of place as differentiation criteria because of the homogeneity with other disciplines. Even qualitative parameters such as observing the current reaction situation of the patient or an individual dysfunction- conform stacking, for example, are also observed in a well-executed manual medical technique. Therefore, this aspect cannot be identified as a differentiation criterion. Also a systematisation of osteopathic techniques, as it has been carried out more or less sensibly in various literature [37; 38; 39], seems to be more disturbing than conducive to overcoming the problem of differentiation. First of all, it should be questioned whether it is possible to systematise osteopathic techniques at all. This is because systematisation first requires a definitional dictate in terms of content, which would be rational and doctable at the detailed level, e.g. in parietal, craniosacral, fascial or visceral techniques or articular and intraosseous techniques, but which seems inappropriate at a meta-level in everyday practice, in accordance with the principle of the body as a unit or even the patient as a whole. It is true that attempts can be made to achieve wholeness with the help of various techniques within a treatment. However, it has been known since Aristotle that the whole is more than the sum of its parts [40], and therefore systematisation as a starting point does not serve any purpose. Due to the