Dr. James Cyriax

The first person here has to be Dr James Cyriax who unquestionably established Orthopaedic Medicine. He told me that it all started one day as he was riding on the upper deck of a London bus and asked himself what he knew about it and was appalled that all he could write filled just two sides of an ordinary letter envelope. That, he claims, was the stimulus for his work, and his contributions became monumental. Yet, another lesson to be derived is truth from the rest of the story. Jimmy was very human, and some of his work was deservedly controversial, as well.

For your beginning reading here, if you haven't already read it, you may wish to peruse Goodley's Travels – A Voyage Among the Giants , in Background History/Archives/NAAMM , a Newsletter in which I describe my first meetings with Jimmy lest you conclude that this necessary balancing is skewed. (And if you then wish to follow how that Newsletter affected the remainder of my career commencing with my being fired from my first year of residency, you may go to Background History/Orthopaedic Medicine for that story. In the end, it all worked for the good and, for that, you may read Release From Pain.

Jimmy was an extraordinarily dedicated man among whose lifelong lessons to me were:

• Remain keen in observation: His posture during every examination was the epitome of hawk concentrating on the particulars.
• Maintain an innocent open mindedness during the examination of every patient – no preconceptions or overbearing loyalties to established procedures, especially of self!

The first of those the lessons, he taught me with positive example; the other by negative example, admittedly later in his life.

At some time, Jimmy seems to have made a decision that, since what he had accomplished opened a new chapter in orthopaedic thinking, everything he concluded must therefore be of the same caliber - thus, the legitimate controversies that impaired traditionalism's acceptance of his greater work – which obviously would have facilitated the broader appreciation of Orthopaedic Medicine. I must state that for the purpose of clarity because Jimmy's true contributions must not be allowed to be diluted with some of what came later.

With no reference to notes or texts but only my memory of Jimmy's impact on me, some of his masterful contributions included his description of what he terms a Coronary ligament Sprain. which, in my experience, is unknown to orthopedic surgeons - as is much of his work. I have cancelled scheduled knee surgeries a number of times by performing his very simple technique a few times. It is another of the therapies made priceless by its bearing no penalty for the attempt if it doesn't work.

His conceptualization of the Capsular Pattern is a pure gem.

His transverse massage techniques, especially for the foreleg, are insightful and valuable.

At the same time, surprisingly to me, Jimmy's examining techniques rarely involve soft tissue palpation. As exquisitely delicate as he was while injecting, I never saw him palpate for subtle soft tissue changes. He would primarily evoke response by stressing the musculo-tendinous structures and noting any pain response.

In my files that I had to leave in 2003 before coming to Israel was a copy of Jimmy's brilliant essay on Orthopaedic Medicine published in the British Medical Journal. A copy must reside with the Society of Orthopaedic Medicine, in England . I assume it has to be on the Internet somewhere, but I haven't had the good fortune to find it. Anyone who wishes to taste Jimmy's brilliance in that focus needs to read it. (And, if you do obtain a copy, I will be in your debt if you send me a copy.)

After I met Jimmy in 1972, we met fairly frequently and corresponded regularly, he with his famous post cards. We were together again for a month, late in 1972, in the Canary Islands , during the predominantly physical therapy training that Freddy Kaltenborn and Olaf Evjenth conducted and where The Federation Internationale Manuelle Medicine was founded. Earlier that year, I had discovered a new diagnosis, and I presented a video of the cineradiography of it at the Canary meeting. (It is here on the website) Jimmy simply said, “ I'm going to put that in my book.” And he did. The next edition of his textbook lists what he called “Entrapped Ligamentum Teres in the hip.”

By that time, also, Jimmy's major theory about manipulation was catching up to him. For those who know his work, he emphatically insisted that the “centripetal” (vs. centrifugal) force he generated with his cervical manipulation could do no harm. In fact, it did. I saw it during my time with him in London .

( From Release From Pain )

DR. CYRIAX'S CATASTROPHE CLINIC:

With all his accomplishments, Dr. Cyriax's manipulative techniques are legitimately criticized, which has retarded consideration of some of his considerable contributions. It seems as if he decided that since he could come up with such an ingenious method of musculoskeletal inquiry, he certainly should be able to come up with a distinct manipulative system, as well – and he certainly did. One particular lumbar maneuver even required a short hop by the therapist immediately after the thrust.

A very properly dressed London physician sat smartly in front of us.

"Well, my good man, I manipulated your neck last week, did I not?"

"Yes, Dr. Cyriax, indeed you did."

"And would you please tell us what happened after."

"Dr. Cyriax, fifteen minutes after you manipulated my neck, I developed paraesthesiae ( "pins and needles") in all four extremities!"

On my very first day in his office, he was visited by an elderly woman with neck pain. Jimmy examined her, had her recline on his table, put a padding between her teeth and assumed his position, which meant holding onto her head with both hands, putting his feet under the table at about her neck level so he could lean way back and exert maximal traction force on her neck. In one of his books, he had an x-ray of a his wife (I think her name was Patsy, or close to it, a very nice, tall, thin lady), in which it states he is applying some enormous force which he specifically stated, well over a hundred pounds. Patsy's vertebrae are all very markedly stretched out. At that point, while maintaining all that force, he would suddenly grossly twist the patient's neck to the right and left as far as he could.

That was what he had done to the London physician and what he attempted to do to the elderly lady. With her, he didn't get far, at all. As he applied first force, here whole body went rigid as she tensed and emitted a pathetic gurgle. He tried a few more times and dismissed her. Despite, Jimmy would insist that his technique was harmless and pain free.

I'd learned considerably since my time with him and then in the Canary Islands I was seated with some of the world's manipulation experts as they were demonstrating their techniques. When it was Jimmy's turn, he knew his audience, and he very significantly modified what he said was his technique. There were smiles around the room. Jimmy was still years from his stroke. He was intellectually strong. He should have learned from that.

The next time I saw Jimmy was in 1975 when he was one of the invited speakers to the first federally sponsored program in the U.S. concerning manipulation. (The Research Status of Spinal Manipulation, National Institute on Neurological Disease, Washington , D.C. ¹) That night, there were perhaps 10 speakers. Jimmy said two things that I remember. He briefly discussed vertebral osteophytes and commented that he didn't know why there was such criticism of them, that if he didn't have them he wouldn't be able to stand at all. British humor – and he got his laughter.

The other was more serious. He turned the discussion of lumbar pain into a contest of will with one comment declaring that if everyone would get into his boat and agree that it was the disc that was responsible then they could all “row together.” (Jimmy's sport was Crew. His oar was mounted high on the wall in his den.) The next speaker was Alf Nachemson, even then a world famous orthopedic surgeon for his research on pressures in the intervertebral discs. ¹Soon, Alf and I would lock horns on several occasions regarding manipulation. I never took satisfaction in bloodying him, but he was an absolute tyrant in his condemnation of manipulation, and he was internationally influential. In the end we became mutually respecting friends, and I hope his openness remained. It's another story that I discuss more fully in Release From Pain. However, on this night, Alf took Jimmy down by stating, in effect, that the facts and the course of research had nothing to do with popularity contests.

Some years later, when Jimmy founded the Society of Orthopaedic Medicine , I flew to London specifically to submit to his examination in my great respect for him so I could officially participate in his work. The examination was conducted in his home. I have long forgotten the name of his nurse, severely dedicated to him. The invitation had been very general. There, she told me that the examination would be in two parts, and they couldn't be done the same time and that I would have to return to England again. I'd severely strained for the first, and Jimmy was well aware of my training. Reluctantly, an exception was perhaps made and I was led into the great man's study.

Jimmy was quite stiff, more than formal. His nurse sat at the table and he asked me to examine her shoulder. For the shoulder, Jimmy's techniques are, for the lack of any other word, marvelous – as far as they go. (For the necessity, I eventually had to extend it. I discuss it in Release From Pain ) As always, during my examination, Jimmy's eyes locked close and stared sharply as he asked me about structures and procedures, his face up close to her shoulder. I was satisfied. He said nothing.

Then, he asked me to examine her neck. I spoke with softly and reminded him that he knew that I didn't examine and treat necks his way. Above all, in our, in any of my relationships, I need honesty and assume the other party does as well. He told me to do what I do and explain it.

For maybe twenty minutes, I described my primarily osteopathic training as I gently examined her neck. I went through all the procedures I knew and told him what conclusions I was reaching. When I finished, Jimmy told me I could leave as he returned silently to his desk.

I waited in his living room. No one said anything. I approached his nurse and asked her what was happening. She said flatly, “You can leave.” It obviously disturbed me. I'd come all the way from the U.S. Not even a short social visit? Not even a word about what had happened? I asked to see Jimmy.

He sat at his desk, a fixed smile on his face. I asked him for a conclusion. “Why, my boy, you obviously failed! You know absolutely nothing about the neck!”

When I had spent my first week with him in London , years before. We had gone outside the hospital together during a respite from one his discussions. He complained to me about never having been given his own Institute, never having been Knighted. I knew enough to gently, directly then tell him that his contributions would not be able to be dispassionately evaluated until after he died. I discussed my reasons briefly, as I have alluded to them here. He listened silently.

The episode of the London physician occurred during that week. The clinic was to reexamine the patients he had seen the previous week. Every one of the approximately seven patients he presented to us was one unmitigated disaster after the next. I had sat next to him at his table, my tape recorder between us, every word recorded.

After, we were in the otherwise uninhabited Men's Room at the same time. From the far end of the “trough,” Jimmy brusquely remarked at what a disaster the day had been. I'd laughed and responded that no one would ever be able to accuse him of being a dishonest man after that, that one would willingly have done that to themselves.

Jimmy never should have insisted that his methods were universally safe, or effective. For whatever reason, he disconnected some of his experience from his inherent honesty.

The results were sometimes silly. As I alluded, he took the osteopathic “million dollar roll” supposedly high velocity, low amplitude thrust and showed us how to do it his way, which was a highly non-specific maneuver that might just cause a release anywhere along the mid to the lower spine. Then the coup de grace. As soon as he did his push, the “thrust,” he jumped off the ground with both feet telling us at the same time that the manipulation needs a “hop.” I never could figure out why Jimmy felt he had to do that.

I didn't see Jimmy again after my examination in London . And then Jimmy had his stroke and passed.

To me, by the definition of greatness - being remembered in history for having caused events that had notable impact, Dr. James Cyriax was a great man. Hopefully, his major, major contributions will be sifted, and his recognition will grow roots and spread. I hope that if he had had the opportunity to look back at medical history, Jimmy would have opted for a place in the Parthenon for facilitating new thinking rather than being frozen into the fatherhood of a circumscribed and completed system.

¹ It would be thirty years before there was another such meeting, “Conference on the Biology of Manual Therapies.” There were only two at the second who had been at the first, Murray Goldstein, D.O., the moderator, still at NINDS, and I was the second.

² He used his residents at the University of Goteborg , in Sweden and smiled but refused to answer if any of them had experienced difficulties from his experiments.