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Wer will was Lebendig’s erkennen und beschreiben, sucht erst den Geist herauszutreiben,
dann hat er die Teile in der Hand. Fehlt, leider! nur das geistige Band.
J.W. von Goethe, Faust
Those who want to study life,
first have to throw out (think away) spirit.
Next you have the parts in your hand,
what now fails, is the context of spirit (and wholeness)
THE ARCHITECTURE OF THE FASCIA AS PARAMETER TO
UNDERSTAND IT AS THE ORGAN OF INNERNESS IN
GENERAL AND TO UNDERSTAND ITS FUNCTIONAL
ANATOMY IN LOCOMOTION IN PARTICULAR.
WARNINGTHIS LECTURE IS ABOUT THEORY AND PHILOSOPHY
NOT ABOUT CAUSES AND PRACTICE
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JAAP VAN DER WAL MD PhD
Why me?
PHILOSOPHICAL AND
METHODOLOGICAL
INTRODUCTION
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AN APPROACH TO DEFINE
THE SUBSTRATE OF FASCIA
AN
THE ARCHITECTURE OF THE CONNECTIVE
TISSUE IN THE MUSCULOSKELETAL SYSTEM
A TRANS-BORDER APPROACH OF THE SPATIAL ORGANIZATION OF ‘PROPRIOCEPTORS’,PLACED IN THE CONTEXT OF
‘FASCIAL ANATOMY’
JAAP VAN DER WAL MD PhD
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AMSTERDAM 2009
THE SECOND INTERNATIONAL FASCIA CONGRESS
MY MAIDEN SPEECH IN THE DOMAIN OF FASCIA RESEARCH
Fascia Congress Brussels 2012
NOT BY BONES, LIGAMENTS AND
MUSCLES ALONE
The Importance of Fascial Architecture for
understanding the locomotion system
JAAP VAN DER WAL MD PhD
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FROM FACTS TO CONCEPTS - INDUCTION –
AND BACK …
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A ‘transborder’ anatomy of fascia
Connective tissue and its functional
organization in the human body
Architecture of connective tissue in the Musculoskeletal
System
Thesubstrate of
proprioceptionin joint regions
1988
…… ON THE WAY BACK I (ALSO) BECAME
EMBRYOLOGIST AND PHENOMENOLOGIST
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PHENOMENOLOGIST
MORPHOLOGY
EMBRYOLOGIST
ANATOMIST
ACTION ACT
GESTURE
MOTION
FORM
JEDES SEIN WIRD UNS NUR DURCH SEIN WERDEN ERKANNT.
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ORGANISM versus CELLULARITY
WHOLENES versusPARTS AND ORGANS
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ANATOMY FOR INTEGRITY AND SYNTEGRITY
THINKERS
ANATOMY DESTRUCTS MUCH MORE THAN YOU CARED FOR
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ANATOMY (IS NOT) FOR INTEGRITY AND
SYNTEGRITY THINKERS
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Wer will was Lebendig’s erkennen und beschreiben, sucht erst den Geist herauszutreiben,
dann hat er die Teile in der Hand. Fehlt, leider! nur das geistige Band.
J.W. von Goethe, Faust
Those who want to study life,
first have to throw out (think away) spirit.
Next you have the parts in your hand,
what now fails, is the context of spirit (and wholeness)
ACTION ACT
GESTURE EXPRESSIO
N
MOTION
FORM
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ANATOMY (FORMS) ON THE MOVE
PHENOMENOLOGIST
MORPHOLOGY
EMBRYOLOGIST
ANATOMIST
UNDERSTANDING NOT EXPLAINING
HOW MANY FISTS CAN A HUMAN BEING MAKE ?12
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UNDERSTANDING VERSUS EXPLANATIONS
I AM NOT A BRAIN, I AM / HAVE A BODY
I AM NOT MOVED BY …. , I MOVE (… my body …)
NOT MY MUSCLES OR BRAIN OR LOCOMOTOR
APARATUS IS / ARE MOVING ME, I MOVE MY
ARMS, MY BODY
ORGANISMS MOVE, NOT APARATUSES
INTEGRITY VERSUS DISSECTION: Anatomy is not
a method alone it became a ‘dissecting and
ana-lytic’ mentality
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STRUCTURE of the lecture
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1. Fascia anatomy is a contradictio in terminis,
architecture is the keyword
2. The “holy locomotion apparatus trinity” (anatomy)
versus the “functional twofoldness” of forces to be
guided (architecture)
3. The architecture of connective tissue (‘fascia’) is
instrumental for as well locomotion as proprioception
4. Fascia AS WELL AS muscle tissue are derivatives and
integral components of the “Meso” and ‘Inner tissue’
5. A transborder matrix organization: “over the woof of
the muscle man, the warp of dynament woman”
STRUCTURE of the lecture
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1. Fascia anatomy is a contradictio in terminis,
architecture is the keyword2. The “holy locomotion apparatus trinity” (anatomy) versus the “functional
twofoldness” of forces to be guided (architecture)
3. The architecture of connective tissue (‘fascia’) is instrumental for as well
locomotion as proprioception
4. Fascia AS WELL AS muscle tissue are derivatives and therefore integral
components of the “Meso” and the ‘inner tissue’
5. A transborder matrix organization: “over the woof of the muscle man, the warp of
dynament woman”
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(‘CLASSICAL’) ANATOMY DESTRUCTS MORE IN
YOUR MIND THAN YOU ARE AWARE OF ..!
The ‘anatomist’ cuts, dis-sects,
separates: capsules, ligaments,
fasciae, muscles, bones.
Anatomical figures / images =
“(self) made” structures.
Continuity has gone!
That continuity was ORIGINAL!
It is the continuity of connective tissue, of
mesenchyme, of the fascia, of Meso
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WHAT IS IN A NAME?
WARNING! A ‘name’ is very important. Names might obscure facts
and induce views. Think on the so-called ‘gill arches ‘or ‘pharyngeal
arches’ in the human embryo. A name might even narrow your mind!
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MUSCOSKELETAL
SYSTEM????????
The Locomotor
System?
Sensu stricto or
sensu lato?
The Musculo-Skeletal
System?
What about the
Connective Tissue
Skeleton?
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WHAT’S IN A NAME?
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TABLE 1. Recommended use of terms regarding fascial structures
Dense connective tissue
Connective tissue containing closely packed, irregularly arranged (that is, aligned in many directions) collagen fibers.
Non-dense (areolar) connective tissue
Connective tissue containing sparse, irregularly arranged collagen fibers.
Superficial fascia
Enveloping layer directly beneath the skin containing dense and areolar connective tissue and fat.
Deep fascia
Continuous sheet of mostly dense, irregularly arranged connective tissue that limits the changes in shape of underlying tissues. Deep
fasciae may be continuous with epimysium and intermuscular septa and may also contain layers of areolar connective tissue.
Intermuscular septa
A thin layer of closely packed bundles of collagen fibers, possibly with several preferential directions predominating, arranged in
various layers. The septa separate different, usually antagonistic, muscle groups (for example, flexors and extensors), but may not
limit force transmission.
Interosseal membrane
Two bones in a limb segment can be connected by a thin collagen membrane with a structure similar to the intermuscular septa.
Periost
Surrounding each bone and attached to it is a bi-layered collagen membrane similar in structure to the epimysium.
Neurovascular tract
The extramuscular collagen fiber reinforcement of blood and lymph vessels and nerves. This complex structure can be quite stiff. The
diameter and, presumably, the stiffness of neurovascular tracts decrease along limbs from proximal to distal parts. Their stiffness is
related to the angle or angles of the joints that they cross.
Epimysium
A multi-layered, irregularly arranged collagen fiber sheet that envelopes muscles and that may contain layers of both dense and
areolar connective tissue.
Intra- and extramuscular aponeurosis
A multilayered structure with densely laid down bundles of collagen with major preferential directions. The epimysium also covers the
aponeuroses, but is not attached to them. Muscle fibers are attached to intramuscular aponeuroses by their myotendinous junctions.
Perimysium
A dense, multi-layered, irregularly arranged collagen fiber sheet that envelopes muscle fascicles. Adjacent fascicles share a wall of
the tube (like the cells of a honeycomb).
Endomysium
Fine network of irregularly arranged collagen fibers that form a tube enveloping and connecting each muscle fiber. Adjacent muscle
fibers share a wall of the tube (like the cells of a honeycomb).
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BUT GIVING NAMES AND DESCRIPTION IS NOT
ENOUGH
In anatomy giving names is associated with location
and localization
It is not only about the WHERE, it also is about HOW
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IF IT IS NO LONGER ABOUT THE PARTS AND ‘WHERE’
BUT ALSO ABOUT THE WHOLE AND ‘HOW’ ….
Tensegrity, integrity is a relationship not an anatomy
We need other ‘elements’ and ‘relationships’
…….. then ARCHITECTURE is the Keyword.
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STRUCTURE of the lecture
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1. Fascia anatomy is a contradictio in terminis, architecture is the keyword
2. The “holy locomotion apparatus trinity” (anatomy)
versus the “functional twofoldness” of forces to be
guided (architecture)3. The architecture of connective tissue (‘fascia’) is instrumental for as well
locomotion as proprioception
4. Fascia AS WELL AS muscle tissue are derivatives and therefore integral
components of the “Meso” and the ‘inner tissue’
5. A transborder matrix organization: “over the woof of the muscle man, the warp of
dynament woman”
‘CLEAN ANATOMY’. AWAY WITH THE ‘ENVELOP’
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‘IMPOSSIBLE ANATOMY’ (‘MUSCULOSKELETAL’)
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WHAT ARE THE COMPONENTS OF
A JOINT?
Articulating bones (with cartilage)
Synovia (synovial fluid)
Articular capsule
In principle the capsule does NOT play a mechanical role !!!!
A “joint is a dis-connection”
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WHICH ANATOMICAL ELEMENTS PLAY A
ROLE IN THE TRANSMISSION OF FORCES
ALONG A SYNOVIAL JOINT (STABILITY)
Articulating bones en articular surfaces
Ligaments and other (collagenous)
connective tissue structures
Muscles including their connective tissue
components (tendons, aponeuroses)
3
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WHAT KIND OF FORCES HAVE TO BE GUIDED /
TRANSMITTED IN SYNOVIAL JOINT?
Pressure
forces
Tension /
traction forces
2 PRESSURE FORCES via
articular surfaces and bone
elements
TRACTION/TENSION FORCES
Statically via ligaments and
so on - ‘passively’
Dynamically via muscles -
‘actively’
3?
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DEFINITION OF A ’MUSCLE’?
MUSCLE =
Sample of muscle fascicles
linked between dense
collagenous connective
tissue elements:
Tendon on the one side,
Aponeurotic plates (fascial
enforcements and septa) on
the other side
DYNAMICAL
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DEFINITION OF A ‘LIGAMENT’?
Ligament = Bundle of dense collagenous connective tissue fibres linked between two bones i.e. the skeletal elements of a synovial joint.
STATIC
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LIGAMENTS AS PASSIVELY FORCE
TRANSMITTING STRUCTURES, MUSCLES AS
‘ACTIVELY’ FORCE TRANSMITTING STRUCTURES
‘CLASSICAL ANATOMY’: COLLATERAL LIGAMENTS AND
MUSCLES AS SEPARATE IN PARALLEL STRUCTURES
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GLIDING AND LOADING –
2 TIMES FORCE TRANSMISSION
DISTAL: MUSCLE UNITS GLIDING ALONG
EACH OTHER AND UNDERNEATH THE
ANTEBRACHIAL FASCIA (‘SLIDING’)
THE ANTEBRACHIAL FASCIA AS
INSERTING AREA FOR UNDERLYING
MUSCLE FASCICLES (‘TRACTION’)
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*
*
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CONSEQUENCES
To the lateral humeral
epicondyl rdCT layers
(and cases) are
converging and inserting
… with in series
muscle fascicles of the
extensor muscles (in a
pennate configuration)
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CONSEQUENCES
To the lateral humeral
epicondyl rdCT layers
(and cases) are
converging and inserting
… with in series
muscle fascicles of the
extensor muscles (in a
pennate configuration)THE CONCEPT OF THE LATERAL COLLATERAL FORCE TRANSMISSION SYSTEM LCFTS
But like this!
Connective and
muscle tissue
not IN PARALLEL
(like ligaments)
but IN SERIES!
Not in this way!
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‘OLD’ SITUATION:
- Connective- and muscle tissue
organized in parallel
- ‘Ligaments’ only ‘functional’ in
one particular joint position
‘NEW’ SITUATION:
- Connective and muscular tissue
organized in series
- Ligaments are ‘functional’ in ‘’ every’
joint position
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‘THE ARTISTS IMPRESSION’: THIS IS NOT HOW ANTEBRACHIAL
MUSCLES ORIGINATE FROM THE SKELETON! PROMETHEUS 2004
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*
*
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NOT THIS
BUT LIKE THIS
M. Supinator
Annular
ligament
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THIS IS NOT HOW AN ANNULAR LIGAMENT
LOOKS LIKE! PROMETHEUS 2004
ANNULAR LIGAMENTS ARE
MADE BY SHARP DISSECTION
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If you cut here, you
make an annular
ligament
Poster by Glaxo about Tennis Elbow
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Slice MRI (in vivo)
THE CONCEPT OF THE LATERAL COLLATERAL
FORCE TRANSMISSION SYSTEM LCFTS
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LCFTS MCFTS
3 D Reconstruction
That is the method
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No intermuscular septa are represented (yellow lines)
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FASCIA
AND / OR
APONEUROSIS?
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FASCIA AND / OR APONEUROSIS ?
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Architecture is a better
functional clou than anatomy!
NOT ONLY WHERE ALSO ‘HOW’
STRUCTURE of the lecture
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1. Fascia anatomy is a contradictio in terminis, architecture is the keyword
2. The “holy locomotion apparatus trinity” (anatomy) versus the “functional
twofoldness” of forces to be guided (architecture)
3. The architecture of connective tissue (‘fascia’) is
instrumental for as well locomotion as proprioception4. Fascia AS WELL AS muscle tissue are derivatives and therefore integral
components of the “Meso” and the ‘inner tissue’
5. A transborder matrix organization: “over the woof of the muscle man, the warp of
dynament woman”
NOT ONLY
WHERE
ALSO ‘HOW’
THE SUBSTRATE OF PROPRIOCEPTION MECHANO-
RECEPTORS: NERVE ENDINGS, BALLS AND SPINDLES
FNE Free Nerve
Endings(s)
Paciniform
‘lamellated’
Ruffini shaped
Tendon spindle / GTO
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USUAL CONCEPT: JOINT RECEPTORS VERSUS
MUSCLE RECEPTORS ?
Joint receptors for statesthesia en kinesthesia,
muscle receptors for muscle motor control
Joint receptors in CAPSULES / LIGAMENTS:
(Paciniform) Lamellated corpuscles (LC),
Ruffini like Corpuscles(RC), FNE
Muscle receptors in MUSCLES:
Muscle spindles (MS), Golgi Tendon Organs
(GTO) and Free Nerve Endings (FNE)
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SPECTRUM OF MECHANORECEPTIVE SUBSTRATE
At the TRANSITION of muscle tissue to the septa so-called proximal GTO’s are present.
In some muscles those proximal GTO’squantitatively dominate the distal GTO’s (e.g. in ECU, SUP)
Classification? Ruffini corpuscle (joints) of GTO (muscle)?
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SPECTRUM OF MECHANORECEPTIVE SUBSTRATE
The innervation pattern of the proximal antebrachial fascia and supinator septum resembles that of a ‘ligament’ ‘
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Spatial distribution of muscle spindles
and GTOs
Non-evenly distributed over the muscles
Organized according to CT (septum)–muscle– CT
(tendon)–units i.e. to ARCHITECTURE = FORCE
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SPECTRUM OF MECHANORECEPTIVE SUBSTRATE
MUSCLE RECEPTORS
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SPECTRUM OF MECHANORECEPTIVE SUBSTRATE
MUSCLE RECEPTORS
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SUP ~ EI quantitatively : 510 MS / gram versus 510 MS / gram muscle
Yet their spatial organization as to MS are quite different and opposite
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ECR ~ ECU quantitatively:100 MS / gram versus 260 MS / gram muscle
As to the spatial organization of the MS they are quite similar.
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FUNCTIONAL
ARCHITECTURAL
PATTERNS
SPECTRUM OF MECHANORECEPTIVE SUBSTRATE
Muscle spindles follow a non homogenous, eccentrical distribution
pattern
‘Monitor zones’ in line with the architecture of ‘connective tissue –
muscle – connective tissue – units’
Patterns of muscle spindle organization:
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(Quantitative) parameters per muscle are not
sufficient to describe their functional pattern
A NEW CLASSIFICATION?
OR NO CLASSIFICATION?
The whole spectrum of mechanoreceptive
substrate in a joint region is represented by:
MS + GTO + LC + FNE
That is:
Muscle triplet MS, GTO/RC en FNE
combined with
Joint triplet RC, LC en FNE
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A NEW CLASSIFICATION?
OR NO CLASSIFICATION?
Mechanoreceptors do not need to be classified
anatomically as to proprioception (in particular
not as ‘joint receptors’ vs. ‘muscle receptors’)
Besides physiological parameters it is the
context that determines whether a certain
mechanoreceptor is activated or not.
And that context is architectural
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The CT architecture is instrumental in
the process of proprioception
NOT ONLY
WHERE
ALSO ‘HOW’
‘BRAINS KNOW NOTHING ..….’
Does the ‘homunculus
motoricus’ posses
muscles?
And what about the
‘homunculus
sensoricus’?
It is not about anatomy
or muscles it is about
forces and movement >
ARCHITECTURE
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STRUCTURE of the lecture
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1. Fascia anatomy is a contradictio in terminis, architecture is the keyword
2. The “holy locomotion apparatus trinity” (anatomy) versus the “functional
twofoldness” of forces to be guided (architecture)
3. The architecture of connective tissue (‘fascia’) is instrumental for as well
locomotion as proprioception
4. Fascia AS WELL AS muscle tissue are derivatives and
therefore integral components of the “Meso” and the
‘inner tissue’5. A transborder matrix organization: “over the woof of the muscle man, the warp of
dynament woman”
A.T. STILL: MAN IS MIND, MOTION AND MATTER
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MIND
MOTION
MATTER
ACTION ACT
GESTURE EXPRESSIO
N
MOTION
FORM
HUMAN BEHAVIOR Blechschmidt
The embryo (still) functions in forms
(‚Gestaltung‘).
The gestures of growth represent the
motions and actions.
The ‘Gestaltung’ of the embryo is a
performance in course of time.
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LIMITING TISSUES AND THE INNER TISSUE
Erich Blechschmidt (1904-
1992) introduced the principle
of Limiting tissues versus/and
Inner tissue.
The classical triad Ectoderm,
Mesoderm and Endoderm
should be interpreted as such:
‘meso(derm)’ as the ‘INNER’
(not the viscera)
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28/10/2009
INNER TISSUE, THE MATRIX TISSUE
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THE QUALITIES OF THE INNER
OR MATRIX TISSUE
As to the connective tissue this leads
to two functional principles:
‘connecting’, binding,
‘disconnecting’, creating room
As extreme examples:
Desmal sutures in the skull
Synovial joints (articulations)
Superimposed on that the
CONTINUITY of the original
mesenchym as the matrix tissue:
“Enveloping Connective tissue skeleton”
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28/10/2009
TENDENCIES IN THE INNER
OR MATRIX TISSUE
• Phenomenologically one could describe two organizing tendencies in the primordial Inner tissue of Mesenchyme:
– Concentration, centering,CONNECTION
– Decentration, peripherizing,DIS-CONNECTION
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‘FASCIA’ IS AN ORGAN OF INNERNESS ?
The primeval dimension
of the mesenchyme as
the matrix tissue is
CONNECTING and
SHAPING SPACE
Morphologically this is
represented by the
tendencies like
‘compaction’ versus
‘dilation’ (formation of
body cavities)
• It connects
and it shapes
space
• It enables
motion
and
it mediates
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TWO EXPONENTS OF THE MESO:
BLOOD AND FASCIA
TWO EXPONENTS OF THE MESO:
BLOOD AND FASCIA
• ‘Blood’ is here defined as
the organ of mediation
• Blood as a tissue, blood
as cardiovascular system
• Blood formation and
vessel formation always
go hand in hand
• ‘Blood’ is the PRIMARY
ORGAN
FUNCTION:
BLOOD
MEDIATES,
BLOOD IS
‘EVERYWHERE
AND
NOWHERE’
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‘BLOOD’ IS AN ORGAN OF INNERNESS ?
Densationsfelder (Verdichtung, d):
Die Entstehung des embryonalen
Skeletts ist bestimmt durch Verlust
an wässriger Grundsubstanz.
Flüssigkeit diffundiert ab, der
Zellverband wird dadurch verdichtet.
METABOLIC FIELDS & KINETICS
ACCORDING TO ERICH BLECHSCMIDT
.
Dilationsfelder (Dehnung, f):
Zonen, in denen Zellen in
bestimmten Hauptrichtungen auf
Zug beansprucht und dabei
gedehnt werden. So dilatierte
Zellen entwickeln sich
gesetzmäßig zu
kontraktionsfähigen Muskelzellen.
METABOLIC FIELDS & KINETICS
ACCORDING TO ERICH BLECHSCMIDT
Retensionsfelder (Straffung, h):
Binnengewebe, das durch
Querdruck beengt und durch einen
senkrecht dazu verlaufenden Zug
gestrafft wird, bekommt
Zugfestigkeit und funktioniert damit
als Halteapparat. Sehnen und
Bänder entstehen in
Retensionsfeldern.
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METABOLIC FIELDS & KINETICS
according to ERICH BLECHSCMIDT
Architectural units of
connective and muscular
CONNECTIVE TISSUE IN THE
MUSCULOSKELETAL SYSTEM
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DISTALLY Muscles with tendons
Muscular units
PROXIMALLY
Septa, walls or
cases of connective
tissue with muscle
parts inserting to
them in series.
Intermuscular
septa
Transmission of
forces occurs here
in a TRANS-
muscular order!
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ARCHITECTURAL ‘UNITS’?
Which means:
transmission of compression forces via bones and joint surfaces
versus
Transmission of tensile forces via muscle and connective tissueUnits of muscle AND connectivetissue (with ligaments as ‘exceptional’)
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ARCHITECTURAL ‘UNITS’?
NOT: OR
But a muscle - connective
tissue -
bone - unit ……
- Call it a ’DYNAMENT’
…… with which you
may ‘construct’ every
structure in the
Locomotor System?
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ARCHITECTURAL UNITS IN THE MUSCULO-
SKELETAL SYSTEM? ‘DYNAMENTS’ ?
Not: OR
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LIGAMENTS * AS ‘EXCEPTIONAL’
AND MEMBRANES AND SO ON
WHAT IF?
If fascia is the adult appearance of the mesenchyme
matrix …
If the mesenchyme matrix on its turn is the
appearance of Meso, of the Inner tissue …
If the two polar tendencies i.e. connection and
disconnection are also represented by the polarity of
contraction and relaxation of the muscular tissue
Maybe that muscle tissue and connective tissue are
two of the same be it dynamically and statically /
structurally?
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FASCIA MAN
Muscle man, where is
your fascia?
Integrity man, don’t forget
your muscle tissue!
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FASCIA AS ORGAN OF INNERNESS ?
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A view