Drainage: Is It All In The Veins?

Andrew_Taylor_Still_1914As seems to happen when reading the written work of Dr. A.T. Still, each time through his work I find another layer that develops more meaning in my still young Osteopathic mind. I have learned many times over the general statement that drainage precedes supply and I have recited it as gospel as we all seem apt to do. I applied it in the manner I thought most accurate to the statement of the principle such that I opened the path of the vein back towards the heart allowing space for venous blood and lymphatic fluid to pass choke points. I have seen good results with this process…until I was challenged by an interesting case that only responded slightly and then came back.

The case I was challenged with was a young person that displayed a dry patch of skin on the medial thigh and nowhere else on the same leg or the other leg. I opened the femoral triangle, inguinal ligament, normalized the lumbar arch, and opened the diaphragm after addressing the lower dorsal spine. This worked briefly and then the dry patch returned. I continued as an insane person might along the same lines a few more times until something that Dr. Still wrote in Research and Practice started smacking my ignorant brain. The most succinct quote that illustrates the thought is as follows:

AtstillseatedIn my Osteopathic work my object is to deliver arterial blood to its destination that it may execute all the physiological duties incumbent upon it. When it has finished the work of construction and repair, then the next step or object that I have in view is to know that it returns to its shop to deliver its waste and be renewed. It did all it could while it was arterial blood, now it must be returned to the lungs to unite with new substances, receive atmosphere and go through all the qualifying processes necessary to the production of pure blood, and return to the heart that it may deliver arterial blood perpetually. Upon this life depends.” (Paragraph 419).

Circulatory SystemAlright, there are a few things in that paragraph that are of supreme importance before I move on to make my primary point with regards to drainage. 1. Arterial blood is responsible for construction and REPAIR (no good blood = no good repairs…sort of like a bad contractor for home repairs). 2. After arterial blood has done its FULL job, it then needs to return the waste products to the shop (the blood needs to travel in the full amount intended for each arterial branch after leaving the heart before moving to the passive venous circulation). 3. The “shop” includes all organs that will impart nutrition or some filtering function to the venous blood (the kidneys are technically the first filter after leaving the heart, the liver, spleen, pancreas, the gall bladder, and all other part of the GI system play a part in this process). 4. The final finishing step for blood is gas exchange through the lungs. This all matters as it establishes a directionality of flow. If the blood is stopped, slowed, or not  allowed to pass the volume intended for any point beyond a restriction then trouble ensues.

hypogastric plexusHere is where my mind has decided to get stuck and start coming to grips with what I am at least thinking is a fuller understanding of drainage. If the full volume needed to supply all structures from the third intercostal vein to the big toe is ejected through the descending aorta and beyond the diaphragm then any restriction at any point may cause an issue with the structures beyond the point of restriction. Enough abstractions for a moment…if the restriction is on the abdominal aorta from the fourth lumbar vertebra moving anterior then the bifurcation to the common iliac arteries will be obstructed. Obstruction of the common iliac arteries will mean that the full volume of blood may not pass in to the common iliac arteries and on to the pelvis and legs. Where then does this blood go? Well, the artery will increase contractile force to try to increase local pressure and the heart will pump harder while the lungs also increase their work but some blood just won’t make it beyond the level of L4 in the abdominal aorta so it must be forced to do something or go somewhere within the renal arteries, the celiac axis and its branches, the superior mesenteric axis and its branches, the gonadal arteries, and the inferior mesenteric axis and its branches. These aforementioned vessels are now carrying more blood then they are calling for which means that their corresponding veins are now also carrying more volume then they normally would. The lymphatics will carry 10% of the total blood volume for the body but they may become overburdened. The passive circulation (veins and lymphatics) are now overwhelmed and swelling/congestion shows up. All the while the arteries are still sending the same amount of blood destined for the big toe and all points between and that full volume is still not getting past L4.

DrStill AutopsyMy previous understanding would have made my narrow mind open the diaphragm and think about the veins while ignoring that the veins are passive, they have no choice but to accept what they are given. The arteries DELIVER the blood that ends up in the veins. The artery is responsible for the active flow while the vein relies on the artery, arteriole, muscles in the local area, and the pressure gradients from respiration to perform its work…any malfunction in any of those will lead to a malfunction in the work of the vein. Now that I at least believe I am seeing more of the picture I am exploring the idea that an arterial blockage is the driving force behind congestion and swelling. If the artery is delivering too much blood to an area before the end of its circulatory path then it will starve the areas further down and overburden the local vein. The drainage pathway may well be set by first sending the arterial blood to all of its destinations.

Saints RestSo, returning to the case that challenged me with this fuller outlook I decided to attempt sending the blood along its arterial path for a few reasons – 1. the patient displayed more general fullness of tissue in the thigh then in the leg and 2. the patient seemed to have a penchant for feet that were cold regularly on palpation. I opened the arterial path and within 24 hours I saw a very marked change that has remained without additional treatment.

Now, after my common ramblings I will say this: the vein may have a direct restriction on it however it is rare due to positional and relational anatomy that this will occur without a restriction on the artery that feeds it. The artery overfilling a region due to a restriction seems to be a very likely driving force behind congestion of tissues as opposed to a compromised vein in isolation.

This is merely a theoretical work until I am able to use this path of reasoning to consistently demonstrate that arterial freedom may do more for drainage than opening the circulatory in the direction of the vein alone. The directionality of flow suggests this as does the founder of the profession who just so happened to be a prolific clinician. Now it is time for me to dig on along this path of reasoning.

atbonePs, maybe I am just dense and had to go through this thought process on my own or too stubborn to look for resources that may be readily available with this information.

Pps, continuing to read Research and Practice pretty much hits me over the head with the dummy mallet and makes me pretty confident that this whole follow the artery then follow the vein deal is sort of important – read it for yourself and it should be pretty clear.

Ppps, DO NOT TAKE THIS AS GOSPEL TRUTH! INVESTIGATE IT AND MAKE UP YOUR OWN MIND (I already noted that this is still an investigation for myself…I believe it to be true, I now need to prove it).

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