Sutherland, Cottam and Toftness: The History of Direct Cranial Manipulation

Long before CFR or Bilateral Nasal Specific, a different tradition of cranial work developed independently: direct manual manipulation of the cranial bones, without any endonasal or balloon component. Two professions — osteopathy and chiropractic — each credit a different founding figure, and the two traditions emerged within months of each other.

Early, isolated precedents

The earliest documented references to manual cranial manipulation for a therapeutic purpose predate Cottam and Sutherland by decades. An osteopath named Barber published the earliest known pictures and description of manual skull manipulation for headaches and neuralgia in an 1898 book. Willard Carver, D.C. is reported to have used a technique on the head as early as 1906, for hydrocephalus, and made statements in his 1909 book Chiropractic Analysis that appear to refer to cranial manipulation. In 1910, Gregory — a medical doctor associated with chiropractic founder D.D. Palmer — published a photograph of a similar adjustment, captioned as a special adjustment that would often relieve a headache.

None of these early efforts developed into a lasting school of practice the way Cottam’s and Sutherland’s did, and for the next two decades cranial work remained scattered and undocumented among a small number of osteopaths and chiropractors. But they show the idea of manipulating the skull for headache relief was already circulating decades before 1929.

1929: two professions, the same year

The modern history of cranial manipulation is usually traced to 1929, when both Nephi Cottam, D.C. and William Sutherland, D.O. independently presented cranial techniques to their respective professions — Cottam in January, in Salt Lake City, Utah, and Sutherland in September. Neither published right away.

Their approaches differed technically as well as in timing: Cottam’s method used high-velocity, low-amplitude thrusts — the kind of quick, targeted adjustment familiar from chiropractic technique generally — while Sutherland’s used low-velocity, low-amplitude pressures, tractions and torques. That distinction still roughly separates the direct chiropractic and osteopathic cranial traditions today.

William Sutherland, D.O. went on to publish The Cranial Bowl in 1939, describing what became known as cranial osteopathy. His approach centered on the concept of a primary respiratory mechanism — a subtle, rhythmic motion he proposed exists throughout the cranial system — which developed into what osteopathic medicine now calls the craniosacral mechanism. Sutherland is the figure most widely credited with originating cranial manipulation, and within osteopathic medicine that credit is well documented.

Some osteopathic historians trace the idea of a subtle, rhythmic motion of the brain and its coverings back further still, to the 18th-century Swedish scientist Emanuel Swedenborg. In manuscripts written in the 1730s and 1740s, Swedenborg described an inherent motion of the brain, which he called its “animation,” along with a corresponding motion of the membranes and, he proposed, the cranial bones. The osteopath David Fuller has argued that Sutherland knew this work and was influenced by it. The parallels are interesting, and it’s a historical connection worth knowing about.

Nephi Cottam, D.C. published The Story of Craniopathy: A Science of Health, Its Theory and Practice in 1936, seven years after his 1929 presentation. “Craniopathy” was Cottam’s own term for his approach to the cranium — it belongs specifically to him, not to Sutherland or Toftness — and it was carried forward by his son, Calvin Cottam, D.C., who researched and wrote about his father’s work, including the 1952 book Head First for Health, which tells Nephi’s story.

Nephi Cottam’s 1936 book, The Story of Craniopathy, documented his approach to direct cranial-bone manipulation, which he had presented to the chiropractic profession seven years earlier.

I.N. Toftness’s 1932 book, Cranial Technique — the earliest full book on cranial adjusting I’ve been able to find, and one that seems to have gone almost entirely unnoticed in the profession’s own historical record.

Robert Fulford and the percussion hammer

Sutherland’s most influential student may have been Robert Fulford, D.O. (1905–1997), who studied cranial osteopathy directly under Sutherland in the mid-1940s and later served as president of the Cranial Academy. Fulford introduced a motorized percussion device into osteopathic treatment — now often called the Fulford percussor — and it became closely associated with his work over a career spanning more than five decades. That same style of instrument, in modified form, is the percussion hammer I use as one of my own tools; see the techniques I use for more.

The upper cervical lineage

Chiropractic’s other path to the skull ran through the neck. In the early 1930s B.J. Palmer developed the “Hole-in-One” upper cervical adjustment, aimed at realigning the top of the spine with the base of the skull. Specific upper cervical methods such as NUCCA, Blair, Atlas Orthogonal and Orthospinology descend from it. Decades later, Walther’s 1984 applied kinesiology text extended the same thinking to the cranial nerves and the membranes inside the skull. These lines of work overlap with direct cranial adjusting. All of them treat the junction where the head meets the neck as a place where structure and function are tied closely together, which is also where I focus much of my own attention.

Why this matters

We’ll probably never know who first had the idea of manipulating the cranial bones for a therapeutic purpose — and it’s entirely possible it wasn’t any of the men usually credited. What the record does show is that direct cranial manipulation and the later endonasal, balloon-assisted techniques developed as genuinely separate traditions, discovered and rediscovered by different practitioners working largely apart from one another. I find that pattern itself telling: multiple independent observers, working decades and disciplines apart, arrived at the idea that the cranium is worth examining and adjusting.

It’s a genuinely interesting piece of professional history, and one I think patients curious about this field deserve to know.