The History and Present Positionof Massage and Gymnastics. Part 2

M.S. Lond., F.R.G.S. Eng.JKCajor R.A.’JXC.C. (*) ; Orthopaedic Surgeon, St. {Bartholomew’s Hospital WITH 182 ILLUSTRATIONS SECOND EDITION LONDON J. & A. CHURCHILL 7 GREAT MARLBOROUGH STREET 1921

time was the home of massage and medical gymnastics, Ling’s pupils, especially de Ron, Thure Brandt and Berglind, helped to strengthen the reputation of these methods of treatment, and Mezger’s massage was also represented in Sweden, amongst others by his pupils Berghman and especially by Helleday, in Norway by Kior, and in Denmarkby E. Johnsen. In the latter part of the sixties Swedish medical gymnastics received a noteworthy reinforcement. About this time Dr. Gustaf Zander beganto construct, and to give treatment by means of, his most ingeniouslythought out apparatus. (Some people, I know not why, have a certain
objection to calling these apparatus machines, although they are partly driven by steam.) By means of these apparatus, movements of all kinds are given : active movements, most concentric and eccentric resistance movements, movements regulated by balance wheels, passive movements. Some of the apparatus concern massage ; of these the vibrators
in particular work excellently. On the whole one may say that the Zander”medico-mechanical” method aimed at and succeeded in partially replacing manual work in the Ling treatment by apparatus and steam power. Moreover, in some for example, in the rhythmical movements regulated by balance wheels it has gone beyond Ling’s manual treatment. Although I cannot refrain from expressing my opinion that the Zander treatment, as well as the manual method, is in these days and by many of my colleagues too highly estimated in regard to its therapeutic range, I will also express my hearty recognition of the great talent of the inventor, of the inherent importance of the subject, and especially of the service it has rendered in spreading the knowledge of mechano-therapy.
During the last quarter of the eighties massage reached a secure position in the medical world, especially in the Germanic and Scandinavian countries. A whole literature arose in which certainly a great many literary products of very minor importance may be found. Meanwhile, many seriously helped on mechano-therapy, e.g., Mosengeil, Zabludowzki, Schreiber, Reibmayer, Nebel, Hoffa, Maggiora, Dujardin Beaumetz, Keller, Gopadse, Bum and others. I, too, have a right to claim a place for my own name in this catalogue, chiefly because of the influence the German and English editions of my ” Manual of Massage” have exercised on the position of this treatment in Europe and America, and because the Swedish editions have now for close on twenty years been
the chief printed guide for students of this subject. In England, however, massage is much less used than it should be, and much less than it is in Germany and Austria. In the United States of America massage is somewhat more used. The quality of its exponents varies much, as almost everything does in this rapidly developing giant community ; a considerable number of the workers are Swedish men or women, more or less fully trained ” medical gymnasts.” On the whole their work is beneficial. I would point out in this connection that a masseur or gymnast may be excellent in his practical work, be he ever so ignorant of theory. One of the best-known and best Swedish ” gymnastic directors ” believes that when he kneads the abdomen he transfers the patient’s digestive juices by his nerves to his own abdomen, but in spite of this absurd idea he kneads the abdomen to perfection. In the United States there are many workers who practise a more or less rational massage to which they give the peculiar name ” osteopathy.” They are almost all very ignorant of anything but the purely mechanical work, but with that often obtain very good results. Among the first doctors who used massage extensively in the United States was the elder Sayre. Weir-Mitchell, in Philadelphia, by the weight of his authority has greatly helped the spread of massage, which plays an important part in his well-known rest and feeding cure. His
son, John K. Mitchell,has written an important work on massage. It may also be interesting to glance at mechano-therapy, especially massage, as a ” popular remedy,” in which character we find it more or less general and more or less developed amongst all the races of the world. In Europe massage is found everywhere, and many”wise men”(or
women) in the country or in towns have it to thank for their best ‘ miraculous cures.” It seems most general in our part of the world among races of Mongolian origin. Amongst the Hungarians and Finns it is still much used along with baths, and besides this is met with in many forms (especially as ” abdominal kneading “). Amongst the Lapps I have seen it used for ” rheumatic ” affections of muscle. In Africa general massage is used along with baths by races on the outskirts of civilisation (as it is by all “Oriental” nations) ; local massage
is also used. Some French authors (Sere, Quesnoy) assert that massage exists amongst all the black races. Amongst the savages of the interior and the south it does not seem to be in very general use ; although at times in accounts of travel one sees statements which point to its existence.! In Asia massage is widespread, is definitely developed amongst the races, and is performed by skilled workers. The conditions are the same among the Chinese, where, as with us. barbers especially dabble in this treatment. Travelling in Japan one may often see blind indi- viduals in the evenings strolling about the streets in the large towns, now and then announcing their presence to the public by blowing a few notes on a little pipe. These are the humble masseurs of Japan, who arc not at fault as regards their touch, but who have probably an even scantier supply of knowledge than their European colleagues “the gymnasts.” One of my friends, who for several years resided in Japan as a doctor, during a visit to a tea-house complained of constipation, and was astonished by the kindly offer of a waitress to remove his trouble by abdominal massage. The conditions among the Hindus are similar. Dr. H. Stolpc of Stockholm, who took a number of interesting photographs in India, showed me one taken at the river bank in Benares of a Brahmin whose leg is being massaged by another dark-skinned individual, probably a”professional.” The Malays, too. use massage extensively(Pidget-tcn).

Bartels has published an essay (Leipzig, 1893), ” Die Medizin der Naturvolkciy’ which I have not been able to obtain. I have contented myself with the above short miscellaneous notes on massage among foreign races. Thus Charles John Anderson, in his work ” Lake Ngami,” mentions a proceeding
Used by the Namaqua doctors which is evidently a kind of abdominal massage.
J Hiinerfauth : ” Geschichte der Massage,” Berlin, 1886, see p. 8 on Dr. Stein’s experience in Java. ” Athenaeum of Rational Gymnastics,” Berlin, 1854, Bd. iv.

The aborigines of America are not entire strangers to massage. It is found among the Redskins of North America, although it seems to play no essential part in their therapy.* Further, one hears of it among South American Indians, with whom massage seems to be somewhat general judging by the repeated stories of it found in tales of travel. In Australia massage is found among the low aborigines of New Holland as well as among the more advanced races of the island groups of the Pacific. Among the last-named people it is used both as general (chiefly as a”restorative measure “) and local massage, and seems to have reached a definite technical development. The different manipulations are classified by the natives of Tonga much as with us.

For the medical worker massage is often more important than gymnastics. The latter is certainly more important in diseases of the respiratory and circulatory organs, in dystrophic conditions and in certain nervous diseases, and in connection with orthopaedics plays a morevital part than massage in the treatment of deformities and anomaliesof position. But gymnastic treatment, especially in respiratory and
circulatory diseases and the commonest dystrophy, obesity, is carried out in its fundamental and most effective form, as “
terrain-cure,”which only differs in a slight degree from the everyday movements of the human body, and which the patient, after a few short descriptions, can perform on his own account. Even the essentials of Frenkel’s gymnastics for ataxic patients can be arranged with quite simple means,
and can be carried out with a little help from the doctor or trained gymnast. In resisted and other gymnastic movements, which require something besides the patient’s own body, apparatus can more easily replace the work of the gymnast than that of the masseur on the soft tissues.

I have received definite reports of this from American doctors, and especially of the existence of tapotement with a therapeutic aim. Reports of it are also found in some of the better known descriptions of North Indian life. On the other hand, in Schoolcraft’s great work “Indian Tribes “(Philadelphia, 1853 1860), in a somewhat detailed accountof Indian therapy, there are no references to anything which could beconsidered massage. While on a visit among Shoshon Indians in Utah I heard from one of them that they are in the habit of using kneadings to cure “aching in the body.”

Franz Keller Lenziger speaks of a cure (” Von Amazonas und Madeira,” Stuttgart,1874) which a medicine man (paye) of the Cazowa Indians living near Madeira River undertook for “
painful rheumatism ” and which (except for some mystic decorations) consisted of his giving the patient very strong massage, and began” ihn alsdann von Scheitel bis zur Zehe und zwar mit solcher Heftigkeit zu streichen und zu kneten dass dem Beschworer sowohl wie dem Patienten der Schweiss in Stromen vom Korper rann.”

It is worth noting that the Indian paye asserted that he transferred the patient’s illness to his own body, exactly as a renowned Swede with little less authority professes to treat the highly civilised inhabitants of London. Dr. K. von den Steinen (” Durch CentralBrasilien,” Leipzig, 1886, p. 260) tells of a medicine man among the Yuruna Indians who gave what must be considered “general massage” to a sick woman.
J Baudin : ” Voyage dans La Nouvelle Hollande,” Paris, 1800.

One comes across many reports of massage in the Islands of the Pacific. The first sailors who visited Tahiti made its acquaintance there. It is mentioned by Wallis, who visited the Islands in 1767, and by Forster (” Cook’s Second Journey “). Dr. Emerson speaks of it (in Beard’s ” Neurasthenia “) in the Sandwich Islands, and lastly we find in the interesting article in the Gazette des Hopitaux (of 1839) that in the Tonga Islands manipulations are divided into “mili “(effleurage and friction), “fota “(petrissage) and” toogi-toogi “(tapotement). It is a pity that the French did not learn from the kindly inhabitants of Tonga their classification of manipulations ; it is distinctly more rational than their own, at any rate as found in Estradere’s book.

Massage, on the contrary, can only in exceptional cases be performed by the patient himself, and is infinitely more important than gymnastics in the commonest cases of illness. The different muscle infiltrations alone, rheumatic, traumatic and others, and chronic constipation form
much the greatest number of all the cases suitable for treatment by manual or ” medico-mechanical ” gymnastics, and in these, in spite of the gymnast’s misrepresentations and assertions, any other kind of gymnastics than ordinary everyday bodily movements is quite unnecessary. Even in the mechanical treatment of joint affections, in whichcertainly passive movements play a definite part, massage is much more important than gymnastics. It is no exaggeration to say that amongthose whose occupation is massage and gymnastics, gymnastics does not represent 5 per cent, of their work. It is also no exaggeration to say that every middle-aged or elderly person has at some time been in need of
massage, and that a great many people need it for long periods of theirlives. * * * * * An enormous need for physical therapeutic work is thus making itself felt all over the world, and will be felt the more as more knowledge of the value of massage reaches the general public. At the same time in
all civilised countries a numerous class of medically untrained workers has arisen who earn their living by massage and to a less extent by gymnastics. The existence of such a class of workers is an absolute necessity, since the general need for the treatment in question is muchgreater than could be fulfilled by doctors. The busy doctor often refrains from mechanical work, for which he not seldom lacks the necessary physical strength and inclination, and which seems to him monotonous and tiresome, accustomed as he is to more purely intellectual occupation. In almost every case it can without the slightest danger be carried out by workers whose training is less expensive, and whose services are
therefore cheaper. Most doctors who employ massage and medical gymnastics in their practices know from experience that they can often hand over such treatment after a short period of supervision to some untrained but intelligent and handy attendant. It is, however, better that massage and medical gymnastics should be carried out by some one accustomed to it and with sufficient knowledge in his own line. Such a worker must know a certain amount of anatomy
and physiology, studied with special reference to his work. In studyingthis he has a right to “skip with discrimination.” He need not study the deep nerves of the head, but it is important that he should understandthe knee-joint ; he can safely leave the mechanism of the accommodation
of the eyes an open question, but he must know the forces which influence the flow of blood in the veins ; he need never hear of acute yellow atrophyof the liver or of acromegaly, but it is of great importance for him to be familiar with inflammation and its various products. He must also be skilled in technique. The uncritical enthusiasm which mechanotherapy, with its often splendid results, is apt to arouse in medically untrained workers renders it necessary that they should learn from the beginning that there are many diseases and conditions which cannot be benefited by massage and gymnastics, and various conditions which
render all such treatment dangerous. But there is one item of knowledge which is of the greatest importance both for himself and others,and which his teacher should take great pains to instil. He must be fully aware of the limitations of his own medical training, and that nothing less than a doctor’s full training justifies completely independent work as a physical therapeutist. The more he sees of the training required by
a doctor, the greater the difference there is in length of study and other things between himself and the latter, the less pretentious the title he himself bears, the easier will it be for him to feel his incapacity for independent work and to submit to supervision by a doctor ; the more difficult also will it be for him to convince the general public of his having any
just claim to such independent work. To this independence the workof the medical gymnast and masseur offers many temptations. In Sweden everything possible has been done to create unsuitableconditions for mechano-therapy.
No one is bold enough or narrow-minded enough to defend the fact that in our medical education, especially at the Carolinska Institute,there is no instruction whatever in medical gymnastics and massage, nor even any recognition of the real practical value of a therapeutic methodwhich is both easily learnt and extremely efficacious. And no one can
think it reasonable that doctors who must be acquainted with themethod of preparation and the appearance of every drug in the pharmacopoeia are for the most part quite unversed in such an effective remedyas this. To supply this omission the Central Gymnastic Institute wasfounded.
The Institute has, however, been a partial failure because it has tried to combine aims which cannot suitably be combined. It aims at being
(1) a place for training teachers of military gymnastics ;
(2) a place for training teachers of educational gymnastics ; (3) a school for mechano-therapy.
The first two aims may very well be combined. School gymnastics stretches out one hand to military gymnastics and exercises and serves
as a preparation for military service, while stretching the other hand to sport, the drama and games.
It is, in spite of the frequently repeated paradoxes from the Institute, as absurd to insist that a medical gymnast and masseur should be familiar with educational gymnastics as to insist that a truss-maker should be a shoe-maker, and as wrong to start an institution which is to be at the same time a (military or other) school for educational gymnastics and a school for physical treatment as it would be to establish something which should be at the same time a shoe factory and a factory for orthopedic instruments and apparatus.
A school for physical treatment must live within the medical world, otherwise it is like a separate society, which breaks away and artificially separates itself from and becomes hostile to the world to which it belongs. This has happened with the Central Institute. A more antagonistic spirit than that which rules there against medicine and its workers cannot be imagined, and except when there is some external advantage
to be gained, the Institute will have as little as possible to do with the medical world. The Institute has therefore no power of attraction for medical students, and least of all for the better equipped among them.
It was, moreover, an unheard-of and calamitous blunder to couple the teaching and practice of two such different things as educational gymnastics and physical treatment, and this was done for no other reason than that a fencer and gymnast won for himself a brilliant namein the latter. Lastly, the law of 1887 crowned a real work of destruction, and it is chiefly due to the utter lack of wit in “the Centralists ” who were the
authors of this law that it has failed to do great harm. The law, which was entirely in the interest of ” the Gymnastic Directors,” and entirely against the interest of the general public, enacted that no one except a doctor or some one trained at ” the Central ” should have the right to treat by medical gymnastics, and this only according to the written
prescription of a doctor. This law lead to the absurd and mischievous diploma of ” Gymnastic Director,” which can easily be misrepresented to the public, giving a false idea of its value. The majority of ” Gymnastic Directors ” have not troubled themselves in the least about written prescriptions from doctors, and the doctors, who seldom understand medical gymnastics, have not troubled themselves to write prescriptions.
But instead, the ” Gymnastic Directors ” have granted so many more diplomas, and have persuaded the public and themselves that this diploma has the same meaning in the domain of physical treatment, as the doctor’s degree has in general medical practice. The law, however, says nothing about massage, which is well. Andmassage constitutes more than 90 per cent, of this work. But ” the Centralists “
will not recognise the word ” massage,” because it apparently came from abroad, and the public did not so quickly associate the idea of massage as that of medical gymnastics with ” the Central.” They therefore hate the word ” massage” and preach the absurd doctrine that its manipulations form part of the passive movements of medical gymnastics. In this hatred lies the reason why the term is omitted from the law. For this and other reasons, as might have been expected, the law fell to the ground. Many workers learnt massage without devoting much time to the comparatively unimportant subject, for them, of medical gymnastics, and without giving any time at all to the quite useless subject, for them, of educational gymnastics. To crown the errors of “the Centralists ” two institutes arose outside ” the ” Central,” which along with the unnecessary two years’ course gave the ” equally unnecessary diploma,” but performed the necessary service of forming much better schools for physical treatment than “
the Central.” (These institutes are Dr. Arvedson’s in Stockholm and the South Swedish in Lund.)
The ” Gymnastic Directors ” went quite astray concerning the
monopoly of this new means of livelihood, especially in regard to that frequently excellent means of livelihood, massage ; and they must havemet with this misfortune in any case, since it is practically impossible to maintain such a monopoly. The ” Gymnastic Directors,” however, did not understand this. The Scandinavian Association of Gymnastic Teachers, the greater
number of whom are ” Centralists,” next went to the King with a request that the King might declare massage to be medical gymnastics, and decree that no one, except a doctor, who had not gone through” the Central” course should practise either the one or the other without becoming liable to more severe punishment than had hitherto been the rule in cases of quackery.
His Majesty referred the matter to the Medical Council, the Medical Council referred it to the Swedish Medical Association, and the latter referred it to a Committee.
The Committee expressed itself caustically on the utterly preposterous proposals, proposals contrary to the public interest, refused the ” Gymnastic Directors’ ” amusing request that massage should be declared medical gymnastics, and pointed out that it was a question of different methods of treatment. The Central Institute, however, without the capacity of being a good school for physical treatment, continued to produce a set of ill-trained workers to practise quackery who were hostile to and independent of the
medical profession, spiteful to and persecuting each other, and prone to advertisement.
If quackery were their greatest fault, for my own part I should criticise them mildly. Those who regard the matter calmly can never be inclined to act with great severity against quackery. For instance, it cannot be denied that quackery has its good side, and the history of both medicineand surgery shows that mankind has gained much from it, that is, from the remedial work of persons without medical education. Physical therapy in particular has cause for gratitude to several such persons, especially to several German and Swedish ” quacks,” among others to our own greatman, H. P. Ling. People of great gifts often go their own ways, perform great things without studying for examinations, and help to protect the qualified world from too much routine, trust in authority and exclusiveness. But the quackery of “the Centralists “
is particularly harmful, since, in spite of an utterly insufficient training, it is supported by titles and a legal diploma, which puts it in a false light, and the nature of the diploma is not understood by the public. And to crown all, these quacks persecute their rivals, who often stand far above the ” “Gymnastic Directors” in ability and knowledge, with rancour and sometimes with boundless ignorance of the subject, try by hook or crook to make the greater part of physical treatment into a monopoly for themselves, and would willingly exercise a tyranny as merciless and reckless as that of any socialistic trades union. I refer medical readers to the newspaper articles written especially each spring by women
” Gymnastic Directors,” with their naively selfish aim, their mean impudent tone to rivals and opponents, and their amazingly ignorant opinions in regard to mechano-therapy.
Meanwhile an important thing happened in 1910, which should mean the beginning of the end of these impossible conditions.

The Council of the Carolinska Institute, in accordance with a reso- lution passed unanimously by the members present at the meeting, approached the King with a request that a Committee should be appointed to consider, along with the reorganisation of the Central Institute, the question of instruction for medical students in medical gymnastics and massage. The object of this resolution was that a department for such instruction should be opened in this our chief medical school. If this takes place, and it seems incredible that it should hot speedilydo so, the Institute of the Gymnastic Directors, in spite of all other possible conditions, must certainly, though perhaps slowly, continue its way to destruction, a result to be desired in the interests of physicaltherapy and the general public. Every impartial doctor with a knowledge of physical therapy must be the sworn foe of this Institute. ” The Centralists ” evidently had their eyes open to the danger threatening, and set in hand an energetic and well-calculated tactical manauvre as a counterstroke.
After having until now praised the Central Institute to the skies, theybegan to speak of the necessity for the reorganisation of the Institute chiefly with the object of saving it as a school of physical therapy.
The Government met them so far as to appoint a Committee and to exclude from this Committee the man most distinguished in Sweden for knowledge of the subject and most dangerous to ” the Centralists.” I mean Dr. P. Haglund, the foremost Swedish doctor now in his prime, who has exclusively devoted the work of his life to physical therapeutics, not only to massage and medical gymnastics, but also to surgical and non-surgical orthopaedics. That he was not appointed to the committee was of itself a sufficient answer to the question asked here and there on the publication of the members’ names : ” What does it mean ? ” A still more suggestive and astounding fact is that on this Committeeappointed for an administrative public health purpose, there is not a single doctor who is in practice.
The Chairman of the Committee, Dr. S. Von Friesen, a man of brilliant culture, is obviously able to grasp quickly a subject entirely new to him. Professors Johansson and Ftirst are the two members on the Committee in whom one might place the greatest hope. But these gentlemen are not doctors, and it is not impossible that the Committee’s proposal maybe the worst possible.
What would be the worst possible ? It would be that, for the benefit of ” the Central” and the ” Gymnastic Directors,” but to the detriment of physical therapy and of the public interest, ” the Central” should be continued as a school for physical
therapy and educational gymnastics. That thus for the benefit of ” the Central” and the ” Gymnastic Directors,” but to the detriment of physical therapy and of the public
interest, the unsuitable combination of the instruction and professional training in physical therapy and educational gymnastics should be continued.
That thus for the benefit of “the Central” and the ” Gymnastic
Directors,” but to the detriment of physical therapy and the public interest, the unsuitably long and ill-used time of training should be kept up, or possibly even increased in length, owing to arrangements to meet unwise demands for preparatory study.
That for the benefit of ” the Central ” and the ” Gymnastic Directors,” but to the detriment of physical therapy and the public interest, the showy title of ” Gymnastic Director ” should continue to be given, and that everything should be done with the (hopeless) object of gaining for them a monopoly in massage and medical gymnastics.
All this would form the worst and most unwise scheme that the Committee could propose, and it is much to be feared that it is just what it will do. On the other hand, what should be done ? In the first place, instruction in massage and medical gymnastics should be inaugurated in the Carolinska Institute ; and the physical therapeutic school of the Central Institute, and the combination of physical therapy with educational gymnastics, as well as the institution of Gymnastic Directors, should be brought to an end. A State Institution in alliance with the medical profession should be formed (after the example of the Gymnastic-Orthopaedic Institute) for the training of men and women medical gymnasts and masseurs, and these should receive a diploma to show that they have passed an examination in their work.
Private competitors against this State Institution should not be done away with, since they have an enlivening effect and protect against the apathy of routine. But by means of inspectors and other control the good quality of these private institutions should be secured.
All this should be done, and it is possible that it will be done. But if it is done, it will in all probability not be due to the existing Committee, but to the body of the medical profession in Sweden, which might well have a decisive word in the matter, and indeed has this decisive word in regard to its practical application, and if it follows its already expressed
opinions will render the Committee’s decision null and void. Even in this way we should not put an end to quackery. But we should be doing our best, not as at present, to make easier, but to make more difficult, the independent practice of physical treatment, especially of massage and medical gymnastics, by medically unskilled persons, and we should obtain a numerically sufficient class of competent workers
who would not be encouraged in, and even strongly tempted to, quackery by showy titles and absurdly long and futile courses of training. As regards quackery, the Gymnastic Directors who practise it daily may cease to trouble themselves over the comparatively innocent practice of it by
others. Quackery will always be kept within reasonable limits by theenlightenment and sound intelligence of the Swedish people, the. professional and moral character and consequent influence of the Swedishmedical faculty, and the penal regulations of the general law againstthose who inflict bodily injury. In the spring of 1911 the medical profession in Sweden stated its positionin regard to the ” gymnastic question.” The medical associations expressed themselves unanimously in favour of teaching in mechanotherapy being given in the Carolinska Institute, and the majority of these associations also expressed themselves unanimously or with large
majorities in favour of separating the teaching of medical gymnastics from that of educational gymnastics, of the Central Institute ceasing to be a school of mechano-therapy, and of the training of masseurs andmedical gymnasts being taken over by medical institutions. When a motion to adopt or reject an expression of opinion in this sense was put
before the Medical Society of Stockholm the motion was carried by 85 votes to 3