Massage and the history of physiotherapy

A few days ago, Kay Nias, Medicine Galleries Research Fellow at the Science Museum in London, gave a talk on massage and the history of physiotherapy (link).  Kay was kind enough to share her slides with us and the text of her talk (see below).  You can find more of Kay’s work here.


In July 1894 the British Medical Journalpublished an article entitled ‘Immoral Massage’ that complained that ‘young women of modesty and proper feeling have found it necessary to sever their connection with otherwise respectable institutions simply because, under medical prescription, they have been detailed to apply “general” massage to men. This is a real evil, and tends to whittle away the boundary line between propriety and impropriety, if not immorality’.

The national scandal sparked by this expose on massage by the British Medical Journal was but a climax of ongoing debates surrounding the status of massage as a medical treatment throughout the nineteenth century. This paper will consider some of the ways in which debates about massage, the status of touch and haptic knowledge stimulated and shaped the professionalisation of physiotherapy in Britain in the late-nineteenth and early-twentieth centuries.

Today I will be focussing on 3 distinct but interconnected processes that have been fundamental for the development of the modern physiotherapy profession as we know it today.

  • The first then, is the medicalisation of massage in the nineteenth century.
  • The second is the technologization of massage and movement therapy in this period.
  • And the third is the professionalisation of massage in 1895.

This paper seeks to investigate some of the ways in which the charged reputation of massage and touch irrevocably shaped these processes.

MEDICALISATION OF MASSAGE

When I first began exploring the history of physiotherapy in Britain I found that the majority of the accounts start in 1894 with the British Medical Journal’s ‘massage scandals’ (as quoted above) and the formation of the Society of Trained Masseuses in 1895, now the Chartered Society of Physiotherapy.

Starting our history here however, raises a number of questions, for example: Why was the British medical profession concerned with massage in the first place? What was so controversial about it? And indeed how did massage come to be a part of medical practice? A medical practice important enough to be incorporated into medicine through professionalisation.

To answer these questions we have to move beyond institutional accounts and institutional sources and look at the history of physiotherapy more broadly.

As I am sure we can all appreciate therapeutic massage and movement has an ancient, transnational and transcultural history. From the therapeutic traditions of ancient China, India and Rome, to the shamanic healing rituals of the Australian Aboriginals, African tribes and the Polynesians, therapeutic massage and movement techniques have been used in a diverse range of medical contexts, by a diverse range of practitioners for thousands of years. 

In the nineteenth century there were a range of personnel who claimed authority over this arena including bonesetters, Swedish gymnasts, rubbers, shampooers and Turkish bath attendants. On the slide behind me, the top three images are of Swedish gymnasts, in the middle working in Sweden in the 1880s and on the left in Britain in the First World War. On the bottom middle there we can also see the famous British bonesetter Sir Herbert Barker teaching the British Orthopaedic Society how to do joint manipulations in 1936.

While traditionally the domain of such lay-practitioners, the nineteenth century was also a time that the medical profession began to take more of an interest in absorbing massage into their therapeutic armoury.

Well, doctors in the nineteenth century often experienced a significant degree of powerlessness in their ability to cure certain illnesses and control patients through long and uncertain courses of treatment. Such conditions included disability, in fact disability was not seen as a medical problem until the first world war, it included all forms of paralysis, and long standing pain conditions such as rheumatism and arthritis. It was then, primarily in these arenas that massage and movement techniques offered hope of cure and relief where there had been nil before.

On the slide behind me is represented a few of these arenas, for example the bottom two images show the kinds of treatment often given in early hospital physiotherapy departments called ‘massage departments’, such as the ‘crawling class’ used to treat curvature of the spine. The image at the top is a still from a British Medical Association film about the advantages of mobilisation in fracture treatment. And on the left, we can see depicted uterine massage which gained international recognition between 1880 and 1910 for being a conservative approach to conditions such as prolapse.

While it was recognised as an invaluable mode of treatment however, the practice of massage raised a lot of issues for the medical profession. We’ve touched on one, that of it being historically undertaken by lay-practitioners, which made it prone to accusations of quackery. Another was the status of haptic expertise – to do massage was considered more of a practical skill than an intellectual profession. A third complaint was its lack of evidence base – something that continues today – as massage relies more on sensory, experiential and anecdotal evidence rather than scientific verification and quantification. A forth issue that charged massage was the controversial status of touching and intimacy in the medical setting in this period, as attested by contemporary debates surrounding gynaecology. Finally, it was also time consuming and labour intensive, and therefore far less remunerative than writing prescriptions.

As you can see then, for the medical elite in Britain especially, who prided their identity on gentlemanly conduct and intellectual qualifications, performing massage was a radical departure from traditional practice.

In fact  to even be considered as a viable medical treatment in the 1880s, massage had come a long way. Throughout the nineteenth century massage had undergone a process of medicalisation, where it had been reformulated into scientific discourse through the writings of medical men attempting to vindicate and promote its practice.

Above all these medical writers were anxious to present massage as a rational and systematic treatment in order to avoid accusations of quackery and empiricism. One strategy was to adopt an entirely new nomenclature; indeed, the word ‘massage’ itself, along with other terms such as ‘medical rubbing’, ‘massotherapeutics’ and ‘kiniseiology’, were all adopted to replace and differentiate it from the lay practice of ‘rubbing’ and ‘shampooing’. It was the Dutch physician Johan Metzger, who first introduced the French terms ‘effluerage’, ‘petrissage’, ‘tapotement’, and ‘friction’ to classify and systematise massage techniques in the mid-nineteenth century.

Alongside a new terminology, massage and movement also became subject of numerous clinical studies and experiments which aimed to prove its scientific validity and therefore rationalise it as part of medicine. One of the most oft cited experiments was that of German professor Von Mosengeil whose ‘accurate and painstaking experiments placed massage on a sound and scientific basis’. His experiments, conducted in the 1870s, injected ink into the knee joints of rabbits, and while massage was performed on the right knees, the left knees were left untouched. After twenty-four hours the animals were killed and dissected showing that massage promoted absorption by the lymphatics.

Numerous experiments were undertaken into the effects of massage in this period, for example upon swelling and inflammation, muscular fatigue, circulation and temperature. The important feature of all these experiments was that they aimed to articulate in the language of science and medicine effects that had for thousands of years been understood experientially and anecdotally.

What then was the difference between massage done by a bone-setter or any other lay-practitioner and a doctor or surgeon? In their texts these medical men argued that there was a difference between ‘scientific’ and ‘unscientific’ massage. British physician Herbert Tibbits for example wrote in 1889, that ‘when people say that massage is as old if not older than any other form of treatment they are wrong. Medical rubbing … slapping and thumbing the body, were …. Common modes of treatment, but we claim something more for massage than this: we say that massage consists of a series of movements classified and arranged in order to produce well-known physiological effects’. Likewise, another British authority whose popular text Massotherapeuticshad been published in five editions by 1890 claimed that: ‘there is as much difference between Massage and shampooing as there is between playing a difficult piece of music and striking the keys of the pianoforte at random’.

As we can see, the medicalisation of massage as traced through nineteenth century medical discourse, occurred very much in tandem with debates about the status of massage. While the medical profession sought to assimilate massage into its therapeutic armoury, it was only accepted after being put upon a scientific basis.

It was not as simple as only scientific reformulation however. While the medical profession wanted to prescribe massage and movement therapy, they felt little enthusiasm towards undertaking these time-consuming manual tasks themselves, and they made efforts to delegate such tasks to subordinates and machines. It is in this context that we see the development of technology and professionalisation.

When we think about the vibrator today, we automatically think of quackery or a sexual object, and while they feature in both these arenas, they were first developed in the medical context.

One of the first electromechanical vibrators to be internationally marketed to physicians was the British model designed by physician Joseph Mortimer Granville in the 1880s. By the turn of the century a wide range of vibratory apparatus had become available to physicians – one report recorded more than a dozen medical vibratory devices at the Paris Exposition of 1900.

Some were floor standing machines on rollers, others were designed to be permanent fixtures suspended from the ceiling (and here on the left are some suspension fixtures for a vibrator, held now at the Science Museum), and some were portable in a carry cases (and the middle image is an example of a Barker vibrator, manufactured in America and sold widely to a medical audience). They were powered by a variety of different means: battery, electricity and steam, and some were designed for local vibration and others could be applied to the entire body (like this Zander apparatus here on the right).

Vibrators and vibration therapy was not just a passing fad; it was widely adopted by medical practitioners at this time for a range of conditions. Here we have some examples of vibration being used in private clinics, the top left shows a private clinic in Paris owned by physician Joseph Riviere, and the machine in the middle was designed by American John Harvey Kellogg who ran a private Sanatarium at Battle Creek in Michigan depicted on the left. Vibration was popular with wealthy clientele for complaints such as: digestive disorders, nervous conditions, paralysis and pain. But vibration was also used in the working class context, and hundreds of early physiotherapy clinics such as that depicted at the top right emerged across Europe to rehabilitate injured workers in the second half of the nineteenth century. It was therefore very much a recognised treatment, and it is hardly surprising that rehabilitation centres developed in the first world war were outfitted with vibrators, as shown on the bottom right.

The mechanisation of massage did not occur spontaneously of course. Firstly, in a wide range of arenas, such as the home, industry and agriculture, various machines and devices had been developed to assist or replace human labour, and this was no different. But mechanisation was also about medicalisation and medical control. These machines made massage acceptable for the medical profession to do ‘en corpore’. Unlike the manual method, machines were measurable, accurate and quantifiable, and therefore made the practice seem more rational and scientific. Whereas prescribing manual massage often meant the physician had to refer his patient to a lay-practitioner with the skill and expertise that they lacked through a regular medical education, machines offered medical control over the practice. Rather than having to manipulate and touch the body of their patients, machines mediated clinical intimacy. By allowing the body and massage practice to be objectified and rationalised, mechanisation negotiated the challenges surrounding massage, touch, and haptic knowledge.

Delegating massage work to others was also a common occurrence in this period. While unappealing to the medical profession, it was deemed acceptable work for nurses, hospital porters and other assistants to whom status was apparently less of a problem. While this sounds like a passive division of labour, it must be stressed that this was an opportunity seized by nurses and other women eager to develop their careers.

Although massage was a common prescription in this period, it was also more often than not a vague one. Medical prescriptions often just said ‘massage’, rarely, if at all, giving any further details, leaving the nurses in charge of the day to day treatment to devise the course of action. The nursing profession quickly developed courses of training in massage to develop their professional expertise, and massage was until the first world war, considered to be a postgraduate skill of nursing. The first image is of a massage certificate given by Margaret Palmer in 1902 at the London Hospital, hired to give nurses a short course on massage.

As we heard in the opening quote, however, in 1894 the British Medical Journal released a series of articles called the ‘scandals of massage’, exposing that massage was being used as a disguise for prostitution in London’s West End, igniting a national scandal.

The British Medical Journal wrote: ‘That under a cloak of a useful form of medical treatment the grossest immorality should be practised… is not only a matter of public importance well worthy of the attention of our police and our magistrates… [but there is also] a professional and medical side to this question of massage to which it is our duty to refer’. They called for action by the Home Office and Police to close down massage establishments not run by medical practitioners, and also to form a register of medically authenticated masseuses, in order to, they argued ‘draw a sharp dividing line between the sheep and the goats, between those who merely make a cloak of massage and those who practise it honestly as a means of cure’.

To think that the British Medical Journalwere only interested in public morality, however, would be naïve, while it was a medico-moral issue it was also interwoven with professional interests. They believed that the medical profession should regulate massage, and they purposefully cast a shadow of doubt over the status of massage in all other arenas as a strategy to gain control.

The result was to stimulate the professionalisation of massage with the formation of the Society of Trained Masseuses in February 1895. This society were formed of a group of nurses and midwives, trained in massage and affiliated to the Midwives’ Institute and Trained Nurses Club. The Trained Nurses Club was an association actively engaged with the campaign for the registration of nurses and midwives, so these women belonged to the nursing elite and were very politically aware. And a rare image third along, shows a number of the founding members.

Not surprisingly then, the professionalisation strategies of the Society of Trained Masseuses were very much shaped by the ongoing controversy about the status of massage. The Society organised an independent examination in the theory and practice of massage, it granted certificates and registered members in order to define a standard professional knowledge and outwardly demonstrate to the public and medical profession that they were trained professionals superior to the many other unregulated, lay practitioners on the market. On the right is one of the first certificates granted by the Society to Julia Newlyn in 1895, signed by the founding members.

Practical proficiency and theoretical knowledge however, was not the only qualification necessary for membership of the society. Masseuses also had to pledge to work under bylaws governing their practice and ethical behaviour. Rules included ‘no General massage for men to be undertaken’, to only undertake cases under a physicians prescription, and to advertise only in professional papers. These rules were not aimed towards the patient’s wellbeing, but rather were intended to regulate the intimacy, relationships and power dynamics between the patient-masseuse, and the masseuse-physician. Ultimately, the Society chose to take these actions that severely restricted their professional practice and subordinated the role of the masseuse to the medical profession, in return for moral and medical legitimacy and authority over a highly controversial area of expertise.

CONCLUSION

So, to conclude, this paper has explored just a few of the many instances where the charged reputation of massage and touch stimulated and shaped the early development of physiotherapy in Britain.

Why is this important? If at all, I was pondering.

Firstly, because the controversial status of massage continues today, and it is therefore relevant to current debates within the physiotherapy profession. While research shows that touch and an embodied health experience is increasingly in demand by patient consumers, the therapeutic effectiveness and ‘scientific validity’ of massage continues to be challenged.

Secondly, because we take the hierarchical structure of the medical and paramedical professions for granted today. Historical examination shows that the professionalisation of physiotherapy did not occur in a vacuum; it was not inevitable that massage should be a part of orthodox medicine, that this manual work should be devolved to women, and that they should work under the authority of the medical profession, there are at any one moment any number of different possibilities and it is up to the historian to examine why certain power structures prevail. As this paper has shown, the division of labour, and professional characteristics of modern physiotherapy in Britain were formulated in tandem with the gender, intimacy and professional interests that intersected the status of massage treatment in the late nineteenth and early twentieth centuries.

Finally, it is important for the history of physiotherapy. One historian has argued that the physiotherapy profession suffers from what he describes as a ‘collective amnesia’, and a general disinterest towards their history, and likewise, within the history of medicine, little to no research has been undertaken. This I would argue, is but another symptom of massage and physiotherapy’s historically low status within the medical hierarchy, seen as something peripheral, less important and less interesting than the work of the medical profession. Still, however, further research does need to be undertaken to illuminate the full extent to which the auxiliary professions and auxiliary practitioners have supported the development of modern medicine as a whole.

Posted by Dave Nicholls

Dr. Nicholls is an Associate Professor in the School of Public Health and Psychosocial Studies, AUT University, Auckland, New Zealand. He is a physiotherapist, lecturer, researcher and writer, with a passion for critical thinking in and around the physical therapies. David is the founder of the Critical Physiotherapy Network, an organisation that promotes the use of cultural studies, education, history, philosophy, sociology, and a range of other disciplines in the study of the profession’s past, present and future. David’s own research work focuses on the critical history of physiotherapy and considers how physiotherapy might need to adapt to the changing economy of health care in the 21st century. He has published 35 peer-reviewed articles and 17 book chapters, many as first author. He is also very active on social media, writing more than 500 blogposts for criticalphysio.net in the last three years. David has taught in physiotherapy programmes in the UK and New Zealand for over 25 years and has presented his work all around the world. The End of Physiotherapy – the first book-length critical history of physiotherapy, and written by David – was published by Routledge in mid-2017.

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