Prehistoric Times

Although there is little direct evidence that massage was practiced as a healing art in prehistoric times, it seems likely that it was. There is a certain instinctive quality to the use of the hands in a rubbing and squeezing motion that is both soothing and comforting. Indeed, many animal species, especially primates, use grooming behavior, and, although it is not necessarily therapeutic, it is certainly part of the behavioral repertoire of many species. In short, touching as an activity probably has its genesis at the earliest times in the development of human culture. It seems quite likely that some type of manual techniques (e.g., massage) were in regular use then, together with the application of various medicinal compounds derived from plants, animal sources, and inorganic materials.

Although such ancient cultures had little, if any, recorded history, massage techniques almost certainly were part of their medical culture. Certainly, prehistoric humans were capable of practicing sophisticated medicine, including brain surgery. The well-known prehistoric practice of removing small circles of bone from the skull, called trephining (or trepanning), clearly shows that the practitioners of the day were capable of complex medical tasks (Broca, 1876; Prunieres, 1874). Not only were they able to make holes in the skulls of their patients, but these latter-day surgeons were able to do this more than once in a given person. In addition, the findings clearly show that many people survived the procedure, as evidenced by the presence of healed areas of bone in the skull. One cannot help but believe that a culture capable of this level of surgical practice must long before have discovered the considerable and obvious benefits of massage-like treatments.

Ancient History

The use of manual massage techniques in many ancient cultures is well documented in extensive written and pictorial records. For example, at the time of Hwang Ti, the Yellow Emperor (d. 2599 bc), the great Chinese medical work known as the Nei Chang was written (ca. 2760 bc). This work contains detailed descriptions of massage-like procedures and a great many details of their use (Veith, 1949). During the Tang dynasty (ad 619–907), four primary kinds of medical practitioners were recognized: physicians, acupuncturists, masseurs, and exorcists; however, following the Sung dynasty (ad 960–1279), the use of massage declined greatly. Massage is also described in one of ancient India’s first great medical writings, the Ayur-Veda books of wisdom (about 1800 bc). Most of the great ancient cultures of the world have described in some detail the uses and benefits of massage, which was often combined with other kinds of traditional treatment, particularly bath treatments. The Egyptian, Persian, and Japanese cultures, in particular, placed great emphasis on the use of massage and these allied treatments.

The ancient Greeks used massage widely to maintain physical health and ensure lasting beauty. Homer described in the Odyssey how war-torn soldiers were massaged back to health. Hippocrates (460–360 bc) also wrote on the subject and described many of the uses of massage in medical practice. In discussing treatment following reduction of a dislocated shoulder, Hippocrates said:

The ancient Greeks, perhaps more than other cultures, are responsible for giving massage such a high level of social acceptance. They established elaborate bathhouses where exercise, massage, and bathing were available, but the patrons were lovers of luxury and questionable behaviors rather than seekers of health. The bathhouses were the playgrounds of the rich and powerful. Ordinary citizens were not so fortunate.

The Romans inherited much of the tradition of massage from the Greeks, and it was widely used, especially in conjunction with hot baths. Galen (ad 131–201), the most famous physician in the Roman Empire, wrote extensively on the topic of massage and described several ways in which it could be administered. Julius Caesar (ca. 100 bc) is said to have had himself pinched all over as a cure for a complaint similar to neuralgia. The influence of Galen on all aspects of medical thinking cannot be overstated; it is probably because of him that massage and its allied treatments survived long after the fall of Rome. Galen strongly recommended that in preparation for impending combat, gladiators be rubbed all over until their skin was red. The use of massage continued, and it was not until the early part of the Middle Ages that it fell into some decline in Europe and Asia. This era was known as the Dark Ages, when many aspects of ancient culture and practice were abandoned.

Modern History of Medical Massage (European, Mainly British)

Much of ancient culture and tradition in medicine and science was lost through the Middle Ages, and it was not until the Renaissance, especially in the sixteenth century, that some of the older methods of medical practice were again used. Advances in the study of anatomy and physiology enabled scientists of the time to understand more about the effects and uses of some of these more ancient traditions. Ambroise Paré (1518–1590), the famous French surgeon, was among the earliest writers to consider and discuss the effects of massage. Paré was particularly interested in the use of friction and general massage movements to treat patients who had dislocated a joint.

Harvey’s discovery of the circulation of the blood in 1628 did much to enhance the acceptance of massage as a therapeutic measure. Despite these seemingly important advances, massage treatments did not become popular throughout Europe until the eighteenth century. At that time, two of the more notable exponents of the treatment were Germans, namely Hoffmann (1660–1742) and Guthsnuths. Another famous physician, who claimed in the 1880s that massage could be a very useful treatment, particularly to the soft tissues following fracture, was the famous French physi-cian Just Lucas-Championniére (1843–1913). In the late 1890s, Sir William Bennett was impressed with Lucas-Championniére’s work and began what was then a revolutionary treatment using massage at St. George’s Hospital in London, England. Other authors also strongly advocated massage for a variety of soft tissue problems, especially writer’s cramp (Robins, 1885; de Watteville, 1885a 1885b).

The era of modern massage is usually said to have begun during the early 1800s, when a wide variety of authors were advocating massage and developing their own systems. A famous thesis by Estradere in 1886 was an important contribution to the developing science of massage (Estradere, 1863).

Arguably, the most famous and enduring influence on massage is the contribution made by Pehr Henrik Ling (1776–1839). Ling developed his own style of massage and exercises, which later gained international recognition as Swedish remedial massage and exercise (Benjamin, 1993; Ostrom, 1918). Ling was a fencing instructor, and in 1805 he was appointed gymnastics and fencing master to the University of Lund in Sweden. He designed a system of his own that consisted of four types of gymnastics: educational, military, medical, and aesthetic. In 1813 he founded the Central Institute of Gymnastics in Stockholm, and he taught there until his death in 1839. Much of Ling’s work was published after his death, mainly owing to the efforts of his students and colleagues (Kellgren, 1890). He gained international recognition for the terminology that bears his name, and in many cases modifications of his basic concepts of exercise have been used throughout the world. In more recent times, however, many of Ling’s original ideas faded from popularity, but his work remains an important influence in the early development of the profession of physical therapy (physiotherapy).

In Holland, Johann Mezger (1839–1909) also used massage widely and developed his own style. By 1900 modern medical massage techniques were being used in most parts of the developed world and, of course, their use continued in the more ancient cultures. In fact, “manual medicine” had become an integrated part of a modern approach to the treatment of trauma and disease (Harris & McPartland, 1996).

In England in 1894, a group of four dedicated women founded the Society of Trained Masseuses with the aim of raising the standards of massage and the status of women taking up the work. In 1900 the society was incorporated by license to the Board of Trade and became known as the Incorporated Society of Trained Masseuses. During World War I, membership rose, and by 1920 some 5000 members were practicing. In 1920 the society merged with the Institute of Massage and Remedial Exercises (Manchester). These two bodies were then granted a Royal Charter and became known as the Chartered Society of Massage and Medical Gymnastics (CSMMG). World War II saw the emergence of a young profession, as large numbers of soldiers returned from various parts of the world, and the role of physiotherapy became more important. Massage alone became less important as other means of rehabilitation were developed. For this reason, in 1943 the name of the society was changed to the Chartered Society of Physiotherapy (CSP).

From similar beginnings in many other countries, the modern profession of physical therapy as it is now known developed and branched into most parts of the world, developing differently in each region to accommodate particular needs. Medical massage is rarely used in modern rehabilitation practice as a treatment in its own right, but it is used as part of an overall treatment plan for some patients. It has largely been superseded by other, more active treatments, but it remains one of the most important means of developing hand skills in the therapist. In physical therapy practice, soft tissue massage has developed into many types of manual mobilizing techniques that take the form of a wide variety of manipulations performed on both soft tissues and joint structures. In effect, the skilled use of the hands is still the cornerstone of the profession of physical therapy and is likely to remain so for the foreseeable future. Although massage is rarely used as the sole treatment in physical therapy and many other manual techniques have become popular, it is still an important part of the range of soft tissue techniques that aspiring therapists should learn (Domenech, 1996).

In many older Asian cultures such as China, Japan, and India, massage is still used extensively as part of the traditional methods of treatment. Massage as a specific treatment in its own right plays a relatively small role in modern Western medicine; however, in recent years in many countries, specific massage professionals (massage therapists) have emerged. In this case, the treatment modality is massage itself. It is important to remember that the modern profession of physical therapy came into existence around the turn of the twentieth century and that massage techniques were established in medical practice long before that time. In fact, massage has a long tradition of use in the nursing profession (Estabrooks, 1987; Goldstone, 1999, 2000), which predates the rehabilitation professions by many centuries. In recent decades, the nursing profession has rediscovered its massage heritage and is once more employing the benefits of massage, along with other newly emerging massage professions (Huebscher, 1998; Mallios, 1996; Palmer, 1992; Wright, 1995).

Massage techniques can be used to promote a general sense of relaxation and wellness. These days, thanks to the resurgence of interest in holistic medicine and popular concepts of wellness, the general public still has great faith in the “laying on of hands”; however, such forms of massage need to be differentiated from the medical massage techniques used in other health professions, especially physical therapy. These more general massage techniques, performed on persons who are otherwise healthy, may be termed recreational massage and should not be confused with the term therapeutic massage. These terms are defined in more detail in Chapter 3.

Another technique that appears to be similar to massage is known as “therapeutic touch.” This somewhat controversial technique needs to be clearly differentiated from therapeutic massage. Essentially, although the name implies that touching is involved, in its original conception therapeutic touch does not actually require the therapist to touch the patient. The therapist’s hands simply move over the part to be treated without actually making contact. Supporters claim that the technique balances energy fields around the affected parts (Feltham, 1991; Ireland & Olson, 2000; Krieger, 1979, 1981).

Because the primary effects of therapeutic massage are mechanical, a technique that does not have a mechanical component cannot work on the same principles. Other effects must be invoked to explain its efficacy. Although therapeutic touch is a popular facet of new age medicine, it is a long way from enjoying strong scientific acceptance. Paradoxically, this concept is not new. Traditional Chinese medicine has many techniques that are similar to so-called therapeutic touch.

This text considers only the theory and practice of therapeutic massage. In this regard, the major influence behind the techniques described is the Swedish remedial massage tradition (Benjamin, 1993; Ostrom, 1918). Before describing these techniques in detail, the history of various aspects of medical massage must be explored. This section is self-contained and may be referred to in relative isolation from the rest of the text, as many of the concepts mentioned here are expanded upon throughout the remainder of the book. The review focuses on a number of aspects of the practice of massage rather than on a chronological history. Readers interested in the history of soft tissue manipulation from these perspectives are directed to the following sources: Beard (1952), Bohm (1918), Braverman and Schulman (1999), Bucholz (1917), Cole and Stovell (1991), Despard (1932), Graham (1884, 1913), Henry (1884), Johnson (1866), Kamenetz (1960, 1985), Mason (1992), Quintner (1993, 1994), and Stockton (1994).

Definitions of Massage

A comprehensive definition of massage cannot be found in the early medical literature. Thomas’s Medical Dictionary (1886) offers the following description: “Massage, from the Greek, meaning to knead. Signifying the act of shampooing.” (Shampoo is from the Hindi, meaning “to press.”) Throughout much of the history of medicine, massage and exercises are referred to simultaneously, and early writers make little distinction between the two. Kleen (1847–1923) of Sweden, who first published a handbook of massage in 1895, claimed to be the first to show clearly that massage is not an exercise therapy (Kleen, 1906, 1921).

William Murrell (1853–1912) of Edinburgh and London, writing at about the same time, was more specific when he defined massage as “the scientific mode of treating certain forms of a disease by systematic manipulations.” He limited massage to the amelioration of disease but evidently realized the need for a system for its use. He placed no limit on the means of massage. At the same time, Douglas Graham of Boston, writing from 1884 to 1918, described massage as

He went much further than Murrell (in recognizing that the term needed definition) and limited the means to the hand and the surfaces involved to the external tissues. Graham identified the objectives as being curative, palliative, or hygienic.

Kleen, one of Graham’s contemporaries, limited the areas involved to the soft tissues. In addition to the hand as a means of administering massage, he included ancillary apparatuses. This seems contradictory given that he eliminated the idea that massage is exercise. In this he differed from his early compatriot, Ling.

Albert Hoffa (1859–1907) of Germany also limited the means of massage to the hand but embraced its broad application—to all the mechanical procedures that can cure illness (Hoffa, 1897). At about the same time, another German, J.B. Zabludowski (1851–1906), also limited the administration of massage to the hand but specified “skillful hand grasps, skillfully and systematically applied to the body.” While limiting the movement to skillful hand grasps, he, like Murrell, recognized the use of systems (Zabludowski, 1903).

C. Herman Bucholz of the United States (Boston) and Germany was as imprecise as any of his predecessors. He did not mention the hand or any other means of administering massage in his recommendations for therapeutic manipulation of the soft tissues. Even James B. Mennell (1880–1957), whose great contributions have made the science of massage what it is today, gave no formal definition of massage.

In 1932, John S. Coulter (1885–1949) said:

In 1952, Gertrude Beard (1887–1971) wrote of massage as

Massage Terminology

A study of the literature in this area might easily lead to confusion over the number of different terms used to describe the various techniques of massage. Despite some similarities, there is considerable confusion, and a comparison reveals that few writers have given the same meanings to these terms. A survey of these differences seems useful if one is to interpret correctly any reading of earlier massage techniques and at the same time possess a clear idea of the meanings as they are presently accepted and used in this text. Much of the background information in this area comes from the work of Graham (1884, 1913).

The various advocates of massage among the ancient Greeks and Romans, from the time of Homer in the eighth century bc through the fourth and fifth centuries ad, used relatively consistent terminology. For example, these writers most frequently used the terms friction, rubbing, and anointing. Celsus of Rome (25 bc-ad 50) used, in addition, the term unction (Celsus, 1665). Hippocrates used the terms anatripsis and rubbing. Galen adopted the term anatripsis from Hippocrates but added tripsis, tripsisparaskeu lasthke, and apotherapeia. Oribasius (325–403), a Roman who followed Galen a century later, described apotherapeia as bathing, friction, and inunction. Other terms used in this period were pommeling, squeezing, and pinching.

There is little literature on medical practice during the Dark Ages, but massage practitioners in many European cultures during the fifteenth, sixteenth, and seventeenth centuries adopted the terminology used in the earlier period. Among those who strongly advocated the use of massage were the noted French surgeon Ambroise Pare and the famous English physician Thomas Sydenham (1624–1689), who confined their terminology to friction. Alpinus (1553–1617) of Italy used rubbing but added maxalation, manipulation, and pressure. Frederick Hoffman (1660–1742) of Prussia adopted Galen’s term apotherapeia. Hieronymus Fabricius (1537–1619), an Italian, seems to be the first to have used the term kneading, and he also used rubbing.

In the early part of the nineteenth century, there was a definite change in terminology, evidently owing to the influence of Ling. Ling, who has been credited as the originator of the Swedish system of remedial massage, traveled widely all over Europe and incorporated into his system the French terms effleurage, pétrissage, massage à friction, and tapotement. To these he added rolling, slapping, pinching, shaking, vibration, and joint movement—a specific example of a part of the present-day exercise in the classification of massage movements.

Mezger (1839–1909) of Holland used the French terminology exclusively, and William Beveridge (1774–1839) of Scotland seems to have originated the use of the term finger rubbing. Lucas-Championniére of France also used unique terminology: his gentle massage, which he termed glucokinesis and effrayan, influenced the massage techniques used to this day. Blundell (1864) of England used the terms inunction, friction, pressure, and percussion. In contrast, the islanders of Tonga in this same period used the terms toogi toogi, mili, and fota; Hawaiians used the term lomi-lomi.

In the early twentieth century, physicians in the United States contributed to the literature of massage. Graham avoided the French terms and listed “friction, kneading, manipulation, rolling, pinching, percussion, movement, pressure, squeezing” and the very early Italian term maxalation. In his 1919 book, J.H. Kellogg (1852–1943) describes different movements, in contrast to some of the English writers of a century earlier (e.g., John Grosvenor), who used only the term friction.

Murrell of Scotland and England, Kleen of Sweden, Hoffa of Germany, Bucholz of Germany and the United States, and John K. Mitchell (1859–1917) of the United States embraced the French terminology, whereas Zabludowski of Germany and Mennell of England dropped it almost entirely.

Kleen, Zabludowski, Mitchell, Bucholz, and Mennell gave a rather simple general classification of the terminology with subdivisions of the movements. Mennell’s general classification identified “stroking, compression, and percussion.” McMillan (1925) used “effleurage, pétrissage, friction, tapotement, and vibration.” Louisa Despard (1932), Frances Tappan (1978, 1998), and Lace (1946) used a mixture of French and English terms. Elizabeth Dicke and associates (1978) used both German and English terms to describe the specialized techniques used in connective tissue massage (CTM).

The chronology described in the previous paragraphs is presented in tabular form in Table 1-1, which presents a chronology of the terminology of massage.

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