People have always known massage "works". As noted in the first introduction to Massage, Manipulation and Traction by Dr. Sidney Licht, even MD's did massage in the past. Massage was put aside by the medicos in favor of pharmaceuticals.

Massage, Manipulation and Traction, edited by Sidney Licht, M.D.

Preface to 1976 Reprint

In the second half of the twentieth century most books on therapy of such age are considered obsolescent, and often, justifiably so. This book claims exception because the methods described have not changed during the life of this book, and in many cases for much longer.

During this period there has been such a renewed interest in the subject of pain, that journals and societies dedicated to the control of pain have appeared. Pain has become a specialty and although new surgical, pharmaceutical and electrical approaches have claimed success, massage, manipulation and traction still enjoy the gratitude OF those who suffer from certain musculoskeletal complaints.

Of greatest interest to readers of this book is the recent development of theories concerning the cause and relief of pain. Much of this has been summarized in a book which we recommend: Pain Relief by Dr. John G. Hannington-Kiff (William Heinemann Medical Books, Ltd., London, 1974). Most of what we discuss in this addendum is discussed and documented in the Hannington-Kiff book.

In 1959, a Dutch surgeon, W. Noordenbos, advanced a concept of pain mechanisms based on the properties of peripheral nerve sensory fibers. He suggested that there were at least two different kinds of fibers: small diameter, which conduct skin and visceral pain impulses to the spinal cord at slow conduction rates and large-diameter fibers which inhibit transmission of impulses travelling the fast route to the brain.

Six years later, Ronald Melzack, a Montreal psychologist and Patrick D. Wall, a London surgeon, proposed the Gate-Control Theory of Pain which has since been faulted by a few reviewers but which remains attractive and useful, especially to those of us who believe empirically that massage can and does offer relief to some patients for whom other approaches are less satisfying. The Melzack-Wall gate-control theory proposes that there is a "gate" or monitor in the substantia gelatinosa of the dorsal horn of the spinal cord in the form of transmission (T) cells. There are thick and thin fibers from the periphery along which impulses travel at different speeds; fast for the thick, slow for the thin. Pleasant stimulus impulses travel faster along the thick fibers than do pain stimuli along the thin. when the pleasant stimuli reach the T cells they influence them to "close the gate" against pain stimuli which may arrive later. If the pain stimuli arrive in great abundance or intensity they can "crash" the gate, and the pain impulses will continue cephalad to cerebral pain centers.

There are also, fibers from the brain which send messages to the T cells from above which may modulate the flow of impulses, inhibition or facilitation. The thin fibers (called A-delta and C) may have a strong influence on the T cells and "open the gate" to pain stimuli allowing impulses to continue upward individually or by summation, or, by permitting spread of pain impulses involving larger areas than subserved by the original site of pain. This is a simplified view of the important contribution of Melzack and Wall, first enunciated in the journal Science in 1965.

This unifying theory of pain is applicable to massage. The stroking of the skin can initiate different stimuli which run the gamut from sensual pleasure (gentle stroking) to pain (hacking, connective tissue massage). Gentle striking is so pleasant that the stimuli it sends along large-diameter fibers arrive at the T cells in the spinal cord before the painful stimuli. The T cells often respond by "closing the gate". Thus effleurage can inhibit the transmission of painful stimuli to higher centers for varying periods of time. Of course, eventually, painful stimuli by their intensity or cumulative effect may "crash the gate". This is one reason the sedating effect of massage may last only an hour or two. Even relief of short duration may break the "vicious cycle" of pain and thus offer longer relief.

What is important about the new theory is that there is now an explanation which lends respectability to the likely reasons why in so many instances massage "works". Of course, previous theories about massage are still viable, for example, improved circulation and thus evacuation of local accumulation in painful tissues of katabolites, and so on.

Sidney Licht, M.D. June, 1976

From one of my favorite bibles(4), Massage, Manipulation and Traction, a compilation of physical medicine techniques by Sidney Licht, MD, comes this preface. I believe the preface to be one of the best explanations as to why massage fell by the wayside until the Human Potential Movement. The HPM contributed to the resurrection of many of the healing arts long pooh-poohed by western medicine.

Preface

The subjects treated in this book share several things in common. Each concerns the application of mechanical forms of treatment, and all rank high on the list of therapeutic procedures that have occasioned extravagant claims, assault, and rejection.

Virtually anyone can give massage, and almost everyone has. the mother who rubs the bumped head of her child is giving massage; the dog who licks his broken leg is massaging himself. There is probably no older analgesic than massage; yet, massage, which was lauded by Hippocrates and applauded by Galen, was ignored by physicians for centuries. Since its medical reacceptance in the middle of the nineteenth century, there have been as many detractors as enthusiasts. During the early years of the twentieth century, medical educators, particularly in the United States, refused even to condemn it lest by mouthing the word massage they might give it even a negative recognition. Most physicians are not against massage; in fact, they may be found among those who make appointments for a "rubdown" at a club (beach, country, or "health"). Many physicians who are against massage are opposed to certain operators rather than to the method, for there have always been and will probably always be masseurs who will continue to "prescribe" and make claims for massage that are not in accord with established medical practice.

Massage is more than the laying on of hands or bodily contact; it is personal contact. Each masseur uses, in addition to his hands, his voice, his assessment of the person massaged (sometimes called "psychology" by masseur and subject), and a knowledge or supposition of fold medicine. We may group masseurs into three classes: the untrained, the trained, and the educated. the untrained are those who may be found in vacation resorts or attached to athletic teams. They learn massage by watching other "rubbers" give massage. They work hard at looking industrious; they make extravagant sweeps of the hand and slapping noises. they use generous amounts of lubricants, sometimes of a "secret formula". These people are often likable extroverts who radiate health-imparting confidence. They are frequently consulted for opinions on health and disease, especially of the muscoloskeletal system. In general, they do no harm medically since they recognize their limitations and will not venture opinions beyond that of folklore medicine (admittedly an occasional danger).

In the second classification are those persons who have taken a few weeks or months of training, during which they have been taught all about massage, anatomy, physiology, disease--in short (very short)--medicine. These people are usually awarded a certificate, sometimes a very impressive-appearing certificate. They usually set up a private practice to fill the prescriptions of referring physicians. Many states now require licensure for private (and even public) massage administration, but such licensure may be based on an inadequate examination given to persons with an inadequate education. In other words,state licensure in itself may not guarantee ethical conduct since, in addition to liberal requirements, inspection and enforcement are too costly to be carried out fully. For example, a masseur who is questioned closely and asked to produce a prescription for a patient may say that he was given the order over the telephone as an emergency and the physician died before he was able to send it. Many of the referrals received by these masseurs are from grateful patients, but a large number are from accredited physicians who for personal reasons, or because they are not well informed on the subject, persist in this practice.

The third class of persons who give massage is limited to qualified physical therapists who have been graduated from schools of physical therapy approved by a national medical association or health ministry. In the United States, such persons are "registered' by the American Registry of Physical Therapy founded by the American congress of Physical Medicine; in Great Britain they are "chartered" by the Chartered Society of Physiotherapists. In the United States, membership in the American Physical Therapy Association is as acceptable as registration since the standards of that association are desirably high. For the most part, registered or chartered physical therapists (as differentiated from licensed) are educated at hospital schools or universities where the program, or a great part of it, is under the direction of a physician. Most qualified therapists work in hospitals, clinics, or the offices of physicians. We have yet to meet a registered therapist in private practice who has gained such complete cooperation from all referring physicians that he is able to prove that each patient admitted to treatment came to him with a written prescription, but this remains a theoretical possibility. Nevertheless, such therapists have had prolonged drill in medical ethics and have remained under the close ethical supervision of other therapists and physicians for two or more years; very few of them breach the ethical code.

Why does massage thrive if, as some physicians content, it does no good? There are several reasons, among which we may cite (a) it feels good, especially when given skillfully, (b) it is a more tangible treatment than advice, and (c) it is a positive and immediate approach in an attempt to relieve symptoms--usually the first concern of many patients.

There was a time--less than a century ago--when some physicians personally massaged their patients. When massage is limited to a five-minute session, this is practicable, but, since many patients asked for longer sessions, physicians employed masseurs or trained their own. The physician who has not himself been massaged and has not learned enough about massage to administer it himself has neglected the art. We question whether such a physician has the right to prescribe massage, for he can assess the technique of his masseurs only by knowing as much about massage as it is possible for him to learn.

Many books and articles have been written about massage; perhaps more than half of these have been by physicians. These writings have seldom been sufficiently objective to be classified as scientific; massage is largely not scientific. In this book, we do not pretend to treat massage from the scientific viewpoint alone since the result would be inadequate for clinical purposes. We do feel that we have presented the subject in a more informative and restrained fashion than is customary. In this book, the history of massage is treated more fully than elsewhere in the English language. The physiologic effects and classic techniques re discussed by physicians who have had long and broad experience in these fields. All chapters in this book have been written by physicians--a distinct departure from recent practice.

There are several forms of massage that are very popular in the countries of their recent origin yet are scarcely known in America. We present these as fully as possible and, in most cases, by the physicians who introduced them or are currently considered leaders in that aspect of massage. Dr. Irmgard Seeberger Bischof has become the editor of the Dicke book on connective tissue massage since the latter's death. This book has been reprinted three times in four years. Dr. Maurice Fuchs introduced syncardial massage, and Dr. W. Ritchie Russell restored vibration to a medially acceptable level. The name of Cyriax is probably more closely associated with medically prescribed massage than that of any other living physician. The inclusion in this book of newer forms of massage does not imply an endorsement upon the part of the editor or any contributors to this or previous volumes of Physical Medicine Library. Some people will question the propriety of including such discussions in a medical book since they have not been proven scientifically, that is, accepted by organized American medicine. What could be less scientific than to deny American physicians the opportunity to learn the rationale and methods advocated? The decision to try or to reject without trial is up to the reader. Surely, methods that are widely used with claimed success should not be condemned before they are examined. The way of liberals is to place the pain of patients above prejudice. In editing each contribution we have tried to emphasize methods, not results.

Manipulation remains an ugly word in many medical and surgical clinics. When applied improperly it may be dangerous, conceivably fatal when dealing with rotation of cervical vertebrae. If manipulation is performed by an informed physician, the hazard should be no greater than with most valuable therapeutic agents.

Manipulations and most other operations requiring the use of the hands are difficult to teach by the printed word or even the printed picture. This book does not presume to make a masseur or a manipulator of anyone without previous knowledge or ability to acquire training from an experienced operator; however, for those who have had or may have the opportunity to watch a skilled worker, this book should serve as a useful reference.

Many physicians prescribe stretching. There are some conditions for which there is no other rewarding approach at the time of this writing; yet, there is little written about the subject. We believe a discussion of stretching belongs in this book since it is performed largely by manually applied forces. We have placed stretching in the section on manipulation since it is probably more closely related to it than to massage or traction. We have reserved methods that employ apparatus for the section on traction. We might say it another way: stretching is manual traction.

Traction is almost as old as massage, yet it is a word which is seldom encountered in ancient writings. The subject was usually discussed in writings on fractures and dislocations. The word traction is lost among description of pulleys, ropes, axles and winches. The traction which is of ancient origin has been used continuously throughout the ages for traumatic bony pathology. As used in this book, traction is concerned largely with minor displacements or pathology not visible on X-ray and in this sense is relatively new--a product of the twentieth century.

For the chapters on manipulation and traction we invited physical medicine specialists rather than orthopedic surgeons. We did this to differentiate surgical from physiatric procedures to the extent feasible and to present to physical medicine specialists the experience of other physical medicine specialists in these ares.

No volume of Physical Medicine Library would have reached book form without the help of many persons, and this volume is no exception. Drs. Michael Carpendale of the University of Alberta in Canada and Roland Harris of Buxton, England must be mentioned first since their help was of the highest order in reviewing parts of the manuscript. Miss Mildred Elson of New York City is mentioned next because of her valued assistance with the chapter on connective tissue massage, not only as a student of the subject, but as an editor of long and appreciated experience.

Portions of the text were critically appraised by our good and able friends, Dr. Alfred Ebel of New York, Drs. Lewis L. Levy and Donald B. Alderman of New Haven, and Professor Michael MacConaill of Cork, Ireland. Ideas and figures of historical interest were graciously offered by Dr. P. Hume Kendall of London and Mr. Frederick G. Kilgour, Librarian of the Yale Medical Library. As has been the custom, Physical Medicine Library material is used in the teaching of residents at the Yale university School of Medicine, and many improvements are suggested during seminars, especially by my colleagues, Dr. Thomas F. Hines, Dr. Robcliff V. Jones, Jr., Lee Greene and Frederick E. Dugdale. Gratitude is also due Miss Edith Nyman of New Haven for editorial assistance. To Mr. Norvell E. Miller, III, and his associates at the Waverly Press, we extend thanks for all their help in the mechanical details of structuring a book. We ask forgiveness of those who helped but whose names are beyond our aging memory.

Sidney Licht, M.D.
New Haven, Connecticut
December 1, 1959