an historical outline of manual therapies
by Jeffrey Burch, Adv. Certified Rolfer
Originally published concurrently in the Journal of the Rolf Institute and the Journal of Hellerwork International
In attempting to write a brief history of manual therapy I have encountered the twin challenges of quantity and diversity of information. While the history of manual therapies could rightfully fill an encyclopedia, certain crucial topics are underrepresented in the literature. The available information also comes from a wide range of cultures and spans a timeframe from the Neolithic to the present. Future articles in this series will present in detail selected topics from this introductory historical outline.
Structural Integration, Osteopathy, Chiropractic, Physical Therapy, CranioSacral Therapy, Myofascial Release, Zero Balancing, as well as Orthopedics and most other kinds of manual therapy we have today in the Western world, grew out of a common root, known as “bonesetting.” The lineages of manual therapy are like the growth of a banyan tree—a primary trunk and root sprouting and recombining continuously for centuries. Modern therapies have been periodically revitalized by renewed contact with bonesetters. On the other hand, some bonesetters read anatomy and other medical texts as they became available and thereby improved their skills.
Much of this brief history focuses on the British bonesetter tradition since 1500, extending into North America, and the several points of exchange between the bonesetter traditions and our present manual healing arts in the West.
Manual therapies of varying sophistication have existed in virtually all traditional cultures. Stone Age skeletal remains evidence healed trephinations and well-set and healed bony fractures, suggesting astute manual therapy and surgical skill. “Iceman,” a 3,000 year old Central European found frozen in an alpine glacier, evidenced a series of lines and points tattooed on his body, most of which are identical to the acupuncture meridians we use today. Manual therapies are recorded in written documents as far back as Old Kingdom Egypt and were present in stone-age cultures which persisted into the 20th Century. Robust manual therapy folk traditions continue today in many geographically diverse parts of the world.
Of the many names traditional manual therapies have been called, the name “bonesetter” has been current in Britain since at least 1400. In the same period in German-speaking lands, similar practitioners were called Wundartze. In Spain the name was algebrista, derived from the Arabic root meaning “to reduce,” which is also the root of our word “algebra.” Today, Mexican curanderos reduce dislocations and remedy other joint problems, along with their application of herbal medicine and other arts. As examples of other names, in Japan bonesetters are known as the hone-tzugi or seifukujitsu-shi; and in Mongolia they are known as the bariachi.
Bonesetter Education and Scope of Practice
The form of manipulation varies from culture to culture and even from practitioner to practitioner. In most traditional cultures, skills are carefully guarded and passed down within families. There are variations on this pattern: at one end of the spectrum, the Wundartze of the German-speaking lands published many books and pamphlets describing their work, starting as early as 1500. At the other end of the spectrum, Mongolian bariachi are said to be born with the healing knowledge and skills, require no education, and may or may not be born to parents who are practitioners.
Some modern bonesetting traditions, including the curanderos of Mexico, also practice other facets of the healing arts, including herbal medicine and surgery. Neolithic evidence suggests that bonesetters worldwide also often practiced a range of healing arts. In Scotland the terms “surgeon” and “bonesetter” were synonymous until 1875, as shown in lists of occupations used by the courts to interpret wills. Practitioners in some traditions set fractures as well as providing joint mobilization, as in present-day India.
Early British Bonesetter Publication History
While the bonesetters of Renaissance and early industrial Britain did not publish papers or books themselves, two contemporary publications give more or less detailed accounts of their methods. The first, a forty-page pamphlet entitled The Compleat Bonesetter, was written prior to 1650 by an Augustine friar named Thomas Moulton. Robert Turner edited and expanded Moulton’s manuscript, publishing it in 1656. We do not have Moulton’s original manuscript. Turner’s edition describes in broad terms the work of bonesetters, along with herbal remedies. Interestingly, the introduction to this book suggests that most if not all practitioners at that time were women. In a second edition, The Compleat Bonesetter Enlarged issued in 1665, Turner primarily added more herbal remedies.
Together the two editions of The Compleat Bonesetter are frequently described as the first publication in modern times on manual therapy, becoming the first publication in the lineage of all of our modern manual therapies. Prior to Moulton’s writing, the previous text on manual therapy in the Western world had been authored by the Greek physician Hippocrates, (470-410 B.C.). If there were other manual therapy texts in the intervening two millennia, they did not survive.
During the 1860s, an English medical doctor, Peter Hood, treated a prominent bonesetter, Mr. Hutton, during a long and severe illness. Hood refused any fee for this service. Upon his recovery, Hutton offered to teach Dr. Hood his bonesetting skills. Peter Hood instead sent his physician son Wharton Hood to learn bonesetting. After his apprenticeship with Hutton, the younger Hood published a 156-page book in 1871 entitled On Bone Setting (so called) and its Relationship to the Treatment of Joints Crippled by Injury, Rheumatism, Inflammation, &c, &c.
While the physicians of the day found a few new insights and methods in Hood’s book, they found a greater number of familiar techniques. In some cases physicians had reinvented the wheel. Bonesetting information had also already entered orthopedics by other routes, often stripped of its origins. Hood’s book served to narrow the gap in understanding between physicians and bonesetters of his day.
Evolution of Medical Philosophy and Education
As an additional step to setting the stage for our chronology, it is important to realize that medical training in the Western world until about 1900 was primarily by apprenticeship. The Hippocratic oath taken by medical doctors to this day speaks clearly of apprenticeship as a primary training paradigm. Hippocrates was the son of a physician and received the greater part of his training as an apprentice. Medical schools certainly existed in Renaissance Italy, as well as later throughout the Western world. However, for any given physician in Europe and North America prior to 1900, medical training usually began with apprenticeship, and might, but not necessarily, later continue at a medical school.
As an example of such apprenticeships, Andrew Taylor Still, M.D. (who will appear prominently below) was the son of a physician-preacher-farmer. As a small boy, Still accompanied his father on rounds, thus beginning his medical training even before attending elementary school. Later, after practicing for some time, Still enrolled in a medical school—which he left before the end of the first term, greatly disappointed in the quality of the information taught.
Medical practice today is plural: medical doctors, osteopaths, chiropractors, naturopaths, and oriental medical doctors are all licensed to practice as physicians in most jurisdictions in North America. The plurality of medical practice in the Western world before 1900 was even greater. Medical skills passed along in apprenticeships were not standardized and the disagreements and competition between physician groups was as great or greater than the present day antagonism between physician groups.
Until the 1870s, barbers and surgeons in Britain held the same license. Possessed of sharp instruments and some knowledge of the body, barber-surgeons performed blood-letting, tooth extractions and minor surgery. The red and white barber pole still in use today symbolized blood letting. In their Parliamentary charter, the British Guild of Barber-Surgeons described their work as a “mystery.” In the 1870s, a large group of surgeons sought and won from Parliament a separate charter, divorcing themselves from the “mystery” orientation of the barber-surgeons and moving toward a scientific research basis.
After the publications by Moulton and Hood came those of Hugh Owen Thomas, a bonesetter whose bonesetter father insisted that he study the emerging dominant paradigm at a medical school. H.O. Thomas became a distinguished and innovative surgeon, publishing several books. Owen’s works give us little if any insight into bonesetting, but rather good information about the early mainstream history of modern surgery. It seems likely, however, that Owen’s bonesetter background contributed to his many successful surgical innovations.
In 1741, pioneer English orthopedic surgeon William Cheselden detailed in his Anatomy of the Human Body his debt to certain bonesetters for knowledge of how to treat deformities and dislocations of the feet.
Expansion to the New World
Several bonesetter families came from Britain to North America starting with the early colonists. The most extensively documented is the Sweet family of Rhode Island. Many members of this large family were blacksmiths and also bonesetters. With the advent of medical licensing laws, many Sweets attended medical school and were absorbed into the medical profession, primarily as orthopedists, bringing with them their bonesetter acumen.
From Surgery to Orthopedics to Physical and Occupational Therapy
The term “L’Orthopédie” was coined as part of a book title in 1741 by the French surgeon Nicholas Andry. Translated into English, his book title became Orthopaedia: or the Art of Correcting and Preventing Deformities in Children. Andry created the term “orthopedics” from the Greek ortho, meaning straight and ped meaning child, and, as its name suggests, orthopedics was originally the applied study of child development, particularly the growth of the musculoskeletal system. In time, orthopedics largely shifted to the study of the adult musculoskeletal system, leaving the developmental aspect as a minor and all-too-often ignored specialty.
Physical therapy and occupational therapy grew out of orthopedics in the immediate aftermath of World War I. In 1917, the U.S. Surgeon General’s office, overwhelmed with the task of rehabilitating the war wounded, established the Division of Special Hospitals and Physical Reconstruction, the prototype of our Veterans Hospitals. Physicians assigned to these hospitals were charged with physical reconstruction of the war injured as well as educational and vocational programs designed to return them to the work force. Because the work load was far too great for the available physicians, a new group of technicians called “reconstruction aides” were trained. Within six years, the twin aspects of rehabilitation, biomechanical remediation and task-oriented training, were separated into physical therapy and occupational therapy. Today distinctions between these two groups have blurred, even though both licenses continue separately.
American M.D. Andrew Taylor Still served the Union as a Civil War surgeon. While his surgical experience gave him a great deal of insight into the mechanics of the body, military medicine also deepened Still’s disgust for the pharmacopoeia of the time. Soon after the war a meningitis epidemic infected several members of Still’s family. As any good physician should do, he engaged another physician to treat his family members. Still attributed the subsequent deaths of three of his daughters more to the medications used than to the disease. These medications included an emetic, Calomel, whose active ingredient is mercuric chloride. During the civil war, Calomel (not to be confused with calamine) was banned by the Surgeon General, yet most field surgeons mutinied and continued to prescribe Calomel as their most-used single drug. With the tragic death of his daughters, Still all but ceased to practice medicine in his search for another way of healing.
Soon he met and studied with bonesetters of both British and Shoshone Indian traditions. He recognized both the efficacy of their methods and the lack of their anatomical knowledge. He renewed his studies of anatomy, sometimes grave-robbing the bodies of his recently dead patients to perform dissection. Still applied his anatomic knowledge to the methods of the bonesetters. In this way, he developed a very sophisticated and broadly applicable manual therapy. For a time he called himself “The Lightning Bonesetter,” then in 1874 began to call his work “Osteopathy.”
The term osteopathy is often taken at its surface meaning, referring to disorders of bones. Going back to its ancient Greek roots, however, osteopathy has another layer of meaning. Osteon was originally not just bone, but flesh in general. Pathos referred to the deep things in each of us, particularly emotion, which long to be expressed. Osteopathy is more precisely “deep meaning yearning to be expressed in flesh.”
For years Still traveled a circuit in rural Missouri. As word of his skill spread, patients came from far and wide to see him at his home in Kirksville, Missouri. Train schedules were expanded to carry the volume of patients who sought his healing.
Although many people asked Still to teach, he resisted for a long time, saying he did not know how. Still’s problem was his discovery of something beyond solutions to biomechanical problems. He had found a spiritual dimension in his work which he never did find a direct way to teach. When his ability to treat patients was greatly reduced by a hernia, he finally began to teach. His solution to the problem of how to teach the deeper part of his work was to teach anatomy and biomechanical examination in excruciating detail, knowing that such close attention to their patients would eventually lead a few of his students into the transcendent dimension of their hands-on experience.
Most of his students were able to do good physical work. A few in Still’s lineage have written of the greater dimension possible in masterful practice. Harold Magoun wrote on this subject in the first edition of his landmark book, Osteopathy in the Cranial Field. While many were eager to learn cranial mechanics, few at mid-20th Century were ready for Still’s spiritual dimension. Magoun’s book was soon revised to eliminate the non-physical and non-rational elements. Only recently has the first edition been reissued. Nicholas Handoll and Rollin Becker are two other osteopaths who have written of this greater dimension in manual practice.
We have little information about the forms of manipulation used by Still in his own practice. In the beginning Still taught only anatomy and the general principles of manipulation. He regularly told his students, “Our three subjects are Anatomy, Anatomy, and Anatomy.” Still wanted his students to create their own manipulative forms, even as he had. He believed detailed anatomy and the general principles of manipulation were sufficient for his students to create manipulative skills in this way. We know that Still’s own practice included medium- and low-velocity manipulation. It is interesting to note that there is no record of Still’s using high velocity manipulation.
The first group of students at Still’s school had a study course lasting one year; this was soon expanded, first to two years, and soon after to four years. Still’s rigorous demand for manipulative creativity based on thorough knowledge of anatomy was too much for most students. Instructors other than Still soon formalized the types of manipulation to be taught, primarily high velocity manipulation which the instructors themselves had created.
Still was already past 60 years of age when he began to teach. He taught for only about five years before he turned over all instruction, except for occasional guest lectures and speeches, to younger instructors. Some of these instructors, such as John Martin Littlejohn, were of exceptional caliber in many dimensions of their lives; however, they lacked depth in osteopathic practice.
By demand from students, and over the objections of Still, the curriculum was gradually increased to include all the education of an M.D. as well as osteopathic manipulation. The early decades of the 20th century were golden years for osteopathy in the United States with this dual focus.
Through both external political pressure and the interests of some students, the place of manipulation in the osteopathic curriculum declined until in the 1970s, it had become possible to graduate from some U.S. osteopathic schools without studying any manipulation at all. Today most American osteopathic graduates have 150-300 classroom hours of manipulative training. Some osteopaths go on to increase their manipulative acumen in post-graduate courses. Of the 60,000 doctors of osteopathy in the United States, about 2,500 practice manipulation at a high level.
The Spread and Divergence of Osteopathy
An early physiology instructor at Andrew Still’s first osteopathic school was English physician John Martin Littlejohn. After just a few years of teaching and service as dean of the school, Littlejohn was fired under circumstances which are not clearly recorded. Littlejohn went straight to Chicago, where he opened a new school which taught the full medical and surgical curriculum, as well as the full osteopathic manipulative curriculum. Including expanded education in medication and surgery in the schooling of an osteopath was still highly frowned on by Still.
After a decade in Chicago, Littlejohn returned to his native Britain where he opened the first osteopathic school outside of the United States, the British School of Osteopathy (BSO). BSO continues today as the largest osteopathic school in the United Kingdom. BSO under Littlejohn’s direction returned to a curriculum closer to Still’s original idea of teaching anatomy and manipulation only. The curriculum today continues the focus on anatomy and manipulation and has become the model for osteopathic education and practice everywhere outside the U.S. Thus Littlejohn successively fostered both sides of the great divide in osteopathic philosophy, education and practice we see today. Manipulation has become a small part of the education of American osteopaths, while everywhere else in the world manipulation remains the central feature of osteopathy. Outside the U.S. and Canada, medication and surgery have no role in osteopathic practice.
In Canada there are fewer than 50 U.S.-trained osteopaths and several hundred European-style osteopaths. The Canadian schools are all European-style. Although European-style osteopaths are more numerous, the U.S.-trained osteopaths in Canada are more entrenched in the governmental and medical power structure. There are now more students in Canadian osteopathic schools than there are osteopaths of any kind practicing in Canada. A turf war is heating up between the two groups using the same name.
Derivatives of Osteopathy
Osteopathy in its turn has spawned several prominent therapies, not the least of which is Structural Integration.
William Garner Sutherland, who gave us cranial manipulation, was an early student of A.T. Still. While Still had practiced some manipulation of the cranium, it was Sutherland who raised cranial manipulation to a high art.
The Sutherland Cranial Teaching Foundation, now headquartered in Fort Worth, Texas, continues to teach Sutherland’s style of cranial manipulation with very little modification or addition. Out of cranial manipulation has grown craniosacral therapy, which applies some of the methods originally developed by Sutherland for the cranium to the whole of the body. It is important to note that while the cranium was a central interest of Sutherland’s, he also regularly worked on the rest of the body. The craniosacral therapists have made further developments of certain of Sutherland’s methods and de-emphasized the cranium in their work.
Several other variants and developments of cranial manipulation have been presented by osteopaths Hugh Milne, James Jealous, Franklyn Sills and others. Other derivatives of osteopathy include: myofascial release, created by Carol Osborne-Sheets; strain-counterstrain, created by Lawrence Jones, D.O.; and Zero Point Balancing, created by osteopath and structural integrator Fritz Smith, M.D.
D.D. Palmer enrolled in Still’s osteopathic school in 1894. He stayed six weeks before leaving in the company of a third-year student. The following year Palmer discovered chiropractic. While Palmer initially used high-velocity manipulation for the spine he also worked on the whole body and also used low- and medium-velocity manipulation. Somewhat similar to the pattern at Still’s osteopathic school, many early chiropractors developed an exclusive focus on high-velocity spinal manipulation. Now many chiropractors are rediscovering and expanding on other aspects of Palmer’s original work, as well as incorporating osteopathic and other methods.
During World War II, Dr. Ida P. Rolf studied movement work with American osteopath Amy Cochran. We clearly see Dr. Cochran’s influence in Structural Integration in some of the movements we use such as “toes up, foot up, toes down, foot down,” etc. In addition to movement, Rolf absorbed osteopathic philosophy from Cochran. Cochran’s followers, practicing “Physio-Synthesis” and represented in print by Ida Thomas, accuse Rolf of using much more of Cochran’s work without proper credit to its creator.
Dr. Rolf also took manipulation workshops with at least one other osteopath and began to develop her own manipulative forms emphasizing the importance of the bodily relationship to gravity. The relationship of the body to gravity has long been a part of osteopathy, where it continues to play a minor role.
Rolf followed in Still’s footsteps in the early years of her work, conducting an itinerant practice. In the 1950s, she taught during summer sessions at the European School of Osteopathy at Maidstone in Kent, England. At that time she taught a seven-session protocol. During those summers Rolf also learned more from the osteopaths. In time she came to feel her osteopathic students were just using her name to get more clients and not really practicing her work, so she shifted to teaching in London through the Gurdjieff School.
In the early 1960s, Dr. Rolf began to teach at Esalen Institute in Big Sur, California, at the invitation of Gestalt Therapy guru Fritz Perls. She taught at Esalen about ten years before moving her school to Boulder, Colorado.
Several major and many minor schools have grown out of the Rolf Institute, including Aston Kinetics, Hellerwork International, Guild for Structural Integration, Soma Institute, Kinesis Myofascial Integration, Entelia Institute of Creative Bodywork and the Utah College of Massage Therapy. The existence of these several schools, each with its unique emphasis and development, fulfills the expressed wish of Dr. Rolf. The process by which these schools established their independence has not followed her wish for licensing by the Rolf Institute.
A.T. Still makes several mentions in his writing of manipulating organs. A small amount of organ manipulation continued throughout the history of osteopathy, but, as the osteopathic literature reflects, manipulation of the viscera had only a minor role in practice until about 1980.
In most of Europe outside of Britain, the usual prerequisite to osteopathic training is licensure as a physical therapist. French Physical Therapist Jean-Pierre Barral began his osteopathic training at the European School of Osteopathy at Maidstone, Kent, England, about a dozen years after Ida Rolf stopped teaching there. After graduation from ECO, Barral did a post-graduate fellowship at a cardiopulmonary hospital in Switzerland. His fellowship included extensive autopsy of patients he had treated. In these autopsies he was able to see many adhesions and contractures he had noticed from treating outside the body of these patients. Since the setting was a cardiopulmonary hospital, these restrictions were often in the pleura and/or pericardium.
Later, in private practice, Barral had a patient with a back problem whom he was not able to help as much as he would have liked. The patient reappeared after an absence of a few months reporting that his back pain was now gone. After some initial shyness, the patient told Barral he had visited a bonesetter in the French Alps, who had pushed on something in his belly, immediately relieving his back pain. This incident sent Barral back to his anatomy books to figure out how this could have been done. He recognized that the visceral support membranes are in large part anchored to the spine. Relieving the membranous tensions in the visceral support system could have relieved the patient’s spine. This anatomical connection led Barral into a decades-long study of the visceral support system and how it can be manipulated for the benefit of the whole body.
Continuing Contact of D.O.’s and Bonesetters
A variant of osteopathy called etiopathy is taught in Switzerland. Etiopathy distinguishes itself from osteopathy in two ways. First, its practitioners consider themselves very lazy because they want to make the least effortful gesture possible. This economy of effort is viewed as beneficial to both client and practitioner. Second, the etiopaths have collected manipulative strategies from bonesetters all over the world. This research and collection of techniques by etiopaths continues today. Etiopaths Alain Gehin and Claudia Kohn have recently reported on their observations of bonesetters practicing in India.
Ideas and techniques continue to flow between the various schools and practitioner groups at many levels. Physicians of every kind, physical and occupational therapists, structural integrators, massage therapists, acupuncturists and other health professionals study each other’s methods. This crossover pattern has been facilitated by John Upledger, D.O., who has made osteopathically-derived methods widely available through his Upledger Institute and the International Alliance for Healthcare Educators (IAHE).
Upledger’s sharing of osteopathic methods with therapists of all kinds has stirred age-old fears and jealousies dating back to the bonesetters. Upledger has even received death threats from American osteopaths for disseminating these methods. As Upledger continues to thrive and expand his teaching, some osteopaths have privately admitted to him that they are envious of his success and wish they had followed a path similar to his, rather than slogging away in managed care. Upledger’s success has been a great boon to those needing manual therapies worldwide. His model has done much to open the doors of other schools.
Ida Rolf’s son, Richard Demmerle, trained as a chiropractor and naturopath after his Rolfing apprenticeship. A small number of osteopaths and chiropractors have trained as Rolfers. Some chiropractors have embraced soft tissue methods from several schools to such an extent that they rarely if ever use high velocity manipulation. Physical therapists worldwide are embracing osteopathic and other soft tissue methods wholesale.
In 1958, an article on the etiology of heart disease co-authored by Ida Rolf appeared in the American Osteopathic Association Yearbook. Occasionally mention is still made in the osteopathic literature of other techniques developed by Ida Rolf, most recently a way of releasing the fascia lata. Rolfers are not just encouraged to study visceral and cranial techniques, they are soon to be required to master the basics of cranial manipulation for entry into the Rolfing advanced training.
The breadth and depth of manipulative skills now available is well beyond the ability of any one person to learn in a lifetime, while the rapid growth of these skills pushes the possibility of boredom further off the map. We can hope the protectionist tendencies earlier expressed by bonesetter families and more recently in the threats to Upledger and between the two groups of osteopaths in Canada will fade with the realization that there is more than enough knowledge and more than enough skills for everyone. Both patients and practitioners will be the beneficiaries of free exchange.
This article is concurrently published in The Journal of Structural Integration, a publication of the Rolf Institute, and in Tensegrity News, a publication of Hellerwork International.
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