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A Brief History of Chinese Therapeutic Massage

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The therapeutic massage branch of traditional Chinese medicine is called "tuina" in modern Chinese, which literally means "pushing (and) grasping." However, this term did not occur in the Chinese literature until the Ming dynasty (1368-1644) where it first appeared in a book on pediatric tuina (a specialized branch \of Chinese massage). Prior to this period, the most popular term for therapeutic massage was "anmo" which literally means "pressing (and) rubbing."

Anmo has played an important role in the practice of medicine in China since ancient times. Archeologists, studying the inscriptions found on bones and tortoise shells used in divination practice, have found references to massage treatment for illnesses written in jiaguwen, the earliest extant form of writing in China, dating back to as early as the Shang Dynasty (16th-11th centuries BC). For example, on one such bone a question is inscribed: "Can the querent's abdominal pain be successfully treated with massage?" Another asks whether or not a certain female massage practitioner named Zao can cure an illness and thus should be sent for.

During the excavation of the Ma Wang Dui tomb (dated 168 BC) in the Hunan Province, numerous medical texts on silk scrolls and bamboo strips were unearthed. Many of these (including Fifty-two Medical Formulas, Illustrated Health Exercises, Health Preservation Formulas, Formulas for Miscellaneous Illnesses and Concerning the Way of Everything Under Heaven) contain references to anmo, gymnastics and breathing exercises. The Fifty-two Medical Formulas contains references to specific anmo techniques such as compression (an), gliding (mo), scratching (sao), scraping (gua), rubbing (fu) and percussing (ji). Anmo is indicated for illnesses in 17 different branches of medicine, including traumatology, pediatrics, internal medicine and gynecology. For example, one prescription in this text for the treatment of anuria is to massage the sacrum while applying burning moxa leaves to points on the back. Another passage describes the treatment of bleeding disorders by massaging topical agents (specifically, charred human hair!) into the skin. Elsewhere, several anmo instruments are described, including various mallets, pestles, a metal spoon used to treat infantile convulsions, and a feather used to lightly brush the site of an insect bite.

The silk scroll text entitled Illustrated Health Exercises contains 44 illustrations which include drawings of specific anmo techniques, gymnastic instruments (such as discs, canes, balls and sacks), breathing techniques and self-massage. Other passages describe the use of anmo in the treatment of various illnesses, including deafness, pain in the joints, "lumps" in the axilla, neck problems and knee pain.

In 1964, excavations at a tomb in the Henan province of China discovered a round, concave stone which is believed to have been used for anmo treatment. The stone includes a depression on its concave surface where the practitioner's finger was inserted in order to assist in applying force. Also found at the site was a series of stone instruments (rods, hammers, pit-shaped stones, cups) used in percussing massage.

The earliest biography of an individual physician in the history of China is an account by Han Dynasty historian Si Maqian of the life of Bian Que, a doctor who probably lived around 500 BC. Bian Que was allegedly a master of all medical trades, skilled in the use of herbal formulas, acupuncture, anmo, therapeutic exercise and even surgery. In one passage of his biography it is written that he could cure an illness "without herbal decoctions or wines, only using stone needles (an early form of acupuncture), exercises, pressing, rocking and applying topical agents."

Several references can be found in the Chinese histories to a 10-volume work entitled Huangdi Qipo Anmo, which was supposedly the earliest Chinese medical text devoted entirely to the practice of anmo. The original is unfortunately lost, but quotes from the text can be found in other books. These include a reference to "cai bei" or massage using the feet, stepping on the recipient's back. In combination with heated topical agents, this treatment was reportedly used to resuscitate unconscious patients.

The Huangdi Nei Jing (Yellow Emperor's Inner Classic, c. 200 BC?) is the earliest surviving canonical text of traditional Chinese medicine. Anmo is referred to in 30 different chapters of the Nei Jing. In one chapter, anmo is said to have originated in the central area of China (Henan, Luoyang). Elsewhere, anmo is indicated for the treatment of various disorders, including joint pain, muscle weakness and atony, facial paralysis and stomach pain.

Other parts of the Nei Jing describe the therapeutic mechanism behind anmo treatment using the physiological language of the time. First, anmo is said to have the effect of "moving qi and invigorating blood." It is written: "When cold qi lodges in the vessels of the back shu points, the vessels constrict; the vessels constrict, thus blood is deficient; blood is deficient, thus there is painä massaging causing hot qi to arrive; hot qi arrives hence the pain ceases." (N.B. this contains a remarkably accurate description of the role of local ischemia in pain syndromes!) Another mechanism of anmo described in the Nei Jing is the stimulation of acupuncture points and conduction of that stimulation along the channels. It is written: "The points along either side of the spineä if pressing them causes the pain inside to resolve, then one has accurately located the point." Finally, the Nei Jing ascribes to anmo the effect of eliminating pathogens and "dispersing heat," thus abating fever in certain cases.

The Nei Jing also describes the intimate relationship between anmo and acupuncture treatment. For example, manually pressing acupuncture points to bring about the alleviation of a patient's symptoms is considered an important criterion for accurately locating these points. Also, in the Lingshu section of the Nei Jing, it is written: "First massage the area to be needled, then insert the needle, then massage again after withdrawal." In a chapter entitled "On the Regulation of the Channels," the Yellow Emperor asks his doctor Qi Po, "How should mild invasion by external evils be needled?" Qi Po replies: "The massage time should be increased, and the needling should not be too deep. By bringing qi to the area of insufficiency, the spirit will recover." Even today in China, the acupuncture major in TCM universities is actually a combination acupuncture/tuina major, which further indicates the close relationship between these two disciplines.

In his medical text Jinkui Yaolue, the influential Han Dynasty physician Zhang Zhongjing describes what may be the earliest recorded example of cardiopulmonary resuscitation. He tells about his successful experience reviving a patient who had hung himself by the neck. He used compression of the cardiac area and abdomen combined with artificial respiration to revive the patient.

Another famous Chinese physician, Hua Tuo (d. 208 AD), was reportedly a skilled surgeon. He advocated the use of anmo for post-surgical recovery. Hua Tuo also created a well-known series of gymnastic exercises based on animal movements, known as the Wu Qi Xi (Five Animals Exercises). The Wu Qi Xi is still popular today in China.

From the Three Kingdoms period (220-280) up until the Tang Dynasty (618-907), the imperial medical schools included anmo as a specialized branch of medicine. Practitioners who specialized in anmo during the Tang dynasty were divided into 3 levels: anmo doctorates, anmo masters and anmo technicians. At that time, the scope of the anmo specialty included therapeutic gymnastics and orthopedics (bone-setting).

Historical records suggest that the Tang dynasty was a period in which great developments were made in both the techniques and range of application of anmo. One popular therapy at this time (which continues today in China) was the combination of anmo with herbal ointments, liniments and salves derived from the Chinese materia medica. A number of "anmo ointments" are described in Tang literature, such as Dr. Fei's Five Toxins Spirit Ointment, Hua Tuo Tiger Bone Ointment, Salvia Ointment and Aconite Ointment.

Tang textbooks prescribed anmo for a wider variety of disorders than ever before. Internal medicine indications for anmo included colds and flu's, hemiplegia, cardiac pain, abdominal pain, fever, convulsions, dementia, anuria, edema, headache and arthralgia. Dermatological indications included furuncles, urticaria, and lymphoid tuberculosis. Otorhinolaryngological indications included nasal congestion, deafness, and toothache. Pediatric indications included fever, abdominal distension, and "failure to speak." Gynecological indications including difficult delivery, infertility, and amenorrhea.

In Tang literature, there are many references to the manual compression of specific acupuncture points (that is, "acupressure"). The most famous example, perhaps, is Ge Hong's use of the thumbnail to compress Renzhong DU26 (in the groove above the upper lip) to treat loss of consciousness, a technique which first appeared in his book Zhou Hou Jiu Zu Fang. It was also at this time that Chinese anmo was first brought to Korea, Japan and other Asian countries where separate developments began (i.e. Japanese amma and shiatsu).

In Tang medical textbooks, anmo was often prescribed for disease prevention. For example, in Qianjin Yaofang, Tang physician Sun Simiao reports that pediatric colds and flu's ("invasion by wind cold") can be prevented by massaging the fontanels, palms and soles of the feet of young children. Self-massage techniques can also be found in Tang literature, usually with an emphasis on their role in prevention. One self-massage technique described in Yang Xing Yang Ming Lu is tapping one's teeth 36 to 300 times in order to "strengthen the teeth and prevent toothache." Another technique, used to "brighten the vision," is warming the hands by rubbing them together, then pressing the palms over the eyes, followed by gently rubbing the canthi with the fingers. Sun Simiao also recommended that after meals one should massage the abdomen with warm hands and go out for a stroll. He wrote that this would help digestion and "prevent a hundred illnesses."

In the Song Dynasty (960-1279), there were several developments in the practice of anmo in China. The first was primarily theoretical. Song was a period of great philosophical speculation and scientific inquiry in China. A number of medical texts began to differentiate the effects and indications of different anmo techniques (i.e. compressing versus gliding). Attempts were also made to explain the physiological mechanisms behind anmo's therapeutic effectiveness. The principal effect of anmo was described as "warming, disinhibiting and releasing blockages and stagnation in the channels." Anmo "mobilizes and free up the joints and opens blockages so that circulation of the defense qi can be restored," which suggests that it helps strengthen the immune function through improving circulation. Certain forms of anmo were recognized as having a diaphoretic effect which "releases the exterior" (hence its use for colds and flu's, which TCM theory sees as evil qi "binding" in the exterior layers of the body ã skin, subcutaneous layers, muscles). In Ru Men Shi Qin, Zhang Congzheng described how percussing the point Fengfu DU16 (at the base of the occiput) until sweating is induced can "release the exterior" and thus treat colds and flu's.

During the Song dynasty, anmo was especially important in the treatment of bone fractures and dislocations. At this time, Chinese anatomical knowledge made great strides, to the benefit of anmo practice. Books such as Ou Xi Fan Wu Zang Tu and Cun Zhen Tu described the location of the all the internal organs, and gave fairly accurate descriptions of the spinal vertebrae and the joints of the limbs. During the Song period, Song Ci (1186-1249) wrote what is probably the earliest systematic treatise on forensic medicine in world medical literature, Xi Yuan Ji Lu ("Collected Records for Righting Injustice"). Anatomy figured prominently in this work. In Shi Yi De Xiao Fang, Song orthopedist Cui Yilin not only described the structure of the elbow and hip joints, but also went into great detail in recording the manipulations used for setting various types of fractures. These manipulations included the use of suspended traction in the treatment of vertebral fractures. Elsewhere, Song physician Pang An described the use of anmo techniques in turning breech babies and assisting in difficult deliveries.

Many self-massage techniques for "nourishing life" (what modern English speakers might call "wellness") were described in Song literature. These included pinching the bridge of the nose 5-7 times a day, combing the hair 100 strokes, and rubbing the soles of the feet together (at the acupuncture point Yongquan K1) until they sweat. Rubbing the soles in this way everyday could supposedly ensure that one's "step would be light and easy." Rubbing the acupuncture points along the paraspinal muscles in the lumbar region was said to relieve frequent urination.

In the Ming Dynasty (1368-1644), pediatric massage (which, for the first time, was referred to as "tuina") evolved into a highly systematic treatment modality which is still popular today. Some sources have suggested the term "tuina" (pushing and pulling) was originally a description of the movements required to pin down the squirming young recipient! In any case, pediatric tuina has a number of unique characteristics. Unlike traditional acupuncture treatment, which is primarily directed at individual points (connected together into "channels"), pediatric tuina recognizes three types of active zones for anmo application: points, lines and surfaces. The "points" include all the traditional acupuncture points. The "lines" include the "Three Gates" line and the "Six Viscera" line, among others. The Three Gates is a line along the anterolateral aspect of the forearm. The line is gently stroked 100-300 times, in the direction of the elbow, using the thumb. The effect is warming and tonifying. The Six Viscera line lies along the medial aspect of the forearm. Gently stroking in the direction of the wrist 100-300 times has a cooling effect and can treat various "heat" diseases (fever, agitation, thirst, mouth sores, mumps, constipation, and so on). "Surfaces" in pediatric tuina include the anterior aspects of the fingers, each of which is correlated with a different organ. Circular gliding of the thumb over the surface of a particular organ's finger is said to warm and tonify the qi of that organ in cases of deficiency. In cases of excess, unidirectional stroking toward the tip of the finger is said to cool and subdue hyperactivity of that organ.

The Qing dynasty (1644-1911) saw the publication of a number of books on tuina, and especially saw the development and refinement of the use of anmo in traumatology and orthopedics.

Anmo has always been (and continues to be) a thriving part of Chinese folk medicine (which, besides using acupuncture points and channels, often has no relationship with TCM theory). Many of these folk practitioners, like the traditional Japanese acupuncture practitioners, were blind. Even today, on street corners across the country, one can still see signs outside small Chinese massage clinics which read "Blind Person Anmo." During the Qing Dynasty, several prominent schools of folk anmo arose. One of the more well-known schools is the "nei gong" (internal art) massage associated with the martial arts masters of the Shao Lin Temple. Many martial artists in China are trained in anmo techniques, especially for treating trauma (including bone-setting).

Another Qing Dynasty school called the "Rolling Method School" derived their therapy from variations on a single technique, "yi zhi chan," a form of oscillating compression using mainly the thumb. Yi zhi chan (literally "one point Zen" or "one finger Zen") is a Buddhist term which means "all things are of one nature." There are no historical records of the Rolling Method School, so all we know of it comes from modern heirs to the tradition, especially the students of Dr. Ding Fengshan, many of whom still practice in the Jiangsu and Zhejiang provinces. Another school ("the Spine Pinching school") evolved around the technique of rolling the skin between the thumb and fingers over the vertebral column.

Like all areas of traditional Chinese culture, anmo suffered its share of setbacks during the tumultuous years of the twentieth century. Perhaps the greatest blow was dealt during the Nationalist period (1911-1949) when the government led a campaign against traditional Chinese medicine. In 1929, at the first meeting of the Central Health Committee, the policy of "throwing out the old medicine and sweeping away obstacles to medical activity" was instituted. In 1936, the government announced that "traditional medicine has no scientific foundation" and its practice was banned. During this time, very few physicians went into anmo practice. Nevertheless, anmo continued to be a popular form of healing amongst the common people, and its techniques were preserved outside the halls of officially-sanctioned medical practice.

After the Communist Revolution in 1949, the new government began a policy of promoting traditional medicine. The disparate and often contradictory theories, techniques and schools which made up traditional medicine in China were standardized and systematized into "zhong yi" ã literally "Chinese Medicine" or, as it is known in the West, "Traditional Chinese Medicine" (TCM). In recent years in the People's Republic of China, there has been a tendency to use the term "tuina" to distinguish massage therapy based on the theories of TCM from popular folk massage, which is now simply called "anmo." If you look up "massage" in an English-Chinese dictionary, you will likely find the word "anmo," whereas "tuina" has become a more specialized TCM term, indicating its foundation in TCM theories of yin/yang, jingluo, zangfu, and so on. In 1956, a government-sponsored tuina training program in was set up in Shanghai. In 1958, the government established both a tuina clinic and a tuina school in Shanghai. Although the practice of tuina/anmo suffered further setbacks during the Cultural Revolution in the 60's and 70's, it continued to develop throughout the rest of the 20th century.

In the modern era, the practice of anmo has evolved into a rich repertoire of techniques, many of which are also found in the classic Western massage developed by Ling, Mezger and others. These include effleurage (gliding), petrissage (kneading), vibration, shaking, rocking, tapotement (percussion), friction and foulage. They also include a number of unique techniques, especially the oscillating compressions, such as "yi zhi chan" and "gun fa" (rolling). In performing anmo techniques, practitioners use their fingers, thumbs, palms, knuckles, forearms, elbows, knees, and feet. One of the trademarks of Chinese anmo, and of the other Asian massage therapies that evolved out of it, is the extensive use of compression, particularly of acupuncture points. Anmo therapy also includes joint manipulations, such as traction, circumduction, stretching, and "mobilization with impulse" (a.k.a. "cracking" or, in Chinese, "ban fa") "Ban" literally means a trigger, wrench or lever. It refers to sudden mobilization ("wrenching") of the vertebrae or other joints following relaxation of the surrounding soft tissue with gliding, kneading, etc. It is traditionally performed with the patient in a side-lying position, seated position or even borne on the back of the practitioner (back-to-back, with elbows interlocked). When done with the hands, the practitioner often uses palpation skills to direct the impulse to a specific vertebra.

In recent years, anmo has seen a renaissance in China. The range of conditions treated by anmo has once again expanded to include most branches of medicine (internal medicine, gynecology, pediatrics, traumatology and otorhinolaryngology). Experimentation has also been done in the field of anmo anesthesia. In 1979, the Shanghai College of Traditional Chinese Medicine established an "acupuncture/tuina" major. In 1982, Beijing and many of the other colleges of TCM across China followed suit. Most of the Chinese-language journals of traditional Chinese medicine regularly feature articles and research on anmo, and at least one national journal (Anmo Yu Daoyin) is devoted exclusively to news and research in the field of anmo. A good deal of research has been done in China on the biomechanical and physiological principles of anmo treatment, and numerous trial studies have been done on its clinical applications. Unfortunately, very little of this modern Chinese research on anmo has been translated into English (the same is true of Chinese acupuncture research). As more of this material is translated, it will probably prove to be of great benefit to the development and understanding of similar manual therapies in the West.

Dr. Matthew Miller, MB(China), L.Ac, is a doctor of Chinese Medicine and a licensed acupuncturist. Dr. Miller received his medical training in China, where he lived for nine years. After completing his undergraduate studies at New York University, he became fluent in the Chinese language and went to China to study traditional Chinese medicine. He attended the Chengdu University of Traditional Chinese Medicine in the Sichuan province, where he took all of his courses in Chinese, alongside the regular Chinese medical students. Matthew earned his Chinese medical degree with a specialty in acupuncture. After graduating in 2002, he returned to his hometown of Lynchburg, VA, USA to set up his medical practice, East West Acupuncture.

The material in this article was translated and synthesized from several Chinese language sources including:

1. Notes taken by the author from lectures given by faculty members of the Chengdu University of TCM Tuina Department, including Drs. Peng Dezhong, Liao Pindong, and Zeng Wenwu.

2. Yu Dafang, et al., Tuina Xue, Shanghai Science and Technology Press, 1984.

3. Bao Laifa, et al., Baijia Tuina Jingyanji, Shanghai Science and Technology Press, 1993.

4. Zhao Ao, et al., Tuina Liaofa Yu Yiliao Liangong, People's Health Press, 1996.

5. Zeng Zhiya, et al. Zhongguo Yixueshi, Shanghai Science and Technology Press, 1983.

6. Li Ding, et al. Jingluoxue, Shanghai Science and Technology Press, 1994.

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