A History of Health & Fitness: Implications for Policy Today [1st ed. 2018] 3319650963, 9783319650968

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A History of Health & Fitness: Implications for Policy Today

Roy J. Shephard

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A History of Health & Fitness: Implications for Policy Today

Roy J. Shephard

A History of Health & Fitness: Implications for Policy Today

Roy J. Shephard Faculty of Kinesiology & Physical Education University of Toronto Toronto, ON, Canada

ISBN 978-3-319-65096-8    ISBN 978-3-319-65097-5 (eBook) DOI 10.1007/978-3-319-65097-5 Library of Congress Control Number: 2017950069 © Springer International Publishing AG 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

1 Those Pesky Dates: A Simple Time Line for the Evolution of Society................................................................................................... 1 Introduction................................................................................................ 1 Nomadic Populations................................................................................. 1 Early Urban Civilizations.......................................................................... 3 The Classical Era....................................................................................... 4 The “Dark Ages”/Mediaeval Era............................................................... 5 The Renaissance......................................................................................... 6 The Enlightenment..................................................................................... 6 The Victorian Era....................................................................................... 7 The Modern Era......................................................................................... 7 The Post-modern Era................................................................................. 7 Questions for Discussion........................................................................... 8 Conclusions................................................................................................ 8 Further Reading......................................................................................... 8 2 The Hunter-Gatherer Idyll...................................................................... 9 Introduction................................................................................................ 9 Energy Demands of Hunting and Gathering.............................................. 10 The Issue of Rest Days.............................................................................. 13 Energy Demands of Games....................................................................... 13 Resulting Levels of Health......................................................................... 14 Resulting Levels of Fitness........................................................................ 16 Attitudes to Health and Fitness.................................................................. 17 Effects of Acculturation............................................................................. 18 Attempts to Recreate the Hunter-Gatherer Lifestyle................................. 18 Practical Implications for Current Policy.................................................. 20 Questions for Discussion........................................................................... 21 Conclusions................................................................................................ 21 Further Reading......................................................................................... 22

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3 Irrigation and the Seductive Sedentary Lifestyle................................. 23 Introduction................................................................................................ 23 Daily Energy Expenditures........................................................................ 24 Resulting Levels of Health......................................................................... 32 Resulting Levels of Physical Fitness......................................................... 33 Attitudes to Health and Fitness.................................................................. 34 Practical Implications for Current Policy.................................................. 37 Questions for Discussion........................................................................... 38 Conclusions................................................................................................ 38 Further Reading......................................................................................... 39 4 Evolution of the Sedentary Lifestyle in Classical Culture.................... 41 Introduction................................................................................................ 41 Crete: The Minoan Culture........................................................................ 41 Greek Civilizations.................................................................................... 44 Roman Civilization.................................................................................... 52 Practical Implications for Current Policy.................................................. 56 Questions for Discussion........................................................................... 57 Conclusions................................................................................................ 57 Further Reading......................................................................................... 58 5 Were the Lights Turned Off During the “Dark Ages?”........................ 59 Introduction................................................................................................ 59 Economy and Government......................................................................... 60 Sport and Fitness........................................................................................ 63 Health and Fitness...................................................................................... 69 Attitudes to Health and Fitness.................................................................. 73 Practical Implications for Current Policy.................................................. 75 Questions for Discussion........................................................................... 75 Conclusions................................................................................................ 76 Further Reading......................................................................................... 76 6 The Renaissance: Daring to Challenge Traditional Wisdom............... 77 Introduction................................................................................................ 77 Sports and Recreation................................................................................ 79 Habitual Physical Activity......................................................................... 84 Health and Fitness...................................................................................... 84 Practical Implications for Current Policy.................................................. 92 Questions for Discussion........................................................................... 94 Conclusions................................................................................................ 94 Further Reading......................................................................................... 95 7 The Enlightenment: How Far Did Reason and Religion Influence Health and Fitness in an Age of Industrialization?............. 97 Introduction................................................................................................ 97 Habitual Physical Activity......................................................................... 98 Sport and Recreation.................................................................................. 102

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Water Sports............................................................................................... 103 Boxing........................................................................................................ 103 Lacrosse..................................................................................................... 104 Dancing...................................................................................................... 104 Strolling..................................................................................................... 104 Sedentary Recreation................................................................................. 105 Physical Fitness.......................................................................................... 106 Attitudes of Physicians, Scholars and Church Leaders............................. 107 Scholars...................................................................................................... 110 Church Leaders.......................................................................................... 112 Practical Implications for Current Policy.................................................. 114 Questions for Discussion........................................................................... 115 Conclusions................................................................................................ 115 Further Reading......................................................................................... 116 8 The Victorian Era: A Wealthier Society Offers New Recreational Possibilities, Especially to Women................................... 119 Introduction................................................................................................ 119 Physical Activity........................................................................................ 120 Sports and Recreation................................................................................ 121 Water Sports............................................................................................... 122 Sedentary Recreation................................................................................. 128 Health......................................................................................................... 129 Physical Fitness.......................................................................................... 130 Attitudes to Health and Fitness.................................................................. 132 Politicians and Statesmen.......................................................................... 135 Practical Implications for Current Policy.................................................. 136 Questions for Discussion........................................................................... 137 Conclusions................................................................................................ 137 Further Reading......................................................................................... 138 9 The Modern Era: Growing Health in the Face of Unemployment and War..................................................................... 139 Introduction................................................................................................ 139 Sport and Recreation.................................................................................. 140 Aquatic Activities....................................................................................... 141 New Forms of Team Sport......................................................................... 142 New Forms of Individual Activity............................................................. 143 Sedentary Activities................................................................................... 145 Health......................................................................................................... 146 Nutritional Status....................................................................................... 149 Physical Activity........................................................................................ 151 The Assessment of Physical Fitness.......................................................... 152 Attitudes to Health and Fitness.................................................................. 158 Philosophers............................................................................................... 162 Practical Implications for Current Policy.................................................. 164

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Questions for Discussion........................................................................... 165 Conclusions................................................................................................ 165 Further Reading......................................................................................... 166 10 The Ludic Impulse: Why Did Early Societies Engage in Play?........... 169 Introduction................................................................................................ 169 Neolithic Societies..................................................................................... 170 Tarahumara Indians.................................................................................... 170 The Aztecs.................................................................................................. 171 Mayan Civilization..................................................................................... 173 Inca Civilization......................................................................................... 173 Minoan and Etruscan Civilizations............................................................ 175 Mediaeval Europe...................................................................................... 175 Practical Implications for Society.............................................................. 176 Questions for Discussion........................................................................... 177 Conclusions................................................................................................ 177 Further Reading......................................................................................... 177 11 The Classical Olympic Movement: An Early Stimulus to Health and Fitness?............................................................................. 179 Introduction................................................................................................ 179 The Classic Olympiad................................................................................ 180 Other Major Athletic Contests in Classical Greece................................... 181 The Ideal of Amateurism in Classical Greece........................................... 182 The Classical Greek Regimen of Athletic Training................................... 183 Nutrition of the Greek Athlete................................................................... 185 Age and Sex Categorization of Competitors.............................................. 185 The Problem of Athletic Injuries............................................................... 185 Death After Running a Marathon Distance: The Specific Case of Pheidippides.................................................................................. 186 Practical Implications for Current Policy.................................................. 187 Questions for Discussion........................................................................... 188 Conclusions................................................................................................ 188 Further Reading......................................................................................... 189 12 The Modern Olympics: A Current Stimulus to Health and Fitness or a Five-Ring Circus?........................................................ 191 Introduction................................................................................................ 191 Progression of Athletic Records................................................................ 193 Opportunities for Female Participation...................................................... 194 The Progressive Erosion of Amateurism in Olympic Sport...................... 195 Politicization of Olympic Competition...................................................... 197 Doping and Other Abuses of Olympic Competition.................................. 198 Other Abuses of Fair Competition............................................................. 201 Costs and Benefits of Competition; Is There a Health and Fitness Dividend?................................................................................ 203

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Other International Sports Events.............................................................. 205 Practical Implications for Current Policy.................................................. 206 Questions for Discussion........................................................................... 207 Conclusions................................................................................................ 207 Further Reading......................................................................................... 208 13 The Early Health Professionals – Unfettered Amateurs, Servants of the Gods or Wealthy Charlatans?...................................... 209 Introduction................................................................................................ 209 Egypt.......................................................................................................... 210 Israel........................................................................................................... 210 India........................................................................................................... 211 Classical Minoa and Greece....................................................................... 212 Middle Ages............................................................................................... 212 Medical Care in the New World During the Enlightenment...................... 220 Professional Regulation............................................................................. 221 Practical Implications for Current Policy.................................................. 222 Questions for Discussion........................................................................... 223 Conclusions................................................................................................ 223 Further Reading......................................................................................... 224 14 Herb Gardens, Naturopathy and Human Health................................. 225 Introduction................................................................................................ 225 Israel........................................................................................................... 226 Minoans...................................................................................................... 226 Mediaeval Era............................................................................................ 227 Practical Implications for Current Policy.................................................. 230 Questions for Discussion........................................................................... 231 Conclusions................................................................................................ 231 Further Reading......................................................................................... 231 15 Bizarre By-ways in the Search for Good Health................................... 233 Introduction................................................................................................ 233 The King’s Touch....................................................................................... 234 Tar Water.................................................................................................... 234 Static Electricity, Magnetism and Electrical Shock Treatments................ 235 Homeopathy............................................................................................... 238 Stimulation and Asthenia........................................................................... 239 Hydrotherapy............................................................................................. 240 Naturism..................................................................................................... 240 Anthroposophical Medicine....................................................................... 241 Osteopathy................................................................................................. 241 Chiropractic................................................................................................ 242 Acupuncture............................................................................................... 242 Practical Implications for Current Policy.................................................. 243 Questions for Discussion........................................................................... 243

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Conclusions................................................................................................ 244 Further Reading......................................................................................... 244 16 Caring for the Sick: Hospitals and Hospices......................................... 247 Introduction................................................................................................ 247 Cappadocia................................................................................................. 248 Baghdad..................................................................................................... 249 Mediaeval Europe...................................................................................... 251 Practical Implications for Current Policy.................................................. 254 Questions for Discussion........................................................................... 254 Conclusions................................................................................................ 255 Further Reading......................................................................................... 255 17 The Emergence of Health Science Education........................................ 257 Introduction................................................................................................ 257 The Arab World and the Nestorian Connection......................................... 258 Europe........................................................................................................ 258 North America............................................................................................ 267 Practical Implications for Current Policy.................................................. 268 Questions for Discussion........................................................................... 269 Conclusions................................................................................................ 269 Further Reading......................................................................................... 270 18 Literature in the Search for Health and Fitness................................... 271 Introduction................................................................................................ 271 Development of General Medical Literature............................................. 272 Texts of Sports Medicine, Health and Fitness............................................ 281 Practical Implications for Current Policy.................................................. 283 Questions for Discussion........................................................................... 283 Conclusions................................................................................................ 284 Further Reading......................................................................................... 284 19 Teaching Health and Fitness to the Growing Child: The Physical Educator............................................................................. 285 Introduction................................................................................................ 285 Physical Education in Ancient Persia........................................................ 286 Physical Education in Ancient India.......................................................... 286 Physical Education in Classical Athens and Sparta................................... 286 Physical Education in Mediaeval Europe.................................................. 289 Physical Education During the Renaissance.............................................. 290 The Enlightenment..................................................................................... 292 Physical Education in the Victorian and Modern Eras.............................. 294 Physical Education in the Post-modern Era............................................... 307 Practical Implications for Current Policy.................................................. 309 Questions for Discussion........................................................................... 310 Conclusions................................................................................................ 310 Further Reading......................................................................................... 310

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20 Co-opting Fitness and Sport for Political Objectives............................ 313 Introduction................................................................................................ 313 Italy............................................................................................................ 314 Germany..................................................................................................... 316 Russia......................................................................................................... 320 Soviet Physical Activity and Sports Programmes for Adults.................... 321 France......................................................................................................... 322 United States.............................................................................................. 324 Britain........................................................................................................ 326 Canada........................................................................................................ 326 Practical Implications for Current Policy.................................................. 328 Questions for Discussion........................................................................... 329 Conclusions................................................................................................ 329 Further Reading......................................................................................... 329 21 Governmental Involvement in Health Care and Health Promotion... 331 Introduction................................................................................................ 331 Health Care in the Arabic World................................................................ 332 Health Care in Mediaeval Europe.............................................................. 332 Health Care in the Post-modern Era.......................................................... 333 Improved Health Services and Life Expectancy........................................ 336 Nazi Subversion of Medical Expertise....................................................... 337 Practical Implications for Current Policy.................................................. 339 Questions for Discussion........................................................................... 340 Conclusions................................................................................................ 340 Further Reading......................................................................................... 340 22 Building the Infrastructure and Regulations Needed for Public Health and Fitness.................................................................. 343 Introduction................................................................................................ 343 Early History.............................................................................................. 344 Classical Civilizations................................................................................ 344 The Arab World.......................................................................................... 346 Mediaeval Europe...................................................................................... 346 The Renaissance......................................................................................... 348 The Enlightenment..................................................................................... 351 The Victorian Era....................................................................................... 353 Current Challenges to Public Health.......................................................... 356 Practical Implications for Current Policy.................................................. 359 Questions for Discussion........................................................................... 359 Conclusions................................................................................................ 360 Further Reading......................................................................................... 360

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23 Health and Fitness in Industry: The Development of Occupational Health............................................................................ 363 Introduction................................................................................................ 363 Early History.............................................................................................. 364 The Twin Scourges of Slavery and Child Labour...................................... 365 Occupational Physicians and Workplace Safety........................................ 366 Health-Care Delivery in the Workplace..................................................... 370 Equal Opportunity Employment................................................................ 375 Health and Fitness of the Armed Forces.................................................... 377 Practical Implications for Current Policy.................................................. 378 Questions for Discussion........................................................................... 379 Conclusions................................................................................................ 379 Further Reading......................................................................................... 379 24 Understanding the Root Causes of Ill-Health: The Emergence of Epidemiology, Bacteriology and Immunology...................................................................................... 381 Introduction................................................................................................ 381 Epidemics Affecting Classical Civilizations.............................................. 382 The Renaissance Understanding of Epidemics.......................................... 382 Epidemics During the Enlightenment........................................................ 383 Beginnings of Epidemiology and Bacteriology During the Victorian Era............................................................................ 383 Introduction of Chemotherapy, Antibiotics and Vaccines During the Modern Era.............................................................................. 386 Epidemics of Chronic Disease................................................................... 388 Immunology in the Post-modern Era......................................................... 389 Practical Implications for Current Policy.................................................. 391 Questions for Discussion........................................................................... 392 Conclusions................................................................................................ 392 Further Reading......................................................................................... 393 25 The Feminine Touch in Health and Fitness........................................... 395 Introduction................................................................................................ 395 The Systematic Exclusion of Women from Medical Schools................... 396 Gender Bias in Health and Fitness Research............................................. 398 Opportunities for Women in Nursing........................................................ 398 The Growing Political Voice of Women.................................................... 399 Range of Opportunities for Women to Exercise........................................ 400 The Impact of Altered Dress Codes and Greater Female Emancipation................................................................................. 401 Birth Control.............................................................................................. 403 Exercise Initiatives Addressed Specifically to Women.............................. 405 Practical Implications for Current Policy.................................................. 408 Questions for Discussion........................................................................... 408 Conclusions................................................................................................ 409 Further Reading......................................................................................... 409

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26 The Emergence of Professional Associations and Journals in Health and Exercise Science........................................ 411 Introduction................................................................................................ 411 Professional Societies and Journals........................................................... 411 Physical Education..................................................................................... 414 Landmark Textbooks.................................................................................. 420 The Key Role of Professional Certification............................................... 421 Practical Applications to Current Policy.................................................... 422 Questions for Discussion........................................................................... 422 Conclusions................................................................................................ 423 Further Reading......................................................................................... 423 27 The Growing Knowledge of Anatomy and Physiology Through to the Enlightenment............................................................... 425 Introduction................................................................................................ 425 Anatomy and Physiology in Early History................................................ 426 Anatomy and Physiology During the Classical Era................................... 427 The Middle Ages........................................................................................ 430 The Renaissance......................................................................................... 433 The Enlightenment..................................................................................... 442 Practical Implications for Current Policy.................................................. 450 Questions for Discussion........................................................................... 450 Conclusions................................................................................................ 451 Further Reading......................................................................................... 451 28 Recent Gains in Knowledge of Anatomy and Physiology.................... 453 Introduction................................................................................................ 453 Knowledge of the Circulation.................................................................... 454 Respiration................................................................................................. 461 Muscle Physiology and Biochemistry....................................................... 468 Body Composition..................................................................................... 469 Evolution.................................................................................................... 470 Exercise in Extreme Environments............................................................ 472 Practical Implications for Current Policy.................................................. 477 Questions for Discussion........................................................................... 478 Conclusions................................................................................................ 478 Further Reading......................................................................................... 478 29 Exercise as Medicine in Antiquity and Today....................................... 481 Introduction................................................................................................ 481 India........................................................................................................... 482 China.......................................................................................................... 482 Classical Greece......................................................................................... 484 Modern Exercise Is Medicine Movement.................................................. 485 Practical Implications for Current Policy.................................................. 486 Questions for Discussion........................................................................... 486

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Conclusions................................................................................................ 487 Further Reading......................................................................................... 487 30 The Post-modern Era and Beyond: Meeting Future Challenges to Health and Fitness........................................................... 489 Introduction................................................................................................ 489 Quality Control of Laboratory Data........................................................... 490 Mass Screening.......................................................................................... 490 Mass Fitness Testing.................................................................................. 491 Critique of Population Surveys.................................................................. 493 Secular Trends in Sport and Leisure Activities.......................................... 495 New Training Techniques.......................................................................... 501 Fitness and Aging...................................................................................... 502 Rehabilitation Programmes........................................................................ 502 Genetics of Health and Fitness.................................................................. 504 Practical Implications for Current and Future Policy................................ 505 Questions for Discussion........................................................................... 506 Conclusions................................................................................................ 507 Further Reading......................................................................................... 507 Glossary............................................................................................................ 509

Introduction

My first encounter with history was disappointing. The high-school teacher was an elderly spinster whose main concern was providing care for two nonagenarian parents. As her class proceeded in unvaried fashion, listless pupils took turns to mumble through paragraphs from a boring text. The narrative plodded relentlessly and with little commentary through the mediaeval kings of England and the various battles they had won or lost, all accompanied by dates that had to be memorized for the end-of-term exam. But history need not take this format. Indeed, from the earliest cave-dwellers, the story of our ancestors has offered an important tool in the education of humankind and the evolution of society. Politicians have recognized this for many years. The wily mediaeval Florentine politician and historian Niccolò Machiavelli declared: Whoever wishes to foresee the future must consult the past; for human events ever resemble those of preceding times....they are produced by men who ever have been, and ever shall be, animated by the same passions, and thus they necessarily have the same result.

In the eighteenth century, the Irish statesman Edmund Burke commented: In history, a great volume is unrolled for our instruction, drawing the materials of future wisdom from the past errors and infirmities of mankind

And more recently, Sir Winston Churchill wrote: Those that fail to learn from history, are doomed to repeat it.

Health practitioners have perhaps been less than willing to learn from the history of their profession. A number of texts have detailed the history of medicine, and recently even the history of exercise physiology, but for the most part they have been content to chronicle events rather than to draw lessons to guide future initiatives. The same criticism could be levelled at a publication that I recently completed (“An Illustrated History of Health and Fitness, from Pre-history to Our Post-Modern World”). But in the present text, after giving a brief sketch of salient events in various eras, I have focussed on specific themes in the history of health and fitness, such as the idyll of the hunter-gatherer lifestyle, seeking more specific implications for current research and professional practice. In some cases, the theme has spanned xv

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many centuries; the hunter-gatherers, for example, first emerged in the Great East African Rift Valley as long as 2.5 million years ago, but some small and isolated communities such as the coastal Inuit persisted with a largely unchanged lifestyle until the mid-twentieth century. The text thus begins with a brief time scale, allowing readers to place the selected themes in their dominant historical context. University undergraduate and graduate programmes in kinesiology and physical education have commonly included one or more courses on the history of the ­discipline, although the focus of teaching has commonly been upon the history of sport, both in ancient Greece and in the modern Olympic movement, with little discussion of implications for personal health and fitness. The medical curriculum, also, has usually devoted little time to historical issues, and has paid only token heed to the dominant needs of modern medicine – the prevention of disease and the promotion of good health. However, such topics should be the prime focus of instruction for all health professionals in the twenty-first century, and much of this learning merits teaching in an historical context. The present brief text has been prepared to meet these requirements. It is written for health professionals who want an objective and unbiased account rather than for the dedicated historian who often likes to interpret the past in terms of a personal social and/or political philosophy. The scholar who wants precise dates and citations for every event discussed in this text can find this information in the Illustrated History of Health and Fitness. The objectives of the new book are to identify and to present without an excessive elaboration of detail some major historical themes relevant to personal health and fitness, and to deduce salient lessons for present and future health policy. Brackendale, BC, Canada

Roy J. Shephard

Chapter 1

Those Pesky Dates: A Simple Time Line for the Evolution of Society

Learning Objective To understand important periods in the evolution of human society as a historical backdrop to the study of central themes emerging in the history of human health and fitness.

Introduction In order to set the central themes of subsequent chapters in their dominant historical context, it is convenient to begin by sketching a simple time line for the emergence of our current human society (Fig. 1.1). This necessarily involves citing a few of the more salient dates in the social evolution of our forbears, including a consideration of nomadic populations, early urban civilizations, the growing sophistication of the classical era, the paradox of the “dark ages” or Mediaeval Era, the excitement of the Renaissance, the scholarly debates of the Enlightenment, the industrialization of the Victorian Era, and the unique social challenges of the Modern and Post-modern Eras.

Nomadic Populations Predecessors of homo sapiens such as homo habilis are thought to have roamed the Great Rift Valley of East Africa, about 2.5 million years ago. Despite a much smaller brain than modern man (about 425 mL volume as opposed to 1450 mL), homo habilis facilitated success as a hunter-gatherer by fashioning simple tools such as choppers and scrapers from pebbles and animal bones.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_1

1

ERA Pleistocene

Mesolithic

DATES 2,600,000 BCE to 11,000 BCE 2000,000 BCE to 11,000 BCE From 10,000 BCE

Neolithic:

From 9,500 BCE

Mesopotamia Sumerians (5,000 to 4,000 BCE) Babylonians (1,750 to 1,300 BCE) Assyrians (1,300 to 600 BCE), Persians (from 600 BCE)

Egypt Egyptians (3,100 to 670 BCE) Assyrians (670 to 332 BCE), Macedonians (332 to 30 BCE), Romans (from 30 BCE)

Crete Minoan culture (2,700 BCE to 1450 BCE)

Greece Helladic culture 2800 to 2100 BCE Persian rule to 480 BCE City states to conquest by Macedonians 338 BCE) & then Romans (146 BCE)

Rome Began as small monarchy in 8th century BCE, grew to super-power in 1st & 2nd centuries CE, conquered by Goths 456 CE

Britain Became pagan, followed by Celtic Christianity in North, Roman Christian evangelization in south

Europe Emperor Charlemagne (748-814 CE) established court in Aachen

Arab world Prosperous caliphates from China to Iberian peninsula, with libraries & universities, but ended by crusades.

Paleolithic

PEOPLES

SKILLS

Old stone age hunter-gatherers Middle stone age people

Use of some flint tools More sophisticated bone and flint tools Bone & flint tools supplemented by copper, bronze & iron implements

Transition from hunting & gathering communities to agricultural settlements Early urban societies

India Harrapan (from 3,300 BCE) Vedic culture (1,000 BCE) Maurya (4th & 3rd centuries BCE)

The Classical Era

China Xia dynasty (2,100 to 1,600 BCE) Shang dynasty (1,700 to 1046 BCE) Zhou dynasty (1,046 to 256 BCE) Han dynasty (206 BCE to 220 CE) Constantinople Persisted as Byzantine Empire after fall of Rome, conquered by Ottoman army 1453 CE.

The "Dark Ages"/Mediaeval Era

The Renaissance

Began in Italy in 14th century CE, spread northward in Europe over 15th & 16th centuries CE. Invention of printing press (1439 CE), arrival of Greek scholars with capture of Constantinople (1453 CE). New universities established with academic freedom.

The Enlightenment

From 1650 CE to 18th Century. Superstitions and dictates of religion replaced by observation and logical reasoning.

The Victorian Era

From 1837 CE to beginning of World War I (1914 CE), marked by massive industrialization and migration of agricultural populations to mega-cities.

The Modern Era

From World War I to mid 1960s, marked by erosion of religious and social norms, female emancipation, mass production and mass communication.

The Post-modern Era

From mid-1960s to date. Questioning of applicability of constant scientific paradigm to all cultures, societies and races

Fig 1.1  Time-line of human social development

Early Urban Civilizations

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Over the next million years, measurements of the cranial cavity show that the brain size of the nomads doubled to about 850  mL.  The skulls of homo erectus, found in the caves of southern France, date from about 450,000 BCE. Here, small communities of hunters and foragers lived in caves; they had discovered the ­mysteries of fire, but still ate much of their meat uncooked. The Palaeolithic or Old Stone Age began around 200,000 years ago and continued until the end of the last ice age, about 11,000 BCE. It was marked by the growing dominance of homo sapiens sapiens, a population characterized by a further enlargement of the brain, and an extensive use of simple tools. The Mesolithic or Middle Stone Age began around 10,000 BCE. The introduction of the adze now allowed people to construct fishing platforms and small boats, and in consequence the techniques of hunting and fishing became progressively more sophisticated. The Neolithic Era began around 9500 BCE, and it was marked by the introduction of copper, bronze and iron implements. Although most Neolithic populations made a gradual transition to a more settled lifestyle, a few isolated groups persisted with a nomadic existence into the middle of the twentieth century; such groups included the Canadian, Alaskan and Greenlandic Inuit, Siberian circumpolar populations, the Sami Lapps, some North American Indian groups and the Kalahari bush people of Africa.

Early Urban Civilizations In many parts of the world, the rich alluvial soil of major river deltas stimulated a shift from foraging to a settled, agrarian pattern of living. We will look briefly at the course of such developments in Mesopotamia, Egypt, Israel, India, China, and Meso-America. Urban civilizations first emerged in the fertile crescent of the Middle East around 9500 BCE, as an early episode of global warming facilitated a progressive transition of lifestyle from hunting and gathering to early agriculture, and flint or bone tools began to be replaced by copper, bronze and iron implements. In Central America and Israel, the shift to a sedentary lifestyle began much later (around 4500 and 1270 BCE, respectively). Mesopotamia  The Sumerians established themselves on the flood plains of the Tigris and Euphrates rivers around 4000–5000 BCE. A progressive salinization of their territory and resulting poor crops led to their displacement by the Babylonians around 1750 BCE. In the northern part of Mesopotamia, the Assyrians became the dominant force from about 1300 to 600 BCE. The entire region was subsequently subjugated by Cyrus II and the Persians. Egypt  The flood plains of the Nile offered a fertile habitat to the Egyptians. Settlement of the Nile basin began around 3100 BCE, and the Egyptian civilization reached its apogee under Ramses II in 1279 BCE.  Subsequently, the region was subjugated in turn by the Assyrians (around 670 BCE), by Alexander the Great and the Macedonians (332 BCE) and finally by the Romans (around 30 BCE).

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1  Time Scale of Human History

Israel  The Israelites entered their “promised land” around 1270 BCE, an event marked by the death of their leader Moses on the banks of the Jordan. Saul was anointed king of the combined kingdoms of Israel and Judah around 1000 BCE, and a national capital was established in Jerusalem. The nation prospered under David and especially under Solomon. However, Solomon was succeeded by a series of inept kings, and Israel fell to the Assyrians in 722 BCE.  Judah retained nominal independence as an olive-oil producing vassal state of Assyria for a further century, but after an attempted revolt in 586 BCE, its leaders were carried as captives to Babylon, where they remained until they were freed by Cyrus (539 BCE). The restored Israeli kingdom was a weak political entity, and it was subsequently assimilated, firstly by the Macedonians and then by the Romans. India  Dominant groups in India were the Harrapa, Vedic and Maura civilizations. The agriculturally rich area of the Indus valley was first exploited by the Harrapa people from around 3300 BCE; they developed large and well-planned cities from around 2000 BCE. The reason for the decline of their civilization is unknown- possibly, there were ecological problems (drought, flooding, deforestaion or a change in course of the Indus), or maybe the Harrapa were overcome by invaders from Asia. The Vedic civilization was established in the Ganges delta from around 1000 BCE, but in the 4th and 3rd centuries BCE they in turn were subjugated by the Maurya, a powerful iron-age dynasty. Then for some 1500 years, India became fragmented into a multitude of small but relatively prosperous kingdoms. China  In China, opportunities for agricultural settlements were found along the Yangtse and Yellow rivers, beginning around 5000 BCE.  Successive dynasties including the Xia (2100–1600 BCE), Shang (1700–1046 BCE) and Zhou (1046– 256 BCE) were followed by a period of decentralization, and then the Chinese civilization reached its zenith with the Han dynasty (206 BCE-220 CE). Meso-America  In Meso-America, adoption of a sedentary lifestyle seems to have begun around 4500 BCE, with the Aztecs and Incas both learning techniques to cultivate maize, beans, squash and turkeys. Water was less plentiful than in other parts of the world, but the needs of agricultural settlements were met by a painstaking terracing of the hillsides and the building of substantial underground reservoirs. The Aztec and Inca empires were conquered during the renaissance by a combination of the military might of the Spanish conquistadores and the diseases that they carried with them, particularly smallpox.

The Classical Era The classical era is dominated by Greek and Roman influences, although we will look first at its beginnings in the Minoan culture of Crete. Substantial economic surpluses in various city-states encouraged the emergence of a social hierarchy, with an ability to support both scholars and philosophers. The trade associated with a

The “Dark Ages”/Mediaeval Era

5

growing demand for imported luxuries favoured a global sharing of knowledge in many areas of science. Minoan Civilization  The Minoan civilization flourished on the island of Crete from around 2700 BCE to 1450 BCE, when it was destroyed by a natural disaster, perhaps an earthquake or an eruption of Mount Thera. Elements of the Minoan culture were subsequently assimilated by Mycaenan war-lords from mainland Greece. Greek Civilization  On the Greek mainland, the Helladic culture is usually dated 2800 to 2100 BCE, but the Greek people were ruled by the Persians until around 490–480 BCE, when various independent city-states such as Athens and Sparta began to emerge. Rivalry and fierce military conflict between these city states led to a weakening of Greek identity, with the conquest of Greece firstly by Philip of Macedonia (338 BCE), and subsequently by Rome (146 BCE). Nevertheless, much of the accumulated Greek culture and knowledge base was assimilated by the Macedonians and the Romans. Roman Civilization  Rome began as a small monarchy during the eighth century BCE, but it grew progressively, becoming an international super-power at its apogee in the 1st and 2nd centuries CE.  But its widespread borders became too long to defend, and social unrest arose from a growing gap between rich and poor. The city of Rome fell to the Goths from Northern Germany in 456 CE. The eastern part of the Roman Empire persisted, and its capital of Constantinople remained the largest city in Europe from the mid fifth to the thirteenth century.

The “Dark Ages”/Mediaeval Era Historians disagree as to whether the period following the fall of Rome should be termed the “Dark Ages,” the “Middle Ages,” or the Mediaeval Era. Much depends on whether discussion is limited to Europe, or whether account is also taken of developments in the Arab world. The departure of the Romans from Northern Europe was marked by economic decline, and in many parts of the continent there was soon dire poverty, depopulation and disorganized chaos. Available money was diverted to the construction of large abbeys and cathedrals, with a powerful church opposing any enquiry into established scientific wisdom. Ignorance was fostered by a systematic destruction of important texts and poor language skills on the part of most of the population. After a period of reversion to paganism, the Celtic church held sway in much of Britain, but on the eastern coastline Saxon raiders progressively seized large tracts of fertile land. The one bright spot in Mediaeval Europe was the German city of Aachen, where the Emperor Charlemagne (747–814 CE) established his court and accumulated a large enough economic surplus to allow a renewed interest in literature and jurisprudence.

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A more general renewal of intellectual enquiry did not come to Western Europe until the fourteenth century, when the concentration of wealth in the hands of powerful barons and prelates in mediaeval castles and abbeys was challenged by a new middle-class of merchants, some of them wealthy enough to sponsor professors or even entire universities. The Arab world stood in marked contrast with Europe. During the Middle Ages, a succession of “rightly guided caliphs” established a prosperous empire that extended from China to the Iberian peninsula. This empire persisted until the crusades, at the end of the twelfth century CE. The tide of Moorish wealth brought new ideas, new universities and new libraries to the Arabic kingdoms. Moreover, some of the ideas of the Arabic scholars were embraced by academics in the on-going Byzantine Empire, centred around Constantinople.

The Renaissance The Renaissance had its birth in Italy during the fourteenth century, in part with a rediscovery of the largely forgotten Greek and Roman cultural heritage in that region. The process was stimulated by wealthy and powerful patrons, such as the Medici and Borgia families in Italy, patrons who not only had the financial resources to encourage intellectual enquiry, but also the political influence to support it when scientific findings ran contrary to the traditional views of the established church. Another potent influence encouraging the Renaissance was the western migration of refugee scholars, as the Ottomans seized control of Constantinople in 1453 CE. The Renaissance movement gathered momentum as it spread northward during the 15th and 16th centuries. The discussion of new ideas was fostered by a growing middle-class, with access to the books that had become widely available with invention of the printing press (1439 CE), and by the establishment of secular universities where faculty could claim the academic freedom needed to promulgate new concepts.

The Enlightenment From around 1650 CE, the Renaissance in turn gave place to a period known as the Enlightenment. Now, a plethora of gifted scholars were eager to replace the superstitions and dictates of an ancient theology by direct observation and the logical reasoning of the individual. Early proponents of the new approach were Isaac Newton in England and René Descartes in France. The logical and mathematical treatment of carefully measured data was now recognized as the authentic source of knowledge, and exponents of the age of reason began to conceive both living organisms and the universe as a whole in mechanical terms.

The Post-modern Era

7

The Victorian Era Strictly speaking, the Victorian Era coincides with the reign of Queen Victoria (1837–1901 CE), although for our present purpose it is convenient to include under this rubric the brief Edwardian Era leading up to World War I (1914–18 CE). In Britain (as in many other European nations), the Victorian Era was marked by a massive migration of former agricultural workers to the slums of over-crowded cities, where they sought work in newly constructed factories, often under dangerous conditions. Throughout this Era, reformers sought to move young children from the factories to schools, to counter the worst industrial hazards, to shorten working hours and to improve the living conditions of the average worker. The seeming social and material progress of the latter part of the nineteenth century was shattered by the horrors of World War I. In many countries such as Russia the conflict also provoked violent social revolutions.

The Modern Era The timing of the Modern Era remains a matter of controversy among various social disciplines. For our present purpose, we will arbitrarily place it from the end of World War I to the early 1960s. In addition to 2 horrific world conflicts, this period in history was marked by a progressive erosion of religious and social norms, by the mass-production of goods (including cars and labour-saving devices that have reduced human energy expenditures), and by the emergence of mass-­communication through radio, television and cinema, with a growing emancipation of women, periods of mass unemployment, and the rise of populist movements such as fascism, communism and national socialism.

The Post-modern Era The date set for the beginning of the Post-Modern Era again depends in part on an individual’s academic discipline, but for our present purpose we will assume it extends from the 1960s to the present day. Post-modernism seems to have arisen in part as a reaction against the apparent success of scientists in providing an objective description of reality. Post-modernists have argued that a scientific explanation of a phenomenon is unlikely to be valid for all cultures, societies and races. The truth encountered by a given individual is relative, and language, power relations and motivations play a crucial role not only in shaping beliefs, but also in determining how issues are investigated and described.

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Questions for Discussion 1. If you were able to choose the era in which you lived, which period would you choose, and why? 2. Which era would be your least favourite choice? Why?

Conclusions Human society has progressed through a series of well-defined stages, from the earliest nomadic communities to the progressively more sedentary lifestyle of large cities. Labour-saving devices have curtailed energy expenditures in the work-place, in the home and during travel. Careful consideration of this evolving environment is needed as we explore each of our themes in the history of health and fitness.

Further Reading Bettman OL. A pictorial history of medicine. Springfield, IL, C.C.Thomas, 1956, 318 pp. Coulton GG. Life in the middle ages. New York, NY, Cambridge University Press, 1967, 244 pp. Ferrone V. The enlightenment. History of an idea. Princeton, NJ, Princeton University Press, 2015, 216 pp. Grant M. A short history of classical civilization. London, UK, Weidenfeld and Nicolson, 1991, 352 pp. Hay D, Rubenstein N. The Age of the Renaissance. London: Thames and Hudson, 1967, 359 pp. Jack D. Rogues, rebels and geniuses. The story of Canadian medicine. Toronto, ON, Doubleday, 1981, 662 pp. Milisauskas S. European prehistory: A survey. New York, NY, Kluwer Academic publishers, 2002, 445 pp. Mitchell S, Daily Life in Victorian England. Westport, CONN, Greenwood Press, 1996, 336 pp. Newman DB. Daily life in the middle ages. Jefferson, NC, 2001, 290 pp. Shephard RJ. An illustrated history of health and fitness, from pre-history to our post-modern world. Cham, Switzerland, Springer, 2015, 1077 pp. Stephenson C. Mediaeval history. Europe from the second to the sixteenth century, 4th ed. New York, NY, Harper & Row, 1962, 639 pp. Trevelyan GM. English social history: A survey of six centuries, Chaucer to Queen Victoria, 3rd ed. London, UK, Longmans Green, 1958, 628 pp.

Chapter 2

The Hunter-Gatherer Idyll

Learning Objectives 1. To appreciate the high energy expenditures involved in some forms of traditional hunting, and the modification of overall weekly expenditures by rest periods and participation in vigorous games. 2. To note the association between high energy expenditures and an apparent absence of the chronic diseases of modern society. 3. To understand the deterioration in both fitness and health that has occurred as traditional hunter-gatherer groups have become acculturated to modern sedentary society. 4. To consider the argument that homo sapiens is genetically adapted to the hunter-­ gatherer lifestyle, and that the health of people today could be optimized by mimicking the patterns of physical activity that this lifestyle entailed.

Introduction Hunter-gatherer communities represent the earliest stage in human social development (Chap. 1). For millennia, closely-knit groups, often consisting of no more than 20–30 people, eked out a precarious existence by hunting game, fishing and collecting berries, nuts and roots over a territory of 20–30 km, using tools fashioned from flints and bones. A number of scientists with interests in the promotion of health and fitness have looked with approval at the seeming idyll of this nomadic or semi-­ nomadic lifestyle. They have argued that over the course of many centuries, a process of natural selection brought about a progressive adaptation of body mechanisms to the physiological demands of hunting and gathering, and the chronic diseases that have become epidemic in current society (for example, diabetes mellitus, atherosclerosis and the metabolic syndrome) reflect the departure from patterns of physical activity to which we are genetically adapted. © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_2

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Christopher McDougall is a strong advocate of the paleolithic lifestyle. He spent much time in Northern Mexico, studying the Tarahumara Indians, a population where long-distance running had been the traditional norm. In his book “Born to run” he speculated: “Perhaps all our troubles- all the violence, obesity, illness, depression and greed we cant overcome-began when we stopped being a running people.” Until the middle of the twentieth century, a number of distinct hunter-gatherer groups persisted in small settlements, and because of their geographic isolation their lifestyle showed little change relative to traditional patterns of social organization. In this chapter, we will look briefly at examples of such groups, including the coastal Inuit in Alaska, Canada and Greenland, some American Indian tribes, Scandinavian Lapps, Siberian populations such as the Evenki and the Chukchi, and Southern African bush-dwellers. Each of these populations has provided investigators with an opportunity to collect objective data on the energy demands of traditional hunting and gathering expeditions, and to make a close study of the resulting impact upon population health and fitness.

Energy Demands of Hunting and Gathering Oral tradition suggests that early nomadic populations had high levels of energy expenditure, at least when they were hunting. During the early 1970s, objective study of the daily energy expenditures of hunter-gatherers was undertaken in the context of the Human Adaptability Project of the International Biological Programme. The greatest amount of information was collected by Andris Rode, Gaetan Godin and Roy Shephard; these investigators studied a group of Inuit who were living in the island community of Igloolik, in the Canadian arctic, close to the Melville Peninsula. Although this community had experienced some contact with Southern Canadians by the year 1970, one substantial segment of the population was still living largely on “country” food, collected during regular hunting expeditions across the arctic tundra. Gaetan Godin was able to accompany a band of Inuit on each of 8 different types of hunt. He recorded the frequency and duration of each of the physical tasks that were performed by the hunters, and he had the hunters carry a Kofranyi-Michaelis portable respirometer to measure the corresponding rates of oxygen consumption. Tasks that were identified included long journeys over rough sea-ice, the construction of temporary snow shelters, the butchering of whales, walrus and seals, and finally the carrying of slaughtered animals back to more permanent camp-sites (Fig. 2.1). In general, the total energy expended over a day of hunting was high; at an average of 15.4 MJ/day for fairly small men, it would be rated as extremely hard physical work if it were to be incurred in an industrial setting. Sometimes, there was heavy lifting of an animal carcass or a short burst of high energy expenditure in pursuit of game, but in general large daily total energy expenditures were accumu-

Energy Demands of Hunting and Gathering

11

Fig. 2.1  The life of the Inuit hunter-gatherer often required long journeys over rugged terrain, with high energy expenditures required to track game and drag it back to base-camp (Source: https://goo.gl/ images/7svN4x)

lated because when environmental conditions were favourable, the hunters engaged in steady moderate physical activity over much of a 24-hour period. The energy costs of traditional hunting by the Alaskan and Greenlandic Inuit have had little formal study, but verbal descriptions suggest that they followed a similar pattern to those observed on Canada’s northern coastline. Other hunter-gatherer groups have also been found to accumulate high daily energy expenditures, although for some populations the distribution of activity over a typical day was quite different from that of the traditional Inuit. For example, typical teams of North American Indians are known to have paddled 300 kg cedar and birch-bark canoes along Canada’s rivers at a high stroke rate (up to 55 strokes/ minute); this would be considered a fast pace for Dragon boat contestants and would represent near maximal effort for a modern city-dweller. Paddling continued for up to 14 hours per day, with the crew of the canoe taking just a few minutes of rest once every hour. Often, the day would conclude with the paddlers carrying not only their canoe but also 42 kg bales of furs over a portage of up to 1 km as they by-passed dangerous rapids. And on the west coast of North America, indigenous Indians propelled large canoes on long journeys over turbulent oceans. In the interior of the North American continent, traditional pursuits of the indigenous Indian population were caribou and buffalo hunting. As recently as 2008, S. Sharma and his colleagues found average energy expenditures of 11.2 MJ/day for men and 8.6 MJ/day for women in one isolated North American Indian community. But many Indian tribes that now have access to southern Canada for at least a part of the year have abandoned their traditional caribou hunting, and in some of the “acculturated” Indian communities of Northern Ontario L.P. Aubrey and associates reported that by 1990, the average daily energy expenditures of the men had dropped as low as 7.9–8.4 MJ/day. In the arctic and sub-arctic regions of northern Scandinavia, Sami Lapp communities have followed the migration routes of the reindeer for some 5000 years. Traditional groups walked and/or skied 10–30 km/day in the course of their work, with an active energy expenditure of at least 4 MJ/day. However, during the 1930s, the Sami children were forcibly taken from their arctic camps, in order to study in distant state or religious schools. The Swedish and Norwegian governments also

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Fig. 2.2  The Kalahari bushmen captured game by pursuing an animal across their arid territory for many hours until the beast of prey was exhausted (Source: https://goo.gl/ images/tHrRHo)

applied strong pressure on their parents to adopt a settled pattern of living, and to assimilate into the dominant Scandinavian society. For many, their prior way of life was no longer possible. The traditional reindeer-herding habitat was progressively disrupted by extensive logging and mining operations, and the development of military bombing ranges and vast wind-turbine farms across the northern wilderness. The dietary studies of L.  Haglin showed a corresponding decrease of total daily energy expenditures to around 12 MJ/day by the 1960s. The indigenous circumpolar populations of Siberia also suffered a major disruption during the 1920s and 1930s; the Stalinist government forcibly displaced small clans of previously nomadic Evenki reindeer herders, requiring them to join collectives of some 60 people, with responsibility for about 1200 reindeer. The displaced Evenki adopted quite a bit of modern technology to assist in their herding and fishing activities, but dietary recall estimates of energy intake completed by Leonard and Crawford during the 1990s suggested that values were still fairly high (averaging about 13.4  MJ/day in quite small men, with some herders reaching levels of 16.2 MJ/day). In the harsh environment of the African Kalahari desert, the traditional bush people (Fig. 2.2) developed the technique of “persistence hunting.” Game such as kudu, antelope, deer and buffalo were captured by running the prey to exhaustion, and finally killing the animals with a spear or arrow-head dipped in a slow-acting cardiotoxic poison (diamphotoxin) that they had extracted from beetle larvae and pupae. Sometimes, the men-folk would spend several days tracking, following and attacking a wounded animal before bringing it back to the community, to be shared equitably among all members of the tribe. The women also walked long distances over a day of harvesting, often carrying a small infant on their backs, as they gathered firewood, fruit, berries, tubers, nuts, onions, ostrich eggs and various insects to enliven the communal diet. During the 1950s, most of the Kalahari population fell victim to a less than successful “modernization” programme initiated by the South African government. The bush people were encouraged to move into permanent

Energy Demands of Games

13

settlements where they could raise goats and cattle, and cultivate a small vegetable garden. However, the end-result was that only a small minority of the population continued with their persistence hunting. The traditional Tarahumara Indians, living in the caves and overhangs of the Sierra Madre in North-Western Mexico, had a similar type of economy; they fostered a capacity for long-distance running and scaling cliffs in order to catch an exhausted rabbit, turkey or deer with their bare hands. Some members of the community also served as message carriers, running as much as 800 km/week and carrying up to 18 kg of mail. We may thus conclude that (at least on days when they were gathering provisions) many hunter-gatherer populations had very high levels of energy expenditure.

The Issue of Rest Days The method of measuring energy expenditures that we adopted in Igloolik necessarily focussed upon the energy cost of specific, identifiable activities such as butchering a walrus or paddling a canoe. Information of this type is important in the context of determining whether daily activities reach an intensity that is likely to develop cardio-respiratory and muscular fitness. On the other hand, from the viewpoint of avoiding chronic conditions such as obesity, diabetes mellitus and atherosclerosis, the critical figure is probably the total energy expenditure for any given week, relative to the quantity of food energy that is ingested. Any energy balance sheet must thus take account of rest days, when conditions are inappropriate for hunting, and/ or time is taken for relaxation or making essential repairs to equipment. R.B. Lee made a detailed energy input-output analysis for the !Kung bush people who were living in the Kalahari desert. He found that the local economy could be sustained if members of the tribe worked for no more than 2.2 days per week. Despite high energy expenditures when hunting, if data were averaged over an entire week, the energy expenditures of the !Kung averaged only 9.4 MJ/day for the men and 7.3 MJ/day for the women. Likewise, when account was taken of rest days, the average energy expenditures of the Igloolik hunters dropped from 15.4 MJ/day to 12.6 MJ/day, much more in line with values for their peers who had found paid work within the community.

Energy Demands of Games In addition to the vigorous physical activity demanded by hunting and gathering, many early communities engaged in very energetic games and dances. Sometimes these pursuits had a religious significance or were simply recreational, but

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sometimes their main purpose seems to have been to maintain physical condition at seasons of the year when conditions were not propitious for long hunting expeditions. Thus, Inuit families were confined to the small area of their igloos during the depths of the arctic winter, but they maintained fitness by a variety of 1 and 2-person games, including an arm-straightening struggle, a wrestling game, various leaping contests (in one, a target hanging at a height of up to 2.6 m for men and 2 m for women was kicked with both feet), blanket-tossing games and sustained drum dancing. With the arrival of spring, these indoor activities were supplemented by foot and dog races, a community tug-of war, and in Alaska a ritual football game that sought to promote a successful whale hunt. Many other hunter-gatherer groups also engaged in vigorous games between hunting expeditions. Thus, the Kalahari bush-people participated in lively sacred dances such as giraffe, drum and tree dances during the rainy season. Again, among the Tarahumara Indians a kick-ball race became a ceremonial rite, with 2 teams of 3–10 men kicking a baseball-sized wooden ball around a pitch for up to 2 days at a stretch. The Tarahumara women also had a very active foot relay race, where a wooden hoop was propelled by a curved stick, and during fiestas they engaged in a fast circular dances. And among the Great Lakes Indians, lacrosse games would range over distances of 5–10 km, continuing for several days, and sometimes serving as a means of settling boundary disputes.

Resulting Levels of Health There is little objective information about the levels of health resulting from a traditional hunter-gatherer lifestyle. However, we may infer that deaths from either acute or chronic infection were rare in small and isolated communities. The main risks to survival would have come from accidents, episodic starvation, and neonatal and early infant deaths. In Alaska, accidental death rates for the indigenous population were still 3 times the American national average in 1970. When the Jesuit missionaries first met the Huron Indians in the region around Midland, Ontario, they reported that their parishioners were healthier than the colonizing French. However, in part because of lack of exposure to European diseases, immunity was lacking to many of the infections that were endemic among the newcomers. Thus, from the sixteenth century onwards, occasional contacts with explorers led to catastrophic epidemics of measles, mumps, smallpox, tuberculosis, anterior poliomyelitis and influenza, with the near annihilation of many indigenous populations. For example, smallpox reached the Hudson House trading post on Hudson’s Bay in 1781 CE, and the store clerk William Walker reported that the disease was “carrying of all before it.” By December 4th, the warehouse was surrounded by “nine tents of Indians, all dead.” More recently, an epidemic of unknown etiology killed a large segment of the Igloolik Inuit and their dogs during the winter of 1959 CE.

Resulting Levels of Health

15

Until recent years, the hunter-gatherer lifestyle seems to have held at bay the chronic diseases commonly attributed to an inadequate level of physical activity. By the time of the International Biological Programme, in the early 1970s, communities that had made substantial contacts with modern society were already showing signs of fat accumulation, but in the more isolated populations skinfold thicknesses were still much lower than in western society. The adverse effects of acculturation to a “modern” lifestyle have continued over recent decades. In 1994, Ku Young found average skinfolds of 8.5 mm and 14 mm in male and female Siberian Chukchi, respectively, but in the more acculturated Keewatin Inuit (a population living to the west of Hudson’s Bay) and Cree Ojibwe (living in the southern half of Ontario and Manitoba), skifolds had increased to an average of 16 mm in men and 24–28 mm in women. It has sometimes been difficult to obtain fasting blood samples from indigenous populations in order to test the regulation of blood glucose levels. In 1991, J.P. Middaugh set the prevalence of diabetes in Alaskan native populations at 1.36%. However, this had risen to 2.3% in Ku Young’s 1980 study of the Cree and Ojibwe, groups that had by then become quite obese and acculturated. In 1990, J.P. Thouez reported that the prevalence of excessive blood sugar levels was still low in isolated Inuit groups (0.38% in women, 0.43% in men), but blood glucose concentrations were much higher in the acculturated Cree groups (4.4% in women, 1.2% in men). Traditional Indian and Inuit groups seem to have had few heart attacks, although some incidents may have been missed because of lack of access to physicians and diagnostic equipment, and many traditional Inuit hunters died from accidents and acute infections before reaching an age when a coronary incident might have been anticipated. Thus, in 1974–1976, Dyerberg and Bang reported that the incidence of heart attacks among Greenlandic Inuit was only 5.3/10,000, as compared with 34.7/10,000 in Denmark and 40.4/10,000 in the United States. Protection may have been gained not only from a physically active lifestyle, but also from a high consumption of fish oil rich in omega-3 fatty acids. More recently, the health of many hunter-gatherer societies has become quit poor, a reflection of poverty, poor nutrition, the emergence of cardiac risk factors as habitual physical activity has decreased, and widespread social alienation as manifested by high rates of alcoholism, drug abuse, and suicide. Environmental changes (for instance, the thinning of sea ice in the arctic) have accelerated a dietary change from “country” food to what are often less healthy store-bought alternatives. But at the same time the establishment of nursing stations in many remote communities has increased the availability of advice on health maintenance, and has provided more effective treatment of injuries and acute infections.

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Resulting Levels of Fitness The International Biological Programme Human Adaptability Project sought objective data on the health and fitness of many hunter-gatherer societies at varying stages in their process of acculturation to a settled “western” lifestyle. The most common measurements were of body fat, aerobic fitness and muscular strength. The high levels of physical fitness observed in some hunter-gatherer populations during the 1970s seem to reflect an immediate response to an active lifestyle rather than an unusual genotype, since these characteristics have disappeared over subsequent decades, as these same populations have adopted a more sedentary pattern of living. Body Mass Index  Epidemiologists have commonly used the body mass index (M/ H2) as a surrogate measure of obesity. This index offers a reasonable approximation in a modern sedentary population, but the same approach is more problematic when applied to hunter-gatherer groups. A short leg length in relation to trunk length complicates the interpretation of mass/height ratios, and in highly active individuals body mass may also be increased by an accumulation of muscle rather than fat. Thus, Rode and Shephard found that the Igloolik Inuit of the 1970s had very low skinfold readings; however, their body mass index was high, and their body mass exceeded height-based actuarial norms by as much as 8–10 kg. Some tropical populations have also had a low body mass relative to actuarial norms, but this has reflected poor nutrition rather than a physically demanding lifestyle. By 1994, when Ku Young compared the physique of Chukchi from the Bering Strait, and Inuit and Cree-Ojibwe living on Hudson’s Bay, the body mass index was lowest in those groups who still spent a great deal of time in traditional hunting pursuits, but values increased progressively on moving southwards to settlements that had become acculturated and engaged in little habitual physical activity. Body Fat  Caliper measurements of skinfold thickness have provided more direct estimates of body fat accumulation in hunter-gatherers, although it has been suggested that European and American equations for the prediction of body fat content from skinfold data may be inappropriate for use with indigenous populations. Thus, determinations of body fat content by underwater weighing and/or the dilution of deuterated water have suggested that arctic hunters store much of their total body fat internally rather than in sub-cutaneous tissue. In 1970, Andris Rode and Roy Shephard noted that skinfold readings for young Inuit living in Igloolik averaged only 6 mm in men and 9 mm in women, and in the 50–60 year age group, the corresponding values were 8 and 19 mm. By 1994, Ku Young reported that averaged triceps and subscapular values for the reindeer-­ herding Chukchi were still only 9 mm in men and 14 mm in women, but for the Inuit and Cree-Ojibwe living on the shores of Hudson’s Bay values had risen to 16 mm in men and 24–28 mm in the women. Aerobic Fitness  Epidemiologists have commonly correlated an individual’s resistance to chronic ill health with a high level of aerobic fitness, as measured by the

Attitudes to Health and Fitness

17

maximal oxygen intake developed on a treadmill or a cycle ergometer. Values are commonly reported relative to body mass (ml of oxygen/[kg.min]). However, such data must be interpreted cautiously in hunter-gatherers because of an unusual body build. Moreover, in some indigenous communities peak oxygen transport has been compromised by anaemia and/or chronic respiratory disease, particularly tuberculosis. Keeping in mind these caveats, measurements of maximal oxygen intake were made on several circumpolar groups during the 1970s. Unusually high average values were observed, including figures for men of 52 ml/[kg.min] in the Igloolik Inuit, 49–52  ml/[kg.min] in the Nellim Lapps and 53 ml/[kg.min] in the Kautokeino Lapps. Moreover, attribution of these values to a high level of habitual physical activity was substantiated in Igloolik by the finding of a 10–12% difference of aerobic fitness between traditional hunters and their more acculturated peers who had found employment within the village, and by a 9–17% decline in average maximal oxygen intake from 1970 to 1990, as the whole community became acculturated to a more sedentary lifestyle. Muscle Strength  Limited data on peak handgrip force and knee extension strength is available for the Igloolik Inuit. In 1970, values were somewhat higher than would have been anticipated in western society, but this advantage progressively disappeared over the following 20 years, with acculturation to a sedentary lifestyle. Deuterated water studies also showed an 18% greater lean mass per unit of standing height in Igloolik residents than in their Toronto counterparts in 1970.

Attitudes to Health and Fitness Health  The connection between the regular practice of physical activity and good health has been quite a recent discovery, even for sophisticated western societies. In pre-history, illness was usually blamed upon the disfavour of the gods, rather than a poor lifestyle. Good health depended upon the pleasure of some regional deity. For the Inuit, Eeyeekalduk was the God of medicine and good health and Pinga was Goddess of the hunt and fertility. However, the local shaman was also thought to have considerable control over nature and thus an individual’s health. Poor health reflected either a loss of one’s soul, or the intrusion of a foreign object. For healing, the shaman might need to seek the advice of a dead relative, or even to do battle with a rival shaman. Traditional North American Indians also saw illness as a spiritual problem, and the goal of treatment was to restore balance to the body through a combination of herbs, sweat baths, massage, fasting and special diets, enemas, hydrotherapy and a variety of poultices. On the North-Western Pacific coast, Kumugwee, the god of the undersea world, had the power to heal the sick and the injured.

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The Scandinavian Sami found fertility and renewed sanity for those afflicted with seasonal affective disorders in Beiwe, Goddess of the sun, while the Aztecs looked to Macuilxochitl for well-being, and to Patecatl for healing and fertility. Fitness  Hunter-gatheres traditionally valued fitness primarily in terms of the ability to meet the challenges of a hostile environment, to protect the community from wild animals and hostile tribes, to secure adequate supplies of food, and to attract a desirable mate. Dancing and other active games and recreation sometimes contributed to the maintenance of personal fitness, but they were seen mainly as rituals appeasing the gods, enhancing good, and warding off evil. The main place for developing the physical activity skills of the young was at home, with the children learning by imitation, trial and error. The boys were often taught by a grandfather who could no longer withstand the rigours of the hunt, and girls learned their social roles and duties from their mothers.

Effects of Acculturation Since the 1970s, the most striking phenomenon among almost all hunter-gatherer societies has been a progressive erosion of any physiological advantages in terms of a low body fat content, a well-developed aerobic fitness and an above average muscular strength, as these populations have become acculturated to a modern, sedentary lifestyle (Fig. 2.3). The loss of physical condition has been closely linked to a reduction in habitual physical activity, but it is important to acknowledge that other factors have also been at play for several decades. In the 1970s, many hunter-­ gatherers were obtaining a large part of their food requirements from the land, but now supplies that are often much poorer in nutrient content are usually purchased at the village store. Destruction of the natural habitat has reduced available supplies of game, and access to traditional foods has been further eroded by the concentration of populations in large settlements where government-sponsored schooling and nursing care are available. Many indigenous populations who are no longer hunting have become largely unemployed, with dependence on government welfare payments, and the resulting social alienation has led to the adoption of an adverse personal lifestyle (alcoholism, abuse of drugs, an almost universal consumption of cigarettes, and frequent attempts at suicide).

Attempts to Recreate the Hunter-Gatherer Lifestyle Some scientists have argued that the chronic ill-health of modern society can be traced to the pattern of genetic selection that operated in Palaeolithic East Africa, where the physical demands of life were high. Currently, there is a mismatch

Attempts to Recreate the Hunter-Gatherer Lifestyle

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Fig. 2.3  The hamlet of Igloolik, where people had been living in Igloos as recently as 1970, is now largely acculturated to a modern western lifestyle (Source: https://goo.gl/images/DxVBMf)

between our resulting constitution and our sedentary lifestyle. A small group in the U.S. has thus attempted to recreate selected aspects of the Palaeolithic lifestyle. Their recommendations have included a diet focussed upon meat, fish, nuts and vegetables, the taking of frequent exercise varying in duration and intensity, the regular performance of complex movements such as jumping, crawling, climbing, carrying, throwing and swimming, maximizing exposure to the sun, sleeping at least 8 hours per day, relaxing and avoiding stress, allowing contact with beneficial bacteria, extended breast-feeding, and close personal contact with young children. Some of the group also advocate walking barefoot. There has as yet been no systematic study of the health dividends coming from such an approach. A number of the recommended policies seem to have merit, but others (such as walking barefoot, or maximizing the sun-exposure of fair-skinned individuals) are more debatable. Also, while most people would like to avoid stress, it is unlikely that living through an arctic winter with only stone age resources was an entirely stress free process! Many indigenous people would certainly like to retain or restore their traditional hunter-gatherer lifestyle, but the fragmentation and degradation of their habitat and the progressive extinction of key animal species has made this a virtual impossibility for them.

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Practical Implications for Current Policy Does the hunter-gatherer idyll carry a relevant message for the health of the modern city dweller? There seems good evidence that a hunter-gatherer lifestyle demanded a high level of energy expenditure, at least for those living in some of the world’s more challenging habitats. For some populations the requirement was for prolonged periods of moderate intensity physical activity, and in other groups successful hunting depended on periods of prolonged and high intensity activity. It has also been suggested that these heavy physical demands were associated not only with high levels of physical fitness, but also with a low incidence of the chronic diseases seen in sedentary western society. It is difficult to be certain about the health of isolated populations, since until recently medical resources were slim, and few accurate records were kept. It could also be argued that acute infectious diseases and accidents caused the death of many indigenous people before they reached the age when many forms of chronic disease would become manifest. However, dramatic increases in the incidence of obesity and diabetes mellitus with acculturation to a western lifestyle point to a health advantage from the hunter-gatherer economy. This may well reflect high daily levels of physical activity, but a further factor may have been a diet with a high intake of fish oils and the absence of refined carbohydrates. It will be interesting to see what statistics emerge from those small groups of people who have made a determined attempt to restore the palaeolithic lifestyle. But there is little disagreement on the need for a substantial increase in the physical activity of the average city-dweller. Current minimum public health recommendations, such as engaging in moderate physical activity for 30 minutes on most days of the week are plainly anaemic relative to the loads sustained by many hunter-­ gatherer communities. Any exercise is likely better than none, and some reports have suggested that in sedentary populations, the main gains in terms of preventing chronic disease are realized through only a small increase in daily physical activity. However, such a view seems at variance with the lessons drawn from study of the hunter-gatherer. Much more adventurous physical activity targets may be needed if we are to optimize human health and fitness by matching our activity patterns to the lifestyle to which we are supposedly genetically adapted. Many governments are currently challenged by high levels of ill-health among indigenous populations. In general, such groups no longer have the option of returning to a hunter-gatherer lifestyle, but it may be possible to encourage both a better diet and an equivalent pattern of physical activity within the communities where they are now living. At the local level, physical activity needs may be met quite simply by arranging appropriate fitness programmes within the local high school. In the community of Igloolik, for example, a programme of this type has been effective in restoring traditional levels of fitness in a small group of enthusiastic participants, although the challenge remains to involve a larger segment of residents. In Canada, more general governmental initiatives have included both the encouragement of “white” sports and the boosting of traditional arctic games. Community

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involvement in “white” sports such as ice-hockey, basketball and volleyball has been hampered both by the rudimentary nature of northern facilities (for instance, a lack of refrigeration for ice-rinks in many villages) and by the vast distance between settlements that has limited the formation of competitive rosters. Sport-related initiatives have probably enhanced the health and fitness of Inuit who have chosen to participate (although there are as yet no objective data on this). However, the impact of the introduction of “white” sports upon the overall health of traditional indigenous communities seems to have been minimal. Because of the small total population of most northern communities, indigenous athletes have found difficulty in competing at a national or international level. Thus, in 1970 the first Arctic Winter Games were held at Yellowknife, in the North West Territories. These Games now attract 2000 or more competitors from almost all circumpolar communities around the world. Events include not only traditional winter sports such as cross-country skiing and biathlon, but also many traditional Inuit contests. Fitness is certainly stimulated among active participants, but again there is little evidence that the Arctic Games have helped to reverse the loss of health and fitness in the community as a whole.

Questions for Discussion 1. What factors other than vigorous daily physical activity might have contributed to a low prevalence of chronic “lifestyle” diseases in hunter-gatherer societies? 2. How far did a high level of physical fitness contribute to success as a hunter in early indigenous societies? 3. Would you recommend that small indigenous populations today try to reinstate their traditional lifestyle in order to improve their health? How could this be accomplished? 4. Would attaining the energy expenditures of the traditional hunter be advantageous to the health of modern city dwellers? If such a target is deemed impracticable, would lesser increases in daily energy expenditure have any health value?

Conclusions In many habitats, participation in the traditional hunter-gather economy required a high daily energy expenditure, and perhaps for this reason the chronic diseases of modern western society had a low prevalence. Most of these populations have now become acculturated to modern sedentary living, and in the process they have developed a high prevalence of conditions such as obesity, diabetes and atherosclerosis. Human metabolism plainly adapted genetically to the energy demands of hunter-­ gatherer society over many generations, and some scientists have argued that to

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ensure optimum health today we should seek to restore the vigorous physical activity anticipated by our constitutional inheritance.

Further Reading Anderson RT. Some aspects of Lapp culture. Berkeley, CA, University of Cailfornia Press, 162 pp. Barrett CA, Markowitz H. American Indian culture. Ipswich, MA, Salem Press, 2004, 712 pp. Crowe, K. A history of the original people of northern Canada. Montreal, QC, McGill/Queen’s University Press, 1991, 251 pp. Culin S. Games of the American Indian. Washinton DC, Bureau of American Ethnology, 1907, 808 pp. Dwyer H, Burgan M. Inuit history and culture. New York, NY, Gareth Stevens Publications, 2012, 48 pp. Eaton SB, Shostak, M, Konner M. The Paleolithic Prescription: A Program of Diet and Exercise and a Design for Living. New York: Harper and Row, 1988, 306 pp. Greenwood M, de Leeuw S, Lindsay NM, Reading C. Determinants of indigenous peoples’ health. Toronto, ON, Canadian Scholars Press, 2015, 281 pp. Harrison GA. Population structure and human variation. Cambridge, UK, Cambridge University Press, 1977, 345 pp. Lee RB.!Kung bushmen subsistence: an input-out analysis. In: Environment and cultural behavior, ed. A.P. Vayda. New York, NY, Natural History Press, 1969, pp. 47–79. McDougall C. Born to run. The hidden tribe, the ultra-runners, and the greatest race the world has never seen. London, UK, Profile Books, 2009, 286 pp. Milan FA. The biology of circumpolar populations. Cambridge, UK, Cambridge, 1980, 387 pp. Shephard RJ. Human Physiological work capacity. Cambridge, UK, Cambridge University Press, 1978, 303 pp. Shephard RJ, Rode A. The health consequences of “modernization.” Evidence from circumpolar peoples. Cambridge, UK, Cambridge University Press, 1995, 306 pp.

Chapter 3

Irrigation and the Seductive Sedentary Lifestyle

Learning Objectives 1. To understand how the economic surplus associated with a settled, urban lifestyle allowed a segregation of society, with development of sedentary behaviour by the elite, priests, administrators and artisans. 2. To see how sport and military training served to maintain fitness and health for some people who no longer needed to engage in physical work for their survival. 3. To note the emergence of passive pursuits such as board games in sedentary societies. 4. To recognize that most societies continued to place the blame for poor health on the disfavour of one or more gods rather than on an adverse lifestyle.

Introduction Many populations made the change from a nomadic hunter-gatherer economy (Chap. 2) to the life of settled, agrarian city-dwellers around 3000 BCE. We will look briefly at such developments in Mesopotamia, Egypt, Israel, India and China. Often, the shift to a sedentary lifestyle was fostered by the presence of a river delta where the cultivation of crops was facilitated by periodic flooding, or there was scope for the development of simple irrigation systems. But some early societies made the transition to an agrarian economy despite more challenging habitats; for example, some South American communities laboriously terraced the hillsides, and in equatorial region such as the Asanti kingdom (the region now known as Ghana) vast areas of dense jungle were cleared for the planting of crops. Often, there was a recourse to slave labour in order to complete massive public works. But the end result of city life was usually an economic surplus. Growing national wealth allowed

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_3

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the development of a class structure, with emergence of a social elite who no longer needed to engage in physical activity in order to survive. Evidence on health and fitness in early cities can be sought in ancient writings (although often the scholar is faced by a complex inter-weaving of myths and historical facts), and in analyses of the mummified corpses of Egyptian and Indian royalty. The dietary intake of at least the wealthy has also been inferred from the contents of burial sites and trace analyses of human remains. Some of the elite used a part of their wealth not only to buy luxury goods, but also to support schools, libraries and scholars. Growing international trade facilitated a melding of ideas on health and fitness from many parts of the globe. The accumulation of possessions also attracted the envy of surrounding tribes, and a substantial fraction of the new resources of most cities had to be allocated to the construction of massive fortifications and the training of large standing armies. In this chapter, we will look at evidence concerning the levels of daily energy expenditure for different strata of society in the new cities, and the resulting impact upon health and fitness. Unfortunately, information is for the most part limited to the upper echelons of society. However, we may reasonably infer that physical activity levels generally remained sufficiently high to maintain the health of foot soldiers, servants and slaves.

Daily Energy Expenditures There is little hard information as to the daily energy expenditures associated with early city life, although the leisure time available to the social elite may be inferred from the development of many types of both active and passive recreation. Descriptions of weaponry and protective clothing indicate the loads borne by the foot soldiers, and massive palaces and fortifications bear witness to the physical efforts of the ordinary labourers and slaves responsible for their construction. We will look now in more detail at each of these sources of energy expenditure. Active Sports  With a few exceptions, active sports were the prerogative of the social elite. Mesopotamia  In Mesopotamia, most of the population had opportunity to engage in some forms of active recreation, since 6 days of each month were allocated to celebrating such things as the reigning monarch, the phases of the moon, equinoxes and solstices. Often, there was a magical connotation- participation in foot races promoted rain, the fertility of a particular crop or local mating practices, and ball games symbolized the passage of stars through the heavens. The women also honoured Ishtar, the goddess of fertility, sex, war and power, with circle and whirling dances. The Mesopotamians organized athletic competitions as far back as 3000 BCE. However, only the nobility attended and participated in such events. Terra-­ cotta plaques and bas reliefs illustrate boxing, wrestling, swimming, a form of polo

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(where contestants rode on the backs of men), rugby (with a wooden ball), and races over distances of 25–50 km between war canoes laden with 100 paddlers. Aristocrats also hunted a variety of wild beasts, either on horse-back or in chariots. A successful hunt not only had hedonistic value, but it also proved the favour of the Gods, and thus the legitimacy of the ruler. Egypt  Paintings in temples and tombs depict the involvement of the elite in a variety of active pursuits, including archery, javelin and knife throwing, fencing, juggling, stick fencing, vaulting, box-and high-jumping, long-jumping, weight-lifting, wrestling, ball-games, swimming, single- and team-rowing, rhythmic gymnastics, yoga, acrobatic dancing (practiced mainly in a ritual and/or funerary context), jousting and bull-fighting. The Egyptian Kings were particularly proud of their prowess as archers and runners. In the Heb Sed festival, dating from about 3000 BCE, the reigning Pharaoh celebrated 30 years of rule by racing a sacred bull. In one instance, Queen Hatshepsut (1508–1458 BCE) had to run this race, apparently because her spouse was no longer well enough to meet the challenge. Amenhotep II (1427 to 1401 BCE) boasted that he had pierced the middle of four thick brass targets set 34 feet apart when firing arrows from his chariot, and he offered a prize to anyone who could match this feat And in the twilight of the Egyptian kingdom Taharqa (690 to 664 BCE) instituted a 100 km race, commemorated by a stele. Elite Egyptian women were often quite active, participating in swimming, ball games (including forms of handball and field hockey), archery, juggling, tumbling, balancing, acrobatics and sacred dancing. Many of the lower classes found some time for ball games, archery, swimming, running, hoop snatching and tip cat (a sport that involved hitting a short billet of wood with a stick). For some people, rowing was also a part of their normal employment. Israel  The nobility in Israel often engaged in hunting. Many of the other documented recreational pursuits in ancient Israel relate to military preparedness. However, by the time of Jerome (347–420 CE), young men who were ambitious to demonstrate their strength followed the contemporary Greek practice of lifting enormous stones as high as they could. Dance was widely used by both men and women in Jewish sacred ceremonies; the women were often accompanied by a tambourine or drum, as when Miriam is reputed to have marked the parting of the Red Sea, and Jephthah’s daughter danced out to meet her father as he was returning from battle. India  A variety of sports were practiced in ancient India, but it is less clear how widely participation was distributed across the various social castes. The Harrapan period was marked by an interest in swimming and dancing. A large artificial lake was constructed at Mohenja-daro, complete with changing rooms and steps providing access to the water. Bronze statues from this era depict teenage dancers, and seals illustrate archers hunting wild boar and deer, and boxers. During the Vedic period, horse riding and chariot racing became popular, as did javelin and discus throwing, archery, wrestling, club-swinging, running, jumping, and ball games (including a predecessor of cricket that was played by both sexes).

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Yoga and breath control exercises were progressively integrated into traditional dance. In subsequent Hindu tradition, one of the forms taken by a major deity (Ṥiva) was as the Cosmic Lord of the Dance. Buddhism generally discouraged martial arts, but swimming, hopping around a diagram traced on the ground, ball games, wrestling and boxing remained popular pastimes for the practicing Buddhist. The non-violent philosophy of Janism, prevalent by 500 BCE, also discouraged martial arts, but Janists enjoyed broad-jumping, high-jumping and water sports. In southern India, the Tamils found physical activity in bull-baiting and chasing, and the martial art of stick play was also popular. China  Confucian and Taoist philosophy discouraged competition, seeing the process of physical activity as more important than the outcome. Events were structured to foster individual development and social harmony rather than to boost individual egos. For much of Chinese history, male chauvinism was rampant, and sitting on a garden swing was regarded as an appropriate pastime for women. However, by the time of the Song dynasty, there were some reports of wrestling matches between women, and even between women and men. Other physical outlets for women included dancing, swimming, fishing and boating. The popularity of long distance running apparently dates back to a legendary giant Kuafu, who decided that fast footwork would allow him to catch the sun. He supposedly drank the Yellow River dry during his attempt, and died shortly thereafter. Contests of extreme strength emerged in the Warring States period (770 -221 BCE); feats included carrying 5 decaL of rice over a distance of 30 paces, lifting massive iron door bolts, 500  kg cooking pots, heavy stones and wheels, and the uprooting of trees. The tug-of-war (bahe) began as an inter-village contest during celebration of the Lantern festival. At first, a bamboo “rope” was used, but by the Tang dynasty (618– 907 CE) a fibre rope had been substituted, and as many as 100 villagers participated in each event. Instruction in archery was an integral part of education in early Chinese society, both for boys and young women. The Empress Dowager of Su Zong (711–762 CE), the daughter of an army officer, set up an archery contest, and after demonstrating her personal skill with the bow, she required both military and civil officials to participate. Archery contests usually included a bout of social drinking and feasting. Sword-play, sometimes using bamboo branches rather than actual swords, was popular among both sexes. A history of the Han dynasty contains 38 chapters on sword skills. Goujian, king of China from 496–465 BCE, appointed a teenage girl named Yuenü to train his army officers. Her explanation of sword-play underlines the ritualistic nature of Chinese martial arts: “The art of the sword is profound and hard to understand … it is similar to a door in that it can be opened or closed; it can be divided into ying and yan. The way of fighting, in general, is to strengthen one’s inner spirit while remaining outwardly calm and well mannered.” Wrestling, boxing, rowing, and kicking shuttlecock were other sporting activities practiced by

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young men during this era. The wrestlers wore ox horns and imitated wild oxen as they fought. Wrestling became a popular method of settling personal differences when the Emperor Qin Shi Huang (259–210 BCE) prohibited civilians from carrying weapons. By the Han dynasty, a distinction was drawn between no-holds-barred fighting, fist-fighting, and sportive wrestling, although as late as 618–960 CE, wrestling matches at the Imperial Palace were sometimes marred by smashed heads and broken arms. Like other martial sports, wrestling became progressively ritualized, and a form of public entertainment, with music and drama added to amuse the court. Hunting was popular among all classes of Chinese society, and for some royalty, it became an all-consuming passion. The personal hunting ground of the Emperor Liu Che (156–87 BCE) covered a terrain of 1000 km2 with some 300 palaces. During the Zhou dynasty, all well-educated people were expected to be competent dancers. Specific dances symbolized the rule of successive Emperors, and/or were a form of worship of the Gods of heaven and earth. Dragon dances and dragon-­ boat contests marked annual festivals honoring ancestors. Other physically demanding pursuits included Cùjū, an early form of football played with a soft, hair-filled ball. Sometimes, a single goal post was set at the centre of the field, and in other formats 6 crescent-shaped goals were placed at either end of the field. This game became popular among both men and women in all ranks of society. Typically, there were 12–16 players per side, although one report speaks of a team of 153 women. During the Tang dynasty many palaces established their own Cùjū field. The Bai Da form of cuju emerged in the Song dynasty, with importance attached to developing personal skills rather than the scoring of goals; points were deducted if the ball was kicked short, too far, too low, or turned at the wrong moment. The Emperor Hui Zong (1082–1135 CE) popularized Chuíwán, an antecedent of golf (Fig. 3.1). Ten holes marked by flags were spread over terrain of varying difficulty, and players used wooden clubs to drive balls from a tee-off area. A form of polo became popular among the elite during the Tang dynasty; indeed the Emperor Xi-Zong (862–888 CE) used a polo match to decide between 4 candidates for a military appointment. Polo was also quite popular among young women. Shimin, the second Tang Emperor ordered the 50 maids at the Imperial Palace to form polo teams, with Eunuchs serving as their coaches. However, many women and children opted for a less violent variant of the sport, riding donkeys rather than war-horses. Summary  Plainly, early cities developed many forms of vigorous sport that could potentially compensate for the loss of physical activity in the upper echelons of society. However, there is little information to determine either how large a proportion of the population availed themselves of these opportunities or the levels of energy expenditure involved. Passive Recreation  One of the concerns of modern epidemiologists is that many children and young adults spend a large part of their leisure time in passive forms of recreation, such as the playing of computer games. However, the historical record shows that from the earliest of times, city dwellers devoted some of their leisure time to sedentary games. For many of the aristocracy, this health problem was

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Fig. 3.1  Many sports and recreations were developed by those living in newly formed city-states. One game popular in China was Chuiwan, a predecessor of golf (Source: https://en.wikipedia.org/ wiki/Chuiwan)

c­ ompounded by attendance at sumptuous banquets where the menu included forcefed geese, ducks and pigeons. Mesopotamia  In Mesopotamia, evenings were spent on board games such as the Royal Game of Ur (2600 BCE), backgammon (using sticks in place of dice), and chess (originally invented in India). Egypt  In Egypt, an elegant board for Senet (an antecedent of draughts) was found in the tomb of Tutankhamun (Fig. 3.2), and musical instruments such as bells, cymbals, tambourines, drums, clarinets, lutes and lyres were available to accompany the dance spectacles given at the feasts of wealthy families. Israel  The early Jews avoided the games of chance that were played by their neighbours, but by the 3rd century CE games of dice had become sufficiently prevalent to merit condemnation in the Mishna. During the Greek occupation, many of the Jewish resistance hid in caves, learning the Torah. When raided by the militia, they would pretend that their children had been playing with a dreidel, a four-sided top that subsequently became associated with the feast of Chanukah. India  Archaeological excavations in India have found forms of chess, draughts, pacheesi, snakes and ladders, playing cards, marbles, and dice from early history. A character in the Sanskrit epic the Marabharata supposedly had such a liking for the dice that he lost his kingdom, his brothers and his wife in one memorable game. China  In early Chinese history, musical instruments were constructed, and philosopher/scientists found time to make observations on Mars and various comets. Spectator activities for the elite included displays of dance, acrobatics and chariot racing. One Tang Emperor brought a team of itinerant jugglers from as far afield as Rome. “Grass-fighting” was a female pursuit that involved picking grass, naming it and writing a verse couplet that included the chosen name.

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Fig. 3.2  The elite of Egypt filled their leisure with board games, such as Senet, an antecedent of draughts (Source: https://goo.gl/images/YS306s)

Horses were increasingly used to provide passive transportation for the wealthy in the early city states, and such mounts were subsequently supplemented by camels and elephants. We may conclude that in each of the societies considered, there were many opportunities to devote leisure time to passive recreation and spectator sport, rather than engaging in physically more active pursuits. Energy Expenditures in the Military  Descriptions of the weapons carried, the protective clothing worn and the distances travelled suggest that foot soldiers in the early cities generally had a high level of physical fitness. Mesopotamia  Figurines from ancient Sumeria show soldiers wearing copper helmets and heavy cloaks, as well as carrying battle-axes, daggers and spears. However, some figurines also represented more lightly equipped bands of archers, and some “mechanized” units, equipped with two-wheel chariots. Egypt  Most of the Egyptian military were foot-soldiers, equipped with bows and arrows, spears and skin-covered shields, although the Egyptian army also introduced horse-drawn chariots about 1500 BCE. Israel  In Israel, most of the early settlers combined the roles of soldier and agriculturist. A guerilla-like infantry, lightly armed with sickle-swords, spears, bows, slings, and daggers proved adept at fighting in hilly and difficult terrain. Running was a popular activity when troops moved on foot against enemies who were oper-

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ating heavy chariots. Around 1100 BC, a swift runner carried tidings of the defeat of the Philistines over a 42 km distance. Saul, Jonathan and others in David’s service were renowned for their speed as runners, as were those who ran before the chariot of a king or a prince. However, Solomon needed to protect a larger city, and he moved from a highly mobile army to a network of defensive fortifications and warriors in large squadrons of horse-drawn chariots. India  The Kşhatriyas were the elite/military class in India. The Buddha himself (c 563 – 483 BCE) is reputed to have had considerable military training in his youth, and he had to pass tests as a warrior before he was allowed to marry. He was an ace at archery, chariot racing, equitation, discus and hammer-throwing. Indian foot soldiers were well-versed in use of the bow and arrow, dagger, axe, mace, long sticks and slings. Although most women had a passive role in Indian society, a myth in the Rigveda speaks of a woman warrior who lost her leg in battle. Women were also trained in self-defense. China  In China, Shang rulers had authority to conscript the population, both as soldiers and as labourers. In the Zhou period, prolonged training sessions were held during the first month of each winter, with time being allocated to the practice of archery, swordsmanship, charioteering, wrestling, running, throwing, jumping and tug-of-war. A military fitness test was introduced in the sixth century BCE; recruits had to complete without a break a cross-country run of some 150 km, wearing full body armour and carrying standard weaponry. Cùjū (above) was seen as a means of maintaining military preparedness, and the Han general Quo Hubing allowed his troops to construct a Cùjū field between battles. Chinese infantry were required to keep pace with the chariots of their commanders, and bodyguards equally were expected to run behind the horse-drawn carriages of the elite. Physical Demands on Workers and Slaves  There seems little doubt that in the early cities the energy demands imposed on workers and slaves were high. In addition to completing a wide range of agricultural tasks with minimal tools, common labourers were expected to carry heavy loads, to build massive temples fortifications and monuments (Fig. 3.3), and to construct and maintain dykes and irrigation canals. In some areas, workers were also assigned to forestry or mining. For female peasants, there were requirements of water-carrying, weaving, and the pressing and milling of grain, in addition to caring for large families. Mesopotamia  In Mesopotamia, physical demands on the farmer were lightened by invention of the plough and use of the Archimedian screw to feed irrigation channels. But much agricultural work still demanded hard physical labour- breaking of the soil with a mattock, the hand-reaping of grain, and the binding and stacking of grain. Egypt  In Egypt, oxen began to drive the water-wheels of the irrigation systems under Ptolemy IV (about 220 BCE). Many manual workers quarried, trimmed and carried granite and limestone to complete the massive building projects in the Nile delta, and other labourers were engaged in copper, lead and gold mining.

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Fig. 3.3  Solomon’s palace. Structures such as Solomon’s massive palace in Jerusalem illustrate the heavy physical work undertaken by labourers and slaves in early urban society (Source: https:// goo.gl/images/Kfg8TZ)

Israel  In Israel, many farmers faced the back-breaking work of terracing barren hillsides and digging cisterns to store limited reserves of water, as well as tending their crops using only a hoe and a mattock. Other trades mentioned in the Old Testament (millers, bakers, weavers, barbers, potters, fullers, locksmiths, jewellers and smiths) included some relatively sedentary occupations. However, the common people undertook much heavy manual work as they were conscripted to construct the temple, the palace of Solomon, and a network of military fortifications. The average person was required to work on one of these projects for one month every year. India  The 2 lowest strata of Indian society were the Vaiśyas (merchants, farmers, cattle–herders, hunters, barbers, vintners, chariot– and cart-makers, carpenters, metal workers, tanners, bow makers, sewing, weavers, and mat-makers); and the Śūdras (the “untouchable” class of menial workers). The majority of men in both of these groups faced substantial daily physical demands. The life of the working-class woman was also hard; in addition to rearing a large family, she was expected to milk cows, card wool, weave and dye cloth, and grind corn. China  In China, a vast army of 700,000 labourers was involved in constructing the main palace and ritual burial sites of the Shang regime. The initial plan was for a large group of commoners and slaves to be buried alive along with their former master, but in 209 BCE the Emperor Qin Shi Huang made the humane decision to replace the workers by an army of terra cotta figurines.

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During the Han dynasty, society became divided into a complex hierarchy of 20 strata, plus occasional slaves. The social organization of this dynasty shows some similarity to the European Feudal period, since the ruling class allocated small plots of land to each of their subjects, allowing them to grow vegetables and to engage in a limited amount of animal husbandry. Many technical innovations modified the work-load of labourers during early Chinese history, including introduction of junk-­ rigged boats, the wheelbarrow, the waterwheel, a mechanical bellows for smelting, pumps for irrigation, a belt drive for quilting, and a crank-driven winnowing machine. Thousands of bronze, jade, stone, bone and ceramic artifacts, many with exquisite workmanship, testify to the substantial work force of skilled craftsmen and manual labourers who were engaged in producing bronze-ware for religious ceremonies and military equipment. The main responsibility of the average Chinese woman, in addition to child-­ rearing, became the weaving of silk cloth.

Resulting Levels of Health The effects of early urban life upon health can be sought in terms of average longevity, and in a few cases a post-mortem analysis of the remains of entombed aristocrats. The average life expectancy for most of the early city dwellers that we have discussed was under 40 years, but this figure is skewed by a high risk of death during infancy and childhood. Because of a societal respect for elders, many older people tended to exaggerate their age, but nevertheless it is plain that many of the elite lived beyond the age of 40 years; 40 indeed was regarded as a person’s “prime,” sixty was said to be “manhood,” and eighty was “old age;” with the Gods allotting a possible maximal lifespan of 120 years. Shulgri, King of Ur in the 20th Century BCE, reigned for 48 years, and the mother of Nabonidus, the last king of Babylon claimed to have lived for 104 years. Thanks to a dry climate and Egyptian skills in embalming, the mummies entombed in the Nile valley still provide glimpses of ill-health among the elite, including evidence of rheumatoid arthritis, tuberculous spinal deformities, bladder and kidney stones, and atherosclerosis. M.A. Ruffer examined arteries from mummies spanning the period 1580 BCE to 525 CE, and he concluded that arteriosclerosis was as prevalent in this elite population as in the average person today, a view confirmed by subsequent radiography and computed tomography. This is hardly surprising, given the banquets enjoyed by the elite; some dieticians have estimated that Egyptian aristocrats consumed as much as 35% fat, including deliberately fattened animals. Over-indulgence in sugars also contributed to obesity and periodontal disease. The consumption of over-rich food was a particular problem for the priests and their families, because they ate the choice food offered to the gods. The common people are less likely to have been affected by obesity and atherosclerosis,

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because in addition to heavy physical labour, they were restricted to a mainly vegetarian diet. The skeletal remains of Indian aristocrats also present evidence of arteriosclerosis, osteomyelitis, cancer, metal poisoning, early dental surgery, and the trephining of skulls. Relatively little is known about the health of the common people in the early city states. They likely suffered spinal problems resulting from the extreme physical labour needed in major construction projects. Venereal diseases were also prevalent in early Mesopotamia. and in the Nile basin known medical problems included Leishmaniasis infections, malaria, schistosomiasis, and bites from crocodiles, hippopotami, and asps.

Resulting Levels of Physical Fitness There is little objective evidence on levels of physical fitness in early urban societies, although a number of pointers suggest that despite a settled lifestyle, physical condition may have been maintained at least in those sub-segments of the population that were trained for warfare. In some groups, such as Persian children, this preparation began at an early age (Chap. 8). Mesopotamia  Hebrew accounts from their Babylonian captivity (586–538 BCE) suggest an increasing decadence among their captors following the rule of Nebuchadnezzar (605 – 562 BCE), with drunken banquets and frivolous undertakings such as constructing the tower of Babylon and the Hanging Gardens. A deterioration of physical fitness among the elite probably contributed to their conquest by the Persians. Egypt  The marked involvement of the Egyptian Pharaohs in various sports points to a strong interest in personal fitness among some of the Egyptian elite. Statues of both men and women portray a fine physique, although it is difficult to know whether these are idealized or are accurate representations of the individuals concerned. In contrast, some of the pictures in Egyptian tombs depict sumptuous and drunken feasts. Israel  The Old Testament frequently underlines that the Jews were a warrior nation, and physical fitness was valued in the context of battle-preparedness. Most of the male population had to fight periodically. Abraham trained all of his household in combat, and the sons of Jacob were masters of the sword. The Judges, also, combined life wisdom with prowess in combat; for example, Ehud Ben Gerah was a master of the dagger, Deborah the Prophetess led Israel into battle, and Samson slew the Philistines with the jawbone of an ass. China  Expectations of the Chinese military, particularly participation in a 150 km race with full equipment, suggests that at least in this segment of Chinese society there was a high level of personal fitness. On the other hand, the wealthy were able

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Fig. 3.4  One of the ways in which wealthy Chinese city-dwellers reduced their daily energy expenditure was by the purchase of chariots. This allowed them to engage in passive transportation, as in this example from the Han dynasty (Source: https://en.wikipedia.org/wiki/ Chariot_(China))

to reduce their energy expenditures in many ways, including the purchase of chariots for passive transportation (Fig. 3.4).

Attitudes to Health and Fitness Health  In all early urban societies, the Neolithic idea that good health depended upon the favour of the Gods (Chap. 2) persisted, and was often greatly elaborated. Mesopotamia  Several deities were reputed to be involved in a Mesopotamian’s health. Namtar, the God of death, commanded some 60 demons that could cause various diseases. Ningishzida, represented by an inter-twining pair of snakes, was the patron of healers, and Ninurta, a solar God, had the power to release humans from sickness and demons. However, the main Goddess of healing was Gula, recognized as a herb-­grower and a vegetation/fertility Goddess. Seals show her as a dog, or as sitting on a dog, and her main shrine was the “Dog Temple” at Isin, in modern Iraq. Gula’s temples became sites not only for diagnosis and treatment, but also for the conservation of medical texts. Disease prevention was conceived in terms of offerings to Namtar, and grotesque masks were fixed to doors and windows to scare away the vicious “south wind,” a dog-bodied eagle that brought fever to both animals and humankind. Irrespective of social rank, sick people were excused from work and even from service to the king. During the Zoroastrian period, the ruffian god Angra Mainyu was believed to have created 99,999 diseases, but Ahura Mazda had countered this by bringing 10,000 healing plants to earth. Ahura Mazda, along with Ameretat, the god of longevity bestowed good health as a reward for obedience.

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Egypt  Egyptian medicine was based on a hodge-podge of herbal remedies, charms, incantations, and witch-doctoring. Ailments were thought to be caused by “something entering (the body) from outside…. the breath of an outside god or death.” Amun-Ra, the sun God, was the giver of life, fertility and health. Amulets were worn to ward off evil spirits, and there was an emphasis upon personal hygiene. People bathed regularly in the Nile, washing themselves with a pasty soap made from animal fat and chalk. Men shaved their entire bodies to enhance cleanliness, and aromatic ointments were applied liberally to cover bad odours and soothe the skin. Wisdom teachings (Sebayt) from the second century CE commended moderation in diet. This advice was probably directed to the elite, as it is unlikely that the common people could choose their menu, afford an excess of food, or drink alcohol on a regular basis; indeed, there were periods of famine when many of the poor people starved. Diets rich in garlic and onions were redommended to enhance overall health and to relieve bronchospasm. Israel  The Jews saw disease as reflecting some violation of the Torah; the question immediately posed to a sick person was “who sinned, this man or his parents?” The patient was considered as ritually unclean, and prayer and repentance were an essential part of any treatment. The term shalom, still widely used in Israel, originally encompassed a sense of wholeness and a right relationship with God. In contrast to many surrounding nations, the Jews recognized a social responsibility to care for the needy. Alms were given to the poor not as a favour but as a basic right, since all possessions ultimately belonged to God. India  Both health and disease were intricately interwoven with religious philosophy in Hindu society. Dhanvantari, the 17th incarnation of Vishnu, was seen as the physician of the Gods and the patron Deity of medicine. In one incarnation, he had appeared as the king of Benares, and had taught sages the Science of Medicine. During the Vedic period, other Deities were associated with health, including the Ashvin twins, sons of the Sun God, Dhatri, the solar god of health and domestic tranquility, Mariamman, goddess of disease and rain, and Ṥitala Devi, goddess of smallpox and disease. Initially, illness was viewed as a punishment for sins committed in a person’s present life or in a previous existence, and relief was sought from medicinal plants. But as belief in reincarnation developed, it was thought that nature would inevitably exact retribution for past transgressions, whatever treatment was applied, and this led to much passive acceptance of suffering. China  In the earliest Chinese civilizations, illness was attributed to demons and devils, with the belief that they could be dispelled by appropriate incantations, charms and offerings. During the Shang dynasty, illnesses were frequently blamed on wind spirits, and appropriate treatment was sought by divination, using bones and shells. The health value of rhythmic breathing with arm movements was often commended, but no other forms of physical activity seem to have been used either in treatment or in rehabilitation. Physical Fitness  The Zoroastrian holy book, the Zend-Avesta, commended the dignity of physical effort. There is disagreement about how far the early Egyptians

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valued physical fitness. Nevertheless, following the Greek conquest, they seem to have recognized the therapeutic value of moderate exercise. Herophilus and Erasistratus were Greek physicians who taught in the burgeoning Alexandria medical school. Herophilus wrote “when health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.” Erasistratus deplored the “plethora” that resulted from an excessive intake of food and he recommended ensuring good health through hot baths, exercise, friction and a diet of simple vegetables. However, the Greek physician Galen was rather scornful of this approach; in his view, Erasistratus was simply emptying the over-stuffed veins by starvation, and a simple blood-letting would have effected the same result much more quickly. Hindu and Buddhist philosophies typically emphasized spirituality rather than physical development. Nevertheless, some Indians sought to develop their bodies by lifting heavy clubs, and a quest for physical perfection became an integral part of Hinduism. Indian physicians were thus among the earliest to embrace the idea that exercise is medicine (Chap. 20). By the fifteenth century CE, strength, stamina and supreme control of body functions had became the keystones of Hatha Yoga. The eight-fold path to Nirvāŋa encompassed breathing control, management of seated posture, and a withdrawal of the senses. One recent review concluded that on all health outcomes except the enhancement of physical fitness, such practices were at least as effective as exercise. Chinese who served in the army, or who were engaged in heavy physical labour on the farms and in the building of public monuments may have attained a fair level of physical fitness, but there was little to maintain the condition of a growing population of sedentary people who preferred to spend their leisure time in feasting and attending public spectacles. Moreover, the prevalent doctrines of Taoism and Confucianism did not encourage vigorous cardio-respiratory or muscular development. Much of the emphasis in ancient Chinese medical texts was upon potential methods to increase longevity. It was believed that Dao Yin exercises, with an emphasis upon tranquility and mental control, were effective in this regard. Herbal remedies were also believed to adjust the balance between the five basic elements of matter (Chap. 12). Some people sought to extend their lifespan by more aggressive measures. A first century BCE text, the Lingshu Jing, suggested that the rate of decline of “essence” and thus aging depended on a person’s lifestyle: “if one leads a moderate and conscious life, being careful of one’s diet, sleep and exercise, living in harmony with the seasons, and using relaxation and meditation to conserve one’s essence, one can slow down the consumption of kidney essence, and the debility and decline it entails.” The first emperor of a unified China, Qin Shi Huang (260–210 BCE) sought longevity by ingesting the large doses of cinnabar (mercuric sulphide) prescribed by his alchemist, and in consequence he died of mercury poisoning at the age of 50 years. Chen Ro (967 CE) adopted even more drastic measures, lying in bed for more than 100 days practising breath control, and adopting a 24-exercise routine of quiet sitting for twelve months.

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Practical Implications for Current Policy In many parts of the world, the shift from a hunter-gatherer society to a settled urban existence occurred around 3,000 BCE. Typically, urban settlement was facilitated by fertile alluvial flood plains, the development of skills in irrigation, and the exploitation of large armies of slaves. Agricultural surpluses allowed the development of quite large cities. This in turn fostered division of the population into social strata: an elite ruling class, government officials, soldiers designated to protect and augment the new-found wealth, artisans making luxury goods for the rich, common labourers, and slaves from subjugated territories. Inevitably, the two lowest categories of society undertook most of the hard physical work required in early city-states. Each stratum of society probably had its own characteristic health and fitness needs, although most ancient civilizations provide little information on the health status of the workers, or indeed of women at any level in the social hierarchy. Occasionally (as in Egypt) the ruler was expected to demonstrate his fitness to rule by performing demanding physical feats. But in general, the elite pursued hunting and other active sports for pleasure rather than an as a means of enhancing their personal fitness. Infantry men usually wore armour and carried heavy weapons. Thus, they developed high rates of energy expenditure, at least during training and when they were engaged in battle; their physical fitness was usually maintained by a combination of military duties and participation in sports. Common labourers and slaves also undertook heavy occupational work for long hours each day, and it is likely that they maintained a high level of fitness, provided that were given adequate food (which was not always the case). However, the number of sedentary workers (government officials and artisans) increased steadily as cities grew in complexity and wealth. There was also a gradual increase of passive transportation (both on horseback and in chariots), and water-power was an early harbinger of the mechanization that progressively reduced human labour. Feasting, the evolution of spectator events, and the development of sedentary board games all contributed to a growing prevalence of obesity and poor physical condition, particularly among the upper echelons of society. In consequence, archaeological evidence points to a substantial prevalence of atherosclerosis and other diseases associated with the elite as suffering from over-eating and a sedentary lifestyle. Today, urban life in many countries presents less stark social contrasts than 5,000 years ago. Certainly, no one is designated as a slave, and often there are claims of an expanding middle class, although careful economic analysis still points to excessive gradients of wealth in many communities, often with a growing gap between rich and poor. Moreover, the proportion of city-dwellers who are sedentary continues to increase. Tasks that still demand physical effort are generally deputed to the modern equivalent of slaves- recent immigrants or transient foreign workers. Long-established residents who have built up an economic surplus delegate the physical tasks needed for their personal care (such as cleaning the house, or the mowing the lawn) to minimum-­wage workers. This reduces the average daily energy expenditure of the

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wealthy, and unless deliberate efforts are made to maintain minimum levels of physical activity, there are adverse consequences for health. The chronic diseases seen in the remains of ancient city-dwellers who succumbed to the seductions of a sedentary lifestyle provide a stern warning to our current generation, supporting recommendations to compensate for the progressive loss of physical activity by a systematic programme of voluntary exercise. As in the early cities, participation in many types of sport today still shows a strong social gradient, militating against the health of the poorer members of society, and there remains a need to counter this trend. The working class once argued that they already found sufficient heavy physical activity at their place of employment, but by and large this is no longer true. Some sports clubs deliberately restrict membership to those of a certain social status, or impose membership fees that effectively exclude poorer individuals. Other recreational facilities are in locations that are accessible only to those with ready access to personal transportation. A further issue is that many entrepreneurs imply that one cannot exercise effectively without the purchase of expensive sports equipment, whereas good physical health can be maintained by incorporating regular physical activity into the daily round, walking or cycling to work and cultivating a garden. Finally, a social alienation of the poorest members of society sometimes discourages them from undertaking the activities that are needed to promote their good health. Other issues foreshadowed by early city life- a growth in passive transportation and the development of sedentary forms of recreation- still remain a challenge to those who are concerned in promoting an active lifestyle.

Questions for Discussion 1. Was the move from a hunter-gatherer society to residence in a large city evidence of human progress? 2. If you were contemplating the shift from a hunter-gatherer economy to urban life, what would be your main health concerns? 3. As an early Egyptian craftsperson, what would be your options to maintain health and fitness? 4. If you had become sick in an early city-state, where would you have placed the blame?

Conclusions The transition from a hunter-gatherer to an urban agrarian society commonly created an economic surplus, allowing a stratification of society. Some groups such as soldiers, manual labourers and slaves still had to engage in hard physical work, but for the elite, administrators, priests and some artisans, heavy energy expenditure

Further Reading

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became an option. Although a growing range of physically active sports developed in the early city-states, not all of the leisured elite chose to spend their spare time in voluntary physical activity, Indeed, human remains from early society suggest that those who became inactive developed chronic diseases such as atherosclerosis, much as in modern society. Good health was generally viewed as a gift of the Gods, and few made the connections between over-eating, a sedentary lifestyle and ill health.

Further Reading Christensen W. Empire of Ancient Egypt. New York, NY, Chelsea House Publishers, 2009, 159 pp. Craig S. Sports and games of the ancients. Westport, Conn, Greenwood Press, 2002, 279 pp. Crowther NB. Sport in ancient times. Westport, Conn, Praeger Publications, 2007, 183 pp. Decker W. Sports and games in ancient Egypt. New Haven, CONN, Yale University Press, 1992, 212 pp. Dong P, Esser AH. Chi Gong. The ancient Chinese way to health. Berkeley, CA, Blue Snake Books, 1990, 215 pp. Johnston SI. Religions of the ancient world: a guide. Cambridge, MA, Harvard University Press, 2004, 705 pp. Kriwaczek P. Babylon.Mesopotama and the birth of civilzation. New York, NY, St.Martin’s Press, 2010, 30 pp. Larre C, de la Valleé ER. The seven emotions: Psychology and health in Ancient China. Monkey Press, Cambridge, UK, 1996, 190 pp. Nunn J. Ancient Egyptian medicine. Norman, OK, University of Oklahoma Press, 1996, 241 pp. Raina BL. Health science in ancient India. New Delhi, India, Commonwealth Publishers, 1990, 317 pp. Scott RM. Palaeoenvironmental change and famine? Diet and health in ancient Egypt. https:// books.google.ca/books?id=UhmtAQAACAAJ, 450 pp. Sen R. Nation at play. A history of sport in India. New  York, NY, Columbia University Press, 2015, 381 pp. Simri U. Physical education and sport in the Jewish history and culture. Natanya, Israel, Wingate Institute, 1977, 24 pp. Wildwood G, Matthews R. Ancient Mesopotamian civilization. New York, NY, Rosen Publishing Group, 2010, 48 pp. Zysk KG. Asceticism and healing in ancient India. Delhi, India, Motilal Banarsidass Publishers, 1998, 200 pp.

Chapter 4

Evolution of the Sedentary Lifestyle in Classical Culture

Learning Objectives 1. To compare the social forces acting on health and fitness during the classical period of history with those operating in earlier agrarian societies. 2. To trace evolution of the concept that good health is dependent on personal lifestyle rather than the whim of the Gods. 3. To recognize the imperative to attain high levels of personal fitness in militaristic societies. 4. To evaluate the adverse consequences of replacing personal physical activity programmes by massive spectator sport events.

Introduction Many of the social trends we have seen in the cities of antiquity (Chap. 3) continued into the classical cultures of Crete, Greece and Rome. In particular, society showed a multi-tiered stratification, with a leisured and sometimes dissolute elite, a powerful, wealthy and rigorously trained military, and overworked slaves and labourers. In reviewing the classical era, we will note the gradual emergence of the idea that health is not dependent upon the favour of the Gods, but rather reflects environmental factors and the personal lifestyle of individual citizens.

Crete: The Minoan Culture The Minoan civilization flourished from the twenty-first to the fifteenth century BCE, and because of the location of Crete, it served an important intellectual bridge, facilitating the passage of ideas on health and fitness from the Middle-Eastern civilizations of Mesopotamia, Egypt and Israel to the Greek mainland. © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_4

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Local Economy  Minoan towns were quite prosperous, with paved roads and substantial buildings. A small leisured class occupied elaborate palaces with out-­ buildings to store surplus olive oil and wheat. Even poorer residents apparently lived in multi-room stone, wood, or mud-brick homes, although archaeological data suggest that sometimes the ordinary people were less than well nourished. Perhaps because of the protection offered by an island habitat, surviving Minoan artifacts provide little evidence for the presence of a large standing army or engagement in any major military conflicts. There were a few slaves, purchased rather than taken in battle, and as time progressed even this group acquired some legal rights. The wooden or bone tools of the labourers were gradually replaced with metal implements, and the innovation of an oval hole in the handle prevented tool-blades from spinning during use. As their technical skills developed, the Minoans traded both basic raw materials (timber, copper, tin, silver and gold) and the aromatic oils used in medicine, athletic massage and the preparation of perfumes. Sport and Recreation  There were opportunities for sport, at least for the elite of Minoan society, but it is less clear how far such pursuits filled the void of essential physical activity among the aristocracy. The best-known sport and/or religious ritual was bull-vaulting (Fig.  4.1). As in other Mediterranean communities, bulls were worshipped, and bull-vaulting became not only a popular spectator pastime, but also a coming of age ritual for upper-crust young Minoans. In the principal city of Knossos, a palace courtyard was set aside for bull-vaulting ceremonies, and these probably attracted a considerable crowd of spectators. Vases, frescoes and seal stones show that the Minoans were interested in other forms of sport and recreation, including boxing, wrestling, archery, acrobatics, hunting, horse racing, dancing, swimming and (in the case of soldiers) running distances of up to 60 stadia (about 11.4 km) in full armour. The narrow waists, well-­ formed thighs and strong muscles depicted on Minoan pottery may reflect the idealism of the artists, but they seem to point to an effective training programme for athletes. Plato wrote many years later: “first of all in sports were the Cretans,” who attended the gymnasium to perform “daily exercises under the superintendence of masters.” Nudity of athletes was a rarity in Minoa, and boxers usually wore not only gloves but also protective helmets. These characteristics of clothing and equipment suggest that Minoan athletes had little influence upon athletic practice in mainland Greece. Perhaps because of egalitarian traits in Minoan society, most athletic activities were open to both men and women. Plato commented: “Women are not to be forced to compete by laws and ordinances; but if from previous training they have acquired the habit and are strong enough and like to take part, let them do so, girls as well as boys, and no blame to them.” Health and Fitness  Minoan ideas of health and illness remained strongly influenced by local religious beliefs. Nevertheless, there was some use of herbal remedies (Chap. 14), and the elite profited from the very effective water and sewage systems that serviced the royal palace (Chap. 22).

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Fig. 4.1  Bull-vaulting was a popular sport for the young elite of Minoa. It had religious significance, marking the young vaulter’s coming of age, and it provided an exciting spectacle for the common people (Source: https://goo.gl/images/p7VXs2)

The average longevity of Minoans dropped from 35 to around 30 years, as a 10-fold growth in population led to serious food shortages on the island. The images of superbly fit athletes displayed on local ceramics, even if true of the aristocracy, do not seem to have reflected the condition of the common people, who suffered from overcrowding, poor nutrition and disease. Standing heights provide one objective measure of social disparities in health, with values of 1.71–1.80  m for male rulers, but averages at least 0.05  m less in the general male population. Rickets, scurvy, and hypoplastic lines in the teeth suggest that famine was episodic among commoners, with periods of arrested growth during childhood. Skeletal remains also show evidence of much walking in rough country. Arthritis was seen in 41% of male and 18% of female skeletons. Findings of gallstones and gout point to over-­ eating among wealthy Minoans. The medical deity of the Minoans was the god Ahhiyawâ. possibly analogous with Paean, the patron of seer-doctors who sought to heal their patients by chanting magical songs. Illness was still considered a manifestation of divine displeasure, and attempts were made to exorcise evil spirits by offering incantations over ferments, gases, fluid and urine. Votive offerings were sometimes left at hill-top sanctuaries, with clay figurines giving the Deity a less than subtle hint as to the body part that required healing.

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Greek Civilizations From the viewpoints of health and fitness, the most widely recognized innovations of Greek society were a codification of professional health practice (Chap. 13) and establishment of the original Olympic Games (Chap. 11). Other important developments included taking the first steps in the transition from mythology and superstition towards evidence-based medicine, with recognition that many diseases reflected an adverse lifestyle rather than the whim of an angry god, the widespread establishment of schools for children and adolescents where academic teaching was leavened by a substantial dose of physical training (Chap. 19), and the introduction of exercise and sport as components of medical therapy (Chap. 29). The Classical Greek Economy  The number and scale of the temples and theatres in classical Greece point to a vast accumulated wealth. Riches were amassed in part through foreign conquests and in part through the massive exploitation of slaves. Under the constitution enacted by Solon (c 638–558 BCE), Athenian males were rigidly stratified on the basis of their personal wealth. An upper class of about 300 families (the Pentacosiomedimni) each owned property producing at least 500 bushels (17,500 L) of wet or dry goods per year. This class devoted their time to government, warfare, literature and philosophy. The hippeis, or knights (Fig. 4.2) were a second social class, with an annual income of at least 300 bushels; they could afford to maintain a war-horse; they also received governmental funding to buy personal equipment and support a groom and 2 other horses. Below the hippeis were the Zeugitae. with an annual income of 200–300 bushels; they could serve as hoplites

Fig. 4.2  The Athenian knights, or hippeis, were the second tier of Athenian society. They boasted an annual income of at least 300 bushels of wet or dry goods, and were wealthy enough to maintain a war-horse (Source: http://en.wikipedia.org/wiki/Hippeis)

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(infantry men) and occupy minor political posts The Thetes comprised all other citizens, including foreigners and men who had been freed from slavery. Many even of the Thetes had relatively sedentary occupations: merchant, contractor, manufacturer, manager, tradesperson, artisan, and artist. Slaves occupied the lowest stratum of society, performing most of the physical work needed to sustain the Greek economy. They accounted for about 80% of the Athenian population, serving mainly as domestic servants and agricultural labourers; they received only a minimum of food, clothing, and very primitive accommodation. Substantial numbers of slaves also toiled in mines and silver-processing plants, and they could serve as soldiers and rowers aboard the trireme warships. There was a marked social stratification among Athenian women. A small number became philosophers, poets, surgeons and even chariot-racers. The hetaerai were independently wealthy women, entertaining men as conversationalists, courtesans and prostitutes. They often took an active role in symposia, and were clearly distinguished from lower class prostitutes or pornai. A few daughters of prominent families became priestesses, passing through various stages of initiation from early childhood until they became the typical fertile virginal maiden bedecked with dried figs. A priestess apparently held a key to the temple, and sometimes had a substantial influence on State policy. One Priestess reported that a sacred snake had failed to eat its honey cake, signifying that the goddess Athena had already departed from the temple, and on this basis the priestess persuaded the Athenians to abandon their city before the arrival of the Persians, in 480 BCE. As for the ordinary housewife, she was typically isolated from society in a specific part of the Greek household known as the gynaikonitis. In addition to child-bearing and child-rearing, her responsibilities included spinning, weaving, baking bread, cooking, serving, cleaning, fetching water, and removing wastes. Poorer women also left their quarters to help around the farm, and possibly sold bread and agricultural products in the local market. Female slaves performed many of the more menial and physically-­ demanding household tasks, at least in wealthy families. Society was more egalitarian in Sparta than in Athens, although distinctions were still drawn between residents, foreigners and slaves. All male Spartans who had completed their schooling were regarded as equals. Education paid little heed to reading or writing; academic skills were valued mainly in terms of an ability to transmit military messages. Military training began from the age of 11 years, and between 18 and 20 years, many men underwent additional training as guerillas, learning to survive by hunting, foraging and stealing. Adults continued to spend much of their time in military duties until 60 years of age, with people captured from other parts of Greece assuming responsibility for the tilling of their land. Nevertheless, the daily lives of most commoners required hard physical work, particularly in rural areas Agricultural work was esteemed because it kept bodies and minds strong and active. The poet Hesiod (c. 700 BCE) in his “Work and Day,” charted the agricultural calendar, as people cultivated olives, grapes, figs, honey, herbs and vegetables, using rather primitive tools such as wooden ploughs, hoes and mallets to till an unpromising soil.

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Spartan women had much greater independence that their Athenian counterparts, and they participated in the rugged physical training of their boys. Spartan brides were chosen primarily for their physical sturdiness, rather than for large dowries or striking physical beauty. Plato sought equality of opportunity for women. In his Republic (c. 380 BCE), he envisaged women exercising naked in the gymnasium alongside the men. Women would also be assigned the same roster of duties as men, including warfare, although assuming a lighter share of the heaviest tasks. We will now look briefly at attitudes of the Greeks to sports, health and fitness during the classical era. Sports  Leisured Athenians had opportunity to engage in active sports and recreation in the gymnasia, which were open to those over the age of 16 years (Chap. 19). A select few also prepared themselves for excellence in the Olympic and similar festivals (Chap. 11), and a growing number of Greek physicians commended a physically active lifestyle (Chap. 29). But many Athenians compounded domestic leisure by simply watching games and athletic contests. Health  Beginning their practice with the mythology and magical cures inherited from the ancient world, Greek physicians showed a steady progression towards the development of a more rational and evidence-based medicine. It is not always easy to identify the chronic diseases prevalent in Greek society, but references are found to the treatment of arthritis, sciatica, gout, and probably malaria. Early Greek attempts at healing centred around the cult of Asclepius (Fig. 4.3), with worship of a deity rather similar to Imhotep, the Egyptian god of Medicine (Chap. 3). Asclepius was said to be a son of Apollo, who had been taught the art of Medicine by the centaur Chiron. Asclepius was assisted by his wife Epione (who was skilled in relieving pain), and by a bevy of daughters, including Hygieia (“Hygiene”), Iaso (“Medicine”), Aceso (“Healing”), Aglæa (“Healthy Glow”), and Panacea (“Universal Remedy”). One of the responsibilities of Hygieia was to feed the non-­venomous but sacred snakes that crawled on the floors of the Greek temples of healing. Hygieia was revered as the personification of health, cleanliness and sanitation. Some Greeks chose to eat the temple snakes in their quest for medical knowledge or even as a means of gaining immortality. The snake-entwined staff of Asclepius remains today as the universal symbol of the medical profession. More than 400 temples to Asclepius were built throughout the Greek Empire. The attendant physicians were known as the Therapeutaes. Many of the early attempts at healing were based on sedation and dream therapy, this process being helped by the surreptitious addition of poppy seed and hemlock to the evening drinks of patients. A renewal of religious belief, surgery, a change of diet and herbal remedies were all thought to contribute to the overall process of healing. Sometimes, the local temple was given a very substantial fee for a “cure,” Thus Phalysius, a rich citizen of of Naupactus, donated 2000 staters (about a month’s average salary) for the supposed restoration of his sight. We will now summarize the specific ideas of a succession of Greek philosophers and physicians, noting how they progressively replaced mythical ideas with a more logical and reasoned (if not always scientifically correct) approach to health.

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Fig. 4.3  Asclepius was the Athenian God of medicine and healing, and reputedly the son of Apollos. Medical treatment took place in the temples of Asclepius; here, his daughter Hygeia tended magic snakes that played a role in the healing process. The serpent-entwined staff has since become the world-wide symbol of physicians. Source: http:// en.wikipedia.org/wiki/ Asclepius

Thales  The philosopher Thales (c. 624–546 BCE) from the city of Miletus was one of the first people to seek an explanation of natural phenomena without recourse to mythology. Heraclitus  Heraclitus of Ephesus (535–475 BCE) ate an ascetic diet based largely on dried grass and herbs. He adopted this practice because he believed that indulgence in an excess of food and other worldly pleasures caused the soul to deteriorate, making it moist. Pythagoras  Pythagoras (570–495 BCE) was born in Samos, but moved to the Greek colony of Kroton in southern Italy. He had a staunch belief in reincarnation, and founded the religious movement known as Pythagoranism; he may also have been an Olympic competitor. Although he was best known as a philosopher and mathematician, his school also achieved wide recognition for its medical teachings. His concepts of therapy relied heavily on the idea that certain numbers had magical properties. Four concentric spheres of earth, fire, air and water provided what he viewed as a sound mathematical under-pinning to the long-held Greek humoral theory of matter (Chap. 27). Disease arose from dissolute behavior, but good health reflected the striking of a balance between the 4 body humours, attained through an appropriate combination of dieting and exercise. Pythagoras emphasized the need for a temperate and well-balanced lifestyle at all ages, with dietary moderation and daily physical activity such as long walks, running, boxing and wrestling: “Boys and girls must be brought up in labour, exercise, and appropriate endurance, with

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Fig. 4.4 Mediaeval wood-cut illustrating Pythagoras examining the relationship between the physical properties of bells and the pitch of the sounds that they emitted (Source: http://en.wikipedia.org/ wiki/ Pythagoras#Religion_and_ science)

food suited to a hard-working, self-controlled and persevering way of life.” According to some historians, Pythagoras prescribed a very ascetic vegetarian menu for his patients. On the other hand, the historian Diogenes Laërtius claimed that Pythagoras was the first Greek sage to recommend meat for athletes. Pythagoras argued that his numerical concepts could be used in answering such medical conundrums as an appropriate period of quarantine (40 days). Music also became an integral part of his practice, and he became intrigued by the relationship between the physical properties of objects and the pitch of sound that they emitted (Fig. 4.4). Music and gymnastics remained important to many of the followers of Hippocrates, who used wild musical harmonies in an attempt to purge their patients of psychological disorders. Alcmaeon  Alcmaeon of Kroton, mid-fifth century, BCE, was possibly a pupil of Pythagoras. He made the then radical assertion that illnesses were not due to the displeasure of the gods, but rather had internal causes. Like Pythagoras, he argued that good health depended on the balance of various opposing qualities such as moist/dry; cold/hot; and bitter/sweet); the balance could be upset by an inappropriate lifestyle, a poor diet, or adverse environmental factors, but equilibrium could be restored by applying the missing element such as heat or cold.

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Herodicus  Herodicus was another Greek Physician from the fifth century BCE; he may have been a teacher of Hippocrates. He had an unusual educational background, being trained not only as a physician, but also as a dietician and physical educator; he is sometimes regarded as the Father of Sports Medicine (Chap. 29). Like Alcmaeon and Empedocles, Herodicus espoused the new philosophy that disease had a physical cause, and he saw illness as primarily the result of an imbalance between food intake and physical activity. Thus, health could be restored by a combination of a good diet, therapeutic exercise, and massage with appropriate herbs and oils. Hippocrates  Hippocrates (460–370 BCE) was the first to describe many of the medical conditions and associated signs taught in modern medical schools, one interesting example being the clubbing of the fingers that is associated with congenital cyanotic heart disease. One important element in the teaching of Hippocrates, was the avoidance of harm to the patient: “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous” Hippocrates saw the body as a unified being, with ill-health in one part affecting the function of the whole. Thus, he advocated a holistic approach to therapy. Moreover, although the Hippocratic Oath of the physician acknowledged Apollo, Asclepius and the other Greek gods of healing, Hippocrates drew an important distinction between medicine and religious superstition Disease was not the result of some ancestral curse, nor was it a divine punishment for past sin. Rather, it was usually the end product of a person’s environment and lifestyle. Often, seasonal factors were also at play: “It is chiefly the changes of the seasons which produce diseases, and in the seasons the great changes from cold or heat” Thus, Hippocrates reinforced the shift from empirical treatment to rational, evidence-based therapy. In discussing epilepsy, he commented: “People call it divine because they do not understand it. If we call divine all things we do not understand, then divine things will be endless.” Much Hippocratic treatment was passive. Hippocrates argued that given sufficient time, nature would itself correct the patient’s imbalance in the four basic humors and thus restore good health. Nevertheless, Hippocratic physicians sometimes attempted to speed the process, removing an excess of the offending humour by purges, blood-letting, and pepper-induced sneezing. Moreover, Hippocrates supported the idea of sport therapy. In winter: “there should be plenty of exercises and of many kinds: gradually increasing dual direction running, wrestling…, walks at an intense pace after the gymnastic exercise… and prolonged walks early in the morning. They will begin calmly, with the pace increasing until it becomes intense, and will end calmly as well” and in the summer: “little and short simple running and dual-direction running, walks in the shadow and wrestling in the dust, to avoid overheating as much as possible.” Plato  Plato (429–347 BCE) sought to optimize health by reaching a balance between mind and body. For the philosopher, this might mean an increase in the volume of exercise, whereas a gymnast might need to take a greater interest in

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music and literature. This doctrine was summarized by B. Jowett as mens sana in corpore sana. Aristotle  Aristotle (384–322 BCE) was an advocate of moderation in both diet and physical activity: “both excessive and insufficient exercise destroy one’s strength, and both eating and drinking too much or too little destroy health, whereas the right quantity produces, increases or preserves it.” Diocles  Diocles (375–295 BCE) lived in Carystus, a city state on the Greek island of Euobea. He argued that good health required an understanding of the relationship between humankind and the universe. In his view, most diseases arose from “an imbalance of the elements in the body and the constitution (of the weather).” He wrote “A letter on preserving health” to Antigonus II of Macedonia, discussing how diet should be matched to the different seasons: “neither warming nor drying in summer, and neither cooling nor moistening in winter.” Epicurus  Epicurus (341–270 BCE) spent much of his career in Athens. He is best known for his advocacy of Hedonism. This helped him to maintain a cheerful spirit despite periods of agonizing pain from renal stones. He saw one form of pleasure as kinetic, obtained from engaging in physical or mental activity; physical pleasure essentially had its roots in the present, and was felt as the activity was performed. Dicearchus  The Greek philosopher and geographer Dicearchus (c. 350–285 BCE) suggested that ill-health had come about because of a change of diet- the original human diet was free of harmful residues that could cause illness. Plutarch  In a treatise of advice on keeping well, the Platonist essayist Plutarch (45–120 CE) followed up on this concept, making the assertion that the least expensive foods were the best for health! Fitness  The idea of developing a perfect, physical fit body as an offering to the gods had deep roots in Greek civilization, and was promoted by many Greek and Roman physicians, Thus, the physician Asclepiades of Bithnia spoke of a “survival of the fittest,” rather in the manner of Charles Darwin. Again, we read in Pindar’s Eleventh .Olympic Ode “strength and beauty are the gifts of Zeus…natural gifts imply the duty of developing them with God’s help.” Perfection of the body was seen as important to development of the mind. Physical well-being was essential to mental well-being, so that gymnastics and music became the most important classroom topics. Plato had Socrates state “what shall be their education? …gymnastic for the body, and music for the soul.” A few scholars also thought regular physical activity could slow the aging process. Thus the Athenian philosopher Xenophon (c430–354 BCE) wrote: “it is disgraceful for a person to grow old in self-neglect before he knows what he would become by rendering himself well-formed and vigorous in body.”

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As in many subsequent civilizations, sport was seen as a valuable means of enhancing fitness for military combat. In the view of Plato: “about all gymnastic contests, …only the warlike sort … are to be practised and … those which are not military are to be given up.” In the mythological time of Jason, some 2000 BCE, even mercenaries were subject to rigid fitness criteria: “In Jason’s army, pay was based on the fitness of each man…rewards were more for bravery (andreia) and physical fitness than for any skills (techne) at waging war.” In northern Greece, the Spartans valued physical fitness even more highly than the Athenians, seeing it almost exclusively in the contexts of military prowess and obedience to discipline. The militant attitude extended not only to Spartan men, but also to their spouses; they were expected to maintain fitness in order to breed healthy offspring, and expected bravery from their children. One mother killed her deserting son, stating: “He was not my offspring, for I did not bear one unworthy of Sparta.” Another woman who heard that her son had fled from the enemy, commented: “A bad rumour about you is circulating. Either absolve yourself at once, or cease to exist.” And a third woman, hearing that her son had fallen in battle, declared: “Let the cowards be mourned. I, however, bury you without a tear.” After graduation, at the age of 18–20 years, all Spartan males had to pass a test that evaluated their physical fitness, military skill and leadership abilities. Those passing the test were expected to serve as shield-carrying soldiers until they reached the age of 60 years, leaving their slaves to tend the fields whenever they were called into battle. However, those who failed the fitness test became perioikoi, non-citizens who were stripped of their political rights. The Spartan army was particularly keen to maintain the fitness of its troops between battles. According to the historian Herodotus, a Persian scout observed the Spartan warriors undertaking calisthenics in order to prepare themselves for Battle at Thermopylae (480 BCE). Even dancing was seen as a useful way to practice the important military art of dodging a flying missile. Spartan women also faced a compulsory fitness test at the age of 18 years. If a woman passed the test, she was assigned a husband, but if she failed, she was also consigned to the non-citizen ranks of the perioikoi. As adults, the Spartan women eschewed make-up, jewelry and feminine graces. They were expected to maintain their physical condition, even though slaves performed the routine household chores. There was also a rigid practice of eugenics in Spartan society. Soon after birth, children were bathed in wine and taken to be inspected by the local council of elders. If the baby seemed puny or deformed, it was snatched from its mother and either thrown over a cliff, or committed to a life of slavery. Assuming that the baby passed this preliminary inspection, it was then raised in an environment where it was expected to enjoy the plainest of food, and to be unafraid of the dark or of solitude.

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Roman Civilization In the late seventh century BCE, the Etruscans from Tuscany conquered the small original Latin settlement on the river Tiber, introducing the city of Rome to their Goddess of Health (Minerva). However, the Latin tribes regained the ascendancy in the sixth century BCE, and, the role of Minerva was increasingly assimilated by the Greek goddess Athena. By the second century BCE, the Romans had conquered the Macedonian and Seleucid empires, and there was a progressive fusion of classical Greek scholarship and ideas from the dominant Roman culture. Rome prospered initially, despite deep political divisions, but finally a population weakened by a life of luxury became unable to defend its far-reaching borders. Local Economy  The Roman people were divided into 10 social categories. At the top of the heap were about 300 patricians. Next in the pecking order came the equites or knights, owning property valued at more than 50,000 denarii, and serving the Emperor as cavalry officers; they earned the modern equivalent of at least Cdn $165,000–300,000 per year. Below them were five classes of commoners, and at the bottom of the social lacdder were the plebs (with less than 400 denarii of possessions), the coloni, and a large number of slaves. The coloni were essentially tied to the large estates of the aristocracy, and were hunted or flogged if they tried to leave the service of their overlords. Finally, the slave population played an important economic role in agriculture and mining, also serving with the legionnaires who were defending distant frontiers. Survival rations for the poorest citizens were dependent on state subsidies, but in the latter part of Roman history, the social status of the plebs was enhanced by a series of “general strikes.” Foreign conquests initially brought great riches to Rome as a nation, but repeated battle calls took soldier/commoners away from their homes for long periods, and during such absences they were unable to tend their small-holdings. An ever-­ growing number of slaves also reduced the availability of paid work for commoners. Proposed land reforms were stalled by arguments between supporters of the urban unemployed and conservatives who wished to preserve the power of the aristocracy. By the third century CE, the Roman Empire faced ever-growing expenditures to defend its borders. Hyperinflation led to a debasing of the coinage, and problems were exacerbated by a series of civil wars and major pandemics. Constantine I made Christianity an official religion with the Edict of Milan (313 CE), and in 391 CE, Theodosius I banned all other religions. The change from paganism to Christianity had a substantial influence upon social policy, including official attitudes towards sport, fitness and health. Sport  In the Etruscan period, the population engaged in much physical activity, typically undertaken to the accompaniment of castanets and bells. Dancing included rapid gestures and jumping movements set to music. Female dancers sometimes engaged in acrobatics, balancing objects on their heads, and male dancers often performed in full armour. The boxing matches of this era were often vicious events, with armed fists. During wrestling matches, the referee carried a heavy staff to deal

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with illegal holds. Other more healthy activities included running, acrobatics, top and ball-games, the climbing of a greased pole, javelin and discus throwing, and horse- and chariot-racing. Etruscan tombs also illustrate muscle-building exercises, performed with dumbbells or halters. During the middle years of the Roman Empire, the poems of Horace and Ovid suggest the continued popularity of wrestling, discus throwing, one form of boxing and ball games, particularly among the upper classes of Roman society . A ball game could sometimes become very vigorous, with the use of “many wrestling holds.” Caesar is said to have been an excellent ball player, and prosperous Romans frequently included a large open space for ball games (the sphaeristerium) when designing their “dream villa.” However, upper class Romans looked with disfavour on the supposed idleness and dubious morals of the Greek gymnasia, and they avoided competing in any public Games. The practices of the gymnasion were seen as an effeminate substitute for adequate martial training. Thus, the poet Ennius (239–169 BCE) suggested that “to strip naked among one’s fellow citizens was the beginning of vice,” and Senator Tacitus (55–120 CE) warned that the gymnasion led youth to indolence and dishonourable amours. In Cicero’s opinion, it was acceptable to exercise for health and strength, but not simply for pleasure. Seneca (c. 4 BCE - 65 CE) also argued that neither wrestling nor riding were of value if they did not teach self-control. For much of Roman Society, sport progressively became a sedentary spectacle, with attendance at athletic events occupying a major role in the social calendar. General Fulvius Nobilor organized an Athletic Festival in 186 BCE, bringing in top competitors from Greece and his example was followed by many Roman leaders. Caesar Augustus (63 BCE-14 CE) organized large-scale games on a 4-year cycle to rival the Greek Olympic festival and to commemorate one of his major naval victories. He also supported the Greek festivals, authorizing funds to restore the Athenian temple of Zeus, patron god of the games. The emperor Nero (37–68 CE) seems to have played a particularly important role in the gradual transition of Roman sport from an opportunity for personal achievement to an epic spectator event. In addition to athletic competitions and 4-horse chariot races, he organized spectacles that included mock naval battles and fights with wild animals, as well as prizes for music, acting and oratory. The stadia provided mass entertainment that used only a limited amount of space, but bought the support of the populace (“bread and circuses”)- a subtle form of social control. Even sports such as running, throwing and jumping became the exclusive domain of professional performers. The construction of the Colosseum (Fig. 4.5) began under the emperor Vespasian in 72 CE, and when completed it accommodated 50,000 spectators. It became the main venue for public gladiatorial combats. Domitian (51–96 CE) added the smaller (15,000–20,000 seat) Circus Agonalis for track events, and the Emperor Trajan (53–117 CE) rebuilt the Circus Maximus to seat at least 150,000 people. Caesar also constructed Greek-staffed baths and gymnasia in a large number of Roman cities. These facilities offered the general public opportunities for both active and sedentary recreation. By 354 CE, the modern complaint of “lack of time for exercise” was no longer valid; Roman citizens enjoyed 200 public holidays per

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Fig. 4.5  In the latter phases of the Roman Empire, the emphasis of most citizens shifted from active recreation to the watching of athletic spectacles in vast stadia. These facilities were constructed by the government in part as a form of social control (keeping the population happy by providing them with bread and circuses). The Colosseum in Rome, begun by the Emperor Vespasian, was one such stadium (Source: https://goo.gl/images/RUHUka)

year, of which 175 were devoted to various “Games”. However, the main focus of these events was on passive entertainment, sponsored by either the state or wealthy individuals, and intended to honour a particular god, to celebrate a military triumph, or simply to keep the ordinary people happy. Fitness and Training  In the early days of the Roman Empire, military training demanded rigorous fitness; legionnaires were expected to march long distances while fully equipped. Galen and his pupil Oribasius argued that all citizens needed moderate training. But in the latter phases of the Empire the quest for pleasure led to physical and moral weakness in many of the population. During their period of world conquest, all Roman citizens between the ages of 17 and 60 were subject to the military draft. The army sought to develop the recruit’s fitness as quickly as possible. The philosopher Seneca the younger (c 4 BCE- 65 CE) commended weight training, high and long jumping, and certain forms of dance; indeed: “any short and simple exercises which tire the body rapidly and so save time.” Other components of Roman military training included running, marching, and discus and javelin throwing. Combat training included marching (progressing to the very brisk pace of 9.4 km/h), running, charging, long and broad jumping and swimming. During a war with Spain, the General Scipio Africanus (236–183 BCE) recommended a tetrad programme to maintain the fitness of his troops: “on

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the first day do a run of nearly four miles in full kit, on the second to rub clean and generally make a close examination of their equipment; on the next day to do nothing, and on the following, some men to fight with wooden swords sheathed in leather with a button at the end, and others to throw javelins similarly fitted with buttons; on the fifth day to revert to marching…and so on”. General Gaius Marius (157–86 BCE) introduced a number of military reforms, including a reduction in the number of mule baggage trains. Under the new policy, recruits were expected to carry most of their personal equipment on their backs, to a load of about 35 kg. Critics derisively called the troops “Marius’s mules.” In the final years of the Roman Empire, the fitness of the troops tended to decline. Many of the legions no longer saw battle, but rather were posted for long months as passive defenders of distant and windswept fortifications such as Hadrian’s Wall along the Scottish border. In Rome itself, wealthy citizens also preferred the pleasure of drunken orgies and sedentary entertainment to the maintenance of their personal fitness. Frequent attendance at gladiator battles, chariot races, and the lounges of public baths came to assume a higher priority than regular exercise. The defense of the realm became entrusted to mercenaries, and the heavy lifting at home was in the hands of slaves, who came to out-number the free population by as much as ten to one. Although physical and moral weakness contributed to the ultimate fall of Rome in 476 CE, other factors included political instability, heavy military expenditures and over-expansion of the Empire’s borders. Health  Roman notions of health and illness were initially imported from both Alexandria and Greece. At first, physicians were despised, and indeed in early Roman society, physicians were often slaves. The head of a household generally decided on any medical treatment that was needed. Pliny (23–79 CE) wrote: “The Roman people for more than 600 years were not indeed, without medical art, but they were without physicians.” Sometimes, rather surprising “remedies” were prescribed: “Unwashed wool… is applied….with honey to old sores….yolks of eggs…. are taken for dysentery with the ash of their shells, poppy juice and wine….bathe the eyes with a decoction of the liver and …apply the marrow to those that are painful or swollen”. As the fortunes of Athens waned, Greek Physicians began to follow the money trail to Rome, and under the combined influence of battlefield demands for surgeons and the impressive learning of Greek immigrants such as Galen, the prestige and influence of health professionals gradually increased. However, immigrant physicians were still roundly denounced by Cato (230–149 BCE) and Pliny as greedy charlatans. In Cato’s view, most ailments could be cured by a liberal administration of cabbage water! And Pliny complained:“the profitability of medicine knew no bounds… the tale of Hellenistic and Roman doctors is told in terms of their money-­ grubbing, making fame as well as fortune out of fads and gimmicks.” Often, physicians enhanced their unpopularity by speaking in Greek, which most of their patients did not understand. Doctors for long remained the butt of jokes on the cocktail circuit. Thus the poet Martial (40–102 CE) stated: “Until recently, Diaulus was a doctor; now he is an undertaker. He is still doing as an undertaker, what he used to do

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as a doctor.” One of the first doctors to arrive in Rome was Arcagathus (219 BCE). He operated so frequently and so rashly that he quickly earned himself the nickname of carnifex, the hangman. However, beginning with Asclepiades (above), who reached Rome around 100 BCE, Greek physicians began to gain professional acceptance among the Roman nobility, and in 46 BCE Caesar granted Roman citizenship to all practitioners. During the Classical Era, most nations had left injured foot-soldiers to die on the battlefield. However, Roman Generals now showed more respect for their troops. They thus assigned 1–4 well-equipped surgeons to support each cohort of 420 home-based troops. Ruins of buildings which are thought to have been rehabilitation centres (valetudinaria) were also attached to many of their major fortresses. The most prominent physician of the Roman era, Clausius Galenus (c 130–200 CE), was of Greek birth,. He began his medical studies at the prestigious Aesculapium in Pergamon, and then travelled to other centres including Alexandria, before returning to Pergamon as team physician to a group of gladiators. Subsequently, he became personal physician to several Roman Emperors. He and other foreign physicians were allowed to stay in Rome during the plague of 46 BCE, when Cicero banned the presence of all other foreigners.

Practical Implications for Current Policy Minoa seems to have been relatively unique in the ancient world in devoting little of its gross national product to either the construction of defensive fortifications or in sending large armies to engage in warfare overseas, and it seems likely that the public health infrastructure developed in Minoa (without reliance on extensive slave labour) reflects this prudent use of public funds. In today’s society, many countries have large health needs that are presently unmet, and it may be asked whether these needs could be satisfied if current massive expenditures upon armaments were redirected to social programmes; Sweden and Switzerland seem countries which have profited from such policies for many decades. In general, our understanding of health has progressed because of the adoption of evidence-based patterns of medical practice, and a reliance on carefully designed randomized controlled studies of potential therapy. However, it may be asked whether the investigative pendulum has swung too far in the direction of objective thinking. Many of the more persistent problems of medicine have their origins not in the ravages of bacteria and viruses, but in disturbances of the mind and soul of the individual, and it may be wise to retain some elements of treatment that are effective in addressing these domains of human experience. Many of the other questions faced by the classical societies of Minoa, Greece and Rome have their echoes in our present world, but the answers remain quite elusive. Debate over responsibility for poor health persists today, with governments urging (as in classical Greece) the importance of wise personal lifestyle decisions, but some sociologists arguing that a variety of environmental constraints make it

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difficult if not impossible for the poorer members of society to adopt a healthy lifestyle. How large a gap between rich and poor is required to sustain urban productivity, and how wide a differential is compatible with health for all? Is there a wage gap where the poorer members of society become socially alienated and are no longer interested in maintaining their own health? Is mandatory recruitment to the army or a civilian force such as katamavik helpful in enhancing the health and fitness of disaffected youth? Is an extended period of required physical education important to adult health? Do highly trained amateur or professional athletes provide role models that encourage greater physical activity among young adolescents, or do they simply encourage drunken spectatorism in sports bars? Does the government gain a health or fitness dividend by financially supporting top performers, and constructing huge stadia where athletes can display their prowess? Can a nation provide adequate defence of its borders unless potential military recruits are in good physical condition, and does a highly trained army encourage aggression (as seemed to be the case in Nazi Germany)? And do the eugenic policies of ancient Sparta have any implications for current foetal testing and “right-to-die” legislation?

Questions for Discussion 1. Should poor health be blamed on personal lifestyle? How far can inheritance, family background and environmental factors excuse lack of fitness or extreme obesity? 2. How far are desperate efforts to preserve the life of an unhealthy newborn child warranted? 3. Would compulsory enlistment of young adults to a period of military or humanitarian service with strong physical demands be a good idea in modern society? 4. What do you think of the idea of that people who fail to meet specified fitness standards should be stripped of their citizenship? 5. Are there social values that justify governments building large and costly stadia for athletic spectacles?

Conclusions The city-states of the classical era continued along the path of a rigid, wealth-based stratification of society, with differences in health and fitness needs among the differing strata. The elite had opportunity to compensate for a lack of occupational activity by participating in various sports and games, but evidence of conditions such as gallstones and gout suggest that not all of the aristocrats countered overeating with appropriate exercise. In contrast, ordinary people were sometimes malnourished, with evidence of rickets, scurvy, and periods of nutritionally retarded

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growth. During the Greek era, health became viewed as an expression of personal lifestyle rather than as a gift of the Gods, and many physicians recommended balancing the body humours through a combination of exercise and dieting. Minoan and Roman societies made substantial investments in health-infrastructure such as clean water and sewage treatment systems, but there were still major epidemics. Respect for fitness developed mainly in a military context. It reached its acme in Sparta, where physical fitness testing was mandatory on reaching adulthood, and physically demanding military service was required until the age of 60 years. Initially, fitness was also highly prized by the Roman army. However, an ever-­ growing population of slaves allowed much leisure time even to the common people, and governmental emphasis shifted to massive sport spectacles as a form of social control. Lack of physical condition in both the army and the general population probably contributed to the ultimate demise of the Roman Empire.

Further Reading Figueira TJ, Brulé P. Spartan Society. Swansea, Wales, Classical Press of Wales, 2004, 389 pp. Frost FJ. Greek Society. Boston, MA, Houghton Mifflin, 1997, 239 pp. Harris HA. Sport in Greece and Rome. Ithaca, NY, Cornell University Press, 1972, 288 pp. Hillbom N. Minoan games and board games. Lund, Sweden, Lund University Press, 2005, 359 pp. Horstmanshoff HFJ, Stoll M. Magic and rationality in ancient Near-Eastern and Graeco-Roman medicine. Leiden, Netherlands, Brill Publishing, 2004, 407 pp. Jouanna J.  Greek medicine from Hippocrates to Galen. Leiden, Netherlands, Brill Publishing, 2012, 402 pp. King H. Health in antiquity. London, UK, Routledge, 2005, 292 pp. Loski-Ostrow AG. The archaeology of sanitation in Roman Italy. Chapel Hill, NC, University of North Carolina Press, 2015, 285 pp. Maynard CW. The technology of ancient Rome. New York, NY, Rosen Publishing Group, 2006, 51 pp. McGeogh KM. The Romans: New perspectives. Santa Barbara, CA, ABC Clio, 2004, 380 pp. Runnels C, Murray P. Greece before history Stanford, CA, Stanford University Press, 2001, 201 pp. Scanlon TF. Sport in the Greek and Roman worlds. Oxford, UK, Oxford University Press, 2014, 338 pp. Toner JP. Popular culture in ancient Rome. Cambridge, UK, Polity Press, 2009, 253 pp.

Chapter 5

Were the Lights Turned Off During the “Dark Ages?”

Learning Objectives 1. To understand the negative effects upon scholarship of rigid thought control by church or state. 2. To recognize that interest in maintaining personal health is likely to be low if interest is focussed upon on happiness in some future life. 3. To note the important contribution that refugee academics can make to the advancement of learning. 4. To appreciate the growing range of opportunities for active leisure pursuits in the latter part of the middle ages.

Introduction The Roman civilization collapsed in 476 CE, when the German chieftain Odoacer deposed the Emperor Romulus Augustus. Christian writers for long contrasted the “pagan darkness” of the classical era with what they saw as the gleaming light of mediaeval Christianity. But the Italian humanist scholar Petrarch (1304–1374 CE) reversed this image, contrasting the enlightenment of classical civilizations with his own era, when scholars such as himself “were surrounded by darkness and dense gloom.” Some scholars now prefer to call the period that followed the collapse of Rome as the “Middle Ages” rather than the “dark ages,” recognizing that despite a fierce repression of scholarship in many parts of Western Europe, important discoveries were made between the years 500 and 1500 CE, particularly in the Islamic world. In this chapter, we will explore the continued growth in our understanding of health and fitness through to around 1500 CE, when the Turkish conquest of Constantinople (1453 CE), the discovery of America (1492 CE), the Lutheran reformation in Germany (1517 CE) and the dissolution of the monasteries in England (1534 CE)

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_5

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heralded the Renaissance. On most issues, we find striking differences between western Europe, the Byzantine empire, and the Arab world.

Economy and Government Western Europe  The Roman influence over Western Europe came to an abrupt end in the fifth century CE. Replying to an urgent call from the Celts for military reinforcements, the Emperor Honorius bluntly admitted in 410 CE that even in Central Italy he was having difficulties in holding back the Goths. Thus, the Celts would need to defend themselves without any further help from Rome. The former imperial territory was soon split into a multitude of small fiefdoms. Some leaders such as Arthur in England and Gwynedd in Wales claimed Roman ancestry. But Celtic chieftains held sway in much of Britain, and along the east coast of Britain, invading Saxons were seizing large tracts of land. In parts of Britain, tin mining and salt production sustained a fairly prosperous economy for a few decades. But in much of Europe trade collapsed as the universally accepted Roman coinage disappeared, and survival came to depend on local bartering. Often, the rule of law was abandoned, with a return to the primitive hunting and agricultural lifestyle of an earlier era:“they took to looting from each other, since there was only a very small stock of food to give nourishment to the desperate people; and the calamities from abroad were made worse by internal conflict, and consequently, the whole area became almost devoid of food, except for what hunters could find.” Small pockets of Roman Christianity persisted in Northumbria and in Ireland, but most of the mediaeval fiefdoms were initially “pagan” in philosophy. Some reverted to the worship of Celtic deities such as Sulis (Goddess of the healing springs at Bath, in Somersetshire) or Faunus, the horned Roman God who was thought to bring fertility to fields and livestock. Pope Gregory initiated attempts to restore Christianity in Western Europe. In 597 CE, the Benedictine monk Augustine was dispatched to Britain to convert the Anglo-Saxons invaders of South-Eastern England, and also to check on the orthodoxy of continuing Christians in other parts of Britain. A strong papal hierarchy was established, and people became afraid of any knowledge that had not been endorsed by the Established Church. Intellectual stagnation was compounded by a systematic destruction of classical texts and poor language skills (most of the British had reverted from Latin to Celtic speech, and few were able to read Greek or Latin texts). European scholars slowly regained their ability to study Latin and Greek manuscripts through the efforts of Augustine (first Archbishop of Canterbury, from 597 CE) and of Charlemagne (below). Theodore of Tarsus (602–690 CE), who was appointed Archbishop of Canterbury in 690 CE, began the trend towards education of the clergy by shipping an entire Greek Classical library to England. From the eleventh century onwards, large cathedrals, abbeys and monasteries were constructed, and gradually these establishments became staffed by scholars who could read and understand classical literature. The French philosopher Pierre Abélard (1079–1142 CE) took a new interest in Aristotle’s work, and began to apply some of

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Fig. 5.1  One bright spot for scholarship during the dark days of the Middle Ages was the union of the Gauls, realized by the Emperor Charlemagne. The picture illustrates the chapel of Charlemagne’s magnificent palace at Aachen (Source: http://en.wikipedia.org/wiki/Middle_Ages#cite_noteBarber73-255)

his ideas to theology. Under the influence of Thomas Aquinas (1225–1274 CE) and Albertus Magnus (c. 1193–1280 CE), the Roman church also began to incorporate certain facets of Greek and Arabic knowledge into western thinking. One particularly bright spot appeared in Germany, when Charlemagne (c. 747– 814 CE) succeeded in reunifying much of Gaul, and set up an imposing court in the city of Aachen (Fig.  5.1). A currency union with Offa, King of Mercia, gave Charlemagne an economic surplus that allowed a resurgence of interest in literature, architecture and law. Legislation enacted in 805 CE required that all students in his kingdom learn some mathematics, and that some young men should also be taught the rudiments of medicine. Charlemagne prohibited Jewish citizens from money lending, but with this exception he does not seem to have been particularly anti-­ Semitic, since he appointed the Sicilian Jew Farragut as his personal physician. In his spare time, Farragut translated some key Arabic books into German. Classical texts that had been conserved by the Arabs were also retranslated into Latin. The Benedictine monk Constantinus Africanus (1017–1082 CE), was a dominant figure in this renewed literary effort. The De Materia Medica of the Greek physician Dioscorides, already available in Arabic, was translated into both Latin and the Anglo-Saxon vernacular. Two other notable books from this era were the Physica and Causae et Curae, both written by Hildegard (1098–1179 CE), Abbess of a Benedictine convent in the German Rhineland. She claimed that humans had the right to exploit the healing properties of plants, animals and stones, and that God had commanded her to treat the sick using remedies gleaned from wise women and folk healers. In the fourteenth century, the Scottish Franciscan John Duns “Scotus” (c.1265– 1308 CE) and the English Franciscan William of Ockham (c.1287–1347 CE) still

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maintained that reason could not be applied to matters of faith. However, this argument was soon inverted, allowing scientific issues to be pursued independently of faith. Ockham is particularly noted for his “razor” (the explanation of a phenomenon in terms of the fewest possible factors); he was eventually excommunicated by the Avignon Papacy for pointing out their obvious neglect of the vow of poverty. Unfortunately, the spirit of European union was lost as Charlemagne’s dominions became sub-divided among his sons and grandsons. In the eleventh century CE, the energy of Western Europe was further dissipated by a series of costly Crusades intended to wrest Jerusalem from the Turks. Other factors disrupting social progress included local climate change (Europe suffered crop failures and a massive famine from 1315 to 1317 CE), and the Black Death (1347 CE), an epidemic that killed two thirds of the European population. From the fourteenth century onwards, trade began to expand within Europe, allowing the growth of substantial cities. Wealth, which had been concentrated among the Barons and the Church was progressively transferred to a new merchant class. Technical developments reduced energy expenditures in some occupations. The windmill provided a new source of power, and mechanical clocks allowed accurate time keeping. Improvements in ship design, particularly the stern-post rudder, increased the speed of vessels, facilitating international travel with the exchange of both goods and ideas. Agricultural production was boosted by a 3-year rotation of crops, heavier ploughs and the replacement of oxen by horses, and the nutritional status of the population was greatly improved. The Church also began sponsoring major universities and medical schools, and providing hospices to care for the elderly. However, squalid poverty too often remained the lot of illiterate serfs who had chosen to leave the land and seek their fortunes in a burgeoning metropolis. Byzantine Empire  The Byzantine Empire persisted in Eastern Europe long after the collapse of Rome, due in part to efficient administration and tax collection systems, although it was finally conquered by the Turks in 1453 CE. Standing at the terminus of the fabled Silk Road, the capital Constantinople became a vast trading hub, importing not only exotic goods but also reports of new scientific findings from the Orient. The Byzantine Empire itself made relatively few contributions to the biological sciences, but it eagerly embraced Arabic discoveries in astronomy and mathematics. One noteworthy figure from this era was the Byzantine monk Michael Psellos (c. 1017–1078 CE). He wrote De Operatione Daemonum (a classification of demons) and studied the supposed medical virtue that could be derived from the wearing of various stones: “The blood stone … is so-called because it is sprinkled with water of a bloody colour, and heals ophthalmia, the amethyst is of a hyacinth colour and heals headaches and makes tipplers sober…” Arab World  Civilization flourished strongly in the Arabic world during the early part of the Middle-Ages. Following the death of Mohammed (570–630 CE), Arabic countries united under the Rashidun (“Rightly guided Caliphs”), and Muslim forces swept across the southern half of the ancient world, retaining control of a vast swath of territory until the Crusades and the Mongol invasion, at the end of the twelfth

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century CE. Thus, for several hundred years, the main focus of scientific enquiry shifted from Europe to cities such as Baghdad. The primary thrust of this “Arab spring” was upon mathematics and astrology, but some important medical discoveries were also made.

Sport and Fitness Most of the information on sports an d fitness during the Middle-Ages relates to Europeans, although it seems that in the Arab world, men were generally encouraged to be active, but women generally had little opportunity for physical activity. After withdrawal of the Roman forces, most Europeans of necessity replaced a lavish lifestyle and indolence by the primitive existence of an earlier era. Most of the general population regained an adequate level of physical activity, as they devoted their days to hunting, gathering food, and tending cattle, but surprisingly, there was sometimes a lack of fitness among adolescents from the farming community. Lambert of Hersfeld (c. 1024–1088 CE) complained that young German agricultural workers were not fit enough for military duty. In the latter part of the Middle Ages, most of the emerging nobility maintained an active lifestyle, as they fought to defend their castles and abbeys. Their armour imposed a heavy metabolic and thermal load, and between military campaigns they maintained their physical condition by hunting, jousting, and tournaments, as well as by mounting and vaulting wooden horses. Hunting remained an important source of activity for the aristocracy, but other formerly vigorous events such as tournaments became progressively more stylized and physically less demanding. Opportunities for participation in a number of newly introduced games were limited to the aristocracy. Moreover, activities such as croquet, bowls and pall mall offered scope for social interaction rather than vigorous physical activity. As the Middle-Ages developed, a growing middle-class had limited incentives to maintain their personal fitness. Members of the trade guilds such as mercers, grocers, goldsmiths and skinners lived with their families and apprentices in the growing cities, and their working days sometimes required little physical effort. The same was true of the “mediocres,” craftsmen with a lesser status than guild members, who sold modestly-priced wares at the local markets. A growing proportion of leisure time was devoted to watching tournaments and pageants, attending Mumming plays, cock and bear-fights, and playing sedentary games. Land within the cities was becoming at a premium, and this led to a modification in the rules for some games, with the encouragement of spectator sports. Nevertheless, many municipalities purchased land outside the city walls, giving scope for fairs and folk festivals with attendant physical activities. Physicians generally had a positive attitude towards exercise, but the attitude of the Church was more equivocal. Efforts of the population to maintain personal fitness were often curtailed by religious edicts that required church attendance on Sundays and Holy Days and Royal commands that free time be devoted to military training.

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Aristocracy  As the Middle-Ages progressed, the aristocracy engaged in an ever-­ increasing range of sports: equestrian activities, tennis, bowling, kolf, cricket and pall mall. In his younger days, Henry VIII was particularly athletic, setting a positive example by building both tennis courts and bowling alleys in his palaces, and wrestling with the King of France. Hunting  All social classes engaged in hunting as a source of food during the early part of the Middle-Ages, but for the aristocracy the hunt later became a stylized pastime, with much of the countryside set aside as private forests. The upper echelons of the clergy enjoyed their share of hunting, sometimes at the expense of their spiritual responsibilities. Thus, Thomas à Becket, Archbishop of Canterbury, thought it essential to take hunting dogs and hawks with him when he became ambassador to France, and in clause 42 of the Magna Carta, King John gave specific hunting rights to senior clergy. Hunting was also popular among Byzantine aristocrats. Equestrian Sports  Chariot, horse and harness racing in the 60,000 seat Constantinople Hippodrome continued to appeal to the aristocracy until the twelfth century CE. Sometimes, as many as 25 age-classified chariot races were held in a single day, with archery, wrestling, footraces, fencing, dancing and acrobatics to enliven intermissions. Gladiatorial contests were banned, and as time passed the festivities increasingly met with the approval of the church. The Emperor now opened events by making the sign of the cross, competing factions sang hymns, and at the end of the day, the victors gave thanks at the nearest Church. And at a national festival on the last day before Lent, the Emperor and the Patriarch of Constantinople distributed vegetables, bread, fish and cakes to the poor. Tournaments  Tournaments were introduced to England by the Norman nobility during the 11th and twelfth centuries CE, and by the twelfth century they were also being organized in Eastern Europe. Initially intended as a form of military training, they later proceeded without hostility, serving as a display of horsemanship and military prowess (Fig. 5.2). At first condemned by the Church because of their violence, tournaments were later accepted in their ritualized form. The bohort was a play tournament for aristocratic youth; it placed emphasis on horsemanship rather than combat. Mock Naval Battles  The River Thames was a popular site for mock naval battles, commonly held as part of Easter celebrations. King Henry VIII staged a mock naval battle shortly before introducing his “Six Articles of Faith.” In this spectacle, the Royal boat suitably trounced the Pope and a boatload of “Cardinals.” Jousting and Tilting  Citizens who held the social rank of esquire (mostly teenagers training to become knights) were entitled to engage in jousting and tilting. Jousting mimicked the tactics of the heavy cavalry, contestants striking opponents with a lance, axe or dagger while wearing armour weighing as much as 50 kg. The joust was normally stopped if it seemed that life was threatened. However, Henry II of France died from an orbital infection following a bout of jousting, and

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Fig. 5.2  Mediaeval tournaments provided military training for the aristocracy (Source: https:// goo.gl/images/DkjlnV)

this led to a recognition of the dangers inherent in this sport. Horse ballets were substituted, including ring tilts. Tennis  Tennis probably originated with French and Italian Monks during the twelfth century CE.  A leather ball filled with hair was originally struck with the palm of the hand, but in the sixteenth century, rackets came into use. During the sixteenth century, tennis became very popular with the French aristocracy, but participation declined during the French Revolution, and politicians locked out of a meeting room at Versailles met on the tennis court to swear the “Tennis Court Oath” seeking a new constitution. In England, King Henry VIII (1491–1547 CE) was a big fan of tennis as a young man. He installed four luxurious indoor tennis courts, a jousting yard, a bowling green and a cock-fighting/bear-baiting pit at his Whitehall palace in London. At Hampton Palace, to the west of London, Cardinal Wolsey constructed the first tenys playe around 1526 CE; when Henry VIII seized the palace, he installed new netting-­ protected glass, changing rooms, and accommodation for distinguished visitors, the master of the court, the markers, servers and ball boys. Henry saw the game as enhancing health: “this game has been created … to keep our bodies healthy, to make our young men stronger and more robust, chasing idleness.” Charles I (1600– 1649 CE) and II (1630–1685 CE) were also keen tennis players. Samuel Pepys (1633–1703 CE) remarked on Charles II’s study of sweat loss during a tennis match: “weighing himself before and after his play, to see how much he loses in weight by playing; and this day he lost 4½ lbs.”

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Pall Mall  Pall Mall was an ancestor of croquet. It may have originated with the Italian game of ball mallet, and it became very popular with the nobility during the sixteenth and seventeenth centuries. The main walk of St. James Park in central London was set aside for Pall Mall, and King Charles II and his courtiers often engaged in this activity. Commoners  Popular physical activity options for commoners during the Middle-­ Ages included foot races, archery, bowling, football, shinty, stoolball, rounders, wrestling, leaping, casting the bar and various energetic forms of dancing. Foot Races  Foot races were popular with the general population because no elaborate equipment was required. Village festivals probably included not only normal races but three-legged and sack races. One well-documented footrace with Mediaeval roots is the Olney Pancake race in the English Cotswolds. Archery  Archery was strongly encouraged by several English monarchs, including Edward I, Edward III, Richard II and Edward IV as a means of increasing the military preparedness of the population. The Assize of Arms of 1252 CE stipulated that all: “citizens, burgesses, free tenants, villeins and others from 15 to 60 years of age” should “provide themselves with arms appropriate to their class and ordered to join the hue and cry when required,” Even the poorest male citizen was expected to obtain a long-bow matching his height, and butts for archery practice were set up in every town and village. Edward I banned all sports except archery on Sundays, and under Edward III, a halfpenny penalty was imposed on all who failed to participate in the weekly archery practice. Skills honed at the butts earned the British victory in several battles including Crécy (1346 CE) and Agincourt (1415 CE). Government interest in archery declined rapidly with the introduction of firearms. Bowling  Primitive forms of bowling were known in Egypt and Rome, where players used leather balls stuffed with corn. During the third and fourth centuries CE, Germans began to place their clubs and night-sticks at the end of the local cloisters to represent the heathen, and then rolled stones to “destroy the infidels.” However, nine-pin bowling did not appear until the reign of Henry II (1133–1189 CE). It was initially played in alleys, such as the ones built for Henry VIII in his Whitehall and Hampton Court Palaces. Local taverns also began to arrange bowling matches in an adjacent hall or on the village green, but such activities were banned by King Edward III (1312–1377 CE), in part because they took people away from archery practice and in part because they encouraged gambling. By 1511, an edict from Henry VIII confirmed that bowling was illegal, with a fine of 6s 8d for those disregarding the law. The Puritan parliament added bans on other games, including ­tennis, skittles, and quoits. Those owning property valued at more than £100 could obtain a “bowling licence,” and commoners were allowed to join games at Christmas, provided that they were supervised by the Master of the house. However, the aristocracy was not immune to the temptation of heavy gambling on the results of bowling matches. In 1648 CE Sir Edgar Hungerford lost his entire estate on the outcome of one such game.

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Martin Luther (1483–1546 CE) is reputed to have built a bowling lane for his children. But in Germany, also, gambling on the outcome of bowls became a social problem, and by 1325 CE bets on matches in Berlin and Cologne were legally limited to an amount of less than $1. Lawn bowling had become prevalent by the time of the Spanish Armada (1588 CE), and tradition suggests that Sir Francis Drake was engaged in such a game at Plymouth Hoe as he awaited the arrival of the Spanish fleet. King Charles I was also allowed to enjoy the occasional game of lawn bowls while he was imprisoned in Carisbrooke Castle. Kolf  The sport of Kolf, a predecessor of golf, originated in the Netherlands during the twelfth century. It was played with iron clubs and a wooden ball, and it became banned in some cities because windows were broken. Kolf evolved into an indoor sport, played in large private houses and in rooms adjacent to taverns. Dutch merchants are thought to have brought kolf clubs to Scotland, and the word golf was first used in 1453 CE. During the sixteenth and seventheenth centuries, people were frequently prosecuted for playing golf on the Scottish “Sabbath:” “good order was keeped the last Sabbath, except that they found some young boys playing at the gowf in the North Inch, in the time of preaching afternoon, who were warned by the officiars to compear before the Session this day.” Soccer  The origins of soccer may lie in Greece, Rome, or even China, and at first the game retained some pagan features. For example, the Good Friday game at Wreyland, in Devonshire, was supposed to ensure a bumper potato crop. The head of a Danish brigand is also reputed to have served as one of the first balls in mediaeval England. As early as the ninth century CE, the Welsh Monk Nennius reported that a group of boys were playing at ball. During this era, soccer was a brutal mob game between rival villages, sometimes with many players, and the goals were set as much as 3 km apart. The contest often involved kicking, biting, punching and gouging of opponents, and many players ended the game with serious injuries or even deaths. In part because of this violence, in 1314 CE the Lord Mayor of London prohibited football within the city limits. Under King Edward III, the ban became nation-wide (1365 CE), with successive re-enactments of the legislation under Richard II, Henry IV and Henry V. However, the ban was largely ignored. Even Henry VIII banned soccer, although he diminished respect for this legislation by ordering a pair of soccer boots for himself. Despite the protests of the Church, soccer games often occupied the leisure-time offered by religious festivals. At Shrovetide: “all the youth of the city go into the field… and address themselves to the famous game of foot-ball.” Occasionally, even clergy ventured onto the soccer field, and in 1584, the Diocese of Oxford ruled that any Minister or Deacon who participated in this sport was to be reported to the Bishop and banned from office. One person who commended soccer was Richard Mulcaster, Headmaster of the Merchant Taylor’s and St. Paul’s Schools in London (Chap. 19). He saw that with fewer participants and a stricter referee, the game could be an effective means to enhance the strength and health of his pupils.

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Cricket  The origins of cricket are obscure. There was a game where a small ball was hit by a cryc, or curved stick as early as the thirteenth century CE, and in 1300 CE, Edward I invested 100 shillings to provide his son instruction in the game of creag. During the fifteenth and sixteenth centuries, cricket became a game for adults as well as children. Often, cricket games were scheduled on Sunday afternoons or evenings, suggesting that the game was open to the working poor. In 1611 CE, two men in Sussex were prosecuted for playing cricket rather than attending Easter services. There were also complaints of Church windows being broken, and a further eight men were prosecuted for missing Church on Trinity Sunday in 1637 CE. Stool ball was probably an ancestor of cricket. It was often played at Easter, and may once have been a pagan fertility rite associated with the goddess Oestre. The contestants were typically milkmaids, who used their milking stools as wickets. The game of rounders has been played in England since Tudor times. It was originally called base-ball. Shinty  Shinty is a predecessor of field hockey with similarities to hurling. It was an Irish sport for many centuries, and the Gaels brought the game to Britain. Contests were traditionally held between adjacent villages on New Year’s Day, with several hundred participants. As rules became standardized, team sizes were reduced to 6 or 12 players, and games were played on fields the size of a soccer pitch. Social Dancing  Dancing was popular on Mediaeval feast days. Maypole dances possibly had some connection with ancient fertility rites. The Church of St. Andrew Undershaft, in the City of London, erected a Maypole each spring, until the wrath of a Puritan mob put an end to the ceremony in 1547 CE.  Morris dancing was inspired by the Moors, and it became widely popular across Europe during the fifteenth century, with sticks replacing the Moorish swords (Fig.  5.3). The related Molly Dance was performed immediately following Epiphany, with ploughboys wearing clogs and some of the group clad as women. In the Horn Dance, participants wore reindeer horns and carried hobby horses, and the Hoodening was a Kentish begging dance performed at the winter solstice, with participants carrying a “hooden horse.” In some parts of Europe, large groups would dance very vigorously and erratically until they dropped from exhaustion. The phenomenon was variously known as dancing mania, St.John’s dance and St. Vitus dance. The cause was unclear. Possibly religious cults were involved, or it may have been a mass psychogenic illness. Sedentary Pursuits  A growing variety of sedentary pursuits amused all classes of mediaeval society during the dark months of winter. Options included chess, an Arabic forerunner of checkers, back-gammon, nine men’s Morris (a Roman board game), fox and geese (a Scandinavian board game), shove ha’penny, shovelboard, hazard (an ancestor of craps), and various card games, Henry VIII took great delight in wagering on backgammon, dice and shovelboard, and in one year alone his losses totalled 3,500 pounds.

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Fig. 5.3  Many forms of social dancing such as the Morris dance provided vigorous physical activity for mediaeval commoners (Source: https://goo.gl/images/UcUG6W)

Health and Fitness During the Middle Ages, measures to prevent the spread of disease were limited by a lack of understanding of infection, and the absence of any effective health infrastructure (Chap. 22). In consequence, there were frequent epidemics of cholera and bubonic plague. Furthermore, efforts to maintain personal fitness were curtailed by edicts that required church attendance on Sundays and Holy Days and Royal commands that any free time be devoted to military training. As discussed above, a variety of new sports and pastimes appeared, but participation depended strongly upon social class. For the aristocracy, formerly vigorous events such as tournaments became progressively more stylized, and other newly introduced games such as croquet and bowls offered an opportunity for social interaction rather than vigorous physical activity. The common people also devoted a growing proportion of their spare time to watching tournaments and pageants, and the playing of sedentary games. During the early Middle-Ages medical beliefs and practice were much less scientific in Europe than in the Arab world. The renewed Catholic Church progressively rejected or adapted earlier Celtic healing practices that had centred on sacred wells, stones, charms and herbs, and the classical texts of Greece and Rome became proscribed reading for the faithful, because they were based upon pagan philosophies. Illness was blamed upon a combination of destiny, sin, and astral influences.

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Western Europe  Celtic rituals and beliefs. Celtic rituals were revived with the departure of the Romans. Healing ceremonies were performed at stone Cromlechs and Dolmens, often set high on the hillside; sometimes these rites involved human sacrifice. Alaunus the Sun-God, symbolizing fire, health and healing, was represented by a wheel, to symbolize his daily movement through the skies. Celtic warriors usually wore a protective wheel-amulet, and miniature sun-wheels were also thrown into springs to enhance their curative properties. Healing wells, magic stones, and charms were part of the armamentarium of many mediaeval folk healers. In Scotland, water from particular wells cured specific complaints: that at Balquhidder, in Perthshire, was said to be effective in treating whooping cough, that at Borve on the Isle of Lewis was efficacious against “stitches and gravel” and that at North Uist in the Outer Hebrides relieved toothache. The Celtic fertility Goddess, Aine of Lockaine, was thought responsible for the body’s life force. She owned a magic stone, and if anyone were to sit on it, they would lose their wits. Other stones could make a barren woman pregnant, assure the easy delivery of a child, and give new vitality to the elderly. Charms were commonly recommended for toothache, ringworm and erysipelas. Usually, their efficacy depended upon the repetition of secret but nonsensical rhymes, as in this satirical example: “Oil from an eel’s foot, milk from a hen’s teat, and the tallow of midges (blended) in the horn of a pig and rubbed in with a feather from a cat’s wing.” The Druids believed that preparations derived from flowers, herbs and trees also had the power to heal and even to ward-off evil influences (Chap. 14). A Christian adaptation of pagan beliefs gradually developed. Thus, the Sun-Goddess Sulis was allowed to presided over the healing waters at Bath Abbey, in Somerset, Apollo Belenus the “Bright One” was still venerated at the shrine of Sainte Sabine in Burgundy, and the shrine of Apollo Vindonnus at Essarois in Burgundy included wheeled images of Alaunus, the Gaulish deity of healing, in the pediments of the building. Christian Beliefs  The mediaeval church assimilated parts of the ancient Celtic traditions, in particular ascribing medicinal properties to specific wells. For example, healing was to be found in water drawn at Holywell Bay, in Cornwall, and Cuddy’s Well in Bellinghgam, Northumberland, both sites being associated with the cult of St. Cuthbert. However, tension quickly developed between the beliefs of mediaeval folk healers and the Christian church, where illness was generally regarded as a divine retribution for recent or past sins. Pagan methods of treating ill health were banned, and legislation was enacted against witchcraft. Preachers also roundly condemned the wisdom of folk healers in their Sunday homilies and pastoral letters. Priests argued that God’s creation was essentially good, and even if humans could not understand the divine rationale, illness should be accepted as a mechanism for attaining a greater end. Intellectual leaders such as Augustine of Hippo (354–430 CE) and Benedict, the Patron Saint of students (c. 480–547 CE) prioritized an understanding of religion over competence in other areas of knowledge such as medicine. If the

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educational programmes of the Church included any medical teaching, this was seen as a means of demonstrating the wisdom of God, rather than as a key to improving health. The Greek bishop Basil of Caesarea (330–379 CE) was a lone supporter of the medical fraternity, declaring that a physician had the noblest of professions. Nevertheless, Basil still argued that many illnesses were sent from God as a trial of faith or punishment for a long forgotten sin. Basil’s views set the stage for a strong reliance on healing by faith, at the expense of accumulating medical knowledge. The prejudice against physicians persisted well into the twelfth century CE. Thus, Bernard of Clairvaux (1090–1153 CE) commented: “The occasional use of herbs from the monastery garden may, indeed, be tolerated; but to buy drugs, to consult physicians, to take medicines, befits not religion.” He also emphasized asceticism, suggesting that: “the spirit flourishes more strongly and more actively in an infirm and weak body.” Because of the continuing rejection of material causes of disease, the basic tenets of the Hippocratic oath became embellished with Christian doctrines of an after-­ life. Physicians were told not to encourage the sick to cling desperately to life. Faith in God and the wonders of the after-life had greater importance than longevity. A major component of the physician’s responsibility was rather to enlighten the patient about the spiritual aspects of sickness and dying. Like many clerics in the Middle-Ages, Bishop Gregory of Tours (c. 538–590 CE), had a strong belief in the healing power of holy relics. He once treated a toothache by applying to his teeth dust collected from the tomb of St. Martin, and he threatened to class as a heretic anyone who sought help from a physician rather than praying at the tomb of St. Martin. One victim of his edict was Leonastes, the Archdeacon of Tours; Leonastes compounded his misdemeanor by not only consulting a doctor, but also seeking treatment from a Jewish physician! (Fig. 5.4). In essence, people such as Gregory of Tours replaced pagan healing practices with their own superstitious rituals. Priests rewrote pagan incantations to give them a Christian flavour, and fervent appeals for miracle cures were addressed to Christian saints at a plethora of local and regional shrines. Specific saints were thought to cure particular conditions because of the nature of their martyrdom. For example, St. Erasmus (who suffered evisceration in 303 CE) was thought to help patients with gastro-intestinal problems, St. Just (who was tortured by wearing a red-hot helmet) could cure persistent headaches, and St. Lawrence (225–258 CE) (who lay on a bed of red-hot coals) could alleviate back pain. In some regions, Catholic Christians today still believe in miraculous cures. Thus, the shrine at Lourdes, in southern France, still attracts 45,000 worshippers to a single Mass. And in Québec, 500,000 pilgrims each year visit the crutch-filled shrine of Ste. Anne de Beaupré on the North Shore of the St. Lawrence Estuary. Byzantine Empire  Church authorities in the Byzantine Empire were little more open to medical scholarship than their counterparts in Western Europe, and the most influential group of investigators (the Nestorian heretics) was eventually expelled to

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Fig. 5.4  Mant mediaeval clerics believed in the healing properties of the relics of saimts. Gregory, Bishop of Tours, believed strongly in the efficacy of dust from the tomb of St. Martin (Source: https://goo.gl/images/bdNJfA)

the Arab world, where they played a major role in stimulating a better understanding of health in that society. Hostility to the views of classical scholars was at first rampant across the Byzantine Empire. The Coptic Pope Theophilus led an angry mob that destroyed precious manuscripts in Alexandria’s Medical Library in 391 CE.  St. Cyril, the immediate successor of Theophilus, aggressively pursued those whom he regarded as pagans, expelling Jews from Alexandria, and inciting a nominally Christian mob to murder Hypatia (c. 350–415 CE), a leading female neo-Platonist philosopher, mathematician and astronomer. Paradoxically, Cyril saw fit to allow a Christianized revival of the “incubation” rituals, where the sick had seemingly benefitted from sleeping in a pagan shrine. The healing temple had now become a church, and Christian legitimacy of the ritual had been assured by placing the relics of Christian martyrs in the basement. Many Byzantine scholars sought intellectual recognition by focussing on the minutiae of theology, rather than considering issues in health and fitness. Gregory of Nyssa (c. 335–395 CE) complained about the religious fixation of his fellow-­ citizens: “This city is full of mechanics and slaves, who are all of them profound theologians…. If you desire a man to change a piece of silver, he informs you, wherein the Son differs from the Father; if you ask the price of a loaf, you are told…. that the Son is inferior to the Father; and if you inquire, whether the bath is ready, the answer is, that the Son was made out of nothing.”

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A few Byzantine scholars, particularly Aëtius of Amida (mid fifth- mid sixth century CE), and Isidore of Seville (560–636 CE) compiled compendia that sought to conserve treasures of classical learning, Unfortunately, many of these compendia were destroyed by marauding armies, including the Berber invaders (711–718 CE), the Crusaders (1204 CE), and the Mongol invaders (1222–1242 CE). The Nestorians were a heretical sect of the Eastern Orthodox Church, condemned for denying that Mary was the mother of God. Nevertheless, they established a very early School of Medicine and two hospitals at Edessa in Northern Mesopotamia, and for a time the Byzantine court accepted treatment from Nestorian physicians. However, in 489 CE the Bishop of Edessa (Cyrus II) prevailed upon Emperor Zeno (c. 425–491 CE) to destroy the Medical School (which Cyrus viewed as a heretical institution) and the associated physicians were summarily expelled from the city. Arab World  Muslims considered illness as a way of atoning for sin, and death was seen as a part of the journey to meet God. But from the early days, there was also a belief that Allah provided a treatment for every illness that he had created. Initially, the only therapeutic options were the traditional Bedouin remedies of honey, olive oil, camel’s milk, cupping and cautery. Imams encouraged treatment, prevention and health promotion through use of the plant and animal products that were ­mentioned in the Quran, and an early Book of Medicine (Kitab al-Tibb) summarized what Mohammed was thought to have said and believed about health. Attitudes were strongly influenced by a cadre of outstanding immigrant physicians. Well-­ staffed hospitals were built (Chap. 16), and scholarship blossomed in extensive libraries (Chap. 18). Surgery was prohibited by an edict of Allah against the cutting of human flesh. At first, the most important classes of doctor were thus general practitioners and ophthalmologists. However, Albucasis of Córdoba (936–1013 CE) ingeniously circumvented Shariah law by using a white-hot cautery to carry out minor operations. Albucasis stressed the importance of a positive doctor-patient relationship, and the need to provide treatment irrespective of the ability of the patient to pay. He carefully integrated new surgical procedures into the scientific knowledge of his day, recognized the hereditary nature of haemophilia, and described how to ligature blood vessels some 600 years before the French surgeon Ambrose Paré described the same technique. In the twelfth century CE, Gerard of Cremona translated the master-work of Albucasis into Latin, and it remained an influential surgical text in Europe until the eighteenth century CE.

Attitudes to Health and Fitness Western Europe  Most mediaeval physicians advised fairly healthy patients to engage in moderate exercise. Thus Arnald of Villanova told patients with palpitations of the heart: “take moderate exercise before eating, and rest entirely after it,

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till the food has left the stomach, and then ride horses or gently trotting mules, avoiding rapid ascents or descents.” Some of the blame for poor fitness in many of the general population can be placed upon the asceticism of the mediaeval church. Church Fathers had strongly opposed both the worship of Zeus associated with the classical Olympic Games (Chap. 11) and the brutality of Roman spectator sport (Chap. 4). In a treatise read by young catechumens, the African bishop Tertullian had condemned attendance at circuses, stadia and amphitheatre spectacles. Likewise, In his “Homily against spectacles,” the Archbishop of Constantinople John Chrysostom (347–407 CE) railed against Christians who preferred watching horse races to listening to his sermons. It is less clear how far the Church despised personal fitness. Indeed, the words “Ascetic” and “Athletic” were initially almost interchangeable, and the athlete was used as a positive symbol in some early Christian teaching. Tertullian wrote favourably about the physical aspects of military training, and other early church leaders advocated regular physical effort. Clemens of Alexandria (150–215 CE) commended athletics for boys and men, although not for women. The Christian convert ws encouraged to engage in moderate (non-competitive) wrestling, ball-play and fishing, although Clemens preferred an emphasis upon the activities of daily living (handling a hoe, working the mill, chopping wood and walking for transportation) rather than participation in sport. Likewise, although Isidore of Seville considered the Olympic Games as idolatrous, he recommended that youngsters should: “exercise yourselves at full through mountains, through sea and you shall see with wonder how good and healthy the body feels with the work and development that the limbs acquire with exercise.” As the discipline of medicine became divorced from the church, a variety of paramedical workers emerged to supplement the healing efforts of a small cadre of formally trained physicians. Tentative efforts were made to extend the available treatment and institutional care to even the poorest of citizens. However, with the exception of certain herbs, most of the treatments offered by mediaeval practitioners had little practical value, and many options were quite harmful to the patient’s health. Arab World  Several Middle Eastern scholars made positive comments on the health value of regular moderate physical activity, notably Avicenna and Maimonides. In the Canon of Medicine (1025 CE), Avicenna argued that walking was the best type of medicine. “Among physical exercises, there are some moderate ones; it is to them that one should devote himself….. Unmoderated exercise is an overload…and causes the body to age before its time…preserve a happy medium… exercise your limbs… until you succeed in panting.” Maimonides (above) was also a strong advocate of a healthy personal lifestyle: “A person should…walk prior to the meal until his body begins to be warmed… Strenuous exercise should be taken every day in the morning till the body is in a glow…. Anyone who lives a sedentary life and does not exercise…even if he eats good foods and takes care of himself according to proper medical principles- all his days will be painful ones, and his strength shall wane.” However, Muslim insistence on wearing the Burka and Hijab undoubtedly did little for the fitness of women in the Arabic world.

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Practical Implications for Current Policy The lack of scientific progress during the dark ages was in large measure due to a rigid control of investigators by those in positions of power, particularly the established church. We now pride ourselves on living in a much freer society, but regrettably we must also recognize that the choice of medical and scientific topics to be investigated is still controlled by the allocation of governmental and commercial research funding, and that permission to publish the findings is often withheld if the conclusions do not fit the desired political or commercial model. The University of Toronto has a policy of not accepting grants with any restrictions upon publication of the findings, and other academic institutions could usefully follow a similar policy. The continuing pilgrimages to shrines such as Lourdes, and the occasional associated cure of illness point to the on-going need for a consideration of the mind and the spirit in the treatment of many chronic conditions. Although it is important to ensure that desperately ill people are not robbed by charlatans, there is an on-going need for spiritual intervention, particularly in situations where modern medicine has no effective cure. Investigators now have access to a wide array of literature from many parts of the world, but because of the limited language skills of investigators, systematic reviews are too often limited to papers published in English, neglecting potentially important discoveries that have been described in foreign language journals. Much medical progress in the middle ages was brought about by refugee physicians and scholars, for example those expelled from the Byzantine empire. Nowadays, many barriers prevent refugee physicians from practicing when they reach a country of asylum. While it is important to maintain professional standards in the west, one may wonder what new medical and scientific insights we are denied because refugees with “lack of North American experience” are unemployed or driving taxis, rather than making a full use of what may indeed be novel skills.

Questions for Discussion 1 . Can religious belief be compatible with scientific progress? 2. Does traditional folk wisdom have any place in health maintenance? 3. The University of London used to require that candidates for a bachelor’s degree in physiology be able to translate articles in both French and German during the course of their final examination. Was this a good idea? 4. Do you think that powerful commercial interests are limiting scholarship and restricting our understanding of health and fitness in the twenty-first century?

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Conclusions With loss of Roman currency and military protection, much of western Europe quickly reverted to subsistence agriculture, with a loss of any pretense at n academic enquiry and return to ancient Celtic health practices. However, in the Arab world the acceptance of refugee scholars allowed the establishment of large hospitals and impressive libraries, and important new scientific discoveries were made in this part of the world. Christian missionaries later brought back to Europe key documents that had been conserved in Arab libraries. Celtic folk healers were suppressed and the Church assumed exclusive responsibility for the treatment of illness and the maintenance of health. Emphasis was placed upon personal asceticism, the passive acceptance of illness, and occasional miracle cures. The brightest minds pondered theological controversies rather than issues of health. Subsequently, a progressive secularization of western medicine and emergence of a growing merchant class paved the way for the Renaissance. Growth in commerce attracted people to major cities, but a lack of clean water and sewage treatment compromised urban health, and Europe was ravaged by the Black Death. Even in the late Middle-Ages, physicians continued to treat patients in terms of balancing the four body humours. An ever-growing range of active sports and pastimes was pursued, despite vigorous objections from the church and the military. But towards the end of the MiddleAges, ritualized social pastimes, spectacles and sedentary games began to sap the fitness of urban populations that had previously enjoyed active sports.

Further Reading Biller P, Ziegler J. Religion and medicine in the middle ages. Woodbridge, Suffolk, York Mediaeval Press, 2001, 253 pp. Green M. Gods of the Celts. Stroud, Gloucestershire, History Press, 1986, 256 pp. Guthrie S. Arab social life in the middle ages. An illustrated study.London, UK, Saqi Books, 1995, 229 pp. Henricks TS.  Disputed pleasures. Sport and society in pre-industrial England. Westport, Conn, Greenwood Press, 1991, 194 pp. Herrin J. Byzantium. The surprising life of a mediaeval empire. Princeton, NJ, Princeton University Press, 2008, 391 pp. Kelly K. The history of medicine. The middle ages, 500–1450. New York, NY, Infobase Publishing, 2009, 158 pp. Larchet J-C. The theology of illness. New York, NY, St. Vladimir’s Seminary Press, 2002, 137 pp. Montville JV. History as prelude. Muslims and Jews in the mediaeval Mediterranean. Lanham, MD, Lexington Books, 2011, 191 pp. Potter D. The victor’s crown. A history of ancient sport from Homer to Byzantium. Oxford, UK, Oxford University Press, 2012, 423 pp. Tierney B, Painter S. Western Europe in the Middle Ages. New York, NY, McGraw Hill, 1998, 672 pp. Wellcome HS. Medicine in ancient Erin. London, UK, Burroughs Welcome 1909, 172 pp. Wilkins S. Sports and games of medieval cultures. Westport, Conn, Greenwood Press, 2002, 325 pp. Ziegler E. Sport and physical education in the Middle Ages. Victoria, BC, Trafford Publishing, 2006, 253 pp.

Chapter 6

The Renaissance: Daring to Challenge Traditional Wisdom

Learning Objectives 1. To appreciate that the new discoveries of the Renaissance were based on a willingness of scientists to challenge long-held views, sometimes in the face of fierce opposition from those in positions of power. 2. To recognize that the urban migration of agricultural workers posed new challenges both to active recreation and to public health. 3. To observe how authoritative statements on health and fitness shifted from the established church to political leaders, firebrand preachers and health professionals. 4. To understand the repressive attitudes of the Puritans, and their manifestations in protestant universities and Lord’s Day Observance movements.

Introduction In Europe, the gradual transition of scholarship from Latin to the vernacular and the new availability of printed texts made the findings of classical writers accessible for the first time to a wide range of enquirers, spurring a Scientific Renaissance. Although many religious leaders still opposed innovative thought, fears of persecution were much less prevalent than in earlier generations. Brighter scholars moved beyond rediscovering the accepted wisdom of earlier ages, and this sparked a Scientific Revolution where the cherished ideas of the mediaeval church were turned upside down. Fundamental to these advances was a renewed freedom to engage in anatomical dissection, and an ability to explore the body’s microstructure, using the newly perfected lenses of Dutch opticians. A new generation of physician/scientists also dared to apply recent discoveries in chemistry and physics to the interpretation of bodily function.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_6

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Fig. 6.1  Invention of the printing press was a major stimulus to Renaissance thinking. In this illustration, William Caxton is demonstrating the first English printing press to King Edward IV and Queen Elizabeth I.  From a painting by Daniel Maclise (1806–1870 CE) (Source: http:// en.wikipedia.org/wiki/William_Caxton#Printing_and_later_life)

The Renaissance began in fourteenth century Italy, with a rediscovery of the classic Greek and Roman cultural heritage, and the movement spread progressively across Western Europe over the next three centuries. The new wave of art, architecture and scholarship was stimulated in part by wealthy research patrons such as the Medici family, who were merchant bankers in the city-state of Florence. The Papacy returned from Avignon to Rome in 1417 CE, and there it fell sufficiently under the sway of the Medicis that it found itself beginning to embrace the art and the philosophy of the Renaissance. A second influence fanning the Renaissance was a westward migration of Greek scholars who were displaced from the city of Constantinople by the Ottoman conquest of 1453 CE. The Greek refugees were able to translate classical manuscripts for their Italian hosts, and many also brought with them an understanding of scientific achievements in the Arab world (Chap. 5). Other trends further stimulated scientific enquiry during the fifteenth and sixteenth centuries. The Middle-Ages had been essentially a two-class society of feudal lords and indentured peasants. However, during the Renaissance many of the rural population migrated to major cities, with emergence of a leisured middle-class of lawyers, civil servants, merchants, and skilled artisans, people who had access to the books printed by the newly invented presses of Johannes Gutenberg (1395–1468 CE) in Germany, Laurens Janszoon Coster (c. 1370–1440 CE) in the Netherlands, and William Caxton (1415–1492 CE) in England (Fig.  6.1). The new printing presses could print as many as 3600 pages per day, and by the year 1500 CE, worldwide sales of books exceeded 20 million volumes. Most books were printed in the

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vernacular rather than in Greek or Latin, and the very act of translating classical texts often led to a questioning of traditional dogma. The new ferment of intellectual enquiry wrought major changes in the attitudes of the church towards medicine and health. During the Middle-Ages, illness had been borne stoically as a preparation for some ultimate heavenly reward. However, catastrophic pan-European epidemics such as the Black Death challenged this philosophy. Charismatic individuals such as Jan Hus (1369–1415 CE), Martin Luther (1483–1546 CE), Henry VIII (1491–1547 CE), Huldrych Zwingli (1494–1531 CE), and John Calvin (1509–1564 CE) placed the tenets of the established church under a questioning lens, bringing a new focus upon the importance of maintaining and promoting good health. Moreover, these ideas were reinforced by the scientifically oriented medical schools and universities that flourished in cities such as Padua, Bologna and Pisa (Chap. 17), and the new teachings of these institutions were soon carried widely across the Western World. Professors began to replace theologically grounded speculation by accurate observation and measurement. The Franciscan Roger Bacon (1214–1294 CE) insisted that a good grounding in mathematics was essential to a correct understanding of natural philosophy, and that this knowledge had to be supplemented by a reading of evidence-based texts. University teachers defended their new-found academic freedom against government, church and merchant burghers, sometimes in the face of excommunication, torture and even death. New curiosity about the universe challenged “flat-earth” views, and explorers such as Christopher Columbus (c.1451–1506 CE) and Giovanni Caboto (c.1450–1499 CE) pushed westward to discover the territories of Cuba and Newfoundland. They quickly imposed their ideas about health upon indigenous populations in the west, dismissing the long-established mysteries of the sweat lodge and aboriginal healing, and importing European infectious diseases and a lucrative trade in “fire-water.” In return, Europe saw the arrival of New-World merchandise, particularly tobacco and the potato. Despite the changes in scientific outlook, three-quarters of the Italian renaissance population remained rural peasants with little formal education, and in other nations of Western Europe ignorance also remained widespread. For the lower echelons of society, mere survival remained a harsh challenge to both health and physique.

Sports and Recreation The Renaissance saw changing patterns of habitual physical activity among the general population of western Europe, important influences including the migration of peasants into large cities, a ritualization of some “courtly” sports, Puritanism, and a growing range of sedentary occupations. Sports  The vigorous leisure pursuits of the Mediaeval aristocracy (Chap. 5) generally persisted into the Renaissance, influenced in part by the Italian quest for proficiency in “courtly” sports. Many forms of physical activity became more ritualized, with a shift from brute force to finesse, and a focus upon appearance, decorum and display. Social distinctions persisted, as some pursuits were restricted to those with

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adequate social standing, and other activities were considered as beneath those of noble birth. In England, the era of the Puritan Commonwealth exerted a strong negative influence on most forms of sport. We will comment specifically on participation in gymnastics, calcio, courtly sports, fencing, archery, walking, swimming and dancing. Gymnastics  The interest of European society in sport was such that the French physician Pierre Jean Burette (1665–1747 CE) wrote a book on the history of sport, and he spoke to the French Academy sixteen times on various aspects of the gymnasticon. He recognized three types of gymnastics: recreational, military, medical, and he was sufficiently impressed with the benefits of exercise that he used ball games and discus throwing extensively in the treatment of his patients. Calcio  In France, peasants continued the mediaeval practice (Chap. 5) of participation in a violent form of soccer (Soule) despite prohibitions from Philippe V (1293– 1322 CE) and Charles V (1338–1380 CE). But the Italian form of soccer (calcio) suffered none of the social stigmata aassociated with the vicious rural games of France and England (Fig. 6.2). Participation in the game of calcio was limited to those of appropriate social rank: “neither artificers, servants, nor low-born fellows, but honourable soldiers, gentlemen, lords and princes.” Players wore elaborate costumes, and spent much of their time parading before the pavilions of rival teams. A form of calcio is still played before large crowds in the piazza in Florence. The sand-covered field is a little smaller than a modern soccer pitch, but accommodates 27 calcanti per team (27 being the number of troops in tactical units of the Roman

Fig. 6.2  The sport of calcio was a stylized form of soccer played by the nobility in the main square of Renaissance Florence. From an illustration by Harald er Stjerna (1688 CE) (Source: http:// en.wikipedia.org/wiki/Calcio_Fiorentino)

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legions). Enthusiasm for calcio during the Renaissance was such that games continued throughout 1530 CE, when the city of Florence was under military siege. Courtly Sportss  Baldassarre Castiglione, count of Count of Casatico in Italy, attached considerable importance to the choice of socially appropriate pursuits by the aspiring courtier. In his First Book of the Courtier (1528 CE), the activities that he recommended included “huntyng, swimming, leapying, running, casting the stone, tenyse and vaultynge.” The last two sports were particularly desirable, being physically demanding, making a young man fast and nimble, and showing off his physical assets. Nevertheless, Castiglione insisted that the skill and physical prowess of the courtier were to be accompanied by modesty and even a hiding of personal ability. The Book of the Courtier was translated into English, and Queen Elizabeth I’s secretary reckoned that a reading of this text was of greater value to a young man than a three-year road trip to Italy. Fencing  Skills in sword-play largely disappeared during the Middle Ages, because warriors were clad in impenetrable armour. However, the art of fencing was revived by Marxbruder of Frankfurt, who in 1487 established a fencers’ guild (“Masters of the Long Sword”). A fencing manual was published by the Spanish warrior and diplomat Diego de Valera (1471 CE), but shortly thereafter fencing duels were banned by the Spanish monarch. Camillo Agrippa was one of the greatest of Italian exponents of fencing. He applied geometric theory to the analysis of armed combat in a book entitled “Trattato di scienza d’arme” (1604 CE). In England, schools for the art of self-defense had been banned by Edward I, but in 1540 CE Henry VIII authorized some instructors as “Professors of the Noble Science of Defence,” giving Letters Patent to the Company of Masters. Fencing instructors taught a variety of weapons, including the pike, rapier, quarterstaff, dagger and broad-sword. The lower classes of British society sometimes engaged in prize sword fights, with more wealthy citizens surreptitiously observing the conflict. Samuel Pepys noted in his diary for September 9th 1667: “there, with my cloak about my face, I stood and saw the prize fought, till one of them, a shoemaker, was so cut in both his wrists that he could not fight any longer.” Archery  Archery showed a steady decline during the Renaissance. Its military importance had long been over-shadowed by the eleventh century invention of gunpowder, although a late archery battle occurred in the British Civil War, when a local militia defeated unarmoured musketeers near the town of Bridgnorth (1642 CE). Recreational archery was still encouraged through the personal participation of Henry VIII and Elizabeth I. During one exhibition match in 1520 CE, Henry VIII hit the bull’s eye at a distance of 219 m. Roger Ascham (then tutor to Princess Elizabeth) published the book “Lover of the Bow” in 1545 CE; he commended use of the long bow as a manly sport. Archery was also warmly commended by the English poet Gervase Markham (1568–1637 CE); in his “Art of Archerie” he wrote: “Shooting…. is an honest pastime for the mind, and an wholesome exercise for the Body, not vile

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for great men to use, nor costly for poor men to maintain.” In the Scottish highlands, archery continued to be popular following the defeat of the Jacobites, since the carrying of other weapons was then prohibited. Badminton  An early form of Badminton was popular in western Europe during the Renaissance. The German travel writer Lupold Von Wedel (1544–1614 CE) noted: “On the 26th [August] I and my companions went to see the queen’s palace…. named Weittholl…. we first saw the tilt-yard, besides a ball-house, where they play at featherballs.” In 1602 CE, the diarist John Manningham further commented: “The play at shuttlecocke is become soe muche in request at Court, that the making of shuttlecockes is almost growne a trade in London.” Courtly approval of badminton was helped by the fact that James I strongly disapproved of violent sports. Swimming, fishing, tennis and billiards all became popular for this reason. In Leicester, the popularity of badminton became such that Shrove Tuesday was renamed Shuttlecock Day. Badminton was also popular in Renaissance France, with Rabelais (1534 CE) making an early reference to the placing of a cord between opposing players. Walking  Active transportation has always been a good source of physical activity. However, foot travel was no easy matter in the Renaissance world, and most of the Roman roads which once criss-crossed Europe had become rough lanes beset by robbers. In England, a Bailiff’s license was needed before walking any great distance; the main objective of this regulation was to prevent the spread of disease, and wandering actors and peddlers were usually viewed with great suspicion. Nevertheless, local peasants who did not own a horse would walk to church on Sundays and Saints’ days, and at least once a week they would travel distances of 10–15 km to and from the local market town. On occasion, they would also join in longer pilgrimages, such as that described in the Canterbury Tales. The British schoolmaster Richard Mulcaster (1581 CE) commended moderate walking: “nature her selfe seemeth to have appointed walking, as the most natural traine that can be” Some Londoners heeded Mulcaster’s advice. Samuel Pepys would often walk down Whitehall, or go for a stroll in Hyde Park. Distance walking also began to attract the interest of bookmakers, with an initial focus on the “footmen” who journeyed ahead of the aristocracy making appropriate arrangements for overnight lodgings. Footmen were hired in terms of an exceptional walking speed, and the nobility often wagered the ability of their staff against that of their peers. Sir Robert Carey (1569–1639 CE), first cousin of Elizabeth I, walked 550 km from London to Berwick in 1589 CE, winning a £2000 wager in the process. He went on to walk 3200 km across Europe in 41 days. Charles II (1630–1685 CE) was also said to have walked frequently between Whitehall and Hampton Court Palace. He was never overtaken on this 22 km journey, although perhaps this was more a matter of etiquette than a consequence of his exceptional walking speed. Swimming  Swimming is not mentioned among the leisure pastimes of apprentices that were listed by William Fitzstephen in his account of life in twelfth century

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London. Nevertheless, he observed water-jousting contests on the River Thames, and these events presumably required some swimming ability. The mediaeval poet William Langland also wrote of men swimming in the Thames in Piers Plowman (c. 1370 CE). In 1425 CE, “diverse persons of low estate” gathered on the banks of the Thames to taunt Cardinal Beaufort, bishop of Winchester, saying that they would throw him into the river and teach him to swim with wings. This comment suggests that swimming instructors may already have been using flotation devices. However, Renaissance women were still expected to limit their contacts with water to the minimal needs of washing their bodies. The schoolmaster Richard Mulcaster considered swimming a good exercise, provided care was taken to ensure water quality. Given the pollution of most Renaissance waterways, public swimming was certainly a mixed blessing, although there does not seem any analysis of the diseases contracted from exposure to contaminated water. In his De arte natandi, one of the instigators of the gunpowder plot (Everard Digby, c. 1550–1606 CE) approached swimming from a scientific point of view; he concluded that the breast-stroke was the most useful swimming technique. In Italy, Leonardo da Vinci made early sketches of life-belts, and in 1539 CE a German Professor (Nikolas Wynmann) published a swimming manual which described both the breast-stroke and the use of flotation devices such as cow bladders and cork belts. Dancing  Dancing played a major role in Renaissance court life. In England, formal dances came under the authority of the Revels Office. Such events provided not only recreation, but also an opportunity to honour the monarch, and to illustrate the movement of the celestial bodies. Court dances gradually evolved into theatrical spectacles. Male participants found opportunities to display strength, stamina, agility, grace and skillful footwork, and the ladies delighted in displaying their beauty as passive members of the pageant. Some accused Sir Christopher Hatton (1540– 1591 CE), Chancellor of England during the reign of Elizabeth I, of winning his appointment by his skills on the dance-floor rather than by his intellect. The opening dances of court spectacles were open only to those thoroughly trained in the appropriate protocol, but after the stately presentations concluded, the music shifted up-tempo, and all were welcome to participate tin livelier forms of dance. As a young king, Henry VIII loved to dance the night away. The Milanese ambassador commented: “From late evening to dawn Henry hopped and dipped and bowed, dancing magnificently in the French style.” Queen Elizabeth I also loved to exhibit her skills on the dance floor, and particularly enjoyed La Volta, a dance where her partner threw her high in the air to display bare thighs. James I had less ability as a dancer, although he enjoyed being the patron of masques; his partner, Queen Anne of Denmark, often took a starring role in such events. Social dancing was also popular among the prosperous middle-class. The man of the house was expected to read sheet music and play the lute for evenings of singing and dancing. Even older members of the family would join in the Pavane, a dance where the feet never left the floor.

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The peasantry held much of their dancing outdoors, since their living quarters were very small. The village musicians could not afford sheet music, so they repeated a limited musical repertoire on the pipe, tabor and fiddle. Often, the dance moved in round, square or rectangular formations, with simple steps but a brisk pace.

Habitual Physical Activity The countryside pursuits of the poorer citizens continued much as in Mediaeval times (Chap. 5). Wool production dominated the Tudor economy, and spinsters would walk as much as 30 km a day when operating a primitive spinning wheel. Sheep drovers covered very long-distances when taking their flocks to market, for example a trek from the mountains of Snowdonia to markets in East Anglia. Often, rural peasant-farmers sought a second income in occupations such as mining, or smelting the lead that was required to roof churches and abbeys. They also walked substantial distances to and from their places of employment and when visiting friends. However, a growing proportion of former agricultural workers migrated to cities, and there they found sedentary occupations within the new Guild structures. The introduction of sedan chairs around 1512 CE progressively reduced the need for active commuting by middle-class city-dwellers. Given the unsanitary and sometimes dangerous condition of city streets, wealthy burghers quickly switched to this method of travel, and soon most had their own sedan chair standing in the front hall. Rental chairs also became widely available. In 1668 CE, Samuel Pepys recounts that when he and his family were visiting Bath they were collected from their rooms at an early hour, carried to the baths and after soaking in the waters for two hours: “wrap in a sheet and in a chair…..carried … home to bed sweating for an hour …” By 1634 CE, the City of London had established a licensing authority. and rental chairs became available at a price that could be afforded by less wealthy citizens.. Single journeys were priced at 6d, and 4 shillings rented a chair for the day. The sedan chair carriers continued to ply their trade until the early nineteenth century, when their services were displaced by horse-drawn hackney carriages. During the Great Plague (1665 CE), the City of London even used sedan chairs to carry victims to their homes or to an isolation ward, in an attempt to limit spread of the disease. By the eighteenth century, the Royal Infirmary in Edinburgh had added a sedan chair service to its emergency department, allowing patients to be carried directly into the operating theatre.

Health and Fitness During the Renaissance, Greek ideals that had glorified the human body found renewed acceptance. Once again, it became acceptable to talk about the physical body, to explore its workings, and to contemplate possible methods of enhancing its

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function. In looking at the views of scholars from this epoch, some historians have distinguished verbal realists, who sought a strong body to help the mind in a search for piety), social realists who saw physical education as contributing to the development of an integrated personality, and scientific realists who valued fitness for its contribution to health and the ability to learn. During the Middle-Ages, acceptable measures to ensure good health had been codified by the established church. However, as the Renaissance progressed, a variety of tactics were advocated by scholars, political leaders, religious firebrands and university administrators. Scholars  Many Renaissance scholars had little interest in promoting regular physical exercise, but we can highlight a brief roster of scholars who commended an active lifestyle; these include Mendez, Castiglione, Mercuriale, Paré, Joubert, Duchesne, Cagmatis, Cogan, Leonardo and Michelangelo. Mendez  Cristobal Mendez (c.1500- 1553 CE) spent much of his life in Mexico, and was scrutinized by the Spanish Inquisition because of his interest in deciphering Zodiacal inscriptions. He wrote a 72-page text entitled Libro del Exercicio (1553 CE) where he defined exercise as: “a voluntary motion upon which ventilation becomes fast… and frequent.” He concluded that exercise was beneficial because it created heat, aided digestion, and rid the body of superfluities: “exercise was invented and used to clean the body when it was too full of harmful things.” Castiglione  Castiglione (1478–1529 CE) was an Italian soldier and courtier. In his “Book of the Courtier” (above) he advocated various physical activities to attract favourable attention at court and to develop the strength, suppleness and speed that a young man needed in battle. Recommended pursuits included horseback hunting, running, leaping, swimming, casting stones and tennis. Mercuriale  Girolamo Mercuriale became Professor of Practical Medicine at the University of Padua in 1569 CE.  After translating the works of Hippocrates, he published a six-volume book on gymnastics (De Arte Gymnastica) (Fig. 6.3). This text was largely a reiteration of classical views on exercise and health. He recognized three types of exercise: gymnastica medica, intended to enhance health; gymnastica bellica, intended to prepare a person for war; and gymnastica atletica, exercise that was taken for its own sake. He distinguished between the preventive and therapeutic value of exercise, and cautioned against the dangers of over-exertion. However, he replaced the passive movements advocated by many Renaissance physicians with activities that demanded heavy breathing. His recommendations including walking, mountain climbing, running, jumping, rope climbing, wrestling, and ball games, also describing activities specifically adapted for convalescents and weaker older people. Unfortunately, his reputation as a physician took a serious hit in 1576–1577 CE, when he made the mistake of arguing against the need for quarantine measures in Venice during an outbreak of the bubonic plague. Paré  After qualitying at the Hôtel-Dieu, the oldest teaching hospital in Paris, Ambrose Paré (1510–1590 CE) was appointed as a military surgeon. He was a

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Fig. 6.3  Gymnasts, as illustrated in the book De Arte Gymnastica, written by Mercuriale in 1573 CE (Source: http://www. google.ca/ imgres?imgurl=http://2. bp.blogspot.com/_ HbaApmpa-Po/ TSRGtL8j2gI/ AAAAAAAADKk/ ZLdPJMDeVfk/s400/six. jpg)

strong advocate of exercise. Because he could not speak Latin, some colleagues looked askance at his views. But just because he used the vernacular in his practice, his ideas became accessible to those apothecaries and barber/surgeons who had only a limited education. One of his more important suggestions was that moderate exercise should follow rapidly on the treatment of fractures. He also advocated vigorous exercise when treating the common cold. Joubert  Laurent Joubert (1529–1583 CE), Chancellor of Montpellier University, in southern France, became personal physician to Catherine de Medici. Like Paré, he wrote in the vernacular. His Erreurs Populaires challenged many established medical concepts. He argued that adolescence was a period of natural robustness, when exercise was particularly important; he also recommended that all people should take an hour of exercise per day, and he introduced a course on Therapeutic Gymnastics into his medical curriculum. Duchesne  The pharmacologist Joseph Duchesne had a strong belief in the value of chemical medication. He became physician to Henry IV of France. In the context of fitness, he is best remembered for his Ars Medica Hermetica (1604 CE), which

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recommended swimming and gymnastics to promote: “deliverance from superfluous humours, the regulation of digestion, the strengthening of the heart and joints, the opening up of the pores of the skin, and the stronger circulation of the blood in the lungs by strenuous breathing” He was the first physician to recommend swimming for its conditioning value, rather than tas a precaution against accidental drowning. Cagmatis  Marsilius Cagmatis (1543–1612 CE), a Veronese physician, wrote “The preservation of health;” in this book, he asked physicians to introduce rowing into school gymnastic programmes. Cogan  Thomas Cogan (1545–1607 CE) was a physician who became Master of Manchester Grammar School. His book “The Haven of Health, made for the comfort of students” (1584 CE) suggested that sedentary ways made students vulnerable to sickness. Cogan particularly liked tenise because it exercised: “all parts of the body alike, as the legges, armes, neck, head, eyes, backe and loynes.” Leonardo da Vinci  In his sketch of the “Vitruvian Man” (Fig. 6.4), Leonardo da Vinci (1452–1519 CE) summarized Renaissance thinking on the symmetry of an ideally proportioned human body and, by extension, he argued for the symmetry of the universe. Leonardo himself exercised regularly, believing that one should accept personal responsibility for health and wellness, and he developed sufficient muscular strength to bend horseshoes. One of his many inventions was an early form of pedometer, although this instrument was designed for military use, rather than as a means of monitoring personal exercise programmes. Michelangelo  The Italian sculptor and painter Michelangelo (1475–1564 CE) greatly influenced Renaissance impressions of the ideal human physique through his art. He saw the human form as the physical symbol of both soul and character; an athletic body had a god-like quality, and physical beauty indicated an underlying spiritual and moral beauty. Political Leaders  A wide range of attitudes towards physical activity can be discerned in Renaissance royalty and the leaders of the short-lived English commonwealth. We will look at just a few, including Henry VIII, Queen Elizabeth I, James I, Charles I, and leading figures in the short-lived Commenwealth and among the Pilgrim Fathers. Henry VIII  Henry VIII was a keen athlete as a young man, and he seems to have realized the importance of sport to health and physical condition. He enjoyed a challenging game of tennis, wrestling, fencing, running, throwing events, ball games and dancing, and was an enthusiastic participant in various forms of horsemanship. However, he neglected exercise as he aged, due in part to a festering leg wound that followed injury in a jousting match. Henry became grossly obese, eventually reaching a body mass index > 52.0 kg/m (Fig. 6.5). He also suffered from severe circulatory problems, and indeed a part of his excess body mass may have been oedema fluid rather than body fat. Eventually, 4 strong men were needed to carry him from room to room as he sat on a velvet-padded chair known as “the King’s tram.”

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Fig. 6.4  Leonardo da Vinci’s sketch of the Vitruvian man, from about 1490 CE (Source: http:// en.wikipedia.org/wiki/Vitruvian_Man)

Queen Elizabeth I  Queen Elizabeth I (1533–1603 CE) was a skilled horse-rider and an accomplished archer. Other favourite pursuits were hawking, long walks, dancing, and watching tennis, jousting and the baiting of bears. Early in the course of her reign, new horses were imported from Ireland, because the available mounts in her stable were neither fast nor strong enough for the Queen’s taste. Elizabeth often spent time at hunting lodges on the outskirts of London. According to legend, she galloped her spirited steed up the staircase at the Chingford Lodge on hearing of the defeat of the Spanish Armada. James I  As a young man, James I preferred male to female company. Possibly for this reason, his book on Kingship not only advised against excessive drinking and sleeping, but also listed sodomy among: “those horrible crimes which ye are bound never to forgive.” In his “Declaration concerning Lawful Sports” (1618 CE), James I rebuked Puritan clergy who were:“unlawfully punishing of our good people, for using their lawful Recreation and honest exercises upon Sundays and other holidays, after the

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Fig. 6.5  Henry VIII was fit and athletic as a young man, but his habitual physical activity was greatly reduced when he developed a festering leg wound. He continued to eat unabated, and towards his death he had reached a body mass index of 52 kg/ m2 (Source: http://en. wikipedia.org/wiki/ Henry_VIII_of_England)

afternoon sermon or service.” In the view of James, “the meaner sort…who labour hard all the week… should be allowed to engage in lawful recreations” and this would make “their Bodies more able for war.” The barrister Michael Dalton (1635 CE) noted that King James I had authorized: “Dauncing of men and women, Archery, Leaping, Vaulting, May games, Whitson Ales, Moris dances, and setting up Maypoles… no such honest mirth or recreation should be forbidden … Sunday or holy dayes, after divine service ended.” However, James warned against the violent village form of football as:”meeter for mameing than making able the [players] thereof.” Bear-baiting, and bowling were also prohibited, and any who refused to first attend the parish church were denied the privilege of participating in Sunday games. Charles I  Charles I reissued James’ declaration on lawful sports in 1633 CE.  Additional clauses covered countryside festivals (wakes and ales). However, many church ministers with Puritanical leanings refused to read the revised declaration from their pulpits. In terms of personal interests Charles I played golf, frequented bowling lanes and enjoyed riding to hounds. The Commonwealth  During the Commonwealth (1649–1660 CE), Oliver Cromwell and his Roundhead adherents quickly reversed positive attitudes towards physical activity, and James I’s Book of Sports was publicly burned. Work and piety were regarded as synonymous, and any form of play was seen as an offense to the Puritans’ Lord. Thus, the Commonwealth government moved rapidly from an attack on Sunday sport to a banning of all types of leisure activity. Even walking (other than to church on a Sunday) could reap a hefty fine. In The Pilgrim’s Progress, the Puritan writer John Bunyan (1628–1688 CE) admitted his recurrent wickedness, as he returned to his favourite game of “Cat,” a predecessor of baseball:“I shook the

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sermon out of my mind and to my old custom of sports and gaming I returned with great delight.” There were occasional more moderate voices among the Puritans, but even they took life very seriously. John Milton (1608–1674 CE) thought that physical strength was worthy if “like Sampson’s, it is used for good purpose.” Richard Baxter (1615– 1691 CE), in his “Directions about Sports and Recreation,” warned against overexertion and expense; in his view, Christians should use their money and time more wisely than hunting with dogs. Thomas Gouge (1609–1681 CE), a Puritan minister from East London, also warned against spending too much time in active recreation; he saw moderate physical activity mainly as a means of boosting productivity. Under pressure from the Puritans, Charles I promulgated an “Act for Punishing Divers Abuses Committed on the Lord’s Day, called Sunday.” This legislation prohibited bear-baiting, bull-baiting, interludes, common plays and other unlawful exercises and pastimes on the Lord’s Day. The net result was that all sporting activities remained effectively prohibited for commoners until introduction of the Saturday half-holiday offered a time other than Sunday for recreation. Pilgrim Fathers  Somewhat in parallel with the English Commonwealth, the Pilgrim Fathers established a Calvinist colony in New England in 1620 CE. The initial antipathy to sport and games was at least as fervent as that shown in England. However, some settlers such as John Winthrop (1587–1649 CE), Governor of the Massachusetts Bay Colony, recognized that there were dangers in abstinence from active leisure: “When I had some tyme abstained from suche worldly delights…I grewe unto a great dullnesse and discontent:…. findinge it needfull to recreate my minde with some outward recreation, I yielded unto it, and by a moderate exercise herein was much refreshed . .” Charismatic Clerics  A number of charissmatic clerics such as Luther, Calvin, Knox and Rabelais all had a strong influence on Renaissance opinions concerniing health and fitness. Luther  Martin Luther (1483–1556 CE) was physically imposing as a man. But in stark contrast with many mediaeval clerics, he was both fleshy and obese, the epitome of a bon vivant who was opposed to the physical deprivations of the monastic age. Luther wrote approvingly of the recreational and moral value of physical exercise:“ I pronounce in favour of … the knightly sports of fencing and wrestling of which the one drives care and gloom from the heart and the other gives a full development of the limbs. And… they keep men from tippling, lewdness, cards and dice…” Although approving of exercise in principle, he seems to have found little time himself for physical activity, and certainly did not accept our modern insistence on the virtues of a low body fat content. Calvin  John Calvin (1509–1564 CE) was another Renaissance cleric who did not support the asceticism of mediaeval monks. Nevertheless, he sought to regulate active recreation as a means of perfecting moral discipline. He himself went for long walks, played bowls and quoits, and when writing the rules for his Geneva Academy, he recognized that children needed play and sport. Thus, he allotted time

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for recreation on Wednesdays, although the instructor was to avoid undefined “silly sports.” He was opposed to forms of physical activity that attracted gambling, and he banned as many as 200 pursuits which had previously been prevalent in Geneva. Knox  John Knox (1514–1572 CE) led the protestant reformation in Scotland. During the reign of the catholic monarch Mary Tudor (1516–1558 CE) he was exiled to Geneva; there, he met Calvin, and adopted many of his ideas. Little is recorded about his attitude to sport, but it probably mirrored the deliberate and purposeful views of Calvin. François Rabelais  Francois Rabelais (1483–1553 CE) was a French physician and humorist who became a Franciscan friar, and then entered the University of Montpellier. He favoured regular exercise, writing: “Nature made the day for exercise, work and seeing to one’s business…Your diet must correspond with your exercise in the open air. ..” He further commented: “the late Mr. Othoman Vadare, a great doctor…told me many a time that the lack of bodily exercise is the sole cause of the paucity of health and shortness of life of you gentlemen and all officers of the law…” University Administrators  The mediaeval university curriculum comprised grammar, rhetoric, logic, arithmetic, geometry, music, and astronomy. During the Renaissance, some European universities supplemented this with games and exercises. In contrast, the administrators of English universities expressed active opposition to sports and games, particularly during the Puritan Commonwealth. Policies at the Universities of Cambridge and Oxford  The universities of Cambridge and Oxford accepted any sport participation with great reluctance. Roger Goad(e), Vice-Chancellor at Cambridge ordered (1595 CE): “That the hurtfull and unschollerlike exercise of Footeball… doe from henceforth utterly cease (except within places severall to ye Colledges, and that for them only that be of ye same Colledge).” Oxford University adopted a similar policy to Cambridge. Six years after becoming Chancellor at Oxford, William Laud (1573–1645 CE) promulgated the Laudian Code, which banned ball-playing in the private yards and greens of the townsmen; students were enjoined to avoid: “every kind of sport or exercise, whence danger, wrong or inconvenience may arise to others.” The Laudian Statutes specifically forbade either participation or watching of other activities such as fencing and rope dancing, particularly if gambling was involved. Stubbes  The Puritan social reformer Philip Stubb(e)s (c. 1555–1610 CE) attended both Oxford and Cambridge Universities, but seems to have graduated from neither. In a book called “The Anatomie of Abuses” he attacked many Renaissance amusements. In regard to football, he commented:“Any excercise which withdraweth us from godlines, either upon the sabaoth, or any other day els, is wicked & to be forbiden … as concerning football playing: I protest unto you, it may rather be called a friendly kinde of fight, then a play or recreation.”

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Stubbs also expressed strong opposition to the pleasures of the hunt and to the village Maypole dances; in his view, the latter often had an explicit sexual connotation. Dalton  Michael Dalton (1564–1644 CE) became Justice of the Peace for the City of Cambridge. He argued that he had the authority to: “enter into any common house or place, where any playing at dice, Tables, Cardes, bowles, coyts, logats, shove-groat, tennis, casting the stone, football, or other unlawfull game, now invented, or hereafter to bee invented, shall be suspected to bee used; And may arrest the keepers of such places and imprison them…” European Universities  The attitudes of European universities to sport varied with their religious affiliation. Ignatius Loyola (1491–1556 CE), Spanish founder of the Society of Jesus, recognized that in his early life he had devoted too much time to fasting, and in a letter to the Duke of Gandia, Loyola urged him to “seek every possible means to strengthen the body.” Cardinal Nicholas of Cusa (1401–1464 CE), papal legate to Germany, also wrote about the cultural and human significance of play in relation to spiritual life in a book entitled “The game of spheres.” His work discussed the creation of the world in relation to a new ball game he had discovered on a visit to Bavaria. As a part of the more open policy to sport, German women were allowed to participate in races during the fifteenth century. In sixteenth century Italy, the Medici were eager sponsors of jousting. Italian students were expected to be competent in every noble exercise, including riding, fencing, running, leaping, swimming and dancing. Again, this involvement in sport apparently had a beneficial impact upon female emancipation. The first Venetian regatta for peasant women in 1493 CE attracted as many as 50 entrants.

Practical Implications for Current Policy One important stimulus to Renaissance investigators was invention of the printing press. This brought the latest scientific findings to the laboratory bench, written in the vernacular rather than in some obscure foreign language. One may wonder whether modern developments in communication- the appearance on-line of books and journals, open access publication, and the growing ability to translate foreign texts electronically may lead to a further striking renaissance of discovery. Another major factor contributing to the blossoming of science during the Renaissance was the emergence of wealthy sponsors who literally gave “carte blanche” to the research of their protégés. Governments have sometimes offered similar unrestricted support to investigators, but in more recent times there has been a trend to require research directed to issues that the government at least momentarily thinks of importance; too often, such government priorities shift even before the research is fully launched. Even more unfortunately, there is currently a trend to shift responsibility for research funding to commercial enterprises, where aims are very narrowly defined. Unless

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this tendency is reversed, and mechanisms emerge to support non-directed research, we may soon find ourselves pushed back into a second “dark age” where few new ideas appear. The Renaissance shift from spontaneous games with few rules to ritualized sports helped to curb the injury rates of participants, but it also reduced physical activity levels. Many commoners found themselves excluded from a wide range of sports because of their low social rank. Nevertheless, there were opportunities for the poor to obtain a substantial volume of physical activity through walking, running, swimming, and rural dances. In today’s more egalitarian society, there still remain social barriers to some recreational pursuits (exclusive club memberships, expensive clothes and equipment). Too often, the ordinary people are content to become mere spectators, couch surfing before a television screen with large quantities of beer and unhealthy snacks as they watch the activities of the elite. But as during the Renaissance, for those who wish to maintain their fitness, there remain physical activity options for working-class people that are not expensive and can help to maintain good health. Prohibition and regulation were singularly unsuccessful in eliminating gambling on the outcomes of Renaissance sport, and gambling continues a major social problem today, with not only addiction to wagering, but also evidence that crime syndicates sometimes attempt to “fix” the outcome of major competitions to increase their winnings from gambling. The sedan chair brought the temptations of passive commuting right to the doorsteps of the Renaissance middle-class. Today, the trend for people to engage in less and less active transportation continues; possibly, this will be exacerbated as “driverless” cars and taxis become widely available. Nevertheless, health professionals have recognized the importance of encouraging active commuting. For the average employee, a daily journey to and from the place of work often meets minimum weekly exercise requirements, and is much less readily forgotten that attendance at a formal exercise class. But most municipalities still require major changes in infrastructure, such as the construction of separate cycle paths, in order to foster this type of physical activity. The puritan government during the period of the English commonwealth had a strongly negative influence upon opportunities to engage in physical activity. One of the longest shadows was cast by the Lord’s Day Observance Act, which determined public policy for several centuries. As highlighted in the film “Chariots of Fire,” the problem persisted as late as the Paris Olympic Games of 1924, when as a staunch Calvinist (Eric Liddell) refused to run a race because he believed that Sunday should remain a “day of rest.” In English Canada, the Presbyterian Church still supported rigid laws on Sunday observance until the mid 1950s. In contrast, French Canada welcomed Sunday as an opportunity not only to attend Mass, but also to enjoy the physical opportunities offered by time away from work. As early as 1906 CE, Québecois members of the Federal legislature sponsored an amendment to the Canadian Lord’s Day Observance Act allowing the Attorney General of each Canadian Province to decide upon local implementation of the Bill.

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There remain those of various faiths who have particular sacred days and festivals, and where possible sport and recreational programmes need to be tailored to meet their needs, With vast world-wide migrations, one particular issue to day is the need to accommodate times of training and competition to the large groups of Muslim émigrés who choose not to eat or drink during daylight hours for the month of Ramadan.

Questions for Discussion 1. Is the lack of active commuting a significant factor in current low levels of health and fitness? Do you think that measures to encourage active commuting by companies and municipalities could have a major impact upon population health? 2. Do you think that there are opinion makers today who could encourage greater population health and fitness? Who do you think might fulfill such a role? 3. Do you think that the rigid prohibition of Sunday sport by the Puritans had any merit? 4. Should university administrations become actively involved in promoting health and fitness among their students?

Conclusions Many factors contributed to a sudden upsurge of scientific knowledge during the Renaissance, including a westward migration of Greek scholars who had been expelled from Constantinople, the emergence of wealthy research sponsors, the development of the printing press (with a much wider circulation of technical books), and a relaxation of ecclesiastic control over institutions of higher learning. The effervescence of scientific enquiry brought about a clearer understanding of both the universe and of human anatomy and physiology. Leading thinkers rejected the tradition of asceticism as physicians and scholars began to think in terms of developing the physical body as well as the human soul. And for at least a minority of the population, regular participation in exercise and sport was seen as an important factor in maintaining good health. A large segment of the general population continued to toil for long hours as agricultural labourers, but the seeds of sedentarism were sown among those who had migrated to the growing cities of Europe. Here, newly established Guilds offered what was often sedentary employment, with few opportunities for recreation. For the wealthy, the trend to a reduction of habitual physical activity was exacerbated as active transportation was replaced by the luxury of transportation in sedan chairs. In many European courts, a vigorous interest in sport was carried over from the Middle Ages, but sport for this elite population evolved in the context of court life. Pastimes became highly stylized, and sometimes demanded much less

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physical effort. In Commonwealth England, the power of Puritan clerics had a strong negative influence upon sport, and this was reflected in the practice of major universities, where games such as football were seen as an unwarranted distraction from both religious observance and academic study.

Further Reading Byrne JP. Health and wellness in the Renaissance and the Enlightenment. Santa Barbara, CA, ABC-Clio, 2013, 259 pp. Cipolla C. Public health and the medical profession in the Renaissance. Cambridge, UK, Cambridge University Press, 1976, 139 pp. Cohen ES, Cohen TV. Daily life in Renaissance Italy. Westport, Conn, Greenwood Press, 2001, 319 pp. Febvre L, Martin H-J. The coming of the book. London, UK, Verso Publications, 1976, 385 pp. Krebs RE. Ground-breaking scientific experiments, inventions and discoveries of the Middle Ages and the Renaissance. Westport, Conn, Greenwood Press, 2004, 321 pp. Leibs A. Sports and ganes of the Renaissance. Westport, Conn, Greenwood Press, 2004, 211 pp. McLelland J.  Body and mind. Sport in Europe from the Roman Empire to the Renaissance. Abingdon, OX, Routledge, 2007, 186 pp. Prioreschi P. A history of medicine: Renaissance medicine. Omaha, NB, Horatius Press, 2007, 801 pp. Ranger T, Slack P. Epidemics and ideas. Essays on the historical perception of pestilence. Cambridge, UK, Cambridge University Press,1992, 351 pp. Saliba G. Islamic science and the making of the European Renaissance. Boston, MA, Massachusetts Institute of Technology, 2007, 315 pp. Siraisi NG.  Mediaeval and Renaissance medicine. An introduction to knowledge and practice. Chicago, IL, University of Chicago Press, 1990, 250 pp. Wear A, French RK, Lonie LM. The medical Renaissance of the sixteenth century. Cambridge, UK, Cambridge University Press, 1985, 355 pp.

Chapter 7

The Enlightenment: How Far Did Reason and Religion Influence Health and Fitness in an Age of Industrialization?

Learning Objectives 1. To see the impact of logical reasoning upon concepts of human health and fitness. 2. To understand how the desire to display new found wealth limited the benefits from many forms of physical activity for the aristocracy. 3. To note the effects of progressive industrialization upon the health and fitness of city dwellers. 4. To examine and evaluate the range of ideas on exercise expressed by physicians, prominent philosophers and the leaders of new religious denominations during the Enlightenment.

Introduction The Enlightenment, which began around 1650  CE, was an age when enquiring scholars and philosophers sought to replace tradition, superstition and theological diktat by logical reasoning. Rapid urban growth, industrialization and early forms of mechanization challenged the health and fitness of many city dwellers. Logic and the mathematical treatment of observations now became the exclusive source of authentic knowledge. Beginning from an appropriate set of principles, logic suggested a conclusion; this was then tested against available evidence, and the underlying principles were revised accordingly. People began to envisage individual living creatures and the universe as a whole in mechanical terms. It no longer seemed necessary to postulate the intervention of a benevolent or a capricious God in the course of human affairs. The ferment of the Enlightenment was particularly strong in France, where new ideas were vigorously debated in the salons of wealthy ladies and at the Académie des Sciences (founded in 1668 CE). In London, the Royal Society fulfilled a similar © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_7

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function to the Académie. A monumental 35 volume encyclopedia “Dictionnaire raisonné des sciences, des artes et des métiers,” was published by Diderot and LeRondde Jambert in 1778 CE; it summarized all the new ideas of the age. During the final decade of the eighteenth century, the Romantics (led by conservative clergy) argued that Enlightenment thinkers had been excessively reductionist, and that greater place should have been given to imagination, sentiment and mysticism. Traces of this viewpoint can still be found among some physical educators who prefer a qualitative to a quantitative description of the phenomena associated with physical activity. A push towards universal public education brought instruction to a much greater proportion of Europe’s children. Scholars such as John Locke and Jean Jacques Rousseau saw the importance of shaping young minds at an early age, and they underlined the important contribution of physical activity to this process. However, many teaching institutions still paid little regard to the need for regular physical activity (Chap. 19). The Enlightenment saw growing waves of Europeans settling in the United States and Canada, both economic migrants and those who had rebelled against a rigid theocracy or an autocratic government. Early French settlers focussed on the fur trade, which did not require the development of large cities. In contrast, English Canada and the United States became populated by farmers, with homesteads grouped around progressively expanding market towns.

Habitual Physical Activity Many factors conspired to decrease the habitual physical activity of wealthier citizens during the Enlightenment. Elaborate tastes in clothing militated against the adoption of an active life-style by either sex. In Europe, active transportation had already been curtailed by the introduction of sedan chairs (Chap. 6). This chapter notes an exacerbation of the trend to sedentary transportation, as wealthy people replaced sedan chairs by coaches, and made rapid inter-city trips along newly-constructed turnpikes. Among poorer people, there was little change in agricultural practices, but in the cities technical innovations, first water and then steam power lightened the physical demands on many workers. Nevertheless, long hours of work, a lack of paid holidays, grinding poverty and over-crowding left most of them with little opportunity for active leisure. Physical Demands of Traditional Agriculture  Most agricultural workers continued their hard daily toil in both Europe and North America throughout the Enlightenment. In Canada, clearing a plot of land, constructing a simple cabin and barn and cultivating crops with a minimum of tools provided more than adequate physical activity for the average settler. Likely daily energy expenditures from this era can be gauged from studies of sects such as the Old-Order Amish, who today still use few mechanical aids in their agriculture (Fig. 7.1). In 2003, average pedometer

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Fig. 7.1  Traditional Amish families today still follow a lifestyle typical of the eighteenth century, with little use of mechanical equipment. They thus provide a window into agrarian life during this era, with evidence of a high daily energy expenditure, a good level of physical fitness and low obesity scores (Source: http://en.wikipedia.org/wiki/Amish_way_of_life)

readings for the Amish population were 18,425 steps/day for men and 14,196 steps/ day for women, compared with typical figures of 7500 steps/day for the current generation of urban North Americans, and 10,000 steps/day for those who are now taking the minimum volume of daily exercise recommended by Public Health Agencies. The routine of Amish farmers still comprises 10.0 h/week of vigorous and 42.8 h/ week of moderate physical activity, plus 12.0 h/week of walking. Corresponding figures for the Amish women are 3.4 h/week of vigorous and 39.2 h/week of moderate physical activity, with 5.7 h/week of walking. The present generation of Amish children remains at least as active as their parents. Pedometer readings for the boys show counts of 17,200 steps/day (>20,000 steps/day on weekdays) and average figures for the girls are 13,600 steps/day, compared with averages of 11,000 and 10,000 steps/day reported for contemporary North American boys and girls. The Amish school curriculum generally includes no allocation of time for formal physical education, and indeed students may remain in a small classroom throughout the school day. On the other hand, the children spend much of their lunch break and two recesses in active games such as volleyball and softball, played under the supervision of their teachers. The main sedentary period is on Sundays, when children travel to church by horse and buggy, and then sit through a long religious service. Transportation Along Turnpikes  In Britain, road maintenance had traditionally been the duty of Parish Councils; they were supposed to collect the necessary taxes and enforce repair work upon local residents, but often failed to do so. However, there was a major change in responsibility in 1738 CE, when parliament authorized the creation of Turnpike Trusts; these Trusts built roads that were adequate to cope with expanding inter-regional trade, and served to counter the potential military threat posed by Napoleon’s armies (Fig. 7.2). Journeys that had required grueling effort on foot or on horseback over appalling roads could now be completed in the relative comfort of an enclosed coach. Trips that previously had taken four or five exhausting days could now be completed in a single day. By 1760 CE, 300 British Turnpike

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Fig. 7.2  Hyde Park Gate was the first toll-point encountered by travellers on the London to Bath Turnpike during the eighteenth century (Source: http://en.wikipedia.org/wiki/Turnpike_trusts)

Trusts controlled a network of 16,000 km of well-graded roads, and at their zenith in the 1830s, tolls were being collected at over 8000 gates along 32,000 km of highway. Ownership of one or more coaches became the norm for the elite. The mere idea of walking to a neighbour’s house was frowned upon, and lack of access to a coach was likely to confine a genteel young lady to her own home. However, the arrival of the railways signaled an abrupt end to Turnpikes in Victorian England (Chap. 8). In seventeenth century Canada, the population density was insufficient to permit construction of many inter-urban turnpikes, although a 7 metre-wide roadway (the 280 km Chemin du Roy) was built between Quebec City and Montreal in 1734– 1737  CE.  Most journeys in Enlightenment Canada were still made by water. Propelling a canoe against the stream remained an arduous task, and journeys were all too frequently interrupted by rapids, where overland portage of both canoe and baggage was required. During the winter months, short journeys could also be made by horse-drawn sled or on foot (wearing raquettes). In the U.S., the New York State legislature authorized construction of the Great Genesee Road towards Buffalo in 1794 CE, and this highway was later privatized, to become the Seneca Turnpike. Construction of the Erie Canal in 1825  CE ate away at revenues for this turnpike, and the demise of most toll routes was further hastened as several major railroad lines were constructed in the eastern part of the U.S. The Impact of Water and Steam Power Upon Industrial Labour  The Enlightenment saw waterwheels powering the cotton spinning frames and carding machines in Britain’s textile mills (Fig. 7.3). Although the daily energy expenditure of employees was reduced by these innovations, working conditions were poor, and the increase in productivity signaled a loss of traditional employment for those who previously had worked as cottage operators of spinning wheels and hand looms.

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Fig. 7.3  An early spinning Jenny. During the Enlightenment, the introduction of water- and steam-powered equipment began to reduce the energy expenditures of industrial workers (Source: http://en.wikipedia.org/wiki/James_Hargreaves)

Typically, factory workers had to sign a one-year contract. Misconduct such as looking out of a window or talking at work resulted in a substantial loss of pay. There were also heavy financial penalties if early termination of a contract was needed for reasons such as pregnancy. Arkwright was one of the more generous employers. But even at his mill, children (many pauper apprentices) worked for 12 hours, six days a week. On Sundays, they were required to attend church, followed by school sessions, leaving the children with almost no opportunity for recreational activity. Unrest among factory workers culminated in the Luddite Riots of 1811–1812  CE, when much of the new machinery was destroyed. Many of the rioters suffered transportation to Australia, and some were executed. Steam power began to replace the water wheel during the latter part of the eighteenth century. In 1698 CE, the Devonshire engineer Thomas Savery had invented a one horsepower steam engine to pump water from mine shafts, but his device did not become very popular; it lacked the power to pump water from any great depth, and the boiler had an unfortunate propensity to explode at inopportune moments. Another Devonshire resident, the ironmonger and Baptist lay preacher Thomas Newcomen brought out a more reliable 5 hp. steam engine in 1712 CE, and it found application in pumping water from the ever-deeper Cornish tin mines. The Scottish engineer James Watt built on these ideas, saving energy by introducing a condenser, and by 1775 CE he was producing much more efficient steam engines. Gradually, these machines provided power for heavy manual tasks such as sawing, drilling, planing and the shaping of wood and metal. By the early Victorian Era, steam-­ driven traction engines were also finding application in threshing, ploughing and other heavy agricultural tasks (Chap. 8).

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Sport and Recreation In the developing settlements of North America, sport and recreation was limited to a select few wealthy residents. But in Europe, many forms of sport became highly stylized, to the point where they made only modest physical demands. Public boxing contests saw their crude beginnings, and the common people continued their interest in football, cricket, hurling, animal baiting and folk dancing. Opportunities for passive recreation also increased substantially, particularly for more wealthy individuals. We will comment specifically on equine and water sports, boxing, lacrosse, dancing and strolling, as seen in Enlightenment society. Equine Sports  The aristocracy continued their interest in hunting, horse racing and horse trotting. However, high costs and specific legislation increasingly excluded the ordinary citizen from these forms of activity. Hunting  William the Conqueror had first enunciated the principle that all game was the property of the crown. However, the pleasures of illicit hunting were abruptly halted for the average Englishman in 1671  CE, as the government of Charles II enacted highly punitive Game Laws. “Unqualified” freeholders were prohibited from killing “game” even on their own lands. The “qualification” threshold was the ownership of property yielding an annual income of at least ₤100. For the average citizen, the practical consequences of the new legislation were a loss of good quality protein and a decrease in physical activity. The punishment of hunters became progressively more severe over the eighteenth century. A penalty of 20 shillings per head of game (or up to 3 months imprisonment) was amended to a blanket fine of 5 pounds in 1707 CE, and the fine was extended to anyone even caught with a snare or a hunting dog. By 1711 CE, fines were also imposed on those whose pantries contained game, and by 1765 CE the penalty for killing a deer was transportation to Australia. The game laws were no problem for aristocracy with adequate property, and the legislation marked introduction of the modern, stylized form of hunting, with packs of hounds chasing the game and elegantly dressed well-mounted gentry in hot pursuit. Horse Racing  Under the Puritans, horse racing had fallen into abeyance, but policies changed with restoration of the monarchy, and Charles II became an annual patron of the popular Newmarket racecourse. When Queen Anne came to the throne, she spent much of her time at Newmarket, accompanied by the aristocracy; the elite not only watched the races, but also proudly displayed the excellence of their horses, carriages and clothing in formal parades before the Royal Enclosure. Horse Trotting  The nobility of the Enlightenment also took pleasure in parading their finest horses at a gentle trot around the graveled walks of private estates, and on designated carriageways, such as Rotten Row in central London. Less wealthy citizens would walk to Hyde Park, renting a chair to sit and watch the passing parade of the elite.

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Water Sports The Enlightenment saw a developing interest in yachting (by the elite) and rowing events (involving working class watermen). Yachting  Recreational yachting first gained popularity as a sport during the early seventeenth century. What had begun as boisterous and physically demanding races between small boats was soon transformed by the wealthy into formal waterborne parades displaying luxurious vessels. King Charles II had developed a taste for yachting while he was exiled to the Netherlands, and on accession to the British throne he built a series of “Royal Yachts,” often choosing to live on a yacht moored on the Thames at the Whitehall Palace. Rowing  The watermen of the river Thames had long provided a convenient form of urban transportation in central London, and from 1715  CE onwards, a contest between apprentice watermen (Doggett’s Coat and Badge Race) became a popular spectator event. Participants rowed a 4-seater ferry 7.4 km against a strong ebb tide.

Boxing Participants in boxing contests were generally from the working class, but sometimes they had wealthy sponsors. Boxing soon became one more spectator sport, with large sums wagered on the outcome of matches. James Figg (1695–1734 CE) was a bare-knuckle boxer supported by the Earl of Peterborough. He managed to spin prize fighting into a commercial spectacle, making money from the “gate,” rather than from ringside bets. He opened an “Amphitheatre” on Tottenham Court Rd, London, in 1719 CE, where he also offered lessons in boxing, fencing and quarterstaff combat. Jack Broughton, an “enforcer” of the rules governing the Thames water taxi business, became one of Figg’s pupils, and in 1741 CE he agreed to fight a challenger named George Stevenson. After 39 min of fierce combat, Broughton was declared the winner, and Stevenson was carried from the ring, to die shortly thereafter. Broughton was filled with remorse, and was spurred to develop formal rules for competitive boxing. The regulations included the use of gloves for sparring (but not for actual contests), 30-second recovery periods between rounds, and prohibition of holds below the waist, and of hitting a contestant when he was down. The London rules remained in effect until the development of the more widely known Marquis of Queensbury’s Rules during the 1860s.

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Lacrosse Lacrosse was a sport with indigenous origins in North America. Most of the early European immigrants who came to “New France” had little time for any type of sport. However, by 1740 CE, some of the settlers began playing a form of lacrosse with the local peoples, in the face of fierce opposition from the Jesuits, who saw such games as a pagan attempt to control the weather or to honour the dead. For at least a century, the First Nations easily beat all French Canadian lacrosse teams.

Dancing Among the European aristocracy, Enlightenment dancing changed from lively jigs to stately and leisurely dances such as the gavotte and the minuet, supplemented by masques in which Royalty played a starring role. A courtly ball of this type was organized in Quebec City as early as 1667 CE, but in the smaller French Canadian communities gigues and vigorous formation dances such as the contredanse continued to be a more popular choice.

Strolling The aristocracy found further opportunity for very light exercise and for public display by strolling and chatting in formal gardens and around large “Assembly rooms.” The Enlightenment saw the development of several “Public Gardens” on the south bank of the river Thames, an area that was then outside of city limits and associated municipal controls. The Vauxhall Gardens covered an area of several acres. At first, the owners recouped the costs of their operation from food and drink concessions, but later, elaborate entertainments were arranged, and “Silver” season tickets were sold for one guinea. In 1742 CE, the Vauxhall Gardens (Fig. 7.4) were up-staged by the more luxurious and aristocratic Ranelagh Gardens. Horace Walpole commented that at Ranelagh:“You can’t set your foot without treading on a Prince, or Duke.” The elite of society engaged in a similar type of public display at indoors sites such as the Pump Rooms in Bath and the Long Gallery at Versailles. This leisurely activity was immortalized in the words of Jane Austen: “Friday, went to the Lower Rooms; wore my sprigged muslin robe with blue trimmings—plain black shoes— appeared to much advantage; but was strangely harassed by a queer, half-witted man.”

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Fig. 7.4  The Vauxhall Gardens, on the south bank of the river Thames, was a popular place for the nobility of the Enlightenment to “stroll,” chat with friends, and be “seen.” Illustration from 1751 CE (Source: http://en.wikipedia.org/wiki/Vauxhall_Gardens)

Sedentary Recreation A rapid growth in pageants and live theatre, an ever-growing number of printed books and magazines, a disposable income that allowed the purchase of musical instruments, and the development of coffee houses offered city dwellers with the necessary funds an ever-expanding range of opportunities for sedentary recreation during the Enlightenment. Drama  The strolling players of Shakespeare’s youth gave place to repertory companies, performing in permanent theatres such as the “Rose.” Southwark was a favourite theatre district, just outside the watchful jurisdiction of the City Fathers. All public theatres were closed from 1592 to 1594 CE because of an epidemic of bubonic plague, but most venues quickly recovered from this setback. Authors such as Ben Jonson (1537–1537  CE) and Christopher Marlowe (1564–1593  CE) provided a growing choice of shows until a Puritan edict closed all theatres in 1642 CE. With the return of the Stuarts to the throne, the theatres reopened with even greater vigour, presenting sexually explicit “Restoration comedies.” Reading and Music  The development of printing made books and sheet music readily available to the wealthier members of society. Large country houses across Europe accumulated substantial libraries. In Russia, Catherine the Great (1729– 1796  CE) is said to have spent 80,000 rubles annually on books. Some 90% of books that were published now covered non-religious topics. Moreover, by the seventeenth century, 30% of English men could read, and in the eighteenth century the literacy rate had risen to around 60%. One popular item of reading matter was the Almanac; this offered advice on medical and agricultural problems, as well as astro-

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nomical predictions for the coming year. The introduction of newspapers provided another incentive to seated relaxation. The German language Relation aller Fürnemmen und gedenckwürdigen Historien hit the streets of Strasburg in 1605 CE, in Paris La Gazette saw its debut in 1631 CE, and in England the Daily Courant began publication in 1702 CE. Music also burgeoned as a source of sedentary evening entertainment both in large country houses and in formal auditoria. Melodies became tuneful madrigals and folk songs, and in the cities concert and opera halls were built. In Paris, the first music hall was a converted tennis court, accommodating 1200, but in 1790 CE the Theatre des Arts opened, with seating for 2800. Attendance at the opera quickly became a social duty, with many of the audience arriving noisily towards the end of the first act of a performance. In London, the Royal Opera House opened its doors in 1732  CE, and in Milan, La Scala replaced an earlier Teatro Regio Ducale in 1776 CE. Drawing room concerts were frequent at country estates, with available instruments now including trumpets, cornets, sackbuts, viols, lyres, harps, harpsichords, virginals and spinets. In New France, many immigrants arrived with a strong interest in fiddle playing. But by the 1630s, the Ursuline school in Quebec City was also teaching viol, violin, trumpet, drums, flute and fife. During the eighteenth century, regimental bands were also performing at dances and festive occasions. Coffee Houses  Coffee houses made their debut in Hungary and Venice during the 1640s. The first English Coffee House (the Angel) opened at Oxford in 1652 CE, despite the opprobrium of King Charles II, who claimed that coffee houses were: “places where the disaffected met, and spread scandalous reports concerning the conduct of His Majesty and his Ministers.” For a penny cup of coffee, the customer could engage in conversation and have access to various newspapers and political pamphlets, notably the Tatler and the Spectator (edited by Richard Steele (1672–1729 CE) and Joseph Addison (1672– 1719 CE), respectively). In one issue of the Spectator, Addison disclosed that he was a keen user of the dumbbell: “I exercise myself an Hour every Morning upon a dumb Bell, that is placed in a corner of my room.” Not only politics, but also the latest medical and scientific discoveries were popular topics for coffee house gossip. One London doctor (Richard Mead, 1673– 1754 CE) discussed the more difficult cases of local apothecaries while enjoying a cup of coffee; his fee for this arm’s length consultation was ten shillings.

Physical Fitness Little is known about the physical fitness of the population during the Enlightenment. Portraits of wealthy Europeans often point to an excess of body fat, although the prevalence of obesity is unclear, since it was often clumped with other causes of “intumescence” such as hydropsy. Some physicians were certainly concerned about a growing tide of obesity. In his book “Of the seats and causes of diseases investigated through anatomy,” the Italian

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a­natomist Giovanni Battista Morgagni (1682–1771  CE) pointed to obesity as a major risk factor for disease, providing numerous post-mortem examples of internal fat accumulation. The Dutch physician M.  Flemyng also noted that corpulence shortened lifespan, and Christoph Wilhelm Hufeland (1762–1836 CE), physician to the King of Prussia, argued that although “natural man” had found purpose, exercise and food appropriate to a long life in ploughing the fields, this constitutionally appropriate lifestyle had been lost in Enlightenment cities. Studies of hunter-­ gatherer populations (Chap. 2) have since advanced similar arguments. A growing proportion of children attended schools during the Enlightenment, but often these institutions did little to promote either physical fitness or a healthy diet. Nevertheless, in Germany and Switzerland, a small group of “Philanthropinists” highlighted the contrast between the vigorous men of former years and the civilized, but sedentary habitués of the Parisian salons. They thus called for children to follow a strict diet and to engage in regular physical education (Chap. 19). Fitness undoubtedly remained greater in agricultural communities than in the cities, a view reinforced by recent studies of Old-Order Amish. In the St. Jacob’s region of Southern Ontario, even today none of the male Amish and only 8.9% of the females are currently obese; the mean body fat percentages for this population are only 9.4% in the men and 25.3% in the women. Amish children typically assist with farming, and they also show a very low prevalence of obesity (1.4%) compared to other Canadian children.

Attitudes of Physicians, Scholars and Church Leaders During the Enlightenment, a growing proportion of opinion-makers began to recognize the value of regular physical activity in developing the human spirit and optimizing human health, although much of the medical fraternity remained skeptical. We will look at the prevailing attitudes of physicians, scholars and church leaders. Physicians  A few physicians continued the Renaissance push to encourage greater physical activity and fitness among their patients, but unfortunately many doctors still accepted outworn theories of disease and treatment. The Dutch physician Herman Boerhaave, regarded as one of the founders of clinical teaching, still clung to the classical theory of four body humours (Chap. 4). Faith healing such as the “King’s Touch” remained very popular, and Graham’s Temple of Healing and Mesmer’s advocacy of animal magnetism exemplified unprincipled quackery (Chap. 15). Voltaire complained: “A physician is one who pours drugs of which he knows little into a body of which he knows less.” In England, the successful physicians of society sported a gold-headed cane, awarded by an uncritical College of Physicians. Other markers of professional status were the size of a doctor’s wig and the elegance of his sedan chair. Names that gained popular notice for their advocacy of regular

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exercise included Sydenham, Fuller, Cheyne, Heberden, Armstrong, Pringle, Hoffman, Burette, Protisov and Rush. Thomas Sydenham  Thomas Sydenham (1624–1689  CE) was perhaps the most famous physician of this era, and his textbook of medicine was widely respected for two centuries. Unlike many of his contemporaries, he eschewed the conventional markers of professional status, believing that plain dealing and frankness were important assets of a successful and effective physician. Fresh air, exercise (particularly horse-riding) and dietary moderation were important components of his therapy. Thus, he treated a clergyman with hypochondriasis by progressively longer rides: “until he got to twenty or thirty miles per day….he rode more than a thousand miles, by which time he had gained perfect health and vigour.” Fuller  Francis Fuller the Younger (1670–1706 CE) was a follower of Sydenham. He cured himself of hypochondriasis and dyspepsia by progressive horseback riding, and he wrote a book (Medicina Gymnastica) stressing the value of exercise in treatment. He advocated regular massage for those who were too obese to exercise, but had little knowledge of other treatment. He recommended application of millipedes for those with rheumatism, and the ingestion of liquorice for those with tuberculosis! Cheyne  George Cheyne opened a medical practice in Bath in 1702 CE. He established a rapport with his patients by witty conversation during visits to the local taverns and restaurants, but his patronage of these institutions left him grossly obese, with a final body weight of 203 kg. At this point, he renounced animal protein, restoring his health. In his book “Essay on Health and Long Life,” he advocated riding, fencing, dancing, billiards, bowls, tennis, cricket, digging, working at a pump, and ringing a dumb bell. Among his rules for health and long life, we find”: • Walking is the most Natural and effectual Exercise.… • Children naturally love all kinds of Exercise, which wonderfully promotes their Health, increases their Strength, and stretches out their Organs. • Feeble Arms (are strengthened) by playing at Shuttlecock or Tennis; Weak Hams by Foot-ball, and weak Backs by Ringing or Pumping. The Gouty best recover the Use of their Limbs by Walking on rough Roads • Without due Labour and Exercise, the juices will thicken, the joints will stiffen, the Nerves will relax, and on these Disorders, Chemical distemper and a crazy old age must ensue…the joint power of warm air and light food cannot supply the place of exercise. He emphasized that exercise must be prescribed in muscle-specific fashion: “to those who have weak arms or hams, playing two or three hours at tennis…to those who have weak backs or breasts, ringing a bell or working at a pump…walking through rough roads even to lassitude will soonest recover the use of the limbs…” Heberden  William Heberden (1710–1801 CE) was a notable English exponent of therapeutic exercise. However, he is best remembered for describing angina pectoris and its relation to physical activity. One patient described the possibility of ­“walking

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through” an attack of angina: “I have frequently…. borne the pain, and continued my pace without indulging it; at which times it has lasted from five to perhaps ten minutes, and then gone off.” Heberden noted his patient was helped by 6 months of sawing logs for 30 minutes per day: “I knew one who set himself a task of sawing wood for half an hour every day, and was nearly cured…” Armstrong  John Armstrong was a Scottish physician and poet. In “The Art of Preserving Health (1744 CE)” he wrote “Toil; and be strong. By toil the flaccid nerves grow firm, and gain a more compacted tone; the greener juices are by toil subdu’d, mellow’d and subtiliz’d; the vapid old expell’d, and all the rancour of the blood…by health the peasant’s toil is well repaid.” Pringle  John Pringle (1707–1782  CE) was a Scot who is sometimes called the Father of Military Medicine. He argued that much necessary exercise for the troops could be purposeful: cutting boughs to shade tents, digging drainage trenches, airing bedding, cleaning clothes and gear and assisting in the mess. In 1743 CE, he reached an agreement with the French commander that military hospitals should be considered neutral zones, setting the stage for development of the International Red Cross. Hoffmann  Frederich Hoffmann (1660–1742 CE) was the first Professor of Medicine in Halle. He wrote on a wide range of topics, including physiology and hygiene, discussing rules for health maintenance that included a regular exercise programme. In his 9-volume Basic Guide to a long and healthy life he emphasized the restorative values of proper diet, exercise, clean air and sleep. He commented on worm-like lesions that he had seen in the coronary vessels at autopsy, but he failed to link these observations to anginal pain. He recommended exercise before meals, at an intensity sufficient to cause a good sweat and make the individual feel somewhat weary. His observations stimulated Guts-Muths (1759–1839 CE) to write Gymnastics for the Young (Chap. 19), and Tissot to publish “Medical and Surgical Gymnastics (1781 CE),” a text that recommended limiting bed rest. Burette  Pierre Jean Burette (1665–1747 CE) was Professor of Medicine and Chair of the Royal College of Medicine in Paris. He was greatly attracted to Greek concepts of sport, and at a time when archaeology was still in its infancy, he gave 16 lectures on Greek gymnastics, including well-researched articles on ball-games, running, dancing, wresting, boxing, jumping and discus throwing. Since health maintenance depended on communicated movement, he argued it was important to move as much of the body as possible, and dancing was thus the optimal form of physical activity. Protasov  A Strasbourg-educated academician (A.P. Protasov) lectured to Russian colleagues on “The Importance of Motion in the Maintenance of Health (1765 CE)” He became physician to the Czar, and recommended that the monarch walk, run, and ride horseback in order to correct his obesity. Rush  Benjamin Rush (1746–1813 CE) became U.S. Surgeon General and Professor of Clinical Practice at the newly founded College of Medicine in Philadelphia. He

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was concerned to ensure the universality of medical care, and set up the Philadelphia Dispensary to provide medical treatment for the poor. He was also a strong advocate of a clean environment, and persuaded the city fathers to eliminate mosquito breeding grounds by draining swampy areas around Philadelphia. In 1772 CE, he published a pamphlet entitled “Sermons to Gentlemen upon Temperance and Exercise,” in which he recommended exercise and sport for young and old alike. He extolled walking, running and swimming, but also recommended skating, jumping, tennis, bowls, quoits and golf. His “A Plan of a Federal University” included exercises to enhance both strength and health.

Scholars During the Enlightenment, a growing number of philosophers presented new concepts on the meaning of life and the nature of reality, both to Learned Societies and to the patrons of aristocratic salons. Individuals such as Bacon, Milton and Locke saw a strong body as helping the search for piety, and Descartes argued for a dualism between mind and body. In contrast, Spinoza saw sport as important in its own right, and Berkeley and Hume argued that engaging in physical activity offered an important means of “knowing” the human body. Voltaire and Goethe, also, were strong advocates of exercise. Bacon  Francis Bacon (1561–1621 CE) was born to a well- established family in central London. He popularized the inductive method of reasoning, insisting on experimentation, observation and the testing of hypotheses, much as in modern research (Fig.  7.5). In an essay on the “Regimen of health;” Bacon reasoned:“A man’s own observation, what he finds good of and what he finds hurt of, is the best physic to preserve health…To be free-minded and cheerfully disposed, at hours of meat, and of sleep, and of exercise, is one of the best precepts….Bowling is good for the stones and reins; shooting for the lungs and breast; gentle walking for the stomach, riding for the head.” Milton  The poet John Milton (1608–1674 CE) was a senior civil servant to Oliver Cromwell during the Commonwealth. He was an ardent defender of the freedom of the press, and welcomed personal fitness from a Puritanical standpoint. Exercise was an appropriate use of one’s time if it offered increased opportunity to serve God and humankind. He became a private school-teacher, and in an essay “Of education” he recommended that boys should spend 3–4 hours/day in physical education, mainly military-type drill. The restoration of the monarchy deprived Milton of his career in public office, and eventually he died in poverty. Spinoza  The Dutch philosopher Baruch de Spinoza (1632–1677 CE) was raised in the Jewish community of Amsterdam, but was expelled from the city for his unorthodox views. He opposed the mind-body dualism of Descartes, and tried to explain both physical and mental functioning as a finite expression of God. He earned his

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Fig. 7.5  Francis Bacon (1561–1621 CE) popularized the inductive method of reasoning, insisting on experimentation, observation and the testing of hypotheses, much as in modern research. He saw a strong place for regular exercise in his “Regimen of Health” (Source: http:// en.wikipedia.org/wiki/ Francis_Bacon)

living as a lens grinder, a solitary occupation that gave him much time for thought. With something of an Epicurian attitude, he maintained:“it is the part of the wise man to use the world and delight himself in it as best he may…. A wise man will refresh himself with temperate and pleasant meat and drink, the fair prospect of green woods, apparel, music, sports and exercises, stage plays and the like. Locke  The philosopher and physician John Locke (1632–1704 CE) followed in the path of Francis Bacon. He was a strong advocate of reason and tolerance, and was a vigorous proponent of the physical body as opposed to the soul. Expressing concern about the effeteness of British aristocrats, he underlined their need for good health and exercise. In “Some Thoughts on Education,” he wrote: “health reduces itself to these few and easily observable rules. Plenty of open air, exercise and sleep: plain diet, no wine or strong drink, and very little or no physic” “swimming, when he is of an age to learn…saves many a man’s life.” Horse-riding was “one of the best exercises for health which is to be had,” and fencing was: “a good exercise for health, but dangerous to life”..[those confident] of their skills being apt to engage in quarrels“Locke also revisited the concept of recreation, re-establishing its original Aristotelian meaning of relaxation:”“Recreation is as necessary as labour or food…” Descartes  The French philosopher René Descartes (1596–1650 CE) is best known for his dictum: “cogito ergo sum (I think, therefore I am)” His philosophy emphasized reason and deduction; he saw the human body as some sort of machine, set in motion by an external God (Deus ex machina). Berkeley  George Berkeley (1685–1753 CE) was the Anglo-Irish Bishop of Cloyne. He developed the concept of immaterialism, arguing that objects could not exist

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unless they were first perceived. His ideas had an impact upon the philosophy of sport, leading to the concept that sensations induced by physical activity offered an entrée into a human understanding of the body and the world in which we live. Hume  David Hume (1711–1776 CE) also argued that humans only had knowledge of things that they had experienced. He gained some recognition as an early epidemiologist (Chap. 24). Voltaire  Voltaire was the nom de plume of Francois-Marie Arouet (1694–1778 CE). One period of exile brought him from Paris to central London, where he spoke of the benefits of exercise relative to traditional medical treatment: “you will find no relief in medicine; I tried it in vain … If I am still alive after all my sufferings…I owe it to exercise and to regimen alone.” Goethe  Johann Wolfgang von Goethe (1749–1832 CE) had a marked impact upon the thinking of Victorian philosophers (Chap. 8). His focus on the continuous metamorphosis of living things strongly influenced nineteenth century natural scientists such as Charles Darwin. He was always conscious of the relationship between the physical and the mental, and found true bliss in open-air physical activity: “Give your body activity, explore the lovely countryside on foot and on horseback….a person never feels more physically free, more sublime, more favored, as when on horseback.” Goethe also pondered the environmental issues associated with industrialization. In his Faust, the normal course of nature is curbed by the construction of a vast dyke and the artificial world of industry, transport and intensified agriculture is prophetically pictured as having perils for humankind.

Church Leaders The Enlightenment saw a progressive splintering of Christianity into sects such as the Anabaptists, Congregationalists, and Methodists. The leaders of each of these new religious groupings offered their own distinctive philosophies on life, science, health and an active lifestyle. Anabaptists  Anabaptist teachings probably began in central Europe. Off-shoots continuing into the twenty-first century include Moravians, followers of Zwingli, and the Amish and Mennonite sects. These various groups have consistently advocated pacificism and simple living. Traditional Amish and Mennonite groups still resist the adoption of modern technology, and they thus provide a useful living model of the physical activity patterns of agricultural labourers during the Enlightenment (see above). For the early Anabaptists, health and healing were signs of God’s redeeming love, and spiritual health was more important than physical well-being. Illness was regarded as a manifestation of sin and cures were often sought through fervent prayer and attempts to exorcize devils. A strong ethic of mutual help permeated the

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Anabaptists, and if an Amish farmer became sick, his neighbours would rally to plough his fields, meet his medical expenses, and provide any needed nursing care. In more recent times, some Anabaptist churches have refused accepted measures of preventive health such as immunization, leading to local outbreaks of diseases such as measles among the families of church members. Anabaptist writings have recognized the need for a child to exercise, although the desire for simplicity has influenced their suggestions on play: “It is perfectly normal for a child to want to play….Organized games which involve physical exercise are profitable for growing children also….My brothers and I often rode horses which were only sticks about five feet long. Those horses ran, bucked, kicked and even whinnied. They were real horses to us when we combined the sticks with our physical strength and imaginations. Now I like real horses due, in part, to the fact that I exercised my imagination that way when I was a boy.” Congregationalists  Congregationalists separated from the Church of England in 1662  CE, over a requirement to read the “Act of Uniformity” from their pulpits. During the English Commonwealth, the Puritans (many of whom were Congregationalists) disapproved of engaging in frivolous pastimes such as dancing (see above). The Congregational hymn writer Isaac Watts (1674–1748 CE) offers an example of such single-mindedness. He attended the Dissenting Haberdasher’s Academy on the outskirts of London, and was so diligent in reading his school books that he had “no time for needful exercise;” this is said to have caused him to suffer from ill-health for much of his life. The Pilgrim Fathers were also Congregationalists, and in their Massachusetts enclave they expressed opposition to such pursuits as bear- and dog-baiting, not so much because of the animal cruelty that was involved, but rather because these activities gave secular pleasure to the audience. However, Congregationalism had no extensive formal creed. Beliefs evolved rapidly, and by the Victorian era they had become the most liberal wing of Christianity. In consequence, they accepted the importance of sport participation more quickly than many other Christian denominations. During Victorian times, they recognized: “A young Christian should attend the gymnasium as well as the prayer meeting…we have a physical as well as a spiritual nature.” Methodists  Methodism stemmed from the populist preaching of George Whitfield (1714–1770 CE) and John Wesley (1703–1790 CE). While studying at Oxford, John and his brother Charles Wesley formed a “Holy Club” that met daily from 6–9 a.m. for prayer, the singing of Psalms and a reading of the Greek scriptures. The devotion of the club members was assessed with mathematical precision. Wesley devised a “list of questions” and recorded his activities on an hour-by-hour basis, noting resolutions he had kept or broken, and ranking his hourly “temper of devotion” on a 1 to 9 scale. In a more practical vein, Wesley was concerned that health care was available only to the wealthy members of society. Although not a licensed physician, he opened “free” clinics, and gave cogent advice on a positive lifestyle in a book ­entitled “Primitive Physick, or an easy and natural method of curing most diseases.”

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This short text was carried by many itinerant Methodist preachers, and ran to 32 editions. In it, Wesley included the following comments on the Methodist lifestyle: “Observe.…the greatest exactness in your … manner of living. Use plain diet, easy of digestion; and.. this as sparingly as you can… Drink only water, if it agrees with your stomach; if not, good, clear small beer. Use as much exercise daily in the open air, as you can without weariness. Sup at six or seven.… go to bed early, and rise betimes.” Wesley was himself a convinced exercise enthusiast, with indoor equipment for use in inclement weather. His dining room contained a “chamber horse”--an exercise chair with a thick air-filled cushion, which, when sat on, flattened like an accordion. Wesley hopped up and down in this chair for hours, simulating horseback riding. He was convinced that adequate exercise was essential for health and long life. Walking was the best approach, followed by riding. He often paced his bedroom, having calculated that 200 trips wall-to-wall equaled a mile’s walk. His “Primitive Physick” contained much practical advice on exercise: “A due degree of exercise is indispensably necessary to health and long life.…Walking is the best exercise for those who are able to bear it; riding for those who are not. The open air, when the weather is fair, contributes much to the benefit of exercise…We may strengthen any weak part of the body by constant exercise. Thus, the lungs may be strengthened by loud speaking, or walking up an easy ascent; the digestion and the nerves, by riding; the arms and hams, by strongly rubbing them daily.”

Practical Implications for Current Policy During the Enlightenment, wealthy hostesses showed a keen interest in both supporting and discussing scientific advances. In contrast, many of the wealthy in today’s society have little interest in science or in medicine, unless their personal health is threatened. Both researchers and society need to address this gap in public interest. Possibly, a growth in materialism is to blame. But a part of the problem may also be that scientists are content to report their discoveries in technical journals, without taking the time to explain the significance of their findings in a form that is accessible to members of the general public. Enlightenment thinkers were sometimes criticized for an excessive reductionism. Most scientists still argue for the simplest possible explanation of known facts. However, a hard scientific approach does not always work well in the promotion of health and fitness, and in seeking the cooperation and compliance of their clients, practitioners may occasional need to resort to touches of the sentiment, imagination and mysticism that were belittled by many enlightenment thinkers. Many Enlightenment aristocracts saw various forms of physical activity as an opportunity to display their wealth in terms of expensive mounts, elegant carriages and extravagant clothing, rather than maximizing the potential health benefits of their chosen pursuits. This same tendency to public display deters poorer people from participation in many activities today, as manufacturers connive to convince

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people that something as simple as cycling cannot be undertaken without investing thousands of dollars in the latest high-tech bicycle and specialized clothing- in fact, many youth today are persuaded that ownership of a variety of types of bicycle is needed to allow riding on different types of terrain, whereas in fact much valuable exercise could be obtained by buying and using an unclaimed bicycle at the local police auction. The Enlightenment interest in visiting public gardens has been lost with our more sophisticated lifestyle. This is a trend that those interested in health promotion could usefully seek to reverse. Most major cities currently boast beautiful parks that provide splendid facilities for brisk walking, jogging, and often cycling in a clean and natural environment, but for much of the year these parks remain empty and deserted spaces. During the Enlightenment, few people were aware of the changes in daily energy expenditure of industrial workers that were introduced by developments in water and steam power, Innovations in industry continue today at an every growing pace, with automation and robotics threatening to eliminate a large proportion of current jobs within a few decades. However, professionals have yet to focus systematically upon the implications of these changes in employment for human lifestyle and health. Although many Enlightenment physicians and philosophers commended regular exercise, it is less certain how far they influenced public behaviour. Despite much study of human motivation, this remains a big challenge for health scientists today. Only a small fraction of the general public respond to calls for greater exercise participation, and many of these who are recruited to fitness programmes lose interest within a few months.

Questions for Discussion 1. Would health science advance faster today if the latest research discoveries were hot topics for drawing room discussion at society events? 2. Does the need to use and/or display the latest and most expensive types of sports equipment and clothing limit participation in physical activity for many people in our current generation? 3. How widely used are your public parks? Does strolling in a public park provide a significant source of exercise today? 4. How far does income influence a person’s commitment to the health sciences today?

Conclusions During the Enlightenment, new discoveries in the health sciences were often made by amateurs, either independently wealthy people, or investigators who were backed by generous private sponsors. Some scholars saw a strong body as helping the mind

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in its search for piety, but others argued for a dualism of mind and body. For some, sport was important in its own right, and for others it offered a means of “knowing” the realities of both our bodies and the world in which we live. Among the aristocracy, hunting, horse racing, horse trotting, yachting, rowing, boxing, dancing and visits to public gardens and spas often became opportunities for social display and spectatorism rather than physical activity. The theatre, opera and ballet, a growing secular literature, musical soirées and visits to coffee houses provided further opportunities for an expansion of sedentary behaviour. In the early stages of the industrial revolution, the introduction of first water and then steam power began to reduce the physical demands of urban occupations for ordinary workers, and the improvement of major highways allowed people to travel in the comfort of a coach rather than on foot or on horseback. However, high levels of physical activity persisted among rural peasants. Today, a few isolated groups of Amish and Mennonite farmers have conserved this lifestyle, and they offer exercise scientists a fascinating glimpse into likely patterns of physical activity and levels of physical fitness that were once widely associated with subsistence agriculture. Some Enlightenment physicians actively promoted physical exercise, fitness and an adequate diet, but many of the medical profession clung to the bizarre ideas of classical medicine in attempts to treat their patients. Philosophers such as Spinoza, Rousseau and Voltaire began to overshadow traditional teachings of the Church on the meaning of life and the nature of reality. Radical ideas on the scientific method, health care delivery and medical treatment were also advanced. A growing proportion of children attended schools, but few of these institutions offered any formal instruction in physical education. Among the newer sects of Christianity, Anabaptists argued for a simplicity of play, Congregationalists showed increasingly liberal attitudes to sport and physical activity, and Methodists included valuable lifestyle advice in medical tracts that they offered to the poorest members of their congregations.

Further Reading Albert W. The turnpike road system in England 1663–1840. Cambrude, UK, Cambridge University Press, 1972, 303 pp. Brown S. British philosophy and the age of Enlightenment. Abingdon, OX, Routledge, 1996, 395 pp. Cassirer E. The philosophy of the Enlightenment. Princeton, NJ, Princeton University Press, 1951, 367 pp. Cunningham A, French R. The medical enlightenment of the eighteenth century. Cambridge, UK, Cambridge University Press, 1990, 331 pp. Deming D. Science and technology in world history. Vol. 4. The origin of chemistry. The principle of progress, the Enlightenment and the industrial revolution. Jefferson, NC, McFarland, 2016, 329 pp. Fitzpatrick M, Jones P, Kneelwolf C, McCalman I. The Enlightenment world. Abingdon, OX, Routledge, 2014, 714 pp.

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Lindemann M. Medicine and society in early modern Europe, 2nd ed.. Cambridge, UK, Cambridge University Press, 2010, 301 pp. Porter R. Medicine during the enlightenment. Amsterdam, Netherlands, Rodopi, 1995, 407 pp. Schofield RE, The Enlightenment of Joseph Priestley. A study of his life and work from 1733 to 1773. University Park, PA, University of Pennsylvania Press, 1997, 307 pp. Steckel R, Floud R. Health and Welfare during industrialization. Chicago, IL, Chicago University Press, 1997, 465 pp.

Chapter 8

The Victorian Era: A Wealthier Society Offers New Recreational Possibilities, Especially to Women

Learning Objectives 1. To understand the impact upon daily energy expenditures of new forms of transit and mechanization at work and at home. 2. To recognize that changes in clothing and innovations such as the safety bicycle offered new opportunities for females to become physically active. 3. To examine emerging evidence linking an individual’s physical fitness with lifespan. 4. To note the continuing adverse impact of John Hilton’s doctrine of “rest and pain” upon medical support for physical activity as a major tool in rehabilitation.

Introduction In Britain, the reign of Queen Victoria was marked by upward social mobility and a growing personal prosperity based on dividends from the industrial revolution and a ruthless exploitation of distant crown colonies. The British population doubled, despite the emigration of some 15 million citizens to the United States, Canada, Australia and New Zealand. The Reform Act of 1832 CE made the British Parliament more representative of the views of ordinary citizens, although women remained disenfranchised. Peasants who had moved to the cities were often housed in appalling slums, but a growing middle-class who wished to conserve their economic and social gains opted for conservative policies. Shorter working hours and a growing disposable income allowed middle-class citizens to contemplate new forms of leisure activity. In Europe, it was the “Belle Epoch,” and a combination of growing wealth and new technology promised progress towards more effective health care. And in North America, the “Gilded Age” was marked by rapid population growth and an unprecedented accumulation of personal wealth by the “Robber Barons” of industry. © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_8

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Child labour and slavery came to an end. Boards of Health recognized the preventive value of clean water and adequate sewage disposal, and housing trusts began to provide poorer workers with adequate living conditions (Chap. 22). The studies of the health scientist were facilitated by laboratory benches that offered coal gas and electrical outlets, and growing national and international travel spurred the growth of scientific societies.

Physical Activity Advances in technology reduced the need for physical effort in industry, the home, and on larger farms, and active commuting was discouraged by new forms of mass transportation. Technological Change in Industry and Agriculture  Power from water, steam, gas and electricity was applied to operate a growing array of machinery in industry and agriculture (Fig. 8.1). Nevertheless, these innovations did not have a uniform impact upon the daily energy expenditure of workers. Many European peasants continued their hard physical labour on the land, and many of those moving to the western frontiers of North America still farmed primitive homesteads using a minimum of equipment. Technological Changes in the Home  Most Victorian women had a very heavy daily workload, caring for large families under difficult circumstances. Easy access to birth control was uncommon until after World War I. But domestic technology slowly reduced the physical demands on middle class matrons and their servants. Piped water eliminated the need to carry buckets from the nearest well, and gas or electric heating replaced the tending of coal-fired grates and cooking stoves. Fig. 8.1  Steam engines that travelled from farm to farm progressively reduced agricultural energy expenditures during the Victorian era (Source: http://en.wikipedia.org/ wiki/Traction_engine)

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The first sewing machine (1790 CE) was intended for sewing leather and canvas, but machines were adapted to the requirements of domestic sewing and embroidery, beginning between 1800 and 1810  CE.  The Singer Corporation alone sold three million sewing machines in the U.S. between 1850 and 1880 CE, in part because they introduced hire-purchase arrangements. Sewing machines reduced the time a woman needed to make a shirt from 14 1/2 h to 1 h. New Forms of Transportation  In 1825 CE, George Stephenson’s “Rocket” began hauling passengers along the Stockton & Darlington Railway at speeds of 19–23  km/h, and the first section of the Baltimore & Ohio Railroad opened in 1830 CE. Long-distance travel by personal coaches or stage coach quickly became a thing of the past. In London, the Metropolitan Railway sent specially adapted steam locomotives burrowing under the city streets, beginning in 1863 CE, and by 1891 CE, electric subway trains were running as far as 76 m below the metropolis. Steam and then electricity replaced the horse as the source of power for surface travel by streetcar. Rivers, lakes and canals also saw the introduction of scheduled steamboat services. These innovations facilitated travel and reduced energy expenditures for the wealthy, but many ordinary workers still chose to walk rather than spend a penny on a bus or subway fare, and often they used a bicycle for longer journeys in their neighbourhood.

Sports and Recreation Water sports such as punting, rowing, canoeing, sailing and swimming provided both active leisure and spectator events during the Victorian era. Many people also engaged in or watched cycling and pedestrian events, including hiking, youth-­ hostelling, and snow-shoeing. Other new pursuits for the Victorians included baseball, basketball, curling and the variants of football played in Canada, the U.S. and Australia. Horse racing became popular across North America during the final two decades of the nineteenth century. And the waltz and the polka increased the vigour of ballroom dancing relative to the courtly dances of the Enlightenment. A relaxation of dress codes allowed women to participate in some of these pursuits, and advent of the Saturday half-day holiday further increased the potential for recreation among ordinary workers. A proliferation of sporting organizations suggests a growing public involvement in active leisure. Spectator sports also flourished as major contests and associated gambling were popularized by a steam-powered printing press, and railway and steamboat companies encouraged supporters to travel to sites of competition using their services. Specific associations helped to develop individual sports, and some groups such as the YMCA both fostered an interest in physical activity and provided low cost accommodation for youth moving to the large cities.

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Water Sports Punting  Pleasure punts first appeared around 1860 CE and their popularity peaked in the 1910s, particularly at Cambridge University (Fig.  8.2). Usually, they were propelled in a leisurely manner, with only a moderate expenditure of energy. Their use declined during the 1950s, with the increased availability of small powerboat rentals. Rowing  Rowing became a popular form of recreation both in Victorian England and in Canada. Sometimes, rowing holidays extended for a week or more along the length of a river such as the Thames, and even on a day excursion the return journey of the boat to its moorings against a fast moving stream was quite hard work. Growing emancipation opened up rowing to women, although frequently they were assigned the task of steering the boat for their perspiring sweethearts. One of the most popular spectator events of the Victorian era was the Oxford and Cambridge boat race, between competing teams of eight plus coxswain from the two universities. The first men’s race was held at Henley (1829 CE), but a 6.66 km course from Putney to Chiswick bridge has been followed since 1839 CE. Women from the two universities have also competed in rowing this course in more modern times, beginning in 1964 CE. When the Prince of Wales visited Ottawa in 1860 CE to open the newly constructed Canadian parliament buildings, a regatta was held in his honour. This event included competitions between skiffs, 4-, 6- and 10-oared vessels, with the Gatineau Algonquins beating the “white” contenders, local lumbermen, in most events. Canoeing  In the early 1800s, Canadians enjoyed watching canoe races between indigenous groups, and such events gradually developed into regattas with both indigenous and “white” contenders, as in Halifax and Ottawa. Recreational canoeing in Muskoka was stimulated by the construction of a railway to Gravenhurst, ON, in 1875 CE, and the launching of a steamship service around the Muskoka Lakes; wealthy Torontonians escaped the heat of the city for several weeks at a summer cottage, and spent much of their days canoeing and swimming. The Toronto Canoe Fig. 8.2  Punting on the River Cam, at Cambridge. Punting became a popular form of recreation in the latter part of the Victorian era (Source: http://en. wikipedia.org/wiki/ Punt_(boat))

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Club was founded in 1880 CE. The best Canadian paddlers became highly proficient, and won every event at the Buffalo Pan-American Exposition of 1901 CE. Recreational canoeing was brought to Britain by the Scottish explorer John MacGregor (1825–1892 CE), following a camping trip in Canada and the U.S., but it never gained the popularity that it enjoyed in North America. Sailing  The construction of railway lines allowed a growing number of wealthier city-dwellers to enjoy recreational sailing. In England, Burnham on Crouch and the Norfolk Broads developed as sailing centres between 1850 and 1870 CE, as new railway routes brought them within commuting range of London. In Norfolk, weekly rentals brought recreational sailing within the financial reach of London’s middle class. In Canada, sailing vessels were needed initially for commerce and military defense, but their recreational use gradually assumed greater importance. By 1924 CE, there were sufficient recreational yachtsmen in Ontario to send a team to the Paris Olympics. A few intrepid sailors also undertook much longer voyages, with Joshua Slocum of Wilmot Township, NS, making the first solo circum-­ navigation of the globe (1895–1898 CE). Ice sailing was popular on the Hudson River as early as 1790 CE. The original craft was simply a square box, mounted on three runners, but in 1853 CE the triangular frame was introduced. The sport was soon widely practiced on the Great Lakes; it continues to this day, although the competitive season has been much curtailed by global warming. Swimming  During Victorian times, much of the River Thames was too polluted to allow recreational swimming. Perhaps for this reason, London, boasted six indoor pools equipped with diving boards as early as 1837 CE. However, many attendees were spectators, who merely lounged, ate and drank. Class-consciousness was very apparent in this sport; for instance, the Lewisham baths, opened in 1884 CE, boasted separate pools for upper- and working-class patrons, each with its own ticket office. Both pools were fed from a small spring, with water passing from the first-class to the second-class pool. Spectators could watch the swimming from a gallery for a fee of twopence. In Paris, Barthélemy Turquin (inventor of the life-jacket) established a floating école de natation on the banks of the Seine in 1785 CE. A more permanent building became the “école royale de natation,” boasting both Charles X and George Sand as regular visitors. But the water of the école was drawn unfiltered from the Seine, and was “dirty, cloudy, often foul-smelling and unhealthy.” A better choice for the health-conscious swimmer was to patronize the Piscine du boulevard de la Gare. Here, warm water was provided by the condensation of vapour from nearby steam engines. Floating swimming pools became commonplace during the latter part of the nineteenth century, as bathing in the Seine was then prohibited. Cycling  The first bicycle-like contraption (a “Laufsmachine”) lacked both pedals and steering, and was essentially a hobby-horse. However, its originator (Karl von Drais, in 1817  CE) used it to cover a distance of 13  km in less than an hour. A

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s­ teering system was added within a year of its appearance, and it became known as the velocipede, a gadget that became very popular among Regency dandies. French designers added rotary cranks and pedals in the 1860s., and a cycling craze hit the New World soon thereafter. Even the small city of Halifax, NS, boasted five velocipede rinks. During the 1870s, the format of the cycle evolved into the “Penny-­ farthing,” with ball bearings, and solid rubber tyres on one small and one very large wheel. In Europe, macadamized roads provided a relatively good riding surface, but in Canada, poor roads remained a problem for most cyclists. During the 1880s the rear-driven safety bicycle with pneumatic tyres opened up the sport to less adventurous people, including a growing number of women. There was also a growing spectator interest in long-distance cycling. A 1200  m speed event, held in St-Cloud, Paris, in 1868 CE, was soon followed by a 123 km race from Paris to Rouen (the latter was completed in 10 h 40 min). Six-day velodrome events were also organized, with contests between pairs of competitors. Pedestrianism  The opening of the Mount Washington Cog Railway (1869 CE) and the Swiss Vitznau-Rigibahn (1870–73 CE) suddenly made mountain paths accessible for weekend treks by average city dwellers. For the less adventurous, public parks modeled after country estates allowed gentle Sunday strolling, although more boisterous pursuits such as ball games were usually forbidden. Competitive walking became a popular spectator sport during the Victorian era. In 1801 CE, Captain Robert Allardice won a wager of 5000 guineas by walking a distance of 145  km in 21  hours. His most ambitious achievement was to cover 1606 km in 1000 hours. During this event, he sustained a cumulative weight loss of 14.5 kg, but he won a purse of over 100,000 guineas. His standard training regimen was rigorous: “He must rise at five in the morning, run half a mile at the top of his speed up-hill, and then walk six miles at a moderate pace, coming in about seven… After breakfast, he must again walk six miles at a moderate pace, and at twelve lie down… for half an hour. On getting up, he must walk four miles, and return by four… Immediately after dinner, he must rung half a mile at the top of his speed, and walk six miles at a moderate pace…next morning proceeds in the same manner.” Perhaps because of this vigorous regimen, his lifespan was 75 years, longer than many of his contemporaries. In the latter half of the nineteenth century, pedestrianism also became popular in North America (Fig. 8.3). The “Olympic Club” of Montreal, founded in 1842 CE, had foot running as one of its main preoccupations. Members who walked 161 km in less than 24 hours were nicknamed “Centurions.” In 1867 CE, a reporter for the New York Herald won $10,000 by walking 1824  km from Portland, Maine, to Chicago in 30 days. The journalist, again, had a remarkable longevity (90 years), despite death threats from gamblers who had bet heavily against his success. Another distance runner was a Seneca Indian named Higasadini, (1830–1897 CE). He toured Canada and the U.S, challenging other runners for stakes of $250, and on one occasion, he won $1000 by outpacing 3 horses over a 16 km distance. During the early twentieth century, the Mohawk Tom Longboat (1887–1949 CE) became one of Canada’s most celebrated distance walkers and runners. He set an ­eye-­catching

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Fig. 8.3  Betting on the outcome of walking events became popular in the latter part of the nineteenth century. The illustration of a “walking wager” is taken from Peter Piper’s Practical Principles of Plain and Perfect Prononciation (Anon, Philadelphia, 1836 CE) (Source: http://en.wikipedia. org/wiki/Pedestrianism)

time of 2-24-24  in the 39.3  km Boston marathon of 1907  CE, but he collapsed before completing the 1908 Marathon. Pedestrian competitions were sometimes held indoors. For example, in 1879 CE, a distance of 698 km was covered at a Toronto skating rink in 6 days. Hiking  Towards the end of the nineteenth century, group hikes across areas of open moorland became a very popular form of recreation. In England, the Cooperative Holiday Association (CHA, founded in 1897  CE by Leonard Griffiths, a Congregational minister) organized such pursuits. Participants stayed in large country houses for modest room-rates, and 10–15 km daytime treks were followed by vigorous country dancing during the evenings. Griffiths left the CHA in 1913 CE to form a very similar organization, the Holiday Fellowship. Other working class people joined one-day rambles such as those organized by Albert Mansbridge of the Workers’ Educational Association. At times, the hikers came into conflict with the local aristocracy, who for many years had regarded the moorlands as their private domain for such pursuits as hunting, fishing and shooting. In England and Wales, the right to roam freely over open moorland was finally resolved by the Countryside and Rights of Way Act 2000, but unfortunately, much of the potential recreational space in North America is still regarded as private property. The Youth Hostel Association (YHA) provided a further important recreational resource for European hikers and cyclists with a limited income. It had its beginnings in Germany, as Richard Schirrmann (1874–1961  CE) offered simple overnight accommodation at his schoolroom during the summer months. Three years later, a permanent hostel was opened nearby, in the recently reconstructed Altena

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Castle. The full blossoming of the youth hostel movement occurred following World War I. Snowshoeing  During the winter months, Victorian North Americans found snowshoeing a popular alternative to walking races. Early militias were trained on snowshoes, and the North American Snowshoe Club was founded at Montreal in 1840  CE.  Indigenous contestants generally won snow-shoeing events, and in 1867 CE, a team of Caughnawagas gave a demonstration of the sport at the Crystal Palace, in London. Baseball  Baseball, like cricket, apparently had its origins in England, under the name of stoolball (Chap. 5). Immigrants brought the sport to North America, and by 1791 CE the game had become sufficiently prevalent in Pittsfield, MA, that the local council passed a by-law prohibiting play within 80 yards of the town meeting house. The first team to play under North American rules was the New York Knickerbockers, founded in 1845 CE. In America, the game became professionalized from the mid-­ 1860s, but in England baseball was almost entirely supplanted by cricket. Basketball  Basketball originated in 1891 CE with a Canadian clergyman and physician James Naismith (1861–1939 CE). Naismith had been charged with inventing a new indoor sport while conducting an international physical education class at the YMCA training school in Springfield MA.  The game was introduced to Canada through the YMCA in Montreal. Naismith saw the new sport as his contribution to “Muscular Christianity,” particularly during the harsh months of the Canadian winter. Curling  Curling was popular in Scotland from the sixteenth to the nineteenth centuries. In 1638 CE, an Assembly of the Presbyterian Church accused Bishop Graham of Orkney of a terrible act: he was a “Sabbath curler.” Curling was brought to North America by Scottish soldiers and immigrants, and the Montreal Curling Club was established in 1807 CE. By the 1830s, there were also many curling clubs in the U.S, and they often engaged in cross-border competition with their Canadian counterparts. Football  Rules for Rugby football were formulated in 1845 CE, and the formal schism between Association and Rugby football occurred in 1863 CE. The Rugby Union game remained associated with privilege and expensive private schools, whereas Rugby League football became a working class, professional sport. Some Canadian schools still play classical Rugby Union football, but new rules introduced by Walter Camp (1859–1925 CE), adviser to the Yale football team, led to the development of American and Canadian football. In Australia, the Melbourne club set rules for Australian football in 1859 CE. Horse Racing  For early North American settlers, ownership of a horse was a status symbol, and horse racing became a popular spectator activity during the eighteenth and nineteenth centuries. The Newmarket course in Salisbury, NY, dates from 1665 CE. The most famous North American races are of more recent origin (the Belmont

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Stakes, 1866  CE; the Preakness Stakes, 1873  CE; and the Kentucky Derby, 1875 CE). In Canada, a Halifax City statute of 1771  CE banned horse racing because it made the population “idle, immoral and gamblers.” This decision had evidently been reversed by 1825 CE, when the Halifax Turf Club was founded. The Québec Turf Club dates from 1789 CE, and the King’s Plate, with a purse of 100 guineas, was first held in Trois-Rivières in 1836 CE. The following year, the Queen’s Plate was held in Toronto for the first time. Harness racing began in rural North America towards the end of the eighteenth century. A trotting race for a purse of $50 was held at St. Pierre, Montreal in 1830 CE, and the Quebec Trotting Club was established in 1864 CE. Pneumatic-­ tired sulkies were introduced in 1892 CE, allowing faster speeds, and a Canadian driver Dave McClary achieved the first 2-minute mile in 1897 CE. The first equestrian competitions were held in Toronto as early as 1842 CE, and by 1909 CE an Equestrian team was able to compete in London, England. Sports Associations  An impressive array of English sporting organizations founded during the nineteenth century encouraged the development of individual sports. These groups included the Alpine Club (1857), the Football Association (1863), the Rugby Football Union (1871), the Yacht Racing Association (1875), the Bicyclists Union (1878), the National Skating Association (1879), the Metropolitan Rowing Association (1879), the Amateur Athletic Association (1880), the Amateur Boxing Association (1884), the (Field) Hockey Association (1886), the Lawn Tennis Association (1888), the Badminton Association (1895) and the Amateur Fencing Association (1898). The U.S.  National College Athletic Association was founded by Theodore Roosevelt in 1906 CE, in order to “protect young people from the dangerous and exploitive athletics practices of the time,” Several institutions not only fostered physical activity among the young men who flocked to urban areas during the industrial revolution, but also provided them with clean and low-cost accommodation. The YMCA proved the most enduring of these initiatives. Its founder was George Williams (1821–1905 CE), who had moved to London, England, to work in a draper’s store. He successfully courted the daughter of his employer, thus persuading his boss to offer him financial support. The first YMCA opened in central London in 1844 CE, with the aim of developing “a healthy spirit, mind, and body.” The prime interests of Williams and his associates were initially religious rather than athletic, and a fledgling branch of the YMCA in Dover was testily informed that they should focus upon prayer meetings, Bible study and evangelistic activity; physical exercise: “should not be looked for …in the Young Men's Christian Association”. Thomas Hughes (1822–1896  CE), author of “Tom Brown’s Schooldays,” abhorred the narrow religious direction that was initially taken by the YMCA. He longed for a revival of the “Muscular Christianity” that many early Victorians had seen as a means of “leading young men to Christ,” and in some cities the YMCA became a practical expression of this philosophy. The Manchester YMCA opened in

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1876  CE with a well-equipped gymnasium, and cricket, swimming and walking clubs offered a complement to its religious activities. Finally, in 1881  CE, the London YMCA succumbed to pressure to include exercise facilities in its building. By the middle of the nineteenth century, there were YMCAs in the United States, Australia, Switzerland, Belgium, Germany, the Netherlands and France. The Christian focus of the YMCA has progressively disappeared, but even today there remains an emphasis upon the core values of caring, honesty, respect, and responsibility, supplemented by the deliberate inclusion of minorities. The YWCA was established in 1855  CE as a parallel organization for young unmarried women. The initial mandate was to insulate middle-class women who had recently moved to the cities against the perils of urban life, but beginning in 1910 CE, the focus shifted to include social and industrial issues of particular concern to women. In North America the YMHA and YWHA were established as parallel Jewish associations catering to Jewish dietary preferences, and helping Jewish immigrants adapt to the New World.

Sedentary Recreation During Victorian times, opportunities for sedentary entertainment varied widely with social class. Well-connected London gentlemen spent long evenings at dining and gaming clubs such as Savages. The less wealthy went to the neighbourhood “pub,” drank large quantities of ale, joined in raucous singing and gambled on foot races and boxing matches. Libraries, both private and municipal, flourished in most cities throughout Europe and North America; in the U.S. and Canada, Andrew Carnegie funded some 2500 public libraries between 1883 and 1929  CE.  Many patrons developed a keen interest in the writings of Dickens, Conan Doyle and Thackeray. Steam printing also allowed the production of cheap, serialized, mass-­ consumption novels. Drama, music and opera were popular with the social elite. Most major cities built imposing opera halls and theatres, but rigid dress codes excluded poorer citizens from most performances.. By the 1890s, ordinary workers were enjoying their own burlesque performances in chains of music halls. During the summer months, the railways offered cheap excursion fares to seaside resorts, where adults could sit in deck chairs watching their children play on the sand. The Quaker industrialist Henry Pease (1807–1881 CE) built an alcohol-free resort on the Yorkshire Coast for his workers in the Middlesborough iron and lime stone quarries and the Darlington woolen mills. Peace found the venture quite profitable, since he owned the Stockton and Darlington Railway (the access route), the bank underwriting the local kilns where bricks were fired for construction, and the Zetland Hotel (the place where most of the holidaymakers found their accommodation)). The Railway Era saw many similar resorts develop within travelling distance of large cities. Thus, the population of Blackpool, in Lancashire, grew from a mere

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500 in 1801 to 14,000 by 1881 CE. At most English resorts, the sea was too cold for prolonged swimming, and much of a week’s holiday was spent sitting with a canvas screen to protect oneself from the wind. For the few who wished to engage in moderate exercise, the larger resorts constructed promenades, gaily illuminated in the evenings. Seaside resorts also appeared within commuting distance of large East Coast cities in the U.S., most notably Atlantic City, which was developed by a local physician (Jonathan Pitney) and some business associates. In Canada, lakeside resorts developed in Muskoka, some 150  km north of Toronto. For some, the holiday meant over-eating, relaxation in a deck-chair and a visit to the Gravenhurst Opera House, but others engaged in fishing, golf, canoeing, swimming and repairs to their lakeside properties. Other sedentary pursuits and spectator events included billiards, bowling, and the watching of boxing matches and horse racing. The first billiards event with paying spectators was held in Detroit in 1859 CE. Settlers from Europe brought bowling to North America as the game of nine-pins. Associated gambling was such a problem that the state of Connecticut attempted to outlaw nine-pin bowling, but the addition of a tenth pin circumvented the legislative prohibition. By 1852 CE, four bowling alleys had opened on Toronto’s Front Street- a measure of the sport’s growing popularity in Canada. Boxing remained a brutal spectator sport for much of the Victorian era, with substantial sums wagered on contests. The government in Ottawa officially banned prize-fighting, but gambling on the outcome of matches continued largely unchecked. The invention of the telegraph also allowed off-track betting on horse racing, and some betting offices installed pool tables to amuse patrons between races.

Health The Victorian era was marked by major epidemics, although a growing understanding of microbiology and improved urban hygiene held growing prospects for the prevention of infectious disease. Greater prosperity allowed people to marry earlier, contributing to a population explosion. Birth rates did not flatten out until around 1900 CE, when birth control became accessible to ordinary women, and the banning of child labour removed the economic incentive to rear large families. Some Victorians lived to a great age, but an examination of statistics for average longevity, height and weight suggest that the health of most people was poorer than it is today. Longevity  At the end of the eighteenth century, James Easton substantially compiled a list of 1712 persons who had supposedly lived for a century or longer. He concluded: “It is not the rich nor the great, not those who depend on medicine, who become old, but such as use much exercise, are exposed to fresh air, and whose food is plain and moderate.”

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But many of these claims of a lengthy lifespan do not withstand serious scrutiny. A tombstone at Chave Prior in Worcestershire ascribed a life-span of 309 years to one of the villagers. However, it seems that the local stonemason, a little hazy about numbers, had first ascribed an age of 30 years, but when relatives of the deceased had criticized his error, he had appended a 9 to the figure shown on the tombstone. Permanent governmental records of births, marriages and deaths did not begin in Britain until the year 1838  CE.  In 1841  CE, life expectancy was 45  years in the wealthy county of Surrey, but the average was only 37 years in London and 26 years in Liverpool. For “labourers, mechanics, and servants,” the average age at death was only fifteen years. Nevertheless, survival prospects improved substantially as the Victorian era continued. Mortality rates in England and Wales declined from 21.9 per 1000 population in 1848–54 CE to 17 per 1000 in 1901 CE, although social class continued to have a major impact upon a person’s likely longevity. Height and Weight  Measures of height and weight have long provided a second index of population health. Large surveys of height and body mass were first conducted by Quetelet (1836 CE) in Belgium, and by John Hutchinson (1846 CE) in England. In the U.S. civil war (1863–1864 CE), soldiers had an average height of 1.73 m and a body mass of 65.2 kg, giving a body mass index of 21.7 kg/m2. Further data collected by the U.S. Society of Actuaries between 1885 and 1900 CE showed body mass indices at the age of purchasing insurance (usually around 25 years) of 23.5 and 21.0 kg/m2 in men and women respectively.

Physical Fitness Some of the clergy called for Muscular Christianity and physiologists argued the need for muscular strength, but objective data for the Victorian era were limited to occasional discouraging reports on the physical condition of military recruits. Occasional attempts were made to link physical fitness and/or habitual physical activity to lifespan. Muscular Christianity  During the latter part of the Victorian era, preachers in liberal segments of the Christian church spoke approvingly of “Muscular Christianity.” Young men were called not only to personal piety, but also to vigorous masculinity and good health. English proponents of Muscular Christianity included Charles Kingsley (1819–1875 CE) and Thomas Hughes (1822–1896 CE, author of Tom Brown’s schooldays). Cardinal Newman also spoke of the “Gentleman Christian,” Thomas Carlyle (1795–1881, influenced by the romantics thoughts of the German philosophers von Herder and Goethe) introduced the idea of the “Healthy hero,” and Herbert Spencer (below) awaited development of the biologically perfect man. Practical expressions of the idea of muscular Christianity included the Holiday Fellowship and the YMCA (above). “Muscular Christians” were called to engage in team games rather than individual sports, sponsors arguing that teams encouraged

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unselfish action, “self-restraint, fairness, honour, unenvious approbation of another’s success and all that ‘give and take’ of life.” Many well-known English soccer clubs such as Aston Villa and Bolton Wanderers began with a non-conformist Minister who introduced football to the younger members of his congregation as a part of the Muscular Christianity movement. Muscular Strength  Some early physiologists conceived physical fitness in terms of the development of prodigious strength. Benedetto Morpugo (1861–1944  CE) developed the concept of enhancing fitness through progressive resistance exercise, and he reported a 55% increase in the girth of the sartorius muscle when dogs were trained by running on an exercise wheel. One interesting Victorian expression of the quest for muscular strength was the systematic wielding of Indian clubs, weighing up to 25 kg each. Dioclesian Lewis devoted an entire chapter of his text “The New Gymnastics” to this topic. Military Fitness  During the U.S.  Civil War, “Stonewall” Jackson trained rural Virginians rigorously by speed marches, carrying a 27 kg pack under winter conditions. But fitness was the exception rather than the rule during the American civil conflict. General Robert E. Lee lost 16,000 unfit stragglers in a single long march prior to the battle of Antictam. In an attempt to rectify this situation, Colonel Herman Koehler integrated gymnastics into the curriculum at West Point Academy (1885 CE), and a gymnasium was constructed there in 1892 CE. In 1896 CE, General Nelson Miles ordered U.S. soldiers to engage in at least 30 minutes of physical activity per day, and 10 years later Franklin Bell required all garrisons to engage in gymnastics, outdoor athletics, and swimming, with weekly marches of at least 19 km, or horse-back rides of 29 km. However, his order met much resistance from officers who could not themselves meet these requirements. President Theodore Roosevelt instituted an annual fitness test for military officers, and himself rode 145 km in 2 rather than the required 3 days, but he failed to persuade his staff of the need to meet the published standards. The U.S. Draft Report for World War I showed that one man in 3 was still unfit for combat at recruitment and many of the remaining soldiers were in poor condition when they were first enrolled. The picture in Britain was similar; 2 of every 5 men who volunteered to fight in 1915 CE were unfit for military service because of poor health and/or fitness. Influence Upon Lifespan  The Victorians made occasional attempts to assess the impact of physical fitness upon an individual’s health by comparing mortality statistics for university athletes with data for life expectancy in the general population. Given the elevated social status of those attending universities in Victorian times, such comparisons were inherently spurious. Nevertheless, they did overturn the argument that involvement in high performance athletics would shorten lifespan by causing “Athlete’s Heart. One earnest physician had previously suggested that no cyclist should continue riding a bicycle if he became short of breath, and many thought cardiac damage from the Boston marathon was inevitable:” repeated

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e­ xercise, such as prolonged training in successive years, may lead to permanent injury of the heart or kidney is unquestionable.” John Morgan showed that Oxford and Cambridge oarsmen lived two years longer than the actuarial norm, and George Meylan noted that Harvard rowers also lived 2.9  years longer than expected; indeed, after allowing for many accidental deaths among the athletes, their advantage was 5.1 years. However, fears about the “athlete’s heart” persisted into the Twentieth Century. In 1901  CE, William Collier, a key member of the Oxford Medical Society, had occasion to examine a University one-mile runner. The student was now falling several seconds short of his best times when he had been at school, and Collier thought that he heard a parasternal systolic murmur after the runner had walked briskly around his consulting room. With superb diagnostic confidence, he declared that he: “had no doubt that this was another example of dilation of the right ventricle…It is in the too frequent repetition of severe muscular effort or its continuance over too long a period of life that the danger lies.” Collier disqualified the unfortunate athlete from further competition. He further suggested that the deep breathing of athletes was likely to engender a “physiological emphysema,” and went on to warn teenage girls against over-exerting themselves, whether by taking up hockey, swimming, cycling or tennis.

Attitudes to Health and Fitness We conclude this chapter with a brief glance at the attitudes of Victorian health professionals, theologians, philosophers and politicians towards health and fitness. Health Professionals  Although many Victorian physicians had little interest in exercise programmes, respected individuals such as Warren, Caldwell and Osler advocated exercise to maintain health, treat selected illnesses, and maximize intellectual development. Towards the end of the era, the entire executive of the American Society for Research in Physical Education were physicians. However, they still fought against the majority of their medical contemporaries, who followed the lead of John Hilton in arguing for the “recuperative power of Nature;” most doctors believed that those who were sick required prolonged bed rest. Warren  John Collins Warren (1778–1856  CE) was the first Dean of Harvard Medical School (1816–1819 CE), one of the founding editors of the New England Journal of Medicine (1812  CE) and third President of the American Medical Association. He was a strong protagonist of regular physical activity, including calisthenics. Largely through Warren’s advocacy, a gymnasium was constructed at Harvard in 1826 CE. Warren also keenly appreciated the importance of programme adherence: “the exercises were pursued with ardor as long as their novelty lasted… but they have been gravely forgotten or neglected…” He played a prominent role in establishing the Tremont gymnasium in downtown Boston (1825 CE), and went on to write “Physical Education and the preservation of health,” arguing: “I have

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known many instances of great increase of muscular vigor and of the general health by the regular use of gymnastic exercises, even at an advanced period of life.” Caldwell  Charles Caldwell (1772–1853  CE) was founding physician of Transylvania University in Lexington, Kentucky. In 1834  CE, he published “Thoughts on Physical Education,” based on a lecture he had given to Kentucky schoolteachers. He was a strong advocate of moderate exercise, with appropriate dress for the participants. Osler  William Osler (1814–1919  CE) (Fig. 8.4) began his career at McGill University in Montreal. and subsequently became one of the four founding professors of the Johns Hopkins Hospital. In frank opposition to Hilton, he argued that patients needed the “quadrangle of health:” rest, food, fresh air, and exercise. He underlined the pedagogic and the preventive value of moderate physical activity: “Within the past quarter of a century, the value of exercise in the education of the young has become recognized…the prophylactic value of exercise, taken in moderation by people of middle age, is very great.” Osler got most of his own exercise from brisk walking, but he also enjoyed swimming. He took up golf for a while, but he was sufficiently time-conscious that he literally completed a course on the run. He did not die until the age of 105 years. Theologians and Philosophers  During the Victorian era, liberal theologians increasingly argued the need for personal and/or societal intervention to enhance community health, whereas social Darwinists asserted that the fight for survival on the factory floor was necessary to the overall betterment of the human species. Most of the clergy upheld the privileged social position of the ruling classes, who controlled their livings. However, John Wesley brought a message of salvation, self-­ Fig. 8.4  The Canadian-­ born Physician William Osler (1814–1919 CE) was one of the few Victorian physicians who argued against John Hilton’s doctrine of “rest and pain.” Osler advocated a “quadrangle of health” (rest, food, fresh air and exercise) to his patients (Source: http://en. wikipedia.org/wiki/ William_Osler)

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improvement and health to tin-miners in Cornwall (Chap. 7), and in North America the Great Religious Awakenings associated with the Caine Ridge Meeting House in Kentucky brought about significant changes in attitudes towards society and health. Many who longed earnestly for the “Second Coming” of Christ thought that this would not occur until they had righted such evils of Victorian society as slavery, child labour, and the inadequate protection of women in factories. We will look briefly at social Darwinism, and then consider the philosophical arguments of Hegel, Kierkegaard, Weber, Heidegger, Engels, Marx, Lenin, Thoreau, Emerson and Dickens concerning personal and societal responsibility for health. Social Darwinism  Herbert Spencer (1820–1903 CE) justified social stratification because it encouraged a “survival of the fittest.” William Graham Sumner (1840– 1910 CE), a Yale sociology professor, even suggested that if the poor were given assistance, this would weaken their ability to survive in society. However, the political economist Henry George (1839–1897 CE) vigorously opposed these ideas, arguing the need for a “single tax” that would level out the disparities of social status. Hegel  Georg Wilhelm Friedrich Hegel (1770–1831 CE) believed strongly in personal freedom and self-determination. However, he also regarded the extreme ­division of labour and the mindless repetition of simple tasks in Victorian factories as enervating for a worker’s mental faculties. Kierkegaard  The Danish philosopher Søren Kierkegaard (1813–1855  CE) highlighted the issues of personal choice and commitment that became central themes for both social Darwinists and advocates of public health. Was a poor lifestyle due to bad personal choices, or should it be blamed upon the overall physical and social environment? Weber  Maximilian Karl Emil Weber (1864–1920 CE) argued that the most important aspect of society was not its productivity, but how people viewed their world. He interpreted progress in population health against a broad canvas of environmental factors, and saw personal lifestyle as an expression of socially determined life-chances. Heidegger  The views of Martin Heidegger (1889–1976  CE) were regarded with some suspicion as it emerged that he had profited from close connections with the National Socialist party to become Rector of Freiburg University in Nazi Germany. He believed in tying together intellectual and physical activity, and engaged in such activities as push-ups while engaged in philosophical meditation. In his view, exercise should encompass a wide range of activities: “not … solely gymnastics, but … to include endurance training (road building, agriculture and horticulture).” Engels and Marx  Friedrich Engels (1820–1896 CE) complained about the adverse conditions of work and housing that were endured by Prussian labourers during the Victorian era: “the work offers the muscles no opportunity for physical activity.” Karl Marx (1818–1883 CE), with Engels, sought to interpret society in terms of a class struggle. Neither author wrote anything substantial about physical culture, but

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their ideas provided the social framework for subsequent communist interpretations of sport and physical activity. Lenin  Vladimir Ilyich Ulyanov (pseudonym Lenin) (1870–1924  CE) gave pragmatic expression to the views of Marx. He came from a comfortable upper middle-­ class family, and is said to have been superbly fit himself. When he assumed power, he shortened the Soviet working day to 8 h, giving Russian workers more time to engage in voluntary physical activity. Thoreau and Emerson  The American author Henry David Thoreau (1817–1862 CE) was a strong advocate of physical activity and the open air. His personal enjoyments included swimming, wading through swamps, walking in the woods and climbing trees. One winter, he skated 48 km in a single day. He valued activity not only for its potential to enhance health, but also for its ability to stimulate the intellect. His friend, the poet Ralph Waldo Emerson (1803–1882 CE) was also an enthusiastic exerciser. Emerson once stated: “I measure your health by the number of shoes and hats and clothes you have worn out.” Dickens  The English author Charles Dickens (1812–1870 CE) made a major contribution to population health by publicizing the appalling conditions in Victorian factories, slums and workhouses. He was also a staunch advocate of physical activity. He routinely walked 30 km a day, thinking of material for his books during the process. During a visit to the United States, he was the promoter and pace-setter of a pedestrian race from Mill Dam Road, Boston to Newton Center (1868 CE).

Politicians and Statesmen The endorsement of physical activity by leading statesmen has sometimes had a major effect on public opinion. During the Victorian era, Franklin, Jefferson and Theodore Roosevelt were all noteworthy for encouraging regular physical activity through their personal example. Franklin  Benjamin Franklin (1706–1790 CE) enthusiastically recommended running, swimming, and resistance training. In an age when few people could swim, he was an avid swimmer, and he is included in the Swimming Hall of Fame. He was also very strong, carrying out dumbbell exercises regularly: “in forty swings (I) quickened my pulse from sixty to one hundred beats in a minute…” He judged the volume of exercise undertaken by the warmth it produced. Franklin was also an early demographer, contributing to the ideas of Thomas Malthus on population growth. Jefferson  Thomas Jefferson (1743–1826  CE) introduced the pedometer to the United States, using it to monitor his own demanding personal exercise programme. In his view, “Not less than two hours a day should be devoted to exercise, and the weather should be little regarded.”

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Theodore Roosevelt  Theodore Roosevelt (1858–1919 CE) developed a strong personal interest in fitness, stemming from a childhood battle with asthma. His father had built a gym for him in the family home, and here Teddy would box and lift weights. He also climbed mountains in all weathers, and he became a fervent champion of the “strenuous life.” Teddy’s doctrine appealed to fears that industrialization and the Women’s movement were sapping the masculinity of the American man. As an adult, he reached a high level of physical fitness, participating in hiking, tennis, rowing, polo and horse riding. He also boxed several times a week until a blow left him blind in his left eye. In 1905 CE, he was one of the first recipients of an Olympic Diploma.

Practical Implications for Current Policy The Victorians vigorously debated the relative importance of public health policies versus economic progress in the quest to enhance population health. In Britain, the issue still attracts much attention, with a stark 8–10 year difference of life expectancy between those living in the wealthy counties immediately surrounding London and those remaining in the “rust-belt” cities along the Clyde, the Tyne, and Merseyside. Differences in longevity persist despite nominally equal access to government sponsored health and wellness programmes. Reasons for the disparities in health remain to be clarified, but it seems likely that when faced with a challenging economic situation such as prolonged unemployment, many people become alienated, and lose the motivation to invest time and effort in enhancing their personal health. Marx and Engel certainly wrote extensively on the issue of worker alienation, and it continues a major theme in the health debate today. The followers of Marx argue that because the proletariat is unhappy with its role in society, they are unwilling to protect their health. Why should one spend leisure time attending a worksite fitness programme if this merely increases industrial productivity and thus augments the profits of the employer? Possibly, the health of alienated workers could be improved if employees were encouraged to compensate for what seems meaningless routine work by finding pleasure and fulfillment in leisure time sport and physical activity. Politicians continue to have a major opportunity and a personal responsibility to encourage a healthy lifestyle among their constituents. Not all leaders have emulated the noteworthy exercise habits of Franklin, Jefferson and Theodore Roosevelt. However, in recent years there has been some official recognition that leadership carries this responsibility. In the United States, there has been organization of a President’s Council on Fitness, and I recall the impression made at a meeting of fitness experts in Ottawa when the then Governor General of Canada Roland Michener invited all of those attending the conference to join him for a little outdoor exercise before lunch. Although then in his seventies, Michener led the delegates in a very brisk 5 km run along the banks of the Rideau canal. A recent photograph of

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current prime minister Justin Trudeau shows him taking the President of Mexico for a similar brisk run through Ottawa’s park system.

Questions for Discussion 1. Have you encountered any situations where actual or assumed private property rights have restricted your opportunities for physical activity? 2. Do you think that the introduction of a comprehensive social welfare programme leads to a weakening of character and personal responsibility for health? 3. How far should we study the teachings of individuals such as Heidegger, who were strong supporters of the Nazi regime? 4. How far should the injury to Theodore Roosevelt’s eye figure in arguments against participation in boxing tournaments?

Conclusions During the nineteenth century, a growing understanding of biochemistry, metabolism, and microbiology set the stage for a modern approach to improving population health and adoption of a healthy lifestyle. The mechanization of industrial and domestic work and an expanding transportation network reduced daily energy expenditures for many Victorians. New recreational opportunities, both active and passive, became available not only to wealthy men but also to workers and emancipated women, with support from by a growing roster of sports associations. Spectator sports flourished, thanks to newspaper publicity and access to major events by mass transit. Reading, drama, concerts and opera performances for the elite, and burlesque shows for the working class offered other new possibilities for sedentary leisure. Individuals with a strong social conscience enhanced living conditions in urban slums and in factories, and some key political leaders encouraged the electorate to adopt a healthy lifestyle. The average longevity increased somewhat due to reductions in neonatal and puerperal mortality, but it is less clear whether fitness improved or worsened during the Victorian era. For many, physical condition was viewed in the context of survival rather than quality of life. Theologians and philosophers argued the relative contributions of personal and societal efforts to wellness. Many doctors still prescribed prolonged bed rest for those who were sick, but some began to advise exercise not only for health but also for intellectual development.

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Further Reading Algeo M. Pedestrianism. When watching people walk was America’s favorite spectacle. Chicago, IL, Chicago Review Press, 2014, 262 pp. Haley B. The healthy body and Victorian culture. Cambridge, MA, Harvard University Press, 1979, 296 pp. Harrington HR. Muscular Christianity: A study of the development of a Victorian idea. Stanford, CA, Stanford University Press, 1971, 498 pp. Hawkins M. Social Darwinism in European and American thought, 1860–1945. Cambridge, UK, Cambridge University Press, 1997, 347 pp. Humphries J.  Childhood and child labour in the British industrial revolution. Cambridge, UK, Cambridge University Press, 2010, 439 pp. Kidd B. Tom Longboat. Don Mills, ON, Fitzhenry & Whiteside, 1980, 64 pp. McIntosh PC. Sport in society. London, UK, West London Publishers, 1963, 208 pp. McRone K. Playing the game. Sport and the physical emancipation of English women, 1870– 1914. Lexington, KY, University of Kentucky Press, 1988, 313 pp. Perkin HJ. The age of the railway. A social history of 19th century Britain. Brighton, UK, Edward Everett Root Publishers, 2016, 368 pp. Roxburgh H. One hundred not out: The story of Nineteenth Century Canadian sport. Toronto, ON, Ryerson Press, 1966, pp. 252. Thomas H. Story of the Atlantic slave trade, 1440–1870. New York, NY, Simon & Schuster, 1997, 908 pp.

Chapter 9

The Modern Era: Growing Health in the Face of Unemployment and War

Learning Objectives 1. To recognize the development of new epidemics of heart disease and obesity, attributable to inadequate physical activity in most of society. 2. To see the gradual development of state-sponsored health care, as exemplified by developments in Great Britain and in Canada. 3. To note the trend to objective documentation of fitness and nutrition. 4. To understand the impact of new media such as radio and television upon health and fitness promotion.

Introduction The present chapter focuses on the Modern Era, which we have arbitrarily placed as running from the beginning of World War I to the early 1960s. Features of this period included the horrors of two world conflicts, the eclipse of traditional religious and social norms, the mass production of goods, a widespread ownership of cars and labour-saving devices, mass-communication by cinema, radio and television, a growing political and social role for women, mass unemployment and decades when the doctrines of Fascism, National Socialism and Communism flourished. Physical educators of the Modern Era still relied largely on simple field tests of physical fitness. However, exercise scientists began to develop more sophisticated and standardized measures of physical condition. Many politicians still showed little interest in the health and fitness of their peoples, but a resolute coterie of writers and philosophers urged governments to improve housing, working conditions, and nutrition, while providing universal pre-paid health care. In most western nations, the Modern Era was marked by decreased fertility rates and an increased life expectancy, thus increasing the proportion of “old” or “very © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_9

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old” citizens. At the same time, younger individuals were threatened by epidemics of heart disease and obesity, apparently linked to inadequate levels of habitual physical activity. Totalitarian regimes saw participation in vigorous fitness programmes as an important instrument of social control, but western governments continued unimaginative physical education policies inherited from the nineteenth century. Active leisure was encouraged by paid holidays, the introduction of new team and individual games, Youth Hostelling, and the opening of National and Provincial Parks. On the other hand, the growing size of cities, the construction of ever-larger sports stadia and movie theaters, the appearance of new forms of sport-linked gambling, and opportunities to follow sport through radio and television broadcasts all favoured the adoption of a sedentary lifestyle by those living in the Modern Era.

Sport and Recreation Considering sport and recreation trends during the Modern Era, we will look first at paid holidays. The widespread construction of public swimming pools by municipalities fostered interest in marathon and synchronized swimming and diving. Team sports gaining prominence included handball, netball, racquetball, volleyball, and ringette, while for the individual there was a surge in popularity of roller-skating, ballroom dancing, table tennis, mountaineering and orienteering. Paid Holidays  During the Victorian era, most countries had required employers to provide a paid Saturday half-holiday to their workers, and this provided opportunity for activities such as a weekly game of soccer. However, employees usually lacked both the managerial permission and sufficient salary to take a week’s vacation without pay. During the 1920s, trade unions began to push demands for a paid vacation, arguing that this would reduce absenteeism and boost productivity. In Britain, a commission headed by Lord Amulree in 1936 CE encouraged the voluntary compliance of management, and by 1938 CE (when paid holidays became the law), 4.5 million workers were already receiving paid holidays. But one concern, typical of the continued class-­consciousness of Britain, was that if workers had opportunity to spend a week at seaside resorts, the available hotels would be swamped by the “wrong” sort of people. This issue was resolved by granting government incentives to expand “luxury holiday camps” of the type introduced by Billy Butlin (Fig. 9.1). Visitors to these establishments rented simply constructed family chalets, and were provided with catered meals and various active and passive recreational facilities at a low and all-­inclusive cost. Many attending such facilities gained some activity through ball-­games, swimming and dancing. In Nazi Germany, workers could attend Strength through Joy (KdF) camps, or take a week-long trip on cruise-boats such as the purpose-built 25,000 ton MV Wilhelm Gustlof. And in Russia, the Soviets introduced the potential for a two-week paid holiday at opulent spas, initially open to employees in vital industries who exceeded their production quotas.

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Fig. 9.1  The concern of the British elite that paid vacations would swamp available hotels at seaside resorts with the “wrong sort” of people was resolved by government incentives to construct “holiday camps” such as Butlin’s Mosney holiday camp (Source: http://en.wikipedia.org/wiki/ Holiday_camp)

In North America, trade unions showed greater interest in pay raises than in obtaining paid vacations. The U.S. Department of Labor recommended the introduction of mandatory vacations in 1939 CE, but to no avail. Nevertheless, some of the urban poor profited from free or low-cost holidays provided by charitable organizations. And in Ontario, the Vacations with Pay Act became law in 1944 CE.

Aquatic Activities Swimming Pools  In England, clean and well-designed municipal swimming pools became widespread during the first half of the twentieth century, providing opportunities for both swimming and water safety instruction to city-dwellers who did not have easy access to the seaside or a pleasant lakeshore. In Canada, many high schools also began to include a swimming pool, and these were open to the general public during the evenings and at weekends. The new facilities also fostered interest in synchronized swimming and diving. Marathon Swimming  Marathon swimming made its debut in the Victoriån era; for example, in 1875 CE, Captain Matthew Webb completed a crossing of the English Channel in 21  hours, 45  minutes, despite challenging tides and a jellyfish sting. Unfortunately, he died some 8 years later, when swimming in the Niagara Rapids. The trend continued into the Modern Era. In 1926  CE, an American, (Gertrude Caroline Ederle) crossed the English Channel from Cap Griz Nez to Kingsdown, Kent in 14 hours 39 minutes. Marathon swims across Lake Ontario also became a popular feature of the Canadian National Exhibition from 1927 to 1938  CE.  In 1954 CE, a Canadian competitor (Marilyn Bell) swam 56 km across Lake Ontario from Youngstown, NY to Sunnyside, Toronto in a total time of 21 hours. In 1974 CE, Cindy Nicholas, a young resident of Ontario, crossed Lake Ontario in the even

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faster time of 15 h 18 min; she went on to set record times for one- and two-way crossings of the English Channel. Synchronized Swimming  Synchronized swimming was originally known as water ballet. Competitive events had been held in Berlin in 1891 CE, and in Edwardian London and New York, synchronized swimming became a Music Hall attraction. The star at the New York Hippodrome (Annette Kellerman) had been arrested on Revere Beach, MA in 1907 CE for wearing a one-piece swimsuit without a dress and pantaloons. She quickly made the sale of “Annette Kellerman” swimsuits a profitable side-line of her performance. During the Modern Era, the sport was drawn to the attention of a broader public with a display by “The Modern Mermaids” at the Chicago World Fair of 1934  CE.  The sport was further popularized when the National Amateur Athletic Union swimmer Esther Williams appeared in films such as Bathing Beauty (1944 CE) and Million Dollar Mermaid (1952 CE). Synchronized swimming was an exhibition event at the Helsinki Olympics (1952  CE) and it became a part of the regular Olympic programme at the Mexico City Pan American Games of 1955 CE. Diving  Competitive diving probably originated with the plunge taken by most swimmers at the beginning of their events. The Victorians held a Competitive shallow plunge for distance in Britain, beginning in 1883 CE, and the British Royal Life Saving Society hosted the first “graceful diving” competition in the murky waters of Hampstead Ponds in 1895 CE. Plain diving events were included in the Olympic Games of 1904 CE, and Fancy Diving was added in 1908 CE, with women allowed to participate from 1912 CE.

New Forms of Team Sport Handball  Handball may be derived from Königsbergerbal, a German game intended to keep soccer players fit during the summer months. Outdoor handball was featured at the Berlin Olympic Games of 1936 CE and indoor handball emerged in Denmark during the 1940s. Beach handball also became increasingly popular during the Modern and Post-Modern Eras. Netball  Netball was conceived as a form of basketball appropriate to the decorum of Victorian women, and its popularity increased further during the Modern Era. Martina Bergman-Österberg (1849–1915 CE) introduced netball at the Hampstead Physical Training College in North London in 1893  CE, and it was soon being played widely at girls’ schools across English-speaking countries. Raquetball  Racquetball is closely related to handball. It is played on either an indoor or an outdoor court, using a hollow rubber ball and a racquet. Its origin in Greenwich, Conn. during the 1940s, is traced to Joseph Sobeck, a professional athlete who was also working at a rubber factory. The game increased progressively in popularity, and the International Raquetball Association was established in 1969 CE.

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Volleyball  William Morgan, director of the YMCA in Holyoke, MA, developed the game of volleyball from German Faustball in 1895 CE. It was a less rough sport than basketball, and thus was thought more appropriate for older members of the YMCA. Volleyball was a demonstration sport at the Paris Olympics of 1924 CE, and was included in the Olympic roster beginning in 1964 CE. Ringette  Ringette is a Canadian game. It was invented by Sam Jacks, in 1963 CE. An air-filled ring is propelled by a stick without a blade, and unlike ice-hockey, body checking is prohibited.

New Forms of Individual Activity Roller-Skating  Roller skates were seen on the London stage as early as 1743 CE. The first public roller-skating rinks opened in Newport, RI, in 1866 CE, and Brussels in 1877 CE; by 1879 CE, Toronto enthusiasts were organizing a 75-hour roller-skating marathon. Ball-bearing skates appeared in 1884  CE, and many ice-skating rinks were modified to accommodate roller-skaters during the summer months. North American interest in roller skating increased steadily through the Modern Era, peaking during the 1970s. Roller-skating championships were held in various places, notably at the Canadian National Exhibition. Ballroom Dancing  A growing interest in jazz inspired new dance crazes during the Modern Era. Some of these innovations required quite vigorous physical activity. During the 1930s, formal ballroom dancing was popularized by the films of Fred Astaire and Ginger Rogers, and large “Palais de Danse” were built in many cities. Commercial organizations such as the Arthur Murray Company taught ballroom dancing to large segments of the urban population, and a visit to the Palais de Dance became a popular weekend entertainment. Table Tennis  The sport of table tennis began among British Army Officers who were stationed in India during the late nineteenth century. The celluloid ball was introduced during the 1880s, and the pimple-rubber covered bat first appeared in 1901 CE. In many parts of Canada, houses had basements large enough to erect a permanent table tennis table, and during the Modern Era it became a valuable source of physical activity during the cold winter months. Table tennis became an Olympic Sport in 1988 CE. Parachuting  Interest in parachuting was fostered by militaristic regimes during the Modern Era. In 1926 CE, parachuting contests began in the U.S. The sport was seen more as a test of a person’s nerve than as a significant generator of physical activity. It remains a dangerous sport, with a current death rate of about 1 in every 150,000 jumps. Mountaineering  Mountaineering in the Swiss and Austrian Alps was a well-­ established pastime for wealthy Victorians. Some of the first Rocky Mountain

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guides came from Switzerland, and they progressively conquered North American peaks. Mount Bonney (3305 m) was first climbed in 1888 CE, Mount Assiniboine (3620 m) in 1902 CE, Mount Robson (3854 m) in 1913 CE, Mount Logan (5633 m) in 1925 CE and Mount Waddington (4020 m) in 1936 CE. The ultimate challenge, Mount Everest, was finally conquered in 1953  CE Commercial tourist parties began this perilous ascent several decades later, often with tragic results. Orienteering  Orienteering was initially introduced as a form of physical training for the Swedish Army. The first large-scale orienteering competition was held in 1919  CE.  The sport spread through Scandinavia during the 1920s and 1930s, as compasses became more reliable. Bjorn Kjellstrom (1910–1995  CE), inventor of the modern compass, organized demonstration events in Toronto and Montreal in 1946 CE. Youth Hostels  Youth Hostelling began in Germany just before World War I (Chap. 8). The British Youth Hostel Association (YHA) was founded in 1930 CE. It offered young people overnight accommodation in tiered bunk beds, together with simple meals and/or self-cooking facilities for a nightly fee of one shilling (sixpence if under the age of 25 years). The only conditions imposed upon travellers were a valid YHA membership card and arrival by mountain hiking, cycling or canoeing. The distances between hostels (sometimes 100–125 km), and the requirement to share in hostel maintenance duties at the nightly behest of the warden ensured that users had a substantial daily dose of physical activity. In 1932 CE, 11 National Youth Hostel Associations came together to form the International Youth Hostel Federation. There are now 70 affiliated associations, and 4000 hostels in 80 countries around the world. Recreation in National and State/Provincial Parks  The idea of creating National Parks is attributed to William Wordsworth (1770–1850  CE), who described the English Lake District as: “a sort of national property, in which every man has a right and interest who has an eye to perceive and a heart to enjoy.” The designation of National and State/Provincial parks was seen as conserving the natural heritage while allowing low-cost recreational activities such as camping, picnicking, hiking, swimming, canoeing, and mountaineering. In Britain, a government inquiry (1931) recommended the creation of a National Parks Authority, but no concrete action was taken for many years. In 1932 CE, the British Communist Workers’ Sports Federation organized a mass “trespass” on a hill in the Yorkshire Peak District named Kinder Scout. The Chair of the local parish council attempted to read the Riot Act to a group of determined hikers. However, the crowd quickly broke through a police blockade, and reached the top of Kinder Scout (altitude 636 m).The police awaited their return, arresting Rothman (their leader) and four other “Jewish-looking” ramblers. All five received prison sentences for organizing the hike. An Act of Parliament creating National Parks was eventually passed by the British parliament in 1949 CE, with Kinder Scout included in one of ten National Parks.

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Perhaps because of a larger unexploited land-mass, National Parks were created much earlier in North America. Yellowstone National Park was established in 1872 CE, and the Banff Hot Springs Reserve in 1885 CE. Large Provincial parks were also established quite early in Canadian history, beginning with Alqonquin Park, ON (1893 CE). A third stage in providing recreational space for a growing urban population was the establishment of regional parks and lakes around major cities. Although a valuable recreational resource for many city dwellers, most of these outdoor spaces were unfortunately accessible only to people owning cars.

Sedentary Activities For many people, the construction of large sports stadia, greyhound racetracks, auto speedways, cinemas, radio and television accelerated the trend to a sedentary lifestyle during the twentieth century. Radio and television allowed people to feel involved in events without even travelling to the site of competition, and spectator interest in events was further stimulated by football pools and off-track betting. Movie theatres provided a further option for sedentary entertainment, and after World War II, the development of powerful amplifiers allowed massive public attendance at Rock concerts. Radio  The radio became a popular source of entertainment during the late 1920s, as temperamental crystal sets were replaced by radios fitted with vacuum tube receivers. Marconi initiated regular public broadcasts in 1922  CE, the British Broadcasting Corporation was founded in 1927 CE, and the Canadian Broadcating Corporation in 1936 CE. Some people listened to the radio while engaged in active domestic pursuits, but many chose to sit in a chair and enjoy sports programmes, musical recitals and their favourite weekly comedy shows. Television  John Baird began television broadcasts in cooperation with the BBC in 1929 CE. By World War II, television broadcasts were reaching 40,000 homes in Britain, although the screen was still very small, and the equipment was a novelty rather than a solid source of passive entertainment. Most people had purchased television sets with larger screens by the 1950s, and in contrast to radio broadcasts, there was little possibility of remaining physically active while watching television programming. Cinema  The Edison Company developed the first commercial cinema projector in 1896 CE. The resulting images were flickering, jerky and not particularly interesting to watch, despite heroic efforts by a pianist or organist to bring emotion to the presentation. However, synchronized sound tracks were added by 1923. Massive (2000–3000 seat) cinemas were built in major cities of Europe and North America during the 1930s and 1940s, and they were filled consistently each week with people seeking 2–3 hours of sedentary entertainment.

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Rock Concerts  Improvements in electronic amplifiers during World War II allowed the organization of large outdoor concerts. The most well known was the 3-day Woodstock Festival of 1969 CE, which attracted 500,000 people for a weekend of very loud rock music, “free-love” and the use of psychotropic drugs. Sports Gambling  Major gambling on the outcome of English soccer matches began in 1923  CE, with the founding of Littlewoods Football Pools. In some countries such as Sweden, football pools became State monopolies. Entry coupons were cheap enough to have mass appeal, and there was potential for a massive pay-out if a person could predict the outcome of all League matches correctly. Entry forms are now available via the Internet, but in the Modern Era the coupons were either mailed to customers or given to an agent employed by Littlewoods. Beginning in 1948 CE, the British government took substantial revenues from the taxation of both football pools and bets placed on greyhound races. Greyhound Racing  Modern greyhound racing began in 1912 CE, with introduction of the electric hare. Urban locations and evening racing made this sport attractive for working-class gamblers. British greyhound tracks reached their zenith following World War II, with an annual attendance of 34 million spectators, but interest declined when the Betting and Gaming Act of 1960 CE permitted off-course cash betting on these events. Auto Racing  Early auto racing was of the city-to-city variety. An auto racetrack opened at Brooklands, on the southern outskirts of London, in 1907 CE, and races continued at that site until the track was damaged by bombing during World War II. Stock-car racing was introduced at Charlotte, NC, in 1949 CE, and a variety of “Super Speedways” were constructed in major cities around the world beginning in the 1960s.

Health The discovery of remedies for many acute infections decreased childhood death rates during the Modern era, thereby increasing average life expectancy at birth. The introduction of insulin was of particular benefit to children with type I diabetes mellitus. However, a continuing decline in habitual physical activity among the adult population led to epidemics of cardiovascular disease and obesity. The preventive value of regular physical activity gained recognition, and studies progressively demonstrated the value of active physical rehabilitation following such conditions as myocardial infarction. In many developed nations, a lower birth rate and an increased lifespan also caused a marked demographic change, with a progressive aging of the population. Diabetes Mellitus  During the 1920s, the pancreatic extraction of insulin by Frederick Banting and Charles Best at the University of Toronto made a dramatic contribution to the health of children with type I diabetes mellitus. Previous attempts

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at the extraction of insulin from the pancreas of horses had been thwarted because enzymes in that tissue rapidly broke down the glucose-regulating hormone. However, Banting and Best overcame this technical problem by ligature of the pancreatic duct; this killed the trypsin-secreting cells in the pancreas, without affecting the Islets of Langerhans and thus the secretion of insulin. A Nobel Prize was awarded for this work, although as in a number of instances the honour may have been misdirected; officially, the prize was shared between Banting and MacLeod, the latter claiming a share of the glory largely because he was then Chair of the Department of Physiology at the University of Toronto. Cardiac Disease  Jeremy Morris (1910–2009  CE), a Professor at the London School of Hygiene and Tropical Medicine, analyzed the Official Statistics of the Registrar General for England and Wales to demonstrate the course of an epidemic of cardiovascular disease in Britain. The epidemic had apparently begun in the 1940s, and by 1946–48 CE the male death rate from acute coronary disease was double that for 1931–33 CE. Many factors had changed in Britain between 1930 and 1950 CE, but in Morris’s view one of the most prominent developments had been a decrease in habitual physical activity, as industry became mechanized, and most households had purchased one or more cars. Obesity  In Victorian times, much of the population was under-nourished, and the emphasis of public health programmers was mainly upon increasing the average body mass. However, by the 1950s, there were concerns about a growing prevalence of obesity, particularly in North America. The U.S. National Health Examination Survey of 1962 classed 45% of adult Americans as overweight (a body mass index >25  kg/m2), and 13% as obese (a body mass index >30  kg/m2). In Canada, the increase of body mass begin in the early 1970s. Life Insurance companies quickly recognized the link between an excessive body mass when purchasing a policy and a reduced life expectancy, and they adjusted their premiums accordingly. Preventive Value of Physical Activity  Many were still questioning the health value of physical activity as late as the 1950s, usually on the basis of findings in university athletes rather than the general population. Henry J. Montoye found that Michigan alumni who were classed as having been athletes while at university had a substantially shorter lifespan than their peers who had not participated in college athletic programmes. However, it transpired that many of Montoye’s athletes had been football players with a mesomorphic body build that predisposed them to cardiovascular disease. Moreover, by middle age, these former “athletes” were often less active and fatter than their peers. Subsequent studies of endurance athletes from Scandinavia found a several-year advantage of longevity relative to the general population, particularly among participants in activities such as cross-country skiing, but again it remained unclear whether this was because they undertook a large volume of habitual physical activity, or whether their advantage was due to an ectomorphic body build and lifelong abstinence from cigarettes.

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Other investigators looked at the effects of differing levels of habitual physical activity in the general population. Morris compared London double-deck bus drivers (who sat in the comfort of a leather-padded seat for most of the day), and “conductors” who had to climb repeatedly to the top deck of the bus to collect fares. The latter accumulated a total of at least 600 steps per shift. At first inspection, the 2 categories of employee seemed ideal for comparison, since both groups of worker had similar salaries and came from a similar social milieu. However, a study of uniform sizes showed that there was some self-selection during the hiring process. At recruitment, the drivers had a larger abdominal girth, a greater body mass, a higher blood pressure and a greater serum cholesterol than the conductors. Nevertheless, these differences were not enough to explain the lower risk of heart disease in the conductors; they also seemed to gain protection from their high level of occupational activity. Morris also studied post-office workers, comparing postal carriers with desk workers, again finding a lower risk of heart disease in those employees who were physically active. In the United States, Henry Taylor compared active and sedentary railroad workers, and Ralph Paffenbarger evaluated San Francisco longshoremen; again, high energy expenditures on the job were associated with a low risk of heart disease and sudden cardiac death. Further proof of the benefits of regular physical activity was sought in British Executive-Class civil servants and Harvard Alumnae. Both of these studies suggested that in order to obtain health benefits, it was necessary to maintain a minimum threshold intensity of effort (what Morris called “vigorous getting about”) and/or a minimum weekly volume of exercise (Paffenbarger estimated an additional energy expenditure of 4–8 MJ/week). Exercise Following Cardiac Disease  The Irish physician William Stokes (1804– 1878 CE) was an early advocate of exercise for his cardiac patients: “The symptoms of debility of the heart are often removable by a regulated course of gymnastics or pedestrian exercise….I have seen the most remarkable examples in persons who have spent the summer walking through the Alps.” During World War I, Sir James MacKenzie also recommended gymnastics for troops affected by “soldiers’ heart” (what we would now regard as neurasthenia associated with post-traumatic stress disorder). However, the idea that physical activity might help those with cardiac disease was largely swept aside over the next 20 years; indeed, some cardiac patients were not even allowed to brush their teeth for 2 weeks following a heart attack. In the U.S., the issue gained new urgency when President Eisenhower nearly died of a heart attack (in 1955 CE). His physician, the cardiologist Paul Dudley White (1886–1973 CE) was a strong advocate of exercise, and indeed White himself remained a vigorous walker and a determined bicycle rider into an advanced old age. Another pioneer was Herman Hellerstein, who began an out-patient programme of exercise and diet for cardiac patients at the Cleveland Clinic in the early 1950s; Hellerstein reported favourable outcomes in 485 patients at the first International Conference on Physical Activity and Cardiovascular Health (held in Toronto, in October 1966). The Israeli physician Viktor Gottheiner argued that graded outdoor

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exercise (walking, running, cycling, swimming and rowing) was more enjoyable than North American rehabilitation programmes, which usually involved sitting on a hospital cycle ergometer for 30 minutes 3 times a week. Gottheiner claimed a very low mortality rate for participants in his programme (0.88% per year, compared with an expected value of 4.8%), although his experience is hard to evaluate, since he did not himself have any control subjects. Changing Demographics  Malthusians had long argued the need to limit the global population to avoid starvation, but until the Modern Era, many countries had seen population growth as important to the expansion of domestic markets and the strengthening of military power, with a corresponding desire to restrict contraception and abortion. However, most developed societies saw a substantial population aging over the twentieth Century. In 1900 CE, 4.1% of Americans were over the age of 65 years, but this proportion had grown to 5.4% by 1930, 8.1% by 1950, and 9.9% by 1970. In 1940, just over a million Americans were older than 85 years, but by 1980 CE there were 2.2 million in this age bracket. These demographic changes reflect the combined influences of a decreasing fertility rate and the progressive control of acute disease. Third-world countries still offered little support to the elderly during the modern era, and in this situation a large family continued to be seen as an important insurance for old age. Malnutrition, disease, and inter-tribal conflicts further contributed to maintaining a steep population pyramid in many third world countries.

Nutritional Status During the Great Depression, malnutrition was rampant among the unemployed, and during World War II, food was in extremely short supply in countries occupied by the Nazis. After World War II, nutrition improved in most of western society, although devastating famines still ravaged parts of India, Asia and Africa through most of the Modern Era; in Maoist China, 30 million citizens died of starvation in one year alone. We will look briefly at the issue of food shortages during the inter-war years, governmental nutritional programmes, incidental benefits of dietary restriction, and evidence of nutritional status obtained from body build. Food Shortages During the Inter-war Years  Lack of work caused food shortages for many people during the inter-war years. Unemployment reached 25% in the U.S. and 30% in Canada, with many of the population relying upon soup kitchens for their survival. Medical examinations in London (1927  CE) and in the ship-­ building town of Jarrow (1933  CE) disclosed many children who were suffering from calcium deficiency and rickets. And in Soviet Russia, food shortages resulted from the enforced collectivization of small farms and an excessive focus on the development of heavy industry.

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Government Nutritional Programmes  Some governments provided school breakfasts and/or lunches in an attempt to correct these nutritional problems. School meals were introduced in poor areas of Britain during the 1870s, and a morning school drink of free or subsidized milk became available in Britain from around 1935 CE, with every child receiving a 190 ml bottle of milk each day. However, the milk supplements did little to reduce the prevalence of rickets. Problems were most common in urban areas, and surprisingly were found to be independent of social class. It was finally concluded that the cause of the rickets was intense air pollution. Until the mid 1950s, the sun in cities such as London had been obscured by smog for much of the year. The rickets problem was resolved once the burning of coal in domestic fireplaces was prohibited (1956). In 1944 CE (when English household rations were severely restricted due to the ravages of Germn U-boats), state schools began to provide low-cost lunches that met minimum nutritional standards. In the United States, President Truman introduced the National School Lunch Act in 1946 CE. It now provides low cost or free lunches to 31 million schoolchildren. School breakfast programmes also began in 1966, and by 1997 6 million U.S. students were attending a breakfast club, with beneficial effects upon both nutrition and learning. Incidental Beneficial Effects of Dietary Restriction  During World War II, many hungry Europeans of necessity replaced fats and sugars by foods rich in vegetable fibre. This enforced dietary change had a beneficial effect on the prevalence of cardiovascular disease in the affected cohort. Body Build  Inter-relationships between body build, nutrition and health have been appreciated since classical times, but during the Modern Era, investigations were greatly facilitated by semi-quantitative ratings of leanness, muscularity and obesity and subsequently by the collection of objective data on the amounts of muscle, fat and bone in the body. Semantic Descriptions  In terms of body build, Hippocrates (Chap. 4) had distinguished the habitus apoplecticus (the red-faced, jovial, and thick set individual who was liable to die of apoplexy) from the habitus phthysicus, (the lean and introspective person who was liable to phthisis). In 1797 CE, Halle went further, distinguishing four body builds: the fat (“Abdominal”) person, the strong (“Muscular”) individual, the long, slender-chested “Thoracic” type, and the large-headed “Cephalic” person. More recently, the German psychiatrist Ernst Kretschmer (1888–1964  CE) distinguished the round and compact “Pyknic” body form, the long and thin “Leptosome” and the muscular, “Athletic” individual, although he recognized that most people were amalgams of the three body types. However, such classifications of body build held much greater interest for psychiatrists such as himself than for exercise scientists. The American psychologist William Herbert Sheldon (1898–1977  CE) used nude photographs to make seven-point ratings in terms of three supposedly orthogo-

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nal characteristics: fatness (“endomorphy”), muscularity (“mesomorphy” and linearity (“ectomorphy”). In well-nourished adults, 7% were classed as endomorphs, 12% as mesomorphs, and 9% as ectomorphs, but the remaining 72% shared two if not three of the proposed body types. After World War II, Sheldon’s views fell into disfavour, in part because he had conserved many nude photographs of young Co-Eds and had developed unpleasant eugenic views based on a person’s physical appearance. A former assistant had also denounced his methods as inaccurate if not fraudulent. Subsequently, Lindsay Carter, an applied anatomist at the University of San Diego, attempted to combine the subjective impressions of somatotyping with objective measurements of body build, but most investigators now prefer to describe physique simply in terms of the objective units of lean body mass, body fat content and bone dimensions. Quantitative Assessments  Quantitative methods of assessing human physique that were developed during the Modern Era included hydrostatic weighing, soft tissue radiography and the use of skinfold calipers. Interest in body density was stimulated by attempts to improve estimates of body surface area, to determine the extent of nitrogen storage in divers, and to predict human tolerance of starvation. To determine body density, subjects were weighed while submersed in water, or were exposed to varying air pressures while enclosed in a rigid chamber. Skinfold calipers were introduced during the 1930s, and they became widely accepted with the development of a precision instrument that exerted a constant pressure over all likely jaw-widths. The Glasgow physiologist John Durnin is remembered for establishing equations that linked such skinfold readings with body density. Working with Reginald Passmore of Edinburgh University, Durnin also created a compendium that listed the energy costs of many common physical activities as measured by a Kofranyi-Michaelis respirometer during the early 1950s. The Compendium was used by work physiologists for many years, but unfortunately it is now largely out-dated because changes in equipment and technology have reduced the energy cost of most of the activities that are listed in this monograph.

Physical Activity We may infer a downward trend of physical activity during the Modern era, given decreasing family size, domestic labour-saving devices, mechanization and automation of industry, the widespread ownership of cars, the partial mechanization of sports (for example, electric golf carts), and ever-growing opportunities for spectator activities. In North America, the construction of suburbs without sidewalks, and the growing speed of motor vehicles hampered active transportation. The 1950s also saw a growing allocation of free time to television. However, field and laboratory tests allowed documentation of fitness levels.

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The Assessment of Physical Fitness Throughout much of the Modern Era, physical educators had little access to sophisticated laboratory equipment, and assessments of fitness were based on simple field. However, physiologists developed progressively more sophisticated laboratory fitness tests. Field Performance Tests  We will comment on the Kraus-Weber test, the AAHPER and CAHPER tests, Jump tests, and measures of flexibility, sprint and endurance performance. Kraus-Weber Test  Following World War II, the Austrian-born sports physician Hans Kraus introduced a simple six-item field performance test to assess the fitness of U.S. school students. Five items tested muscular strength and endurance, and the sixth measured the ability to touch the floor for 3 seconds while standing erect. The results of a national survey aroused a great furor; 58% of U.S. students failed to meet the minimum criterion for at least one of the 6 tests, usually the floor-touching item. In contrast, it was claimed that European students had no problems completing the entire test battery. Some evaluations of children have also included a softball throw. This is one skill where North American students have usually outshone their European peers. Maxwell Howell from the School of Physical Education in Alberta demonstrated the important impact of test learning upon performance of the Kraus test battery. Over 4 days of instruction, he was able to bring the performance of Canadian children up to that of their European counterparts. Moreover, a retesting of the European students found a similar failure rate of the Kraus-Weber test (58%) to that reported for children in the United States. AAHPER and CAHPER Tests  The American and Canadian Associations for Physical Education and Recreation (1958, 1966) each developed broadly-based field test batteries that examined muscular strength and endurance, flexibility and aerobic and anaerobic power of school students. Findings for any given individual were expressed as a percentile of the mean for the national population of the same age and sex. However, it was soon appreciated that individual scores depended heavily on height, body mass and body fat content. Technique, motivation and practice also influenced scores. Jump Tests  Dudley Sargent (1849–1924 CE), a leading American physical educator from the turn of the century, proposed an index of explosive muscle force based on the product of body mass and the height jumped when standing erect. Variants of this test, still widely used, have allowed a preliminary flexion of the knees (a counter-­movement jump), a squat jump with or without additional weighting of the subject, a drop-jump, and standing long jumps. The precision of scoring for such tests has been much increased in recent years by having subjects jump while standing on a force platform.

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Flexibility  During World War I, a simple protractor goniometer served to measure increases in the range of motion of battle-injured limbs during rehabilitation. By the mid-twentieth century, plastic and plexi-glass goniometers had become widely available. A Russian born physician, Peter Karpovich, working at Springfield College, added a potentiometer to the goniometer, allowing him to obtain a continuous electrical read-out of data during body movement. In 1952 CE, goniometers and toe-touching were widely replaced by the simple sit and reach test of Wells and Dillon, 1952. This was originally conceived as evaluating low back and hip flexibility, but more recently it has been shown to reflect mainly the length of the hamstring muscles. Sprint and Endurance Performance  Physical educators often tested sprint performance on an outdoor track, with scores influenced by the ambient temperature, wind-speed and ground conditions. Because of concerns about the dangers of an all-out aerobic effort without medical supervision, AAHPER adopted a 549 m walk-­ run test, and CAHPER opted for an even shorter 274 m run when devising their test batteries (above). The duration of the endurance run was such that both aerobic and anaerobic processes contributed to performance. By 1980, confidence in the safety of field testing had increased, and Luc Léger of the University of Montreal was able to introduce a shuttle-run procedure that brought children to peak, if not absolute maximal aerobic effort. Working with the U.S. armed forces, Kenneth Cooper determined the maximum distance recruits could run in 12 minutes. In part because body mass influenced the individual’s running speed, scores on this test showed a relatively close correlation (0.90) with treadmill determinations of maximal oxygen intake. Laboratory Tests of Physical Fitness  Laboratory measures of physical fitness began with various manipulations of systemic blood pressure and heart rate. Attention was also directed to pulse pressures and pulse recovery rates following a standard bout of exercise. Studies were made of the electrocardiogram and the cardiac dimensions as seen at radiography, and blood samples were collected from the heart by cardiac catheterization. Aerobic fitness was evaluated by ergometry, and direct measurements of oxygen consumption during all-out exercise, while attempts were made to predict the maximal oxygen intake from the responses to sub-­maximal exercise. Tests were also devised to examine anaerobic power and capacity, and dynamometry determined various types of muscular strength. Information from Blood Pressures and Heart Rates  Early laboratory tests of fitness were based on the blood pressure and pulse rate seen following standard bouts of exercise or a sudden change of posture. Graüpner (1906) reported the impact of cycle ergometer work on pulse rate and blood pressures, and T.B. Barringer (1917) noted the rise of blood pressure following the repeated lifting of 1.5–10  kg dumb-bells. The tests of Crampton (1905) and Schneider (1920) presupposed that if a fit person moved rapidly from a supine to an upright position, the systolic blood pressure would be maintained without any large increase of heart rate, whereas in an

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unfit individual the blood pressure would fall. Scores on both the Crampton and the Schneider tests showed some relationship to the gains of cardio-respiratory fitness induced by daily exercise. However, heart rate and blood pressure are modified by many other extraneous factors, making postural tests relatively poor indicators of fitness; C.H. McCloy bluntly concluded that such tests gave little more information about a person’s fitness than a random guess. Pulse Pressures  Otto Frank (1899) suggested that (other factors being equal) the pulse pressure depends on the left ventricular stroke volume and thus an individual’s cardio-rspiratory fitness. However, the potential for a clinical interpretation of pulse pressures is limited, since they also increased if an individual has developed arteriosclerosis. Tom Cureton (1901–2002 CE) developed a device for recording details of the pulse wave (his “Heartometer”). Despite the fact that he recorded the pulse wave after transmission through overlying muscle and skin, Cureton carefully measured the amplitude and duration of primary and secondary pulse waves, and valiantly calculated velocities and accelerations of the pulse waves, which he thought were related to myocardial contractility. Pulse wave recording gained a new lease on life with the appearance of lightweight electronic tambours that could be positioned over the carotid artery and other large blood vessels. The waveform was still distorted by skin and muscle, but the use of these devices enabled observers to estimate arterial stiffness and thus the likely extent of arteriosclerosis by the speed of transmission of the pulse wave through various segments of the arterial tree. Pulse Rate Recovery Curves  Because of difficulties in counting the pulse rate during exercise either manually or by ECG recording, many early fitness tests were based upon pulse rate recovery curves. Rapid recovery of the resting pulse rate is certainly one criterion of cardio-respiratory fitness, and in 1922 the British Medical Research Council concluded that the recovery curve gave the best simple index of a person’s physical condition. Heart rates counted during and 10–15 seconds following a bout of exercise showed good agreement with each other, but if pulse counting was delayed for 30–60 seconds, a third of the information content about the exercise heart rate was lost. Wright Tuttle (1893–1969  CE), Marcus Pembrey (1868– 1934  CE), Jean-Edouard Ruffier (1874–1964  CE) and Lucien Brouha (1899– 1968 CE) all espoused fitness tests based upon heart rate recovery. Electrocardiogram  Soon after Einthoven had introduced the first practical electrocardiogram (in 1903 CE), resting ECG records were carefully studied in both health and disease, Examination of 260 participants in the Amsterdam Olympic Games (1928 CE) suggested that fit athletes displayed a long P-Q interval (reflecting a slow pulse rate) and a large T wave (probably reflecting a lack of superficial fat). For many years, poor skin contacts precluded ECG recordings during exercise. However, in 1928, Master noted that a substantial ST depression immediately following a period of vigorous step climbing was a consistent harbinger of subsequent myocardial infarction.

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Cardiac Radiography  Many Victoeian cardiologists had suggested that “injudicious” exercise could strain the heart, causing an enlargement of the ventricles. However, Sir Thomas Lewis (1881–1945 CE) argued that the fibrous nature of the pericardium prevented excessive dilatation of the heart during vigorous exercise, Resolution of the question of a possible overstrain depended in part on accurate determinations of heart size. Clinical percussion of the thorax had yielded at best qualitative approximations, but PA radiographs showed that the hearts of previously sedentary individuals became larger during military service. Distance runners and cyclists were also shown to have larger hearts than weight-lifters and short distance runners. Unidimensional estimates of heart size were enhanced by taking lateral radiographs, and as data accumulated, the idea emerged that the large heart of the endurance athlete was a favourable adaptation to regular and vigorous physical activity rather than a manifestation of pathological change. Cardiac Catheterization  Cardiac catheterization greatly facilitated the accurate measurement of cardiac output. During the 1930s, Werner Forßmann (Fig. 9.2) succeeded in introducing a narrow ureteric catheter into his own right atrium. His surgical chief was initially angry at this unauthorized and potentially dangerous initiative, but when he saw the resulting radiograph and recognized the potential of the method, he allowed a repetition of the procedure on a terminally ill woman. After World War II André Cournand (1895–1988  CE) and Dickinson Richards (1895–1973  CE) found clinical application of this procedure in evaluating patients with various types of congenital heart disease, and in 1956 CE they shared the Nobel Prize in Physiology with Forßman. Ergometry  During the early 1800s, the earliest type of ergometer had been a giant stepping wheel or treadmill, operated for up to 8 hours per day as a punishment in Fig. 9.2  Werner Forßmann (1904–1979 CE), who carried out the world’s first cardiac catheterization on himself (Source: http://en. wikipedia.org/wiki/ Werner_Forssmann).

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British prisons. Edward Smith had used one of these devices in some of his early respiratory experiments, and Gustave-Adolphe Hirn (1815–1890 CE) set a stepping wheel inside a closed chamber to examine the composition of expired gas and determine the mechanical equivalent of heat when exercising on this device. Nathan Zuntz constructed a more conventional motor-driven treadmill in 1889. The external work performed by the subject was calculated very simply from the belt speed, slope and the individual’s body mass. In 1866, Max von Pettenkoffer and Carl von Voit had subjects enclosed in a small metabolic chamber turn a flywheel carrying a 25 kg load. Carl Speck invented the first mechanically braked cycle “ergostat” in 1883 CE; an arm crank with a resistance adjusted by pulling up a screw was operated from a standing position. Although the apparatus was usually used in an uncontrolled manner, it was possible to approximate the braking force in kg-m. In 1896, Elisée Bouny introduced the first quantitative cycle ergometer, applying a braking force to the wheel of a jacked-up bicycle. By the beginning of the twentieth Century, Nathan Zuntz had developed a friction-belt cycle ergometer, loaded by a box of weights, Jules Amar (1909) established that the mechanical efficiency of cycling was in the range 20–25%, and August Krogh adopted a mechanical cycle ergometer for his extended studies of respiratory gas exchange. Mechanical braking of the ergometer was greatly facilitated in 1954, when Wilhelm Von Dőbeln introduced a pendulum weighting system, as in the commercial Monark ergometers that are sold today. U.S. laboratories developed an alternative type of ergometer, where subjects exercised against the resistance provided by an electrical generator. Hugo Wilhelm Knipping (1895–1984  CE) constructed a very sophisticated electrically-braked ergometer of this type; loadings could be accurately graded over a range of 0 to 750 Watts. Direct Measurement of Maximal Aerobic Power  The classic description of aerobic and anaerobic contributions to maximal exercise was provided by A.V. Hill (1923– 1924 CE). Observations were made on subjects running in the field, using a photoelectric timing system. Hill suggested that the maximal oxygen consumption provided a useful criterion of an individual’s cardio-pulmonary performance. He also developed the concepts of oxygen deficit, oxygen debt and steady-state exercise. In Stockholm, Goran Liljestrand (1886–1960 CE) also took field measurements of oxygen consumption, studying walkers, runners, rowers, and cross-country skiers. In 1928, Robert Herbst made some early measurements of maximal oxygen intake for sedentary young men and athletes, finding values that ranged from 1.82– 4.02 L/min. He suggested that one reason for inter-individual differences might be a failure of the lungs to fully saturate the arterial blood with oxygen during maximal effort, a concept that more recently received limited endorsement from Loring Rowell (1964). An American middle-distance champion (Sid Robinson, 1938) studied the aerobic performance of subjects aged 6 to 91 years, noting that the maximal heart rate and maximal oxygen intake were lower in older individuals. The widely used prediction of maximal heart rate (220-age in years) dates back to Robinson’s research.

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Fig. 9.3  P-O Astrand, a Swedish exercise physiologist, reported high maximal oxygen intake values for Swedes, creating the myth of a very fit Swedish population, but unfortunately the high averages arose largely because he did not test a representative population sample

Robinson also demonstrated the value of maximal oxygen intake as a measure of aerobic fitness, showing that with 26 weeks of training, values increased by 17%, The standard criterion of maximal effort, an oxygen consumption plateau where consumption increased by less than 150 ml/min or 2.1 ml/[kg.min] with an increase of work rate) was proposed by Henry Taylor in 1955 CE. Taylor further demonstrated that over a three-week period of bed rest a subject’s plasma volume shrank by 15.5%, with recovery over 6 weeks of subsequent reconditioning. Taylor examined the possibility of conducting a randomized controlled trial of exercise for the primary prevention of heart disease, but he concluded that such an experiment was too complex, would require too large sample, and had too many confounding factors. Per-Olaf Åstrand (Fig. 9.3) collected a large body of maximal oxygen intake data in 1952. His reported figures for Stockholm residents were substantially larger than averages for other parts of the world, causing the Canadian motivational agency ParticipACTION to create the myth of a 60-year-old Swede who could easily walk past his 20-year-old Canadian counterpart. However, the idea of seeking out a representative national sample had yet to gain currency, and Åstrand later acknowledged that his subjects were not truly representative of the Stockholm population. In 1966, a working party of the Human Adaptability Project of the International Biological Programme met in Toronto to standardize methodology for both direct and submaximal estimates of maximal oxygen intake. However, the process was not a total success, since many laboratories that had not been involved in the Toronto trials unfortunately continued to use their own widely divergent procedures. Sub-Maximal Testing  Many clinicians remained nervous about the risks of maximal exercise testing throughout the Modern Era. One alternative approach, popular

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in Scandinavia, was to report the individual’s cycle ergometer power output at a standard heart rate of 170 beats/min (the PWC170). However, because of the age-­ related decrease in maximal heart rate, the test became progressively more severe as a person aged, and in elderly subjects some observers resorted to reporting a PWC150. A second simple submaximal approach was to extrapolate the relatively linear relationship between heart rate and oxygen consumption from 50 to 95% of an individual’s maximal oxygen intake. Irma Ryhming used this principle in developing the familiar Åstrand-Ryhming nomogram (1954). Anaerobic Power and Capacity  The Wingate Test, developed by the Israeli exercise scientist Oded Bar-Or in 1974, offered a simple estimate of anaerobic power and capacity in terms of the maximal cycle ergometer power output developed over periods of 5 and 30 seconds respectively. Other submaximal tests have included the lactate threshold (Hollman, 1963) and the anaerobic threshold (Wasserman and McIlroy, 1964), both being work rates associated with a significant accumulation of lactate in the blood stream. A further use of the cycle ergometer has been the determination of force-velocity curves. A.V. Hill (1938) described the relationship between the maximal force of a muscle (with zero shortening) to its maximal velocity (a contraction with zero loading), and subsequent investigators have applied this concept to measurements made on the cycle ergometer. Dynamometers  Handgrip dynamometers became widely used to assess muscle strength during the mid-1950s. Commonly, resistance was provided by a strong spring, but occasionally an electrical strain gauge measured the force that was developed. Although such instruments are still a common tool in fitness surveys, it remains debatable how far handgrip force is representative of an individual’s overall muscular strength. Clarke’s cable tensiometer (1973) offered a simple method of quantitating the force developed by larger muscle groups, although unfortunately the scores obtained with this technique varied with a person’s limb length and thus the leverage exerted.

Attitudes to Health and Fitness We conclude our survey of the Modern Era by looking briefly at the attitudes of some politicians, philosophers, authors, and radio/TV personalities of this period. Politicians  In the totalitarian regimens of Germany, Italy and Russia, fitness programmes became an important element of governmental policy (Chap. 20). However, in democratic Europe, frequent changes of government gave individual politicians little opportunity to impose their visions of fitness and health upon society, and in the U.S. and Canada, the primary concern of the authorities was to resolve the massive unemployment associated with the Great Depression.

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Britain  Like many developed countries, Britain faced severe economic problems during the Modern Era. The first World War had depleted British coal mines, and a return to the “gold standard” had made exports too expensive for overseas purchasers. At the peak of the economic crisis, there were over 2 million unemployed, and the 9-day General Strike of 1926 apparently presaged a Communist insurrection. Prosperity only returned as the nation began to rearm in the mid 1930s. Nevertheless, some health initiatives were introduced under the leadership of Lloyd George, Kingsley Wood and Nevill Chamberlain. Promises of enhanced social benefits spurred British troops to victory during World War II, and important new measures were introduced by the governments of Attlee and Macmillan after the defeat of the Nazis. Lloyd George. The Liberal government of the wily Welsh politician Lloyd George (1863–1945 CE) initiated many of the reforms that reached their apotheosis in the modern Welfare State, welcome initiatives including state support for the sick and the infirm. In 1918, the Fisher Education Act raised the official minimum school-leaving age to 14 years. Local education authorities were also required to provide regular medical inspections of schoolchildren, as well as: “(a) Holiday or school camps, especially for young persons attending continuation schools; (b) Centres and equipment for physical training, playing fields (other than the ordinary playgrounds of public elementary schools not provided by the local education authority), school baths, school swimming baths; (c) Other facilities for social and physical training in the day or evening.” Under Lloyd George, local municipalities also received subsidies, allowing them to replace the worst slums by municipally-owned low-rent housing. Often, this reform remained tainted by class-consciousness; for example, the government sponsored housing units did not contain baths, because “the poor would only use them to store coal.” Kingsley Wood and Chamberlain. Chamberlain accepted the need for Treasury-­ funded public feeding stations during the Great Depression, recognizing that the diet of the unemployed was “insufficient to keep the workers in fit condition to take up work when this is made available.” By 1936  CE, Sir Kingsley Wood (1881– 1943 CE) as Minister of Health was still expressing concern about the lack of physical fitness in the population, particularly in areas that had seen high rates of unemployment. He urged the government to encourage relocation of factories to the deprived areas of Britain. Wood’s ministerial responsibilities included social housing; under his administration “slum clearance … was pursued with energy, and overcrowding was greatly reduced.” He also worked hard to enhance both industrial and old age insurance provisions, and opened workshops for the blind. Other social initiatives followed in 1937, as Nevill Chamberlain introduced a Factory Act that restricted work hours for women and children, the Holidays with Pay Act, and further expansion of slum clearance and rent controls. The National Playing Fields Association had been founded in 1925  CE.  It received its official Royal Charter in 1933 CE. Physical recreation was supported through the Physical Training and Recreation Bill of 1937 CE. Objectives included: acquiring, protecting and improving playing fields, and playgrounds, and setting

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standards of play-space for new housing developments. One member of parliament (Wavell Wakefield) declared: “our aim is to try to make the great mass of the people, young and old, physically fit and to provide facilities for improving their general physical fitness and well-being.” A budget of £2,000,000 was voted for a National Fitness Council, but given the pacifist leanings of the early 1930s, politicians thought it necessary to apologise for the possible military context of the Council: “Was it necessary for us…to encourage men, women and children to be lazy, obese and malformed in order to convince the world that we did not wish to fight?” Certainly, Aneurin Bevan, from the parliamentary benches of the Labour party, roundly condemned the enthusiasm of the Council for fitness rather than sport or play: “the desire to play is a justification in itself…. The idea that you must borrow some justification for playing is one of the worst legacies of the Puritan revolution.” Nevertheless, the message publicized was “Get fit – Keep fit,” and with the outbreak of World War II the campaign shifted to a promotion of “fitness for service.” Attlee. After World War II, Clement Attlee (1883–1967 CE) oversaw implementation of the social policies outlined in the Beveridge Report, which had attacked the five giant evils of squalor, ignorance, want, idleness and ill health. The most far-­ reaching change was introduction of the National Health Service, which gave all British citizens free access to medical and dental care. Macmillan. In 1956 CE, Harold Macmillan introduced the Clean Air Act. This legislation banned the burning of soft coal in domestic fireplaces, greatly reducing particulate air pollution in large cities (Fig. 9.4). Macmillan also oversaw construction of 300,000 new houses per year to replace slum and war-damaged property, and he introduced a graduated pension scheme. United States  We will comment briefly on the contributions of Harding, Hoover, Roosevelt and Eisenhower to population health and fitness in the United Sates. Harding. During his Presidency, Warren Harding (1865–1823 CE) established a Department of Public Welfare and the Veteran’s Administration. Passage of the Sheppard-Towner Maternity Act also funded 3000 Child and Health Centers across the U.S., spurring physicians to begin thinking in terms of prevention rather than the treatment of disease. Hoover. Herbert Hoover (1874–1964 CE) was a strong believer in the “Efficiency Movement,” a concept that was very popular with ergonomists and industrialists during the Modern Era. During World War I, he had made valiant efforts to bring food supplies to Belgian cities starved by the German blockade. His interest in adequate nutrition continued even after World War II, when he instituted a school meals programme for hungry schoolchildren in the American zone of Occupied Germany. Roosevelt. Franklin Roosevelt developed some form of paralytic illness in 1921, although he hid the extent of his physical limitations from the general public. Perhaps in consequence of his illness, he was instrumental in establishing the National Foundation for Infantile Paralysis. He also developed a specialized hydrotherapy spa at Warm Springs, GA.

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Fig. 9.4  Nelson’s Column, London, as seen during the Great Smog of 1952; a period of dense air pollution lasted a week and led to an excess of about 4000 deaths (Source: http://en.wikipedia.org/ wiki/Great_Smog).

Eisenhower. In our present context, Dwight Eisenhower (1890–1969 CE) is best known for making the first moves towards formation of the President’ Council on Fitness (Chap. 21). Canada  During the Modern Era, Canadian politicians showed a varying level of interest in physical fitness and health. We will comment on the contributions of Borden, King, Bethune, Douglas, Saint Laurent and Diefenbaker. Borden. In 1919 CE, Robert Borden advanced a rather cautious parliamentary motion: “That so far as may be practicable, having regard for Canada’s financial position, an adequate system of insurance against unemployment, sickness, dependence in old age, and other disability, which would include old age pensions, widows’ pensions and maternity benefits, should be instituted by the Federal government in conjunction with the governments of the several provinces” However, no active steps were taken to make this vision a practical reality. King, Bethune and Douglas. MacKenzie King (1874–1950 CE) introduced legislation that provided family allowances, unemployment insurance and a needs-­ based old-age security plan, and he greatly expanded the role and funding of the National Research Council. His “Green Book” of 1945 CE is of particular interest in the context of Public Health. Specific proposals included: (1) grants for planning and organization; (2) health insurance; (3) health grants; and (4) financial assistance in the construction of hospitals. Unfortunately, implementation was delayed by jurisdictional disputes between the Federal and Provincial governments. Henry Norman Bethune (1890–1939  CE) was a strong advocate of socialized medicine, urging such a policy while he was working as a physician in a poor district of Montreal. He reacted strongly to the rejection of his ideas by the local medi-

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cal association: “Their prime interest appeared to be their own social status, the direct results of their profits from the practice of medicine.” In 1947  CE, a national conference that was convened to examine the “Green Book” proposals quickly collapsed. But the Province of Saskatchewan, led by Premier Tommy Douglas (1904–1986 CE), decided to go it alone, establishing Canada’s first publicly-funded comprehensive insurance plan in 1947 CE. Other Provinces soon followed suit, although a national health care plan was not implemented until 1965 CE, and the Province of Quebec did not join the system until 1972 CE. Saint Laurent. The Canadian Sickness Survey of 1950–51 CE demonstrated a substantial prevalence of untreated medical conditions across Canada, at considerable cost to the economy. However, Louis Saint Laurent (1882–1973 CE) was reluctant to move on the introduction of a National Health Insurance, in part because of continuing disputes with the Provinces, and in part because of fears that hospitals might be overwhelmed by pent-up demand. Finally, an early and restricted form of Medicare was introduced under the Hospital Insurance and Diagnostic Services Act of 1957 CE. But St. Laurent also allowed the National Fitness Council to founder, and the Act establishing the Council was finally repealed in 1954 CE. Diefenbaker. John Diefenbaker established the Royal Commission on Health Services (the Hall Commission) in 1961. Its mandate was: “to inquire into and report upon the existing facilities and the future need for health services for the people of Canada and the resources to provide such services, and to recommend such measures, consistent with the constitutional division of legislative powers in Canada, as the Commissioners believe will ensure that the best possible health care is available to all Canadians.” The Fitness and Amateur Sport Act of 1961 CE was also passed while Diefenbaker was prime minister.

Philosophers We will comment briefly on issues of health and fitness as seen by a group of philosophers that includes Husserl, Merleau-Ponty, Popper, Russell, and Foucault. Husserl  The German philosopher Edmund Gustav Albrecht Hasserl (1859– 1938 CE) established the idea of phenomenology. He argued that exercise and sport were essentially lived experiences, appreciated uniquely by the person involved, and the sub-discipline of exercise phenomenology still has a place in the curriculae of many Schools of Kinesiology. Merleau-Ponty  Maurice Merleau-Ponty (1908–1981  CE) was a French philosopher and phenomenologist, strongly influenced by the work of Husserl and Heidegger. He emphasized that body movement, rather than consciousness, was the primary means of knowing the world. Popper  The Austrian philosopher Karl Popper (1902–1994 CE) set the stage for evidence-based health care. He emphasized the important concept of an asymmetry

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between verifying and disproving an idea. No hypothesis could ever be proven absolutely, but a single negative result could negate it. Russell  The British philosopher Bertrand Russell (1872–1970  CE) deplored the separation of academic learning from physical education: “What I am complaining of is that physical and mental care are so completely separated, and that the person who possesses the knowledge required for the one has, as a rule, no inkling of the knowledge required for the other.” Foucault  Michel Foucault (1926–1984 CE) was a French philosopher interested in relationships between power and knowledge. Some exercise sociologists have applied his ideas to gender issues in sport, and the contributions of sport to self-­ identity and freedom. Foucault spoke out particularly strongly against the medicalization of sport. Authors  Among prominent authors of the Modern Era, Shaw, Kipling, Lawrence, Orwell and Broadfoot each expressed very different views on health and fitness. Shaw  The Irish playwright George Bernard Shaw (1856–1959  CE) believed in “selective breeding” leading to emergence of a super-race, an idea that became popular in the Third Reich. In The Doctor’s Dilemma (1906 CE), he castigated traditional medicine as dangerous quackery, and he argued strongly that it should be replaced by a combination of salaried physicians and public health measures such as sound sanitation, good personal hygiene and a meatless diet. His solutions were radical: “Make up your minds how many doctors the community needs to keep it well…. let registration constitute the doctor a civil servant with a dignified living wage…” Kipling  Rudyard Kipling (1865–1936 CE) was a product of British Imperialism. He had strong links with Baden-Powell and the Scouting movement. He was also a strong exponent of exercise. In the Jungle Book, he wrote: “in the Orient, blokes hit the road and think nothing of walking a thousand miles in search of something.” Lawrence  D.H.  Lawrence (1885–1930) wrote extensively on the dehumanizing effects of industrialization. However, he saw that sports contests could dignify a person’s life: “If you will have the gymnasium, and certainly let us have the gymnasium… as the Greeks had it….pure perilous delight in contest and profound mystic delight in unified motion.” Orwell  Eric Blair (1903–1950 CE), better known under the pseudonym of George Orwell, spent time in the coal mining community of Wigan, Lancashire. While living in that region, he studied local public health records to determine the prevalence of industrial illnesses, and went down the local pits to see the deplorable working conditions of the miners. Broadfoot  In “Ten lost years,” the Canadian journalist and historian Barry Samuel Broadfoot (1926–2003 CE) offered a graphic history of how the Great Depression affected working people in Canada. He gave a particularly graphic description of the heavy energy expenditures of the coal delivery man: “each sack weighed 125

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pounds,.. it was a 60 foot walk to the chute and…the snow was always two feet deep…you could just see him running down in the winter…how many’s the time (in the evening) he’s just lain down on the kitchen floor”. Radio and Television Personalities  In Victorian times, mass circulation newspapers had opened up a potential new channel for health education (Chap. 8). During the Modern Era, this role was progressively taken over by radio and television. Radio  In Britain, the “Radio Doctor” (Charles Hill, 1904–1989 CE) gave common-­ sense health advice to families throughout World War II, although he did not often mention the need to exercise. In Canada, Allan Roy Dafoe (1883–1943 CE), a country obstetrician who had delivered the Dionne quintuplets, assumed a similar role. In 1941 CE, Lloyd Percival initiated the CBC Radio Sports College, which at its peak boasted 750.000 registrants. This programme had a more specific focus on fitness, but unfortunately, Percival failed to lead by personal example. He was a heavy smoker, and preached the message “become fit so that you can enjoy your vices more.” Television  When television became widely available in the early 1950s, it focussed more on fitness and athletic ability than on nutrition and medical problems, although “commercial breaks” often offered supposed remedies for common ailments.

Practical Implications for Current Policy The average age of the population increased in many nations, beginning in the twentieth century. Such aging has many important implications for society, one of the most challenging being an ever-growing need for health services and physical support. Both the nature and the prevalence of common ailments change with age, and there is a corresponding need to reassign hospital beds and medical personnel to meet these requirements. Measures to increase the physical fitness and health of the population health may help to moderate these demands, in particular by “squaring” the morbidity curve and reducing the terminal years of dependency. It has also become mandatory to change the character of sports, fitness and recreation programmes and facilities to match the preferences and abilities of older people. The resting electrocardiogram has sometimes been viewed as providing a good impression of an individual’s cardiac health. However, debate continues on the merits of using a resting ECG in order to screen-out athletes and highly active individuals who may be at an increased risk of sudden death when exercising. European Cardiologists continue to press for a mandatory annual screening of athletes, but most North American cardiologists maintain that such an approach generates an undesirably large number of false positive results, with a need for costly additional investigations of apparent anomalies and much iatrogenic disease, without altering mortality rates or detecting any significant number of individuals with major contra-­ indications to exercise.

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Although there are now many objective tests of fitness, and these are used frequently in testing both patients and healthy individuals, the value of such individual assessments remains debatable. Even with direct measurements of maximal aerobic power rather than indirect predictions of fitness inferred from submaximal testing, the error of data is such that it is quite difficult to distinguish a fit from an unfit person. Measurements are more useful in examining changes of function in response to training and rehabilitation programmes, and (providing that the tests have been standardized, and subjects have been selected in a representative manner) in comparing fitness between substantial populations. The epidemic of cardiovascular disease now seems to be moderating in western society, suggesting that its main cause may have been cigarette smoking rather than a lack of physical activity. However, the obesity epidemic continues unabated, and it remains a challenge to all whom are concerned with enhancing population health. The self-catheterization of Forßmann raises important issues in human experimentation for today’s research ethics committees. An investigator should certainly be a willing subject for any demanding investigation he or she wishes to undertake, but any proposed procedures should be reviewed by a panel of peers to ensure that the risks are not excessive relative to the new knowledge that is likely to be gained, and that appropriate safety precautions have been put in place before an experiment is carried out. Forßmann certainly had little prospect of any help if some misadventure such as a jamming of the catheter had occurred while the tube was in situ, and more might have been learned from his study if he had been helped by a colleague.

Questions for Discussion 1. Do you think a further shortening of the working day, compression of the working week, or a longer paid vacation would improve health and fitness today? 2. Has the objective assessment of physical condition among individual exercisers encouraged the population to increase their levels of physical fitness? 3. What is your opinion on the genetic manipulation of embryos? Is this ethically acceptable? If so, what could it contribute to future society? 4. Should much of traditional medical practice should still be considered as quackery? How many of current procedures and treatment have met the current criteria of evidence-based medicine?

Conclusions The average longevity of populations in developed countries certainly increased during the Modern era, with many fewer deaths of children and young adults due to acute disease. However, containment of chronic disease remained less effective, and

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few statistics addressed the important variable of increases in the quality-adjusted, disease-free life-span. Several indicators point to a decrease in personal fitness during the twentieth Century. But on the positive side of the ledger, paid holidays have given new opportunities to participate in active pursuits. New team games, roller skating, ballroom dancing, indoor swimming, visits to National and Provincial Parks, mountaineering, orienteering, and Youth Hostelling all offer opportunities to engage in regular vigorous physical activity. The arrival of the cinema, radio and television programming has brought a widespread diffusion of health and fitness messaging to the general public. Universal pre-paid medical care became available in many countries during the modern era, and governments increasingly took active measures to meet the housing, nutritional and social needs of poorer citizens. Information also began to accumulate on the importance of regular physical activity to the maintenance of good health, and well-­standardized laboratory tests of physical fitness were developed. But at the same time, mechanization of heavy industry, widespread car ownership and the purchase of labour-saving domestic appliances reduced the daily energy expenditure of the average person. Health statistics showed a parallel growth in the burden of chronic disease, particularly obesity and atherosclerosis. Moreover, new forms of entertainment - the cinema, radio, television, rock-concerts and off-track betting all encouraged sedentary behaviour.

Further Reading Ainsworth BE, Macera C. Physical activity and public health practice. Boca Raton, FL, CRC Press, 2012, 356 pp. Barton S. Working class organisations and popular tourism, 1840–1970. Manchester, UK, Manchester University Press, 2005, 217 pp. Bouchard C, Shephard RJ, Stephens S, Sutton JR, McPherson B. Exercise, firtness and health. Champaign, IL, Human Kinetics, 1988, 720 pp. Bouchard C, Shephard RJ, Stephens S. Physical activity, fitness and health. Champaign, IL, Human Kinetics, 1992, 1055 pp. Cernak L. Totalitarianism. Edina, MN, ABDO Publishing, 2011, 161 pp. Dugdill M, Crone D, Murphy R. Physical activity and health promotion. Evidence-based approaches to practice. Chichester, West Sussex, Wiley-Blackwell, 2009, 263 pp. Eckersley R, Dixon J, Douglas RM. The social origins of health and well-being. Cambridge, UK, Cambridge University Press, 2001, 349 pp. Maud PJ, Foster C. Physiological assessment of human fitness, 2nd ed. Champaign, IL, Human Kinetics, 2006, 321 pp. Meyer M. Health education by television and radio. Munich, Germany, Saur, 1981, 476 pp. Nadadur SS, Hollingswoth JW. Air pollution and health effects. London, UK, Humana Press, 2015, 438 pp. Naylor D. Canadian health care and the state: A century of evolution. Montreal, QC, McGill/ Queen’s Universoity Press, 1992, 240 pp. Prohaska TR, Anderson LA, Binstock RH. Public health for an aging society. Baltimore, MD, JHU Press, 2012, 456 pp. Rothang H, Cacace M, Frisma L, Grimmeisen L, Schmid A, Wendt C. The state and health care. Comparing OCED countries. New York, NY, Palgrave-MacMillan, 2010, 276 pp.

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Schedt B, Redmond G, Baka R. Sport Canadiana. Edmonton, AL, Executive Sport Publications, 1980, 224 pp. Shephard RJ. The fit athlete. Oxford, UK, Oxford University Press, 1978, 214 pp. Shephard RJ. Aerobic fitness and health. Champaign, IL, Human Kinetics, 1994, pp. 357. Zweinger--Bargielowska I. Women in Twentieth Century Britain. Social, cultural and political change. Abingdon, OX, Routledge, 2014, 392 pp.

Chapter 10

The Ludic Impulse: Why Did Early Societies Engage in Play?

Learning Objectives 1. To recognize that the impulse to play is an inherent biological characteristic, found in human societies around the world from the earliest of times. 2. To understand that this ludic impulse may be exploited for teaching essential skills to the young, maintaining physical fitness and developing religious rituals. 3. To note how information on ancient games and pastimes can be gleaned from sources as diverse as archaeology, period paintings and oral history.

Introduction Anthropologists have given detailed descriptions of play in various animal species. We have seen above that from the earliest of hunter-gatherer societies, people have also chosen to participate in a variety of games (Chap. 2). Sometimes, such ludic activities were undertaken when conditions were unfavourable for hunting, and they then served to conserve physical fitness. However, the usual objectives were either hedonistic (a pleasant type of cerebral arousal) or the gratification of the gods, with sacred dances commonly serving the latter purpose (Chap. 2). Mehdi Kacem suggested that play was essentially religious, although religion was not necessarily playful. In his book Homo Ludens (1938), Johan Huizinga, a Dutch historian and one of the founders of modern cultural history, defined humans as playful beings; he argued that the impulse to play is a fundamental facet of human expression. For the Greeks, also, the terms paidela (education/culture), paidia (play/game) and paides (children) had essentially the same root, implying that games served an important role in the education of children during the Classical Era. In this chapter, we look briefly at expressions of the ludic impulse in the games of neolithic communities, the pastoral societies of Central and South America (the © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_10

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Tarahumara Indians, the Aztecs, the Mayan and the Inca civilizations), and the Minoan and Etruscan cultures, noting also a few expressions of the continuing need for play in mediaeval Europe. The religious significance that was attached to the original Olympic Games is discussed in the following chapter (Chap. 11).

Neolithic Societies In some neolithic societies, it has been suggested that the impulse to spontaneous activity and play was depressed by economic hardship, a lack of competitive drive, and/or by the time demands of pubertal initiation rites. However, Josef Reibner, a missionary who lived for many years on the New Guinea coast, observed that even in that impoverished region the youngsters knew many games, which he saw: “as a natural reaction of the body longing for movement” Some of these games were rather dangerous, involving spears! Often, the pursuits of children have served a practical function, teaching skills that will be required as an adult. My studies in the Inuit community of Igloolik found a few organized events- a protracted weekly “square dance,” imported from “white” settlers in the Canadian west, an Easter “track and field” event that seemingly involves running through deep snow in heavy clothing, games of baseball on the frozen sea surface, tobogganing and the use of snow shoes. But most of the activities of the Igloolik children were informal: snowball fights, stone throwing contests, fishing, and practice in the use of dog whips. The boys also spent much time experimenting with small dog teams and in carving small pieces of soapstone, selling the latter to gain the price of admission to a weekly itinerant cinema performance. In many prehistoric communities, wrestling, use of the bow and arrow and the hurling of a javelin have served to teach youth the skills they need for survival as adults. A surprising proportion of games also have cultic significance. Thus, a tug-­ of-­war becomes a source of rain magic in Laos, and is a fertility rite in eastern Indonesia. In New Guinea, even bow and arrow shooting is linked to fertility rites.

Tarahumara Indians The traditional Taramuharan Indians lived in ranchos of up to 20 households, located in caves and overhangs at 3000  m on the cliffs of the Sierra Madre Occidentale in Northwestern Mexico. The men of the community were called Rarámuri, a word that literally means “foot runners.” Their children were taught to run almost as soon as they could walk. There is no evidence of unusual genetic endowment, or of unusual patterns of endurance training in this community. Indeed, according to the anthropologist J.G. Kennedy, who has studied many “primitive” communities, the average Tarahumaran spent as much as 100 days per year in the

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preparation of a potent corn beer (tesgüino), often consuming this to a point of drunken stupor. However, the local diet was largely carbohydrate, usually with less than 10% protein and 10% fat, and this may have contributed to their remarkable capacity as endurance runners. The unusual running ability of the Trahumara Indians reflects not only persistent daily physical activity, but also community acceptance of the social and religious importance of running. Races between adjacent communities are still frequent today. Distances of around 300 km are typically covered in 2 days but on occasion a single race has extended over as much as 700  km. The Mexican historian F.R. Almada provides detail on one race as follows: “Nevárez fell exhausted during the eighth lap. It happened… with a total of 527 km… run. There he was overtaken by Rosas who, believing that his opponent was still able to get up and continue running, completed the lap and returned to the place where the other had fallen. At that point [the people] declared him the victor. Having run 550 km he was still able to continue running…. However this runner became crippled and never was able to participate in a race again.” Often, the Tarahumara wagered substantial stakes on the outcome of individual races. Traditionally, the religious significance of the event was also emphasized, with the local shaman sprinkling the course with powder from a crushed shinbone, and administering supposedly helpful potions such as a mixture of bat’s blood and tobacco to members of the local team immediately before a race; losing competitors were sometimes beheaded., to appease the gods. However, the religious significance of the run has now been lost for many participants, and it has become more of an organized sport. When the run has a ceremonial component, the men kick a baseball-­ sized wooden ball in relay fashion. The event involves 2 teams of 3–10 men who race for up to 2 days at a stretch, and it is has been described as the most strenuous sport in the world. The Tarahumara women also engage in a team foot-race, propelling a hoop by means of a curved stick. During fiestas the women share in a very fast circular dance. Narcotic and hallucinogenic preparations of the Peyote cactus containing mescaline are commonly consumed during the performance of these various religious rites.

The Aztecs The Aztec civilizations reached its apogee in the early 1400s; their chief city of Tenochtitlan was built on the site of the current Mexico City. At its peak, the Aztec economy was sufficiently successful that only 20% of the commoners engaged in the heavy physical labour of agriculture and food production. Most of the population served as warriors, artisans and traders, including a substantial group of travelling merchants. The population also included some war-captives, debtors and criminals who became slaves.

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Fig. 10.1  The wall-­ mounted stone goal used in the Aztec game of tlachtli. Solid rubber balls weighing 3–4 kg had to be thrown through the ring in order to score (Source: http://en.wikipedia.org/ wiki/ Mesoamerican_ballgame)

Agriculture was based on terraced hillsides fed by lengthy irrigation canals, and the preparation of land required physically demanding work in construction and maintenance. The ability to farm successfully was considered a measure of a man’s fitness; the bad farmer was: “a shirker, a lukewarm worker…one who drops his work… noisy, decrepit, unfit….who gorges himself.” In their leisure time, the Aztecs played a variant of the brutal and physically-­ demanding Meso-American ballgame of tlachtli. This pursuit seems to have developed around 1400 BCE, and in its final form the sport took place within structured courts as large as 126 × 25 m. Two teams of 7 players apparently struck the ball using their hips, their forearms, rackets, bats, or hand stones, with the general pattern of play bearing some relationship to racquet ball. The original objective was probably to keep the ball in play, but subsequently stone rings were introduced as a form of goal. In order to win, contestants then had to throw the ball through the ring, which was mounted on a wall 6–7 m above the ground, (Fig. 10.1). Archaeologists have discovered examples of solid rubber balls that were used in this sport; they had a diameter of 0.10–0.22 m, and a mass of 3–4 kg. The popularity of the game can be judged from the fact that at the peak of the Aztec empire, 16,000 lumps of raw rubber were imported every 6 months. One inventory located 260 ball courts across Central America, 87 in Arizona, and 24 in the Dutch Antilles. Tlachtli not only served as a sport for the aristocracy, but it also had a strong religious significance, involving Xochipilli, the prince of flowers and the god of youth, music and games. The largest ball-court in the Aztec capital was called Teotlachco (the holy ball-court); here, games were marked by the sacrifice of 4 war captives. At the height of the Aztec era, the game became professionalized, and substantial sums of money (or sometimes even children) were wagered on the outcome of key contests. One player “won everything from all who watched there in the ball court” including many costly items: “golden necklaces, green stone or fine

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turquoise, quetzal feathers, slaves, houses, fields, precious capes, mats, large capes, green stone lip plugs, duck feather capes…” The Aztec nobles also had leisure for less demanding forms of amusement, including the chasing of birds with blow-pipes and poisoned darts in gardens set aside for this purpose. However, such activities were probably leisure diversions rather than religious ceremonies.

Mayan Civilization The Mayan civilization flourished in the southern part of Mexico, beginning at least 4000  years ago. As their society developed, the Mayans shifted from a hunter-­ gatherer economy to life in permanent settlements, where maize, beans and other vegetables were cultivated, and animals such as dogs and turkeys were domesticated. The Mayas shared with the Aztecs an amazing ability to construct massive stone public buildings, using human strength unaided by draught animals or pulleys. Like the Aztecs, the Maya people supplemented the physical demands of daily life with vigorous physical activities that had both recreational and religious significance. The most obvious recreational pursuit was their version of the Meso-­ American ball-game, described in their Holy Book, the Popul-Vuh. Stone artifacts suggest that players were equipped with face masks, arm wrappings and knee protectors. The game symbolized for the Mayans not only the victory of the mythical twins Hun Ahpu and Xbalanque over the underworld and the powers of darkness, but also the cyclic nature of life. The Spanish bishop Diego de Landa Caldéron (1524–1579 CE) wrote that watching a ball-game was like seeing lightning strike, because the players moved so swiftly. At one time, it was believed that the losing team (or at least the captain of the losing team) would be killed at the end of the match. However, more recent study suggests that the winning. team or the winning captain was given the honor of a quick sacrificial death and thus instant passage to paradise. Diego de Landa spoke also of the Mayans playing a sedentary gambling game (patolli), where dried beans or clay counters were used. It was played on a stone “board,” measuring about 0.5  m per side, or a reed mat of similar size, with the counters being moved across rectangles of various dimensions marked on the surface. This game may have served not only as a form of amusement, but also as a means of divination.

Inca Civilization During the fifteenth century CE, much of the western part of South America became assimilated into the Incan empire. Most of the Incas were agriculturalists, peasant-­ farmers who produced their own food and clothes. The llama became an important

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Fig. 10.2  Inca runners carried messages (sometimes coded in the form of knotted strings) at a speed of about 400 km/ day, using a relay system. A conch shell summoned a replacement runner at the relay points (Source: http:// en.wikipedia.org/wiki/ Chaski)

component of their livestock, serving as a beast of burden, and providing wool for clothing. The alpaca also provided wool for the weaving of intricate tapestries. Sometimes, the work-load of the common labourer was extremely heavy. Inspection of Incan structures has revealed massive walls, incorporating stones that were 7 metres tall, each weighing several thousand kilos. Moreover, these materials were dragged 15 km from quarries to the construction site. In typical bureaucratic fashion, the state was perpetually busy dreaming up new projects, leaving the general population with little time for leisure. Enforced labour terraced hillsides, constructed a 22,000  km road network (mainly paved), built many woven reed suspension bridges, and installed irrigation systems that provided drinking water and allowed the cultivation of crops in arid areas. Running was a specialized profession among the Inca, with couriers transmitting messages over a distance of 400 km in a single day (Fig. 10.2). A relay system was organized on the main highways, with runners blowing on a conch shell to summon their replacement. Sometimes, the messengers carried news of a distant battle, but at other times they simply imported luxury goods for the nobility. Messages were coded, using a system of knots and coloured thread. The Inca provide the first documented example of the doping of runners. The chewing of coca leaves not only had religious and sexual significance for the Inca population, but it also helped to counteract feelings of cold, fatigue, and thirst during long distance runs over very challenging terrain.

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Like the Aztec and Mayan civilizations, the Incas played tlachtli, often concluding games with a ritual human sacrifice. They also found time for music, and having access to metals they made bells, trumpets, and intricate gold jewellery. The children played games with tops, balls, and pieces of broken pottery.

Minoan and Etruscan Civilizations Minoan sports were commonly performed to honour the snake goddess, probably a fertility figure. Since the snake shed its skin periodically, the ancients considered this creature as a source of new life. The sport of bull-­leaping (Chap. 4) may have had a religious significance linked to legends of Heracles and the bull of Minos. On mainland Greece, perhaps the most savage recreational pursuit of the Etruscan era was the game of Phersu, where a man with a sack over his head fought against a vicious dog and/or served as an executioner. Possibly, this was intended as a re-­ enactment of the scene where Hercules claimed Cerberus from the underworld. Many of the games of the Etruscans were apparently intended to appease the gods and avert epidemics and other misfortunes.

Mediaeval Europe Many of the sports and games in mediaeval Europe retained some pagan significance; for instance, football games were originally played in the hope of ensuring a bumper potato crop. Dances around the maypole were also a part of fertility rites, with links to ancient Druid ceremonies, and in part recognizing the great vitality of trees. Some saw the central pole as a phallic symbol. One unique event in mediaeval England was the Pancake race, which has been held continuously in the village of Olney, Buckinghamshire, every Shrove Tuesday since 1445 CE. According to legend, a village housewife who was busy ridding her pantry of butter, lard and other foods forbidden during the season of Lent found herself late for the Shriving church service; in consequence, she ran all the way from her kitchen to the Parish Church, still clutching her frying pan. Subsequently, the pancake race became an annual event, and contestants were required to run 380 m from the Bull Inn to the local Church, tossing their pancakes en-route. The reward for the winner was a kiss from the verger of the church. William Fitzstephen describes the wide range of physical activities that vigorous young men (probably drawn from the mediaeval apprentice guilds) performed in twelfth century London on public holidays: “Leaping, Shooting, Wrestling, Casting of Stones [in jactu lapidum], and Throwing of Javelins fitted with Loops…. they also use Bucklers, like fighting Men” To this list may be added hammer- and horse-shoe throwing, quarter-staff contests, quoits, and skittles. And during the winter months,

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Fig. 10.3  Children’s games in the Netherlands, as pictured by Peter Bruegel (1560 CE) (Source: https://en.wikipedia.org/wiki/Children%27s_Games_(Bruegel))

Fitzstephen described the youth of London amusing themselves on the frozen marshes, wearing shin-bone skates, and dragging their friends along on sleds. For the children, there were also games of hopscotch, blind man’s buff, and the many other sports recorded by Pieter Bruegel the elder in his painting Kinderspiele (Fig. 10.3). Bruegel also recorded the ice sports of the Dutch peasantry (see, for example, his Winterlandschaft mit Eisläufern und Vogelfalle (Winter landscape with skaters and a bird trap, 1565 CE).

Practical Implications for Society Given the inherent human desire to play, the incorporation of a playful element into modern physical activity sessions might help to maintain interest and compliance in long-term programmes, although this possibility has received little formal study. The religious imperative of appeasing the gods was often a central part of motivation in earlier times, and it is difficult to envisage how such a stimulus can be maintained in today’s sophisticated society, but the hedonistic element of play could prove more enticing than a 30-minute slog on a treadmill. Possibly, one approach to motivation of the present generation may be to link participation in vigorous physical activity with some altruistic modern “cause” such as environmental conservation.

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It is interesting that for a proportion of young people in the twenty-first century, a weekly trip to the gymnasium has assumed the significance that was once attached to participation in a church service.

Questions for Discussion 1. Do you find that an element of play increases your desire to engage in physical activity? 2. Is there some community or social cause to which you could link your physical activity programme as a means of increasing motivation?

Conclusions Humans have shown an interest in play from the earliest of times. Play serves not only to satisfy Ludic interests, but it also provides the means to conserve physical fitness, teach important skills to growing children and adolescents, and meet the needs for religious ritual. Exploitation of the human desire for play could possibly serve as a means of increasing adherence to current day fitness programmes.

Further Reading Cobo, B. Inca religion and customs. Austin, TX, University of Texas Press, 2010, 279 pp. Craig S. Sports and games of the ancients. Westport, Conn, Greenwood Press, 2002, 192 pp. Culin S. Games of the North American Indians. New York, NY, Dover Publications, 1975, 847 pp. Hillbom N. Minoan games and game boards. Lund, Sweden, University of Lund, 2005, 359 pp. Irigoyen-Rascón F. Tarahumara medicine. Ethnobotany and healing among the Rarámuri of Mexico. NormaN, OK, University of Oklahoma Press, 2015, 416 pp. Johnson JE, Eberle SG, Hendricks TS, Kushner D. The handbook of the study of play, vol. 2. Boulder, CO, Rowman & Littlefield, 2015, 600 pp. Malpass MA. Daily life in the Inca Empire, 2nd ed. Westport, Conn, Greenwood Press, 2009, 176 pp. Orlick T. Cooperative games and sports joyful activities for everyone, 2nd ed. Champaign, IL, Human Kinetics, 2006, 165 pp.: Patterson S. Games and gaming in mediaeval literature. New  York, NY, Palgrave-MacMillan, 2015, 241 pp. Shirley S. Inuit Games. Baker Lake, NU, Keewatin Board of Education, 1995, 136 pp. Somervell BA. Empire of the Aztecs. New York, NY, Infobase Publishing, 2009, 160 pp. Wasserman M. Sport, games and gambling in the Aztec world. Bloomington, IN, XLibris Corporation, 2017, 50 pp.

Chapter 11

The Classical Olympic Movement: An Early Stimulus to Health and Fitness?

Learning Objectives 1. To understand that Greek city-states initiated major athletic competitions in order to stimulate young men to develop perfect bodies as an offering to the gods. 2. To recognize that because of the long training period for Olympic contestants, the opportunity to participate was initially restricted to the wealthy members of society. 3. To observe that the Games were democratized by the introduction of large cash prizes, but to see that this change led to many of the abuses associated with the sponsorship of modern athletes. 4. To examine the dietary and training regimens proposed by Greek coaches, and to explore the factors leading to the cardiac death of Pheidippides when carrying the message of military victory to the Athenians.

Introduction The link between play and religious ritual, seen in early civilizations (Chap. 10), continued into the sports festivals of Egypt and Greece. An early “international games” was organized at Akhmim, in Upper Egypt to honour the mythical Perseus (late 1200s BCE). However, it was the Greeks who developed the idea of fostering top-level international competitions, linking such events with the search for a perfect, physically fit body that would be an appropriate offering to the gods. In Pindar’s Eleventh Olympic Ode we read: “strength and beauty are the gifts of Zeus…natural gifts imply the duty of developing them with God’s help” Perfection of the physical body was also seen as important to development of the mind. Thus Socrates commented: “what shall be their education? ….. gymnastic for the body, and music for the soul.” Some, such as the Greek philosopher Xenophon, appreciated the importance of continued athletic participation into old age: “it is disgraceful for a person © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_11

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to grow old in self-neglect before he knows what he would become by rendering himself well-formed and vigorous in body.” Public interest in athletic prowess goes back far into the mists of Greek myth, with gods such as Achilles and Odysseus reputedly enjoying their participation in sports. Major Greek athletic festivals probably began around 1300 BCE, and such events continued to garner public support until the collapse of the Greek empire. Nevertheless, occasional voices such as the philosopher Xenophanes (570– 475 BCE) protested the public obsession with athleticism: “wisdom is better than the strength of men and of horses…. it is not right to prefer strength to good wisdom.” The tragedian Euripides (480–406 BCE) also roundly condemned athletes: “Of the countless evils in Greece, none is worse than the race of athletes, for, first of all, they do not learn to live well, indeed they could not, for how could a man who is the slave of his jaw and the subject of his stomach acquire happiness to surpass his father?” The prominent Greek physician Galen, although generally in favour of moderate exercise, made disparaging comments about the professional athlete: “Athletes live a life quite contrary to the principles of hygiene, and I regard their mode of living as a regime more favourable to illness than to health… when they give up their profession, they fall into a condition more parlous still….. some die shortly afterwards; others live for some little time, but do not arrive at old age.” Because of their pre-occupation with military preparedness, some of the Spartan leaders also despised athletes. In the late seventh century BCE, the poet/general Tyrtaeus wrote: “I should not mention nor count as aught a man for excellence either in running or in wrestling, even if he had the size and the strength of the Cyclops…” We begin this chapter by describing the classic Olympiad and other major athletic festivals in ancient Greece, then move on to discuss the ideal of amateurism, classical Greek recommendations for athletic training and nutrition, issues in the age and sex categorization of competitors, the problem of athletic injuries, and the specific case of the death of Pheidippides, apparently while carrying a message over a marathon distance.

The Classic Olympiad The first classical Olympic contest was held at Olympia is 776 BCE, building on earlier athletic competitions at the behest of the Delphic oracle (Fig.  11.1). The celebration was seen in a religious context, as a cost-effective means of appeasing the Gods and avoiding the risk of plagues and constant warfare. The Games only lasted 5 days, but contestants arrived a month in advance of competition to train under the supervision of 10 judges; these officials determined admissibility, carried out age-categorization, decided on the pairing of contestants, and administered fines to any who were caught cheating.

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Fig. 11.1  Artistic impression of ancient Olympia, site of the classical Olympic Games (Source: http://en.wikipedia.org/wiki/Ancient_Olympic_Games#cite_note-17)

The festival was initially a local event, with all winners of the first 12 Games coming from the north-eastern part of Peloponnesia. Despite the class-structure of earlier competitions, the Olympiad was nominally open to all men born to free Greek parents. Women with the exception of the high priestess of Hera were excluded from the Games under penalty of death. However, a separate foot race for women was held as a part of the festival of Hera. The female event decided who would become the next priestess of Hera, and a foot race for men (the stadion) determined who would be her consort. The stadion was a single-lap 190 m event, supposedly covering a distance that matched 600 foot-lengths of Hercules. In 724 BCE, the diaulos (400 m) and the dolichos (24 laps, or about 4.8 km) were added, followed in 708 BCE by the pentathlon (triple jump, running, ingot throwing, javelin and wrestling), boxing, wrestling and mixed martial arts events. Finally, in 520  BCE, a specific race (the hoplitodromos) was introduced for the military; this required contestants to run 800 m wearing 27 kg of military gear, and wielding large shields. There were 293 successive Olympiads before eclipse of the Greek civilization. The ultimate demise of Olympic competition was hastened by the decision of Theodosius to replace paganism by Christianity; it was difficult for Olympic protagonists to argue that the classical Olympic Games was other than a pagan festival.

Other Major Athletic Contests in Classical Greece In the sixth century BCE, enthusiasm for athletic competition in Greece was such that major regional competitions were organized in many of the nation’s city-states.

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The Panathenaic Games  The annual Panathenaic Games began in 566 BCE, as part of a larger pagan religious festival. Some events were open to all-comers, but a torch race (the fore-runner of the modern Olympic torch relay) was restricted to Athenians. The main focus of the Panathenaic Games was upon chariot racing, with a substantial prize of 140 amphora of olive oil for the winner of this event. The Pythian Games  The Pythian Games were held at the Delphic shrine on Mount Parnassus, from 582  BCE.  This event honoured the god Apollo and celebrated establishment of the Delphic oracle. Events included foot and chariot races and also music and poetry contests. Like the main Olympic Games, a truce between warring cities was arranged, allowing wide participation. Winners were acknowledged simply by receiving a sacred laurel twig. The Isthmian Games  The Isthmian Games (dating from 581  BCE) began as a funeral rite for a Corinthian marine deity, and expanded into a major event honouring Poseidon, God of the Sea. Roman as well as Greek competitors were admitted to the Isthmian competitions. The Nemean Games  The Nemean Games began around 573 BCE, and from their war-like nature were probably intended primarily to honour the god Zeus. At first, events were only open to warriors and their sons, but later all Greeks could compete. Features emphasized in the Nemean Games were horse races over distances of 4.2– 8.4 km, and a two-lap diaulos that was run in full military uniform. The traditional prize was a celery sprig. The Nemean Games were revived in 1994 CE as an alternative to the commercialism that had come to surround the Modern Olympics.

The Ideal of Amateurism in Classical Greece The classical Olympic Games are commonly lauded for their emphasis upon amateurism, a position theoretically maintained by the organizers of the Modern Olympic Games until the 1980s. Aristocratic Olympic victors in the classical events received no more reward than a laurel wreath, with the right to place their statues in the sacred enclosure at Olympia, to hear choral odes chanted in their honour, and perhaps to earn honorary citizenship of the host city. In the words of Pindar (522– 443 BCE):“There is no greater glory for a man….than that which he gains with his feet and his hands… the song sung in honor of an Olympian victory lies above the reach of envy.” Hero worship of the classical victors matched that accorded to modern athletes. In the words of the poet Oppian: “An athlete crowned with fresh laurels is beset by boys, youths and men, who conduct him to his house and crowd round him in troops…” Unfortunately, the ideal of amateur status was soon compromised. Even at the mythical athletic ceremonies marking the interment of Patroklos, the Iliad notes that contestants received valuable prizes such as a horse, or a tripod that was worth 12

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oxen. Soon, the very word athlon came to mean “prize.” Athenian competitors were later rewarded very handsomely, perhaps in an attempt to democratize the Games and allow the participation of ordinary citizens. Solon (638–558 BCE) offered 500 drachma (about a year’s salary for a top wage-earner) to every Athenian who won an Olympic prize. This was supplemented by free meals for life and premium seats in the Athenian theatre. At one Athenean contest in the fourth century BCE, prizes of 30 to 60 ampullae of oil were awarded even to young boys. Other Greek city-states quickly began to provide equivalent rewards to athletes competing in their cities. The small Anatolian community of Aphrodisias, for example, offered purses of 350 to 2000 denarii for youths, and 250 to 1000 denarii for boys, one denarius equating to a day’s wages. And at the PanAthenaic Games, the male winner of the Stadion received 100 amphorae of oil, with a market value of 1200 drachma. Theagenes of Thasos, a professional boxer and runner claimed to have won at least 1300 prizes. The purses in chariot races were usually even larger than in other events, although the beneficiaries were often the owners of the chariots, rather than the drivers. At less prestigious events, athletes sometimes circulated among spectators, taking up a collection for themselves after they had completed their race. The Games still began with competitors swearing a solemn oath: “that in nothing will they sin against the Olympic games.” However, the quest for riches brought all of the abuses that have plagued the modern Olympics. Carbohydrate stores were boosted by eating large quantities of honey, and there were attempts to augment muscle mass by drinking a diuretic decoction of horsetail. Herbs, wine, hallucinogenic mushrooms, opium, animal hearts and raw testes were all ingested in attempts to enhance physical performance, and wrestlers covered themselves in oil to make it difficult for opponents to hold them. One punishment for those caught in such offences was for their faces to be engraved on paving stones in the pathway leading to the Olympic stadium. There were also all-too frequent reports of athletes “throwing” contests after receiving a bribe. At the Isthmian Games, a wrestling bribe came to light when the victor was taken to court for non-payment of the fee to his opponent! The boxer Eupolus of Thessaly persuaded 3 opponents to lose matches, and the fine exacted for this offence was that he construct six large statues to Zeus.

The Classical Greek Regimen of Athletic Training Under the influence of Hippocrates, Greek athletes had been taught that victory depended on sticking to a rigorous personal training regimen rather than on making copious offerings to the gods. All Olympic participants were required to devote 10 months to conditioning, and until the introduction of large prizes for the victors, this necessarily excluded poorer citizens. Coaching guidance came from former athletes, who were always demanding and sometimes cruel. One coach reputedly stabbed an athlete who yielded to his opponent during a boxing match.

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Competitors held their final month of preparation in the Olympic facilities, using halters, weights, and a punch-bag for the boxers. Some athletes developed their strength by bending iron rods or pulling heavy wagons. Others chased animals to increase their speed, or ran in the sand to improve their endurance. The coaches commonly used a long stick to point out and to punish errors of posture, and flute music helped to ensure a harmonious pattern of movement. We catch a glimpse of progressive resistance training in tales of the regimen followed by the wrestler, Milo of Kroton, a five-time Olympic victor. He supposedly prepared himself by carrying a young bull around a field each day from its birth until the animal it had reached an age of 4 years. The writer of this story, undoubtedly with some poetical licence, suggested that Milo ate 10 kg of meat and 10 kg of bread per day, washing this down with 9 litres of wine! Sometimes, training was sufficiently intense as to skew an adolescent’s development. Thus, a runner might have very muscular legs, but narrow shoulders. Galen (130–210 CE) was very critical of this approach, and regarded moderate activities as a much better means of enhancing an individual’s overall health. In particular, he advocated exercise with a small ball, played in a walled court or sphaeristerium; in his view, this type of pursuit “exercises every part of the body, takes up little time, and costs nothing.” In his Treatise to Thrasyvoulos, Galen further argued that excessive exercise against very fit opponents could produce a highly specialized and muscle-bound athlete who had difficulty with ordinary activities such as digging, mowing or rowing. However, he also commented on the beneficial effects of repeated exercise (a thinning of the body, and a hardening and strengthening of the muscles). Galen recommended that exercise sessions should not begin until the “first digestion” of food had been completed. The ideal regimen should include a warm-up and a warm-down, the latter to be followed by massage and the drinking of an adequate volume of fluids. Galen seems to have recognized the association between acute exercise and such normal physiological responses as an increase of heart rate, ventilation, sweating and body temperature. For some keen athletes, the intensity and volume of training sessions was quantitated through the use of odometers, observation of breathing patterns, and pulse counts as determined by a water clock. Philostratus wrote the book Gymnasticus around 220  CE; he recognized the value of a 4-day training cycle, with “priming” exercises on day 1, a heavy work-out on day 2, rest on day 3, and moderate training on day 4. Oribasius (fourth century CE), a personal physician to the Roman Emperor Julian, argued for a more vigorous approach; he suggested that the intensity of exercise sessions should be sufficient to leave a person temporarily exhausted, although he also underlined that exercise had to be carefully supervised and followed by appropriate bathing and massage in order to avoid adverse reactions.

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Nutrition of the Greek Athlete The food choices of athletes in classical Greece were rigidly controlled by their coaches. The philosopher Epictetus (55–135  CE) commented: “You will have to obey instructions, keep away from desserts, eat only at set hours…. you must not drink cold water, nor can you have a drink of wine whenever you want. You must hand yourself over to your coach just as you would to a doctor…” At first, the diet was usually very abstemious: fresh cheese, dried figs, and porridge. However, weight was considered an advantage in many sports, so some athletes were subsequently put on a high meat diet. By the time of Philostratus, many athletes were eating fancy foods, including white bread spread with poppy seeds and fish (previously spurned). To the disgust of Philostratus, they had become: “gluttons with bottomless stomachs.”

Age and Sex Categorization of Competitors Greek athletic competitions were rigidly classified by age and sex. The boys (aged 12–18 years) threw a discus that was smaller than the size used by the men, ran only a half-length of the stadion and received much smaller rewards as victors. The youngest known Olympic winner was 12-year old Damaskos of Messene, who won the boys’ half stadion in 368 BCE. Given the absence of birth certificates, age verification was problematic and depended largely on a study of secondary sex characteristics. The category of the ageneioi (adolescents aged 17–19  years, a group distinguished in some Greek Games) refers to youths who were beardless. The foot race was regarded as the most suitable event for female competitors. Distances were shortened by one sixth relative to their male peers, based on the shorter average stride length of the women. Competition was open to all unmarried women; during the race, they wore a knee-length tunic covering the left shoulder and breast. Married women officially were not allowed to participate or to watch the male competitors, although Callipateira saw her son participate in the Olympic Games by disguising herself as a gymnastic trainer.

The Problem of Athletic Injuries The sports prominent in Greek athletics (wrestling, boxing, pankration and chariot racing) caused frequent injuries to the head, chest, and limbs, and we may infer from his medical treatises that a substantial part of Hippocrates’ practice was devoted to the treatment of sports injuries.

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Fig. 11.2  The gloves worn by a professional boxer from the classical era, Note especially the reinforcement of the gloves that made them a deadly weapon (Source: https:// www.google.ca/search?q= boxer+in+Museo+delle+te rme+Rome)

Wrestling frequently led to spinal dislocations, and in the words of Galen it produced: “men lame and wrinkled and eyes askance.” Boxing was introduced into Olympic competition in 668 BCE. Individual contests continued until one of the fighters either refused to fight further or became unconscious. Early Greek statues frequently display individuals with a boxer’s “cauliflower ear,” although ear-guards were introduced during the fourth century BCE. Deaths were not uncommon during boxing matches, and there was no prosecution of an athlete who killed an opponent. In an unpleasant incident during the Nemean Games, around 400 BCE, a boxer had bound his hands with cattle skin, but his fingers remained bare. He pierced the chest wall of his opponent with a vicious blow: “this man struck his opponent a single blow, opened up his side, then thrust his hand inside and seized his internal organs” As boxing became a professionalized sport, gloves were reinforced with nails and pieces of lead, making them ever more lethal weapons (Fig. 11.2).

 eath After Running a Marathon Distance: The Specific Case D of Pheidippides Pheidippides, the original “marathon man,” provides the first known instance of death apparently associated with a prolonged bout of endurance exercise (Fig. 11.3). The drama began with a battle against the Persians in the late summer of 490 BCE. Pheidippides was a professional distance runner, accustomed to covering distances of 130–140 km a day when delivering important messages. The Athenians had dispatched him to Sparta with a plea for military support in their struggle against the Persian invaders. However, Pheidippides returned to Athens with the disappointing news that the Spartans would delay sending any reinforcements until they had completed celebration of the full moon. He completed the mountainous two-way trip of 452  km in 3  days. He then donned full armour, and marched with the

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Fig. 11.3  The death of Pheidippides as he announces to the Athenians their victory over the Persians at Marathon. The incident probably reflects a combination of ultra-long distance running, heat stress and autonomic excitement. From a painting by Luc-Oliver Merson, 1869 (Source: http://en.wikipedia.org/wiki/Pheidippides)

Athenians to the plain of Marathon, where a valiant battle was fought against the Persians. Finally, (and presumably still wearing his armour), he ran a further 42 km back to Athens at an average speed of 22.5 km/h, conveying the exciting news of victory. He burst into the Athenian Assembly crying “We have won.” but shortly afterwards he collapsed and died. The incident is often described as a death resulting simply from running over a marathon distance. But assuming the legend of Pheidippides to be true, there were probably several reasons for his demise. He had packed an extraordinary volume of physical activity into 4 days of Mediterranean summer heat, and death was probably caused by a combination of repeated bouts of exhausting exercise, the heat stress imposed by wearing a full suit of armour and high blood catecholamine levels associated with the news of victory that he carried.

Practical Implications for Current Policy The questions raised by the classical Olympic contests remain with us today. Is it possible for working people to participate in international competition as amateurs, or are large cash prizes, commercial sponsorships and other forms of professionalism inevitable concomitants of a democratic contest? Moreover, does the intense, year-round preparation for competition enhance or worsen the individual’s long-­ term health? Is it likely that once they retire from competition, former athletes will be in poorer physical condition than their peers? And although in the short-term the Greek victors were surrounded by crowds of cheering admirers, is there any

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evidence that their athletic feats encouraged greater health and fitness among members of the general public? Galen was inclined to view the demands upon the athlete as excessive, and he was the first person to draw the important distinction between the pre-Olympic exercise programme (which in his day included running, shadow fighting, wrestling, jumping, throwing a discus, games with a small or a large ball, and leaping with weights, followed by massage), and the incorporation of vigorous physical activities into daily life (pursuits such as digging, ploughing, pruning, reaping, riding, fighting, hunting and travelling). In recent years, Health Canada and the Coalition for Active Living have both followed Galen’s lead, recognizing that Active Living is less readily forgotten than formal training, and can often contribute as much to population health as formal exercise sessions.

Questions for Discussion 1. What do you think was the main motivation that led Athens and other Greek city-­ states to invest so much effort into establishing the Olympic Games and other international athletic events? 2. How do you think participation of the average individual in top-level competition should be facilitated? Are large governmental stipends warranted when long periods of training are required? 3. Do you think that the firmly stated requirements of modern coaches help or hinder the preparation of top athletes? 4. Would any of the dietary items selected by Greek athletes have been effective in boosting their athletic performance?

Conclusions The Greeks introduced the Olympic Games to encourage the young men of Athens to develop perfect bodies as a means of honouring their Gods. Because of the long period of preparation demanded of Olympic contestants, participants were initially drawn only from the wealthy aristocracy. Large cash prizes were subsequently offered to victors, thus allowing participation of the common people, but professionalization of the Games soon led to the cheating and abuses that have besmirched the modern Olympic Games. The training required of competitors was very rigorous, and dietary restrictions were often severe, but it is less clear how far the regimen imposed by the coaches enhanced athletic performance. Injuries and even deaths during competition were frequent. However, the cardiac death of Pheidippides should not be attributed simply to running over a marathon distance. It reflected several days of distance running while wearing heavy armour, severe heat stress and the autonomic stimulation caused by carrying the news of military victory. Greek

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athletes were generally well-received and even feted by their fellow citizens, but it is less clear that their exploits stimulated adoption of a healthy lifestyle by the general population.

Further Reading Finley ML, Pleket HW. The Olympic Games: The first 1000  years. Mineola, NY, Dover Publications, 2012, 208 pp. Golden M.  Sport and society in ancient Greece. Cambridge, UK, Cambridge University Press, 1998, 211 pp. Graziosi B. The Gods of Olympus: A history. New York, NY, Metropolitan Books, 2014, 290 pp. Harris, H.A. (1972). Sport in Greece and Rome. Ithaca, NY: Cornell University Press. Horstmannshoff HFJ, van Tilburg CR. Hippocrates and medical education. Leiden, Netherlands, Brill Publishing, 2010, 564 pp. Mattern SP. Galen and the rhetoric of healing. Baltimore, MD, Johns Hopkins University Press, 2008, 279 pp. Miller SG, Ancient Greek athletics. New Haven, Conn, Yale University Press, 2006, 293 pp. Scanlon TF. Sport in the Greek and Roman worlds, vol. 2. Oxford, UK, Oxford University Press, 2014, 388 pp. Sweet WE. Sport and recreation in ancient Greece: A sourcebook with translations. Oxford, UK, Oxford University Press, 1987, 280 pp. Webster FAM. The evolution of the Olympic Games, 1829 BC to 1914 AD. London, UK, Heath, Cranton & Ouseley, 1914, republished by Forgotten Books, 2015, 326 pp.

Chapter 12

The Modern Olympics: A Current Stimulus to Health and Fitness or a Five-Ring Circus?

Learning Objectives 1. To understand the original goals of De Coubertin and others reviving the Olympic Games. 2. To note that the subsequent loss of amateurism and various forms of cheating have largely nullified these objectives. 3. To see how many governments have inappropriately exploited the Olympic Games for political objectives. 4. To recognize that any postulated health and fitness dividends from the Olympics are small, and certainly not justifiable in cost-benefit terms.

Introduction The idea of reviving the Olympic Games of ancient Greece is often associated uniquely with Pierre de Coubertin, but efforts began several centuries earlier. In England, the Cotswold Olimpick Games were first held in 1612 CE (Fig. 12.1), with a relatively comprehensive programme that included horse-racing, coursing with hounds, running, jumping, dancing, sledgehammer throwing, fighting with swords and cudgels, quarterstaff, and wrestling events. The Puritans halted the Cotswold event during the Commonwealth Era, and despite subsequent attempts at its revival, it gradually degenerated into a drunken spectator orgy rather than a serious athletic competition. There were subsequent stirrings of Olympic interest in Enlightenment and Victorian Europe. An Olympiade de la République was held in Paris from 1796 to 1798  CE, and in Grenoble, Le Rondeau Seminary organized an “Olympic Promenade” each leap year from 1832 to 1952 CE. “Olympic Games” were also held on three occasions within the framework of the Munich Oktoberfest (1820, 1850 and 1852 CE), and other “Olympic Games” were held in Montreal (1844 CE), © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_12

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Fig. 12.1  Robert Dover introduced a Cotswold Olimpick Games in 1612 CE (Source: http://en. wikipedia.org/wiki/Cotswold_Olimpick_Games)

New  York (1853  CE), Ramloesa, Sweden (1834 and 1836  CE), and Lake Palić, Serbia (from 1880 CE). Nevertheless, the birth of the Modern Olympic movement is usually attributed to the French educationalist Pierre de Frédy, Baron de Coubertin (1863–1937  CE). The Baron had rightly or wrongly credited Thomas Arnold’s system of physical education begun at the Rugby School (Chap. 19) with the extraordinary expansion of British colonial power during the Victorian era, and the incorporation of equally rigorous regular physical education classes into the French school curriculum became an enduring passion for de Coubertin. de Coubertin’s interest in international competition was further triggered by his contacts with William Brookes (1803–1895 CE), one of a small minority of surgeons in Victorian England who believed that the best way to prevent illness was through regular vigorous physical exercise. Brookes had already held a local athletic competition at Much Wenlock, Shropshire, in 1850  CE, and had organized what he termed “Olympic Festivals” in Liverpool (from 1862 to 1867  CE), at London’s Crystal Palace (in 1866 CE), and in Leicester during the same year. With the enthusiastic support of Brookes, de Coubertin founded the Comité pour la

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Propagation des Exercises Physiques In 1888, and it was decided to organize an International Olympic event. de Coubertin wrote: “Germany has brought to light what remained of Olympia. Why should not France succeed in restoring its past spendours?” The International Olympic Committee was officially born in 1894  CE, in the back rooms of an Athletic Congress held in Paris. Greek interest in a formal revival of the Games had been strong since their War of Independence (1821  CE), and indeed an event termed an “Olympic Games” had already been held in Athens in 1859 CE. With the support of several substantial Greek legacies, the Panathinaiko Stadium (which had been rebuilt for the events of 1859 CE) was further refurbished for the first Modern International Olympic Games of 1896 CE. This event brought together 241 athletes from 14 nations, participating in 43 competitions. de Coubertin put a premium upon amateurism (possibly in part as a snobbish attempt to restrict athletic participation to the “right” sort of people), and he also saw the friendships formed during the Games as encouraging international harmony. Although he looked forward to a high level of performance from competitors, for de Coubertin the important thing was participation rather than winning an event. Initially the Olympic Games had quite a low profile, and Queen Wilhelmina did not think it necessary to return from a holiday in Norway to attend the Amsterdam Games of 1928 CE. However, that year saw arrival of the first commercial sponsor (Coca Cola). Thereafter, the Olympics grew rapidly in terms of participants, audience and public appeal, with negative consequences such as a politicization of the Games and a growing prevalence of unfair practices by participants. Positive features of the Games during the Post-Modern era have been an impressive progression of athletic records and the gradual increase of opportunities for female participation in all classes of competitive sport. But against this must be set steady erosion of the ideal of the gifted amateur, the politicization of the Games, and abuses that include the doping of human competitors and horses, replacement of athletic prowess by laboratory-based enhancements of performance, biased judging, deceit regarding the age and gender of participants, deliberate injury of opponents, unfair practices in Paralympic competition, and the payment of massive bribes to those choosing the location of the host city. And in terms of costs and benefits, any small stimulation of health and fitness in the general population pales into insignificance beside the enormous current costs of facility construction and the provision of security services. We conclude the chapter with a brief consideration of other forms of international competition, particularly events for the elderly and the disabled.

Progression of Athletic Records Performance in most athletic events has shown a steady advance over the history of the Modern Olympics. Contributing factors have included a combination of more effective training, begun at an earlier age, a more complete search of national

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populations for outstanding participants in a given event, in many sports the introduction of technically more advanced equipment, and regrettably the abuse of doping agents such as androgenic steroids (below). Restriction of a child to training for a single sport at an early age certainly enhances his or her performance in a particular class of international competition, and it has become an increasing emphasis of national training policies in many countries. However, it seems most undesirable from the viewpoints of the overall health, fitness and social development of the individual youngster. International athletic records have sometimes shown dramatic surges coincident with the introduction of new technology. For example, the height attained in pole-­ vaulting increased from 4.57  m in 1960 to 5.03  m in 1964 and 5.50  m in 1976, coincident with introduction of the fibre-glass pole. Likewise, alterations in the design of skis and racing bicycles have greatly enhanced performance. However, these advances in sports technology have sometimes had a negative impact upon the health of the population as a whole. The latest equipment is extremely expensive, and ordinary people have been discouraged from participating because they have been persuaded by equipment manufacturers that they cannot enjoy a given type of activity without buying the latest equipment such as an ultra-lightweight $12,000 bicycle.

Opportunities for Female Participation At the beginning of the Modern era, there was a strong prejudice against female participation in any type of top-level athletic competition. Maurice Boigey, of the Jonville-le-Pont School of Physical Education in France wrote: “a woman is not built to struggle, but rather to procreate,..In no event will we dare to maintain the usefulness of competitive sport for women: no distance events, no long-jumps or high-jumps, no wrestling or boxing, not even equitation).” At the Paris Olympics of 1900 CE, the bias against female participation was such that women were officially only allowed to participate in lawn tennis, croquet, golf and equestrian events; however, one woman also managed to sneak onto a sailing team. Female swimmers were first admitted in 1910, but there were no competitors from America, because all U.S. female contestants were still required to wear long skirts. Female athletic and gymnastic competitions began in Amsterdam (1928); however, in apparent confirmation of the earlier fears of many committee members, a number of women runners collapsed during the 800 m track event. The New York Evening Post commented: “Below us on the cinder path were 11 wretched women, 5 of whom dropped out before the finish, while 5 collapsed after reaching the tape.” Based on these incidents, female track races longer than 200 m were prohibited until 1960. Women’s shooting events were added to the Olympic roster in 1984, and weight lifting in 2000. However, Saudi Arabia, Qatar and Brunei prohibited all female participation until the London Games of 2012, when (under strong

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i­nternational pressure) they permitted limited female involvement, with their contestants required to wear what was termed a “sports hijab.” In the Winter Olympic Games, women were likewise restricted to figure-skating until 1924, when skiing was added. Restrictions upon female athletic participation attracted attention at the United Nations World Conference on Women in 1995. A session on gender, development and sport recognized the potential of sport to promote gender equity and empower women. The International Olympic Committee has also hosted conferences on women in sport over the past two decades, noting sport as a vehicle for social change, the business advantages of increased female participation, the benefits women bring to sport, methods of promoting gender equity, cultural barriers to female participation, and the need to give women a greater leadership role in the management of the Games. As a result of these deliberations, the Olympic Charter was amended in 2007 to state: “The IOC encourages and supports the promotion of women in sport at all levels and in all structures, with a view to implementing the principle of equality of men and women.” Despite this progressive emancipation of female competitors, ski-jumping and Nordic combined events remained a male prerogative in the Whistler Winter Olympic Games of 2010. The anomaly was finally corrected in the Sochi Winter Games (2014). Sexual bias has been particularly strong in the sport of ice-hockey. Through the1960s, ice-hockey was regarded as a uniquely male pursuit. As a nine-year-old, Canadian track and field star Abby Hoffman had challenged the “boys only” policy in the Toronto Junior A hockey league, playing for most of the season with the boy’s team while disguising her sex. However, the sexual bias in hockey was seemingly confirmed in 1956, when the Ontario Supreme Court ruled against her continued participation. The revival of Canadian female hockey clubs began in the 1960s, as ice-time was slowly gained for female teams. Women’s intercollegiate ice-hockey began in the 1980s and by 1990 eight countries contested the first Women’s World Ice-Hockey Championship. Women’s ice-hockey made its Olympic debut in Nagano (1998),

The Progressive Erosion of Amateurism in Olympic Sport In the early days of the modern Olympic movement, de Coubertin insisted on the scrupulous amateurism of all participants. One unfortunate early twentieth Century casualty of this policy was James Thorpe, the American Indian winner of the pentathlon and decathlon in 1912. Thorpe was stripped of his Olympic medals within a few months of his victory, when it was discovered that he had previously earned a little money (a mere $2 per game) by playing two seasons of semi-professional baseball as a student. This harsh decision was finally reversed in 1983. The requirement of amateurism was reiterated by the International Olympic Committee in 1958: “An amateur is one who participates and always has

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p­ articipated in sport solely for pleasure and for the physical and mental benefits he derives therefrom, and to whom participation in sport is nothing more than recreation without material gain of any kind, direct or indirect”. Some countries continued to honour the requirement of amateurism through into the 1980s. In Britain, there was heated discussion even over Government funding to cover the travel expenses of athletes who were attending the Melbourne Games (1956). The Duke of Edinburgh stated in typical forthright fashion: “The team we want to send should be composed of amateurs and not temporary civil servants.” In 1962, British direct aid to all athletes still totalled no more than £670,000, and the Wolfenden Committee vigorously rejected the idea of establishing a Ministry of Sport. One possible reason for a continued rejection of professionalism in Britain was that most of the amateurs had been educated at “Public” schools, and they were reluctant to mix socially with professionals, most of whom had passed through the socially inferior state school system. However, already during the 1950s, Soviet-Bloc countries saw the Olympic Games as an opportunity to showcase the physical advantages of a Communist lifestyle, and they poured huge sums of money into the selection and training of athletes (Fig. 12.2). Government sinecures were created for their top athletes, allowing them to train full-time, and if they were successful in international competition, they received additional privileges such as apartments and cars that the general population could not have hoped to obtain even after many years on official waiting lists. By 1957, all sports organizations in East Germany were funded by the state, with the exception of the sports clubs for the police (Dynamo) and the Army (Forwärts), where at least a pretense of amateurism remained. Now, most Western nations also provide top athletes with substantial funding. Payment is available for coaching, travel, and equipment, and there is much less

Fig. 12.2  The massive investment of the Soviet Union in athletic training during the 1950s was accompanied by a major surge in the printing of postage stamps celebrating the achievements of Russian competitors

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need for competitors to seek employment while they are training. Canada spent $100 M on the support of promising athletes during the 3-year period leading up to the London Games of 2012, incidentally with a negligible effect in increasing the national medal count (18, exactly the same number of medals as were won in Beijing 4 years earlier, when the added funding was not available). Many countries now offer cash prizes to Olympic victors. In 2012, amounts disbursed to gold medal winners were - Italy $135,000, China $50,000, USA $25,000, and Canada $20,000, but Britain (who incidentally won 26 gold medals in the 2012 Games) gave out no such cash prizes. An even greater challenge to amateur status has come from commercial sponsorships. The US swimmer, Michael Phelps, reputedly has an annual income of $4  M from companies that use his name in their advertizing.

Politicization of Olympic Competition On many occasions, participation in the Modern Olympics has been exploited for political goals. In the early part of the twentieth century, there was a sharp conflict between the German Turners, dedicated to the idea of a free and united German Fatherland and the Olympic movement, which many Germans saw as an example of British hedonism. Thus, until 1906, gymnasts associated with the Turner movement refused to participate in the Olympic Games. During the 1936 Olympics, Hitler saw an opportunity to vaunt the prowess of National Socialism and his “Master Race.” Berlin had already been approved as host city before the Nazis came to power, but Hitler was determined to make the event much more spectacular than the Los Angeles event of 1932. The facilities constructed in Berlin included a 100,000-seat track and field stadium, six gymnasia, and many smaller arenas, all equipped with closed-circuit television and a radio network reaching 41 countries. Hitler stripped “Non-Aryan” German athletes of their titles and also proposed to exclude all “Blacks,” “Jews” and “Roma” from the Olympic Games. This overt racism provoked an urgent search for an alternative venue. Barcelona had previously been a candidate city for the 1936 Games, but de Coubertin had urged against a Spanish location because he feared the rising influence of Spanish Republicans. A rival Barcelona Popular Olympics was set for July of 1936, with 6000 athletes from 22 countries, including exiles from Germany and Italy registering to participate. However, the hosting of the event was foiled by the outbreak of civil war in Spain. In response to strong international pressure, Hitler made a token reversal of his racist policies, adding one woman with a Jewish father to the German team, and temporarily removing the omnipresent “Jews not wanted” signs from central Berlin. Much to Hitler’s chagrin, the U.S.  African American track and field star Jesse Owens (1913–1980  CE) was the hero of the Games, winning four gold medals. Hitler commented: “People whose antecedents came from the jungle were primitive... their physiques were stronger than those of civilized whites and hence should

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be excluded from future games.” Olympic officials insisted that Hitler either congratulate all winners or none, so a private ceremony was arranged for German athletes away from the main stadium. Subsequent Olympic Games have faced boycotts from various groups: in 1956, Egypt, Iraq and Lebanon responded to the Suez crisis by withdrawing their support, the Netherlands, Spain and Switzerland reacted similarly to the Russian invasion of Hungary, and the Chinese withdrew their competitors in protest against the inclusion of “Formosan” competitors. The IOC banned South African athletes from 1964 to 1992 because of their state policy of Apartheid. The U.S. boycotted the 1980 Games in response to the Soviet invasion of Afghanistan, and in 1984 the USSR and 14 of its allies exacted revenge for the U.S. boycott of 1980. Finally, North Korean competitors withdrew from the Seoul Olympics of 1988. Many of these protests had little practical effect, either upon the success of the Games or the underlying political issues. However, the prolonged exclusion of South Africa did contribute, at least in small measure, to the eventual collapse of the Apartheid regime and its replacement by the African National Congress.

Doping and Other Abuses of Olympic Competition From the viewpoint of health and fitness, one unfortunate concomitant of top-level competition has been that a proportion of athletes have attempted to enhance their performance by the administration of stimulants, depressants, and other drugs and have also engaged in various dangerous and unsavoury practices to gain an unfair advantage over their competitors. The practice of doping has quite a long history, but athletic governing bodies only began to implement serious control measures in the mid 1960s. Despite a subsequent massive investment in sophisticated laboratory testing, it seems that too often Anti-Doping Agencies still remain several moves behind dishonest athletes. Stimulants  Early long-distance competitors took cocaine and/or strychnine to postpone fatigue and increase endurance. The problem was particularly prevalent among distance cyclists. One contestant from the late Victorian Era commented that he had: “developed such a tolerance to the drug (strychnine) that he took doses large enough to kill smaller men.” In this era, far from being banned, many considered that the ingestion of strychnine was essential to maximal endurance performance. The menace of doping to health and fair competition had yet to be appreciated. One official report noted: “The marathon has shown from a medical point of view how drugs can be very useful to athletes in long-distance races.” Strychnine abuse continued until the ­introduction of formal drug testing in the mid 1960s, but from the 1930s, amphetamines had replaced strychnine as the athletic stimulant of choice. In 1942, the Italian cyclist Fausto Coppi took “seven packets of amphetamines” in an attempt to beat the world one-hour track record.

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Amphetamine abuse continued throughout the 1960s, with the disqualification of 3 women’s swim teams in the Olympic trials of 1961 CE, 11 of 139 competitors at the World Cycling Championships in Holland (1967 CE), and 8/57 cyclists at the Pan-American Games in Winnipeg the same year. Other stimulants discovered during drug testing included reactivan (fencanamine), coramine (nikethamide), methyl-­ hexanamine and dimethyl-pentylamine. Depressants  At the Antwerp Olympics (1920), an American 100-m contestant drank sherry and raw eggs before his event, and nevertheless was awarded a gold medal. More recently, the usual reason for ingesting alcohol, barbiturates, morphine or heroin prior to competition has been to suppress hand tremor during pistol shooting events. In Mexico City (1968), a Swedish pentathlete was disqualified for drinking two beers immediately before competition. Steroids  The abuse of steroids began in the 1930s, when German chemists began synthesizing androstenone. There were rumours that German soldiers received testosterone injections during World War II to increase their aggressivity. Soviet and East German athletes first used anabolic steroids to increase the strength and power of their weight-lifting and shot-put competitors during the 1950s. One East German contestant showed a 2-meter increase in her shot-put performance over the three-­ month period leading up to her Olympic Gold Medal in 1968, and this seems more likely to have been accomplished by anabolic steroids than by a normal training programme. Steroid abuse soon spread to the U.S., and the maximum weights handled by international shot-putters increased by a striking 14% between 1956 and 1972. During this era, some athletes were endangering their health by giving themselves as much as 20 times the therapeutic dose of steroids over long periods. When the Berlin Wall fell, details of the East German government’s systematic doping programme was exposed; it had yielded a crop of gold medals, but it had also precipitated various medical abnormalities, including (for the women) infertility, sex identity problems, and at least one possible case of death from breast cancer at the age of 32 years. Doping Control Measures  The International Amateur Athletic Federation officially banned the administration of stimulants to athletes in 1928. However, these restrictions were largely ineffective, in part because no tests were undertaken. Albert Dirix, Ludwig Prokop and Arnold Beckett took the first tentative steps towards enforcement of anti-doping regulations at the Tokyo Olympics of 1964; they searched the equipment and clothing of competitors and tested their urine for amphetamines. Finally, in 1967, the International Olympic Committee specified a long list of prohibited substances. Formal drug testing began at the Olympic Winter Games in Grenoble and at the Olympic Games in Mexico City, and was fully implemented at the Munich Olympics of 1972. Current Attitudes of Athletes Towards Doping  Despite formal controls, doping has continued. In 1997, Sports Illustrated obtained some disturbing responses to two questions that were presented to Olympic athletes: “If you were given a perfor-

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mance enhancing substance and you would not be caught and win, would you take it?” 98% responded “Yes”. Even more seriously: “If you were given a performance enhancing substance and you would not be caught, win all competitions for 5 years, then die, would you take it?” More than 50% still said “Yes.” Notable disqualifications for doping during recent history have included Ben Johnson (Fig. 12.3), Marion Jones and Lance Armstrong. All used multiple banned substances, achieved suspiciously good results during competition, and gained lucrative product endorsements. They repeatedly denied their misconduct, but eventually they all lost both their medals and their commercial sponsors. Unfortunately, the use of performance enhancing agents has spread to U.S. high school athletes, and the black market in anabolic steroids now nets $100 M annually. Following the drug scandal that stripped Ben Johnson of his Olympic gold medal, the Canadian Federal Government established a Commission of Inquiry Into the Use of Drugs and Banned Practices Intended to Increase Athletic Performance (the Dubin Commission). Several months of shocking testimony revealed the rampant use of performance-enhancing substances among athletes, and in response to the report of this commission Canada strengthened its athletic drug-testing programme, with the creation of the independent, non-profit Canadian Anti-Doping Organization. Some countries have ignored the recommendations emerging from the Dubin Commission, but generally the scope and effectiveness of doping control have increased over the Post-Modern era. The British laboratory at the 2012 London Olympic Games tested over 6000 urine and blood samples, and was given a $10 M operating budget, spread over 5 years. However, at Rio in 2016 there were reports Fig. 12.3  The Canadian sprinter Ben Johnson, has repeatedly been found guilty of steroid abuse (Source: http://en.wikipedia.org/wiki/ Ben_Johnson_(sprinter))

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that the integrity of the process had been compromised by security lapses and a failure of attendance by many programme volunteers. In the U.S., the Mitchell Report of 2006 examined rumours that many top baseball players were still abusing steroids and growth hormones, and that the honesty of drug testing among major league teams was open to serious question. After mandatory testing was introduced in 2004 CE, many of the players were said to have switched from steroid use (which was detectable) to human growth hormone (which was not then detectable). The Mitchell report specifically named 89 top players who had been abusing drugs. By 2012, the league had become more serious about preventing doping, and players caught abusing banned drugs were suspended for 50 games following a first offence. Doping was also identified in the mounts of Olympic show-jumpers; in 2004, this caused German and Irish show-jumpers to be stripped of their gold medals. Nevertheless, 6 of 20 doping cases in the Beijing Games still involved horses, 4 of the animals having received capsaicin either to relieve pain or to hyper-sensitize the horse.

Other Abuses of Fair Competition Other abuses of fair competition in major events have included unfair subjective judging, match rigging, the deliberate injury of opponets, misrepresentations of the age and sex of competitors, and the bribery of officials responsible for deciding the sites of competition. Unfair Judging  All sports with subjective judging are plainly open to abuse, particularly collusion between judges from a particular region or political bloc. This malpractice became particularly evident in the figure-skating competitions at Salt Lake City (2002). The uproar over blatant vote-swapping led to introduction of a new international judging system. Match Rigging  In 2006, several top Italian soccer teams were implicated in a match-rigging scandal, and a similar issue arose in the Canadian Soccer League in 2009, when several semi-professional players from the Toronto Croatia Football Club received a total of $15,000 in order to lose a match against the Trois Rivières team. A German trial suggested that a crime syndicate had manipulated soccer games in many countries including Canada, Germany, Switzerland, Austria, Belgium, Turkey, Hungary, Slovenia and Croatia. Cricket has suffered from similar game-throwing abuses. Sometimes, individual athletes have manipulated scoring systems for their particular sport, most notably in the 1976 Olympic Games, when a modern pentathlete (Boris Onischenko) used an épée with a device on the pommel that caused a “hit” to be registered, even when the épée had not actually made contact with the target.

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Deliberate Injury of Opponents and Damaging of Their Equipment  The deliberate injury of opponents has become all-too common in ice-hockey and football games, and attacks upon opponents have also sullied Olympic competition. Notably, the husband of ice-skater Tonya Harding attacked her rival Nancy Kerrigan, bruising her femur. The U.S. short-track speed-skater Simon Cho also tampered with the skates of his Canadian opponent. Age and Gender Controversies  In 1996, the IOC ruled that Olympic gymnasts must reach an age of at least 16 during their year of competition. There have been persistent rumours that several petite Chinese gymnasts have flouted this rule, although passports, ID cards and family registers have been advanced to deny such charges. There have long been complaints of athletes with male characteristics participating in competitions intended exclusively for women. At the first Los Angeles Games (1932), Stanislawa Walasiewicz won a Gold medal in the women’s 100 m race, but she was later discovered to have had partially developed male genitalia. Dora Ratjen competed at the Berlin Olympics of 1936, and during the 1960s it transpired that she was really a man disguised as a woman. Ratjen later claimed that the Nazis had forced him into competing “for the sake of the honor and glory of Germany.” The International Association of Athletics Federations (IAAF) began sex-testing in 1950, and a Dutch sprinter was expelled from the National team after she refused a physical examination; later DNA investigation revealed that she had a 46,XX/46,XY chromosome anomaly, leading to hyperandrogenism. On-site sex testing at the European Athletic Championships began in 1966 CE, and in consequence 2 Russian competitors quickly withdrew from their events. Poland’s Ewa Klobukowska was the first woman to fail an Olympic ‘gender’ test (in Tokyo, in 1964); she had the rare XX/XXY genetic mosaicism, and was subsequently banned from competition. The buccal epithelial tests currently used to determine the sex of competitors are unfortunately not infallible. In Atlanta (1996), 8 contestants failed these tests, but all were cleared by subsequent physical examination. Thus, the IAAF ceased gender testing in 1992 CE, and the IOC voted to ban the practice in 1999 CE, although both groups have retained the right to test individuals if it is deemed necessary. Trans-sexual individuals who have undergone a sex-change operation and 2 years of hormonal therapy are now allowed to compete in their new gender category. Bribery of Officials Choosing Host Cities  There have been persistent rumours of IOC and soccer officials accepting large bribes in order to secure competitions for specific cities. The most flagrant scandal involved bidding for the 2002 Salt Lake Winter Games. The allegations resulted in the expulsion of several officials, and the U.S.  Department of Justice brought charges against members of the organizing committee, although they were eventually acquitted.

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 osts and Benefits of Competition; Is There a Health C and Fitness Dividend? Apologists for the Modern Olympics have frequently implied that there is a substantial health and fitness dividend from such events. However, given the enormous costs of construction and especially the expense of security arrangements, this argument cannot be sustained in cost-benefit terms. Security Issues  Major concerns over security at the Olympic Games stem from events in Munich (1972). The Munich Olympics had been designed as a carefree event, to reverse the militaristic image of the Berlin Games of 1936. Unfortunately, members of the Israeli team were taken hostage by a Palestinian group called Black September. Their demands included the release of 234 Palestinian prisoners, as well as Andreas Baader and Ulrike Meinhof (leaders of the German Red Army Faction). The German government offered the kidnappers unlimited funds, and replacement of the Israeli hostages by top-ranking German officials, but at the request of the Israeli government, no deals were made with the hostage-takers. Eventually, 11 of the Israeli athletes and coaches, one German police officer, and 5 of the Palestinian kidnappers were killed; the remaining 3 kidnappers were captured, but later released following the hijacking of a Lufthansa airliner. A memorial service for the victims was attended by 3000 athletes and 80,000 spectators, and the organizers of the Munich Games suggested cancelling the remaining competitions, but as president of the IOC, Avery Brundage insisted: “The games must go on, ....and we must continue our efforts to keep them clean, pure and honest.” The Israeli Premier, Golda Meier, subsequently authorized the bombing of both Syria and Lebanon, killing some 200 people, and Mossad began a ruthless 20-year tracking and slaying of Palestinians suspected of involvement in the incident. This led to the death of one innocent Norwegian and four by-standers in Lebanon. A more long-term consequence of the Munich kidnappings has been an almost paranoid concern about security at subsequent Olympic events. At the Whistler Winter Olympics of 2010, security precautions cost $900 million, with Canadian and U.S. jet fighters threatening to shoot down any commercial or private aircraft that had the bad luck to wander into a large “exclusion zone” around Whistler. At the London Olympics of 2012, the world’s largest security company fell 3600 personnel short of their personnel requirements in a 20,000-person recruitment drive. During this event, a naval combat vessel was stationed in the River Thames, four fighter jets were ready for instant take-off, and six surface-to-air missiles were installed on buildings surrounding the main stadium. The total costs of security for London Games were estimated at $15 B.  At the Sochi Winter Games of 2014 (Fig. 12.4), there was a further escalation of expense, with total costs for the event exceeding $51 B. Despite these precautions, there were 2 suicide bombings in the nearby railway station at Volvograd, causing the death of 34 travellers.

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Fig. 12.4  The costs of Olympic events have become ever larger with each succeeding Games. The Sochi Winter Games of 2014 CE cost over $51 Billion, due largely to the expense of tight security precautions (Source: http://en.wikipedia.org/wiki/2014_Winter_Olympics#Measures)

The Impact of International Competitions Upon Population Health and Fitness  Although organizers have frequently claimed health and fitness benefits, for much of the world’s population, the Olympic Games have in fact become one more sedentary spectator event. Some Olympic feats may have stimulated a few youngsters to pursue excellence in a particular athletic discipline, but top-level competitors typically train to the exclusion of normal social development, which does little to enhance the overall health of the individual concerned. Some competitions also carry risks of serious injury and death [as with the fatalities encountered in the Luge events at Innsbruck (1964) and Whistler (2010)]. Moreover, poor host countries such as Brasil have diverted an inordinate fraction of their Gross National Product to building facilities for the Games at the expense of health care and other pressing social needs among their own citizens. Do the Games have any positive effect upon motivation to greater physical activity on the part of the general population? Information from Greece and Britain does not support such a view. In Greece, sport participation rates in 2009 were actually lower than before the 2004 Games. The Manchester Commonwealth Games of 2002 had a very limited impact on the membership of local sports clubs, and in 2007 a select committee of the British House of Commons concluded: “No host country has yet been able to demonstrate a direct benefit from the Olympic Games in the form of a lasting increase in participation.” In 2004 the former runner Sebastian Coe made ambitious claims for the London Olympics of 2012: “…London’s vision is to reach young people all around the world. To connect them with the inspirational power of the Games. So they are inspired to choose sport.” Nevertheless, epidemiologists who evaluated 10–16 year old schoolchildren in Eastern England in 2009 and 2013–2014 found decreases in a shuttle-run assessment of maximal oxygen intake, a reduction in a questionnaire assessment of habitual physical activity and an increase of body mass index following the Games.

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Other International Sports Events We will comment briefly on Workers’ Olympiads, the Pan-American and Commonwealth Games, the Masters’ Games, and events for those with various types of disability. Workers’ Olympiads  As a reaction to the perceived “upper crust” nature of the Olympic Games, Labour movements sought to establish alternative international competitions with a socialist philosophy. The Confédération Sportive Internationale du Travail was founded in Belgium in 1913, and after the disruption of World War I, it resurfaced as the Socialist Sports Workers International, organizing Workers’ Olympiads. The first Workers’ Olympiad (Frankfurt, 1925) attracted around 150,000 spectators, and the second event in this series (Vienna, 1931) drew 80,000 athletes and 250,000 spectators (incidentally, larger totals than those for the Los Angeles Olympics of 1932). A third event was hosted by Antwerp (1937), but a proposed fourth gathering in Helsinki was abandoned because of World War II. Pan American and Commonwealth Games  Athletic events associated with the Buffalo Pan-American Exposition of 1901 presaged introduction of a formal Pan-­ American Games in Buenos Aires (1951), and the Festival of Empire held at the Crystal Palace in London (1911) was the early forerunner of the British Empire Games, which began in Hamilton, ON, in 1930. These events have provided opportunities for athletes to gain competitive experience prior to entering Olympic events. Masters Games  The World Masters Games were inaugurated in Toronto, ON, in 1985. The initial event attracted 8305 participants from 61 countries, with competition in 22 types of sport. Other major cities have since hosted the Masters Games at 3–4  year intervals, with events attracting some 25,000 participants in Brisbane (1994 CE) and Melbourne (2002 CE) and nearly 29,000 in Sydney (2009 CE). The total number of Masters participants is large relative to the Beijing Olympics of 2008 (10,500 athletes) and the Beijing Paralympics (4200 participants), although the number of countries involved in the Masters Games (about 100) is as yet smaller than that for the Olympics (around 205 nations). To date, the Masters events have attracted relatively little financial support from the host Nation. The Sydney event received a grant of only $100,000, but it was estimated to have contributed $60.2 M to the New South Wales economy. The Masters events are open to participants at all levels of ability, and some events such as lawn bowling hardly make for exciting television. Nevertheless, it has been argued that the lifestyle of Masters athletes can have a positive effect upon the overall attitude of seniors towards physical activity. The Sydney Games also set a good example in terms of “Green” principles, with use of energy- and water-­ efficient facilities, free public transportation included in the registration fee, 90% of correspondence handled on-line, back-packs made largely from recycled material, and the provision of reusable water bottles for registrants.

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Events for Those with Disabilities  Beginning in Paris in 1924, the Games for the Deaf have been held on a quadrennial basis, one year following Olympic competitions. A quadrennial Winter Games for the Deaf was initiated in 1949, and a Pan-­ American Games for the Deaf in 1958. Wheelchair sports took shape following World War II as an initiative of Ludwig Guttman, director of the Stoke Mandeville Rehabilitation Centre in England. Guttman argued that competitive sport could counter the anxiety, self-pity, and antisocial behaviour of wounded military veterans with paraplegia or quadriplegia. The first formal Wheelchair Games (1948) attracted 14 male and 2 female participants to archery, table tennis, bowling, punch-darts and snooker competitions. More vigorous sports, including polo, badminton and basketball were quickly added. The first International Paralympic Games (Rome, 1960) attracted 400 competitors, and a Winter Paralympics was introduced in 1976. Activities for the mentally retarded began with day sports camps organized by Eunice Kennedy Shriver. The Kennedy Foundation held the first International Special Olympics in Chicago (1968), and the Winter Special Olympics was inaugurated at Steamboat Springs, CO, in 1977. France hosted the first games for those with cerebral palsy in 1968. Winter sports for amputees were brought to the United States from Germany and Austria in 1967, but amputee and blind athletes were not admitted to the Summer Games until Toronto (1976). A Games for “Les Autres” (those with other forms of disability) was introduced by the International Sports Organisation for the Disabled (ISOD) in 1976. Unfortunately, attempts to gain an unfair advantage over fellow competitors have now spread to Paralympic sport. Two of the most common practices are seeking inclusion in a category not merited by the extent of an athlete’s disability, and the boosting of blood pressure by retention of urine or sitting on a sharp object immediately prior to competion. It is difficult to prove that the blood pressure has been artificially increased in this way; the main control measure so far has been a threat of excluding athletes with an abnormally high pre-event blood pressure. The abuse of steroids has also become a concern; prior to the 2004 competition in Athens, Canada’s best-known single-amputee sprinter received a 2-year suspension after testing positive for both testosterone and nandrolone, and at the Beijing Games three power lifters and a basketball player were banned after positive tests for “steroids.”

Practical Implications for Current Policy Although the Modern Olympics was initially conceived as a relatively low-key interaction between a small group of amateur athletes with an interest in mutual competition rather than victory at all costs, this worthy objective was quickly lost. The vast expenditures now involved are facing growing criticism, and many countries are no longer interested in hosting such competitions.

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The startling responses to recent questionnaires shows that for a large proportion of individual participants, the pressure has become to find an illegal but undetectable method of gaining an unfair advantage over one’s rivals, sometimes with the complicity of national sports organizations. The quest for international understanding and friendship seems hardly likely to flourish in such an environment. And for the nations involved, both hosting of the Games and the sponsoring of participants has become a method of demonstrating national prestige and a superior political system, with ridiculously large expenditures on facilities that often have subsequently remained unused. Claims have been made repeatedly that the hosting of the Games provides a significant stimulus to national health and fitness, but there is little evidence to support such claims; indeed, recent objective data from England point to a decline in fitness and habitual physical activity, and an increase in obesity subsequent to hosting of the 2012 London Games. But even if it were possible to show some marginal effect, this could not be justified in terms of a cost-benefit analysis; there are many less costly methods of promoting physical activity. There does still seem some possibility of recapturing the spirit and aims of the original organizers of the Mosdern Olympics through other events such as the Masters Games; these competitions have remained low budget, but have attracted large numbers of participants, and have succeeded in promoting “green” organizational principles.

Questions for Discussion 1. Do you think the progressive increase in financial support of top-level national and international athletes has been a good idea? 2. Should international sport be used for political objectives such as pushing an end to the Apartheid regime in South Africa? If so, how effective are such initiatives? 3. Will extensive laboratory testing ever be successful in eliminating the problem of doping from international athletic competition? 4. Are the vast expenditures on the Olympic Games justified in terms of a positive impact upon population health and fitness?

Conclusions There have been a number of attempts to revive international Olympic competition, particularly during the nineteenth century, but the most successful and long-lasting initiative was that of Pierre de Coubertin, which led to formation of the International Olympic Committee. From modest beginnings in 1896, the Modern Olympic Games has burgeoned into a huge and extremely costly quadrennial festival. The initial idea

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of elite amateur athletes competing in a friendly fashion quickly morphed into a relentless, cut-throat competition between nations, with participants abandoning their amateur status and using doping and many other abuses in an all-out effort to win. Nations, also, have repeatedly used participation and/or withdrawal from competition for their political ends. The expenditures needed for a successful Olympic bid have now become so large that even wealthy western nations are refusing to support the idea of becoming a host country. Moreover, attempts to justify these expenditures on the basis that they stimulate population health and fitness have little credibility. Parallel competitions have now emerged those with various types of disability, but the abuses that have marred the Olympic movement are now also creeping into these events, bringing disrepute upon the Para-Olympic Games. To-date, the Masters Games seems one shining example of a low-cost competition with mass appeal and a positive impact upon the health of older individuals.

Further Reading Bennett CJ, Haggerty K. Security Games: Surveillance and control at mega-events. Abingdon, OX, Routledge, 2014, 208 pp. Bermond D. Pierre de Coubertin. Paris, France, Perrin, 2008, 429 pp. Boykoff J. Power Games: A political history of the Olympics. Brooklyn, NY, Verso, 2016, 352 pp. Cashman R. History and legacy of the Sydney 2009 World Masters Games. Sydney, Aiustralia, Sydney World Masters Games Organizing Committee, 2009, 144 pp. Chappelet J-L, LKubler-Mabbott B.  The International Olympic Committee and the Olympic System. Abingdon, OX, Routledge, 2008, 224 pp. Drinkwater, B. The Encyclopaedia of Sports Medicine, Women in Sport. Chichester, East Sussex, John Wiley, 2008, 880 pp. Durry J. Pierre de Coubertin, the visionary. Paris, France, French Olympic Committe, 1996, 98 pp. Gleaves J, Hunt T. A global history of doping in sport. Drugs, policy and politics. Abingdon, OX, Routledge, 2016., 176 pp. Goldblatt D. The Games: A global history of the Olympics. New York, NY, Norton & Co., 2016, 528 pp. Guttmann A. Women’s sports: A history. New York, NY, Columbia University Press, 1991, 341 pp. Guttmann A. The Olympics: a history of the modern games. Urbana, IL, University of Illinois Press, 2002, 214 pp. Hoberman J.  Mortal engines: The science of performance and the dehumanization of sport. New York, NY, Free Press, 1992. 374 pp. Holmes B. The Olympian Games in Athens, 1896: The first Modern Olympics. New York, NY, Grove/Atlantic Inc, 1920, 112 pp. Jokl E, Jokl P. The physiological basis of athletic records. Springfield, IL, C.C. Thomas, 1968, 147 pp. Large DC. Nazi Games. The Olympics of 1936. New York, NY, Norton, 2007, 416 pp. Morris M (Lord Killanen), Rodda J. The Olympic Games: 80 years of people, events and records. New York, NY, Collier-MacMillan, 1976., 272 pp. McNamee M, Møller V. Doping and anti-doping policy in sport. Ethical, legal and social perspectives. Abingdon, OX, Routledge, 2011., 264 pp. Preuss H. The economics of staging the Olympics, 1972–2008. Cheltenham, UK, Edward Elgar Publishing, 2004, 332 pp. Steadward RD, Peterson CJ. Paralympics. Edmonton, AL, One Shot Holdings, 1997, 258 pp. Toohey K, Veal AJ. The Olympic Games: A social science perspective, 2nd ed. Wallingford, OX, CABI, 2007, 368 pp.

Chapter 13

The Early Health Professionals – Unfettered Amateurs, Servants of the Gods or Wealthy Charlatans?

Learning Objectives 1. To trace the changed understanding of ill-health, from a punishment imposed by the Gods, needing treatment by a priest or shaman, to a physical problem, requiring treatment by a professional physician. 2. To observe the ambivalent attitude of the church towards the provision of health care by its clerics. 3. To note the emergence of a diverse range of health professionals during the Middle Ages. 4. To recognize the important contribution of the intelligent housewife to the maintenance of good health in her family throughout much of history.

Introduction In early history, illness was seen as a punishment inflicted by angry gods, and the logical individual to provide treatment was a person who had close contact with the godsa shaman or priest. We have already noted the role of the shaman as a health expert in hunter-gatherer communities (Chap. 2). The close linkage of healing with religious practice continued in the technically more advanced societies of Egypt, Israel and India (Chap. 3). However, in classical Greece, healers adopted progressively less magical and more logical attitudes to health and wellness (Chap. 4). In mediaeval Europe (Chap. 5), also, health care was progressively divorced from the ministrations of the monasteries, new sources of treatment ranging from often ill-­informed individuals who carried the title of physician to well-intentioned lay people. In this chapter, we will look briefly at health care in early Egypt, Israel and India, and will explore more deeply the health care options available in mediaeval Europe and the New World during the Enlightenment, before tracing the development of regulatory bodies intended to protect the public from medical charlatans. © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_13

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Egypt In ancient Egypt, healing generally remained linked to religious superstition, and the official doctors were members of the priesthood. Initially, they served the goddess Seckmet, who was thought to inflict plagues, war and death. Subsequently, people also sought medical assistance from other Egyptian deities, including Thoth, Isis and Horus. In general, priest-physicians were aided by various magicians, who carried papyrus scrolls with appropriate incantations and sometimes performed massages. The training of health care professionals was centred around the temples of the Nile valley; these buildings contained vast stores of therapeutic herbs. One salient medical emphasis in ancient Egypt was upon keeping the teeth in good condition. Pharmaceutical remedies for aching teeth included dough, honey, onions, incense and fennel seeds. The thinking of the most famous Egyptian physician (Imhotep, c. 2650– 2599  BCE) marks an early move away from superstition and magical notions. Imhotep emphasized the value of anatomical observations, describing over 200 illnesses and making recommendations for their cure.

Israel The early Jewish people were monotheistic, but yet believed in an angry God who could visit illness upon sinful people. Initially, the Jews were inclined to disparage health professionals. Nevertheless, Moses claimed an ability to protect his followers against the fatal snake bites that were common in the Nile valley. Those who had been bitten were instructed to look steadfastly at a brass serpent that Moses had mounted on pole, and in doing so they escaped death. But later in Jewish history, King Hezekiah destroyed the brass serpent, because people had begun treating it as an idol rather than as an instrument of God. God’s healing power was subsequently seen as delegated to major prophets such as Isaiah and Elisha, with the latter performing a successful mouth-to-mouth resuscitation on a young Shunnamite boy, and healing Namaan of his “leprosy.” Nevertheless, such cures were attributed to God rather than to the medical abilities of the prophet, and indeed it was thought inappropriate to claim any personal skill as a healer. Even in post-exilic times, King Asa was condemned because he sought the services of a physician who had learned the pagan magical practices that were current in Babylon, rather than turning to God and his prophets for healing. The Jews gradually recognized that certain herbs had healing properties. In the apocryphal book of Tobit (~200 BCE), the angel Raphael prescribed a mixture of fish gall and butter or salt to treat a “white film” (cataract) that had impaired the sight of the father of Tobias. The Book of Watchers/Book of Enoch (from the first half of the second century BCE) also speaks of a race of Giants or Fallen Angels

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who had knowledge of Arabic therapeutic root cuttings and plants (although these remedies were forbidden by God). The Essene sect practiced herbal medicine, and the imported Arabic knowledge eventually became acceptable to Jewish healers, so that by the tenth century CE, Asaf had prepared a Book of Medicines describing the therapeutic uses of trees, herbs, roots and seeds. One of the first Jews to describe himself as a physician was Jesus ben Sirach, in around 180 BCE. His “Wisdom” sought to marry Jewish zeal with insights from the Hellenistic culture. The sick were urged to prayer and penitence, thus anchoring his treatment within Jewish mores. Ben Sirach also argued that the physician was to be respected by both his patients and the community, since he was created by God, and his wisdom came from God, even though his remedies were often drawn from the earth. Much of the information gathered by Ben Sirach was catalogued in the Testament of Solomon (~200 CE). Jesus apparently saw himself as a healer in the tradition of Isaiah and Elisha. His persona offers an interesting contrast with that of austere and remote Greek healers such as Aesculapius- according to sketches found in the catacombs, Jesus was young, beardless, and above all prepared to touch those who were sick (often in defiance of rabbinical laws). In Talmudic times (70–500  CE), medical practice gained the blessing of the establishment, and rabbis such as Hanina ben Dosa and Ishmael ben Elisha actually developed medical practices as a source of income to facilitate their unpaid rabbinical duties. The community acceptance of a medical career became even stronger in mediaeval Europe, where anti-Semitism excluded Jews from most professions other than medicine.

India Early Indian medicine developed within the framework of the Hindu religion. The earliest Indian physicians were the priestly class, the Brahmins, but later the third highest caste, the Vaiṥyas, assumed this role. India’s first surgeon, Sushruta (c. 600 BCE) claimed to have gained his knowledge from an incarnation of the God of Medicine, Dhanvantari. Among the discoveries of Sushruta were the preservative properties of salt and the antiseptic properties of turmeric, a relative of the ginger plant. For the Vedic physician, the flight of birds and other natural sounds were thought to provide indices of the severity of an illness. However, rational empirical tests were also used, with sweetness of the urine being recognized as a sign of diabetes mellitus, and elaborate systems developed to assess differences in the characteristics of the pulse with various forms of illness.

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Classical Minoa and Greece Minoan Art-work points to medical soothsayers as engaging in ecstatic dances, possibly brought on by drinking psychotropic fruit juice in a quest to enhance their healing powers. Minoan physicians made some use of plants, in particular preparing the oils of laurel, sage and lavender to treat the chest complaints of local miners. In the time of Homer (ninth century BCE), most Greek healers continued the traditional magical practices of surrounding societies, embracing ideas derived from Egypt and Minoa. The Asclepian serpent itself was probably derived from the Minoan cult of the snake goddess. However, subsequent Greek physicians progressively shifted from magical practice to more logical forms of treatment. Orpheus was probably the first shaman of Greek classical mythology, and was credited with giving the knowledge of medicine to humankind, and a mystery religion developed around stories of Orpheus. Shrines containing his purported relics subsequently became respected oracles. Hippocrates of Kos (c. 460–370 BCE) is often regarded as the Father of Western Medicine. He claimed to be descended from the mythical Asclepius. Hippocrates and/or his disciples are remembered for their extensive medical writing, including the Hippocratic Oath, which has long provided a formal code of conduct for health-­ care practitioners. Hippocrates collected data to show that disease was essentially a natural process, and he argued that the main task of the physician was to aid the body to restore its natural balance and thus restore an internal harmony. Asclepiades of Bythnia (c. 124–40 BCE) achieved even greater fame as a classical physician. At the peak of his career in Rome he had 50 or 60 patients in his waiting room each morning. After listening quickly to their various complaints, he sorted them into 4 lines, to receive either a bleeding, a purge, an enema, or simply a change of air. Despite denouncing the humoral theory of Hippocrates, Ascelepiades carried many Greek medical traditions to Rome, particularly the view that the world was built from atoms. He distinguished between acute illness (which he saw as caused by an obstruction of the flow of atoms) and chronic illness (which he thought due to an excessive flux of atoms through pores in the body). In his view, drugs were of no value. However, health could be restored by combining a wine diet with gentle massage, emetics or bleeding, and such forms of exercise as walking, running and riding. He believed that treatment should be both pleasing and painless; the wine diet and sensuous massage undoubtedly contributed to the popularity of his medical practice.

Middle Ages In the early part of the Middle Ages, a return to pagan beliefs affected medical practice, with a renewed reliance on the advice of wizards and witches.

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One early Scottish folk healer immortalized by Sir Walter Scott reputedly gained his healing powers by drinking the broth of a white snake, although some have noted that he was also widely travelled and a skilled linguist, so he may have gleaned his knowledge from translating Arabic texts such as the “Secret of Secrets” (a tenth Century Arabic encyclopaedia of alchemy, magic and medicine). The mysterious powers of witches were long feared. As late as 1597 CE, King James VI of Scotland fulminated against “The fearfull aboundinge…in this countrie, of those detestable slaves of the Devill, the Witches or enchaunters.” However, as Christianity was re-established in Western Europe, pagan remedies assumed a reduced importance. The pharmacists of major monasteries were assigned responsibility for healing in and around religious communities, and they often developed extensive herb gardens. Clerics also engaged in some healing, but later in the Middle Ages, medical treatment progressively shifted outside the orbit of the church. Depending on both social status and the nature of the ailment, the search for health care turned to physicians, barber/surgeons, apothecaries, wise women, female heads of households, and well-erucated lay people. Clerics  Monasteries and religious orders offered help to the sick within their walls. Initially, this care was provided by the monks, but later the larger monasteries also put visiting physicians on their pay rolls. Benedict of Nursia (c 480–547 CE), venerated as the father of European monasticism, specifically ordered abbots to make arrangements to tend the sick. Thus, when Rabanus Maurus was designing a new Abbey in Fulda, Germany, in 820 CE, he included a special wing for sick and elderly brothers, a Lazaretto for those with contagious diseases, and an apartment to accommodate a monastic medical specialist. The Abbess Hildegarde of Bingen (1098–1179 CE) also wrote extensively on the value of herbs and holistic therapy, and by the end of the thirteenth Century, monasteries across Europe offered as many as 19,000 leprosaria. As the division between medicine and theology became more clear-cut, many monasteries decided to appoint resident or visiting lay doctors. At one monastery, the physician’s stipend was set at “one loaf of bread, one gyst of best beer, 40 shillings per annum, and on fish or flesh days to be served as one of our monks”. One or more monks or nuns usually retained the role of herbalist, acting under the advice of the visiting physician. Monasteries added new sick bays and cultivated extensive herbariums, and an elite group of master physicians and apothecaries emerged as a result of these initiatives. By the late middle-ages, enlightened clerics were arguing that humans could move beyond the passive acceptance of illness or a search for miracles at the shrines of great saints. Rather, relief from their suffering could be sought in the wonders of nature, particularly in the herbs that were increasingly prescribed by monastic pharmacists (Chap. 14). Physical healing was now an important part of the church’s mission, and if a cleric was successful in medical practice, he was often appointed to a prestigious and well-endowed “Living.” Unfortuately, Henry VIII’s destruction of the monasteries (1534  CE) brought an abrupt end to this type of health care in England.

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In Flanders, the Alexian brothers were a lay Augustinian order, recruited initially to care for victims of the bubonic plague. They were nick-named the Lollebroeders, or soft-singers, because of the gentle chants that they sang for the dying and the dead. Their services were badly needed in mediaeval Europe, since the civil authorities often forced terminally ill patients outside the city walls in an attempt to contain epidemics such as the Black Death. During the fifteenth century, the Alexian Order spread rapidly throughout Germany and the Low Countries. They still operate a small number of hospitals in the U.S. and the U.K. Physicians  The emergence of medicine as a profession distinct from the Church had begun with an edict of Charlemagne that had allowed promising young scholars to be sent to learn medicine (Chap. 5). Some mediaeval prelates found medicine to be a lucrative side-line. However, in response to this abuse, the Council of Clermont (1130  CE) decreed that monks and canons were not to learn medicine for their material gain, and the Council of Tours (1163 CE) formally stipulated that clerics must avoid secular study. Thus in 1214 CE, Master Gilbertus Angelicus was summoned to Rome to explain why he was still combining a medical practice with his priestly duties. The new breed of secular physicians were commonly termed “leeches,” because they so frequently used leeches to reduce a patient’s blood volume (Fig. 13.1). Some early doctors such as Eadricus (c. 1150 CE) were also termed fleubotomarius (phlebotomist). Magister Arnaldus de Villanova (c. 1235–1313 CE) is one example of an early independent physician with broad academic interests. He translated the medical texts of Avicenna and Galen from Arabic into Latin and wrote extensively on such interests of the alchemist as the “Philosopher’s stone,” as well as authoring a medical text (Breviarium Practicae Medicinae). He moved to Paris, France, and there he came in conflict with the Church because he sought to meld his ideas of medicine with those of the theologians. Despite attempts at licensure, the professional competence of even the most highly “trained” physicians was often pitiful, with the proposed remedies likely to exacerbate the original illness. For example, in “The Art of Medicine,” the renowned Royal physician John Arderne (died c 1377 CE) suggested that kidney stones should be treated with: “a plaister of pigeon’s dung and honey applied hot.” Often, mediaeval physicians opted to ply their calling on a part-time basis. In the fifteenth Century, Richard Knyght was described as: “ffesicissian, ironmonger, surgeon and dogleche” An Italian physician practising in mediaeval London, England, had a thriving side-line as a wool merchant, and in Essex, a Dr. John Crophill served as local bailiff, rent-collector and ale taster for the local Lord of the Manor. Occasional female medical practitioners were usually not well received. In 1302 CE, Margery the Leech of Hales, Worcestershire, accused a villager of throwing her into the river, an action probably taken to determine whether she was a witch rather than a physician. Physician/patients ratios were generally low. King Magnus of Norway and Denmark (1024–1047 CE) was particularly concerned that there were few surgeons

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Fig. 13.1.  Mediaeval physicians and barber/surgeons made extensive use of blood-sucking leeches in an attempt to restore a healthy balance between the body humours of their patients. The illustration shows a fasting leech, and one that has drawn its full of blood (Source: http://en.wikipedia.org/wiki/Leeching_(medical)#Medicinal_use_of_leeches).

Fig. 13.2.  Coin minted for King Magnus the Good of Norway. After the battle of Lyrskog Heath (1043  CE), he was faced by a shortage of medical orderlies, and selected medical aides from among those of his troops with the softest hands. They quickly became excellent “leeches.” (Source: http://en.wikipedia.org/wiki/Magnus_the_Good)

to treat his wounded army at the battle of Lyrskog Heath; he walked among those who were uninjured, and selected 12 soldiers who had “the softest hands,” ordering them to bind the wounds of his troops (Fig. 13.2). They began their task with no medical knowledge, but some were quick learners, and were said to become “perfect leeches.” In thirteenth century Worcester (with a tax-roll of 10,000 citizens) there were only 3 residents who described themselves as “physicians.” In fourteenth

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Fig. 13.3  Unsuccessful medical treatment sometimes had fatal consequences not only for the patient, but also for the physician. King Guntram of Burgundy carried out the wish of his spouse that her doctor should be executed the day following her death. Illustration from Les Grandes Chroniques de France (Source: http://en.wikipedia.org/wiki/Guntram)

century Paris, France, 38 medical practitioners (mostly unlicensed) gave a physician-­ patient ratio of 1.9 per 10,000, as compared with the 37/10,000 ratio in Post-Modern Vancouver, BC.  The obvious implication is that in mediaeval society, access to qualified physicians was usually limited to the middle and upper classes of society. Certainly, the professional fees charged by some doctors were very high relative to mediaeval incomes. Chaucer wrote scathingly about the silken-clad Doctor of Physic: In blue and scarlet he went clad, withal, lined with a taffeta and with sendal… gold in physic is a fine cordial, and therefore loved he gold exceeding all.” For the surgical treatment of an anal fistula, the English Royal Physician John Arderne expected an immediate payment of 40 marks, a gift of clothing, and continuing payments of 100 shillings per year for the remainder of the patient’s life. This equates to a total fee of about $48,000, measured in 1956 U.S. dollars. On the other hand, there was no Medical Defense Union, and doctors sometimes faced physical danger if their treatment was ineffective. When Queen Austragild of Burgundy died in 580 CE, her final command was that her doctor be executed on the day following her demise (Fig. 13.3). One tactic of wily physicians in avoiding such a fate was to refuse treatment unless a patient signed documents indicating that he or she considered themselves as already dead before they began any treatment.

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Barber-Surgeons  Barber/surgeons were usually individuals who had gained a modicum of professional knowledge through apprenticeship to a physician. At the end of their apprenticeship, they met a Latin language requirement, and took a test from the Barber-Surgeon’s Company. Because they worked with their hands, they were regarded as “manual labourers,” and class distinctions denied them entry to most mediaeval universities. Physicians usually relegated such mundane tasks as the annual blood-letting to a barber/surgeon who was serving as an assistant. Sometimes, barber/surgeons decided to set up their own independent practice, soliciting patients on the street, erecting a small booth at the town market, or (because of the cosmetic components of their trade) opening a barber/surgeon salon in a city’s “entertainment district.” Given the poorer nature of their clientele, barber/ surgeons were often reimbursed in-kind, and because their income was precarious, many simultaneously plied other trades such as metal work, making surgical implements both for themselves and for their colleagues. Apothecaries  The preparation of therapeutic drugs and herbs gradually devolved from the doctor to a coterie of paramedical professionals known as apothecaries. Baghdad is thought to have had apothecary shops (Fig. 13.4) as early as the eighth Century CE, and in mediaeval Britain, the trade of apothecary is described in Chaucer’s the Nun Priest’s Tale: “though, in this town there is no apothecary, I will teach you about herbs myself, that will be for your health and for your pride.” The independence of apothecaries was well established in 12th and 13th Century France. Thus, a 12th century document from Arles specified that apothecaries were to keep out of medical affairs, while doctors were forbidden to own or hold an interest in pharmacies. Rabelais and Nostradamus were examples of successful mediaeval apothecaries. The French Benedictine monk Rabelais (1483–1553  CE) was very interested in herbal remedies, and indeed had read many of the Arabic texts officially proscribed by the church. He was familiar with the armamentarium of a well-equipped apoth-

Fig. 13.4  An apothecary’s shop (late fourteenth Century CE) (Source: http://en.wikipedia.org/ wiki/Apothecary)

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ecary: “a Silenus… a little box, of the kind we see today in apothecaries’ shops… inside these boxes were kept rare drugs, such as balm, ambergris, cardamum, musk, civet, mineral essences, and other precious things… had you opened that box, you would have found inside a heavenly and priceless drug.” Nostradamus (1503–1566  CE) graduated from Montpellier University, in the south of France. He assisted a Marseille-based physician in fighting an outbreak of plague, claiming to have protected himself against this epidemic with a mysterious secret powder. He became quite rich from the sale of his remedies, and at his death his estate was valued at the current equivalent of US $300,000. Like physicians and barber/surgeons, apothecaries often developed substantial side-lines to supplement their basic income from the sale of drugs. In the City of London, a John Hexham took up the dangerous hobby of counterfeiting coin, and he was hanged for this offence in 1415 CE. Other apothecaries, such as John Parkinson (1567–1660  CE) achieved fame as botanists. Some prepared not only herbal ­remedies, but also viles and poisons. Thus, in Romeo and Juliet, an apothecary sells Romeo the fatal elixir with which he commits suicide. And in France, Madame de Sevigné (1626–1696 CE) described an apothecaire empoissoneur who sold lethal potions in an attempt to recoup losses that he had sustained in a fruitless quest for the Philosopher’s stone. Wise Women  Typical Wise Women had an extensive practical knowledge of both midwifery and herbal folk remedies, and despite being barred from most European universities, they were a ready source of effective pain-killers, digestive aids and anti-inflammatory agents. A few gained the formal title of Midwife, but during the fourteenth Century they were more commonly known as sage-femmes. They made a particularly important contribution to the care of female patients in the mediaeval period, since many male physicians: “believed their dignity and self-esteem were diminished by the manual nature of care for the pregnant patient.” In 1469  CE, Marjory Cobbe of Devon was granted an annual pension of 10 pounds for attending Elizabeth, wife of King Edward IV, during childbirth. However, Wise Women were often ill-regarded by medical practitioners, who saw them as potential rivals. In 1322 CE, the Faculty of Medicine in Paris forced a Wise Woman to face trial on charges of practicing medicine illegally. The doctors were particularly incensed because she charged her patients no fee unless they were cured! English physicians, likewise, petitioned parliament to impose fines and “long imprisonment” on any woman who attempted to “use the practyse of Fisyk.” In 1421 CE, King Henry V banned all practice of medicine and surgery by women, forcing midwives to refer difficult pregnancies to physicians who usually had less knowledge and experience of childbirth than themselves. Fearing a resurgence of witchcraft, the mediaeval church also required all midwives to be licensed by a Bishop and to swear an oath that they would eschew any form of magic when assisting women through labour. Sometimes, the midwives did elect to introduce pre-Christian rituals into their practice. Formal witch-hunts began in Germany during the fourteenth Century, and

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persecution swept across Europe, with an eventual burning of as many as 60,000 women over some three centuries of terror. Female Heads of Households  The female head of the household was an important source of health care for the sick child or the injured husband in Mediaeval Europe. Husbands expected their wives to become proficient in treating minor ailments, and on occasion even to provide the means of poisoning an enemy. The English housewife was required to: “have a physical kind of knowledge; how to administer many wholesome receipts or medicines…. as well as to prevent the first occasion of sickness.” During the Mediaeval Era, the physicians of the Salerno medical school frequently referred to treatments administered by: “those wonderful mulieres Salernitance,” Most of the women concerned were probably ordinary intelligent householders, although Dame Trotula of the Salerno medical school (Chap. 17) may have guided their domestic healing efforts. One record speaks of the mulieres treating dropsy by herbal diuretics: “they go to the woods and collect plants indiscriminately, diuretic and others… These they boil in salt water, and the patient first inhales the steam, then drinks, and finally bathes in it.” Unfortunately, the guidance provided to the mediaeval chatelaine by the local physician was itself suspect. Sometimes, also, the ladies used their herbal preparations in practical jokes. One popular trick was to sprinkle a bunch of roses with euphorbium, and then give it to an unsuspecting young man, causing him to engage in a violent fit of sneezing. The mediaeval lady of the manor was expected to provide health counselling not only for her own family, but also for her tenant farmers and their families. Thus, in Le Ménagier de Paris (c. 1393 CE), a wealthy husband aged about 60 years advised his 15-year old bride on ways to prepare soups and stews for the sick and also for himself in his old age (Fig. 13.5). Occasionally, a chatelaine’s knowledge of plants was used to kill an enemy. Chaucer was quite cynical about wifely advice in mediaeval England. In the Nun’s Priest’s Tale, Chanticleer was nearly poisoned by drastic remedies such as an extract of black hellebore used for the treatment of worms. Other Well-Educated Lay-People  Well-educated lay people often learned a little medicine as a part of their general education. Isodore’s De Medicina seems to have been written mainly for lay practitioners, a group sometimes known (perhaps justly!) as the idiotae. De medicina begins by defining health care as: “the art that protects or restores the body’s health. …ultimately every defense and fortification by means of which our health is preserved.” Henry of Mondeville (1260–1316 CE), perhaps the first well-qualified Surgeon in France, distinguished two classes of “idiot”: the proud and stupid who boasted of hereditary knowledge and opposed orthodox medical practitioners, and those whose circumstances had prevented them from acquiring a regular education, but who respected the advice of surgeons, and were ready to learn from them.

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Fig. 13.5.  In mediaeval society, female heads of households were expected to be able to treat minor ailments. In the “Goodman of Paris,” a wealthy sixty year old man instructs his 15 year old bride on how to prepare nourishment for the poor and the sick (Source: http://books.google.ca/ books/about/The_Goodman_of_Paris_Le_M%C3%A9nagier_de_Par.html?id=Argb7PmV3fkC)

Medical Care in the New World During the Enlightenment In Europe, the dominant role of the physician in medical care had become well established by the Enlightenment. But on the frontiers of the new world, there was still a vital role for midwives and lay medical advisors. The few available doctors in North America were much less elegant than their European counterparts. Often, they had begun their practice as scantily equipped ship’s surgeons. Given the absence of medical schools, practitioners acquired a smattering of medical knowledge by serving as apprentice, stable boy and personal servant to an existing physician. At the outbreak of the American Revolution (1775 CE), less than 400 of the 3500 physicians practicing in the United States held any sort of university degree.

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In North America, obstetrics was commonly the responsibility of midwives, as exemplified by the Puritan spiritual advisor Anne Hutchinson (1591–1643 CE) in the Massachusetts colony. She had herself given birth to 12 children, although 3 of these had died in infancy. Her midwifery was at first highly esteemed in the Boston region, but later, she was banned from the State of Massachusetts because of her strident views on both theology and women’s rights. Although once again pregnant, Anne had the strength to walk 80 km from Boston to Providence in a New England winter, following her expulsion from Massachusetts.

Professional Regulation Medical licensure was first introduced to Sicily in 1140  CE, with penalties of imprisonment and confiscation of property for anyone ignoring this law. Less than a century later, Frederick II (1194–1250  CE) had established uniform standards across the Holy Roman Empire not only for medical licensure, but also for pre-­ medical and medical training. In Bologna and Padua, the universities early set standards for qualification as a physician. Northern and Central Italy were proud of their regional independence, and they did not see the need to establish a regulatory College. However, self-­ regulation was later reinforced by the surveillance of newly appointed Public Health Boards, and a College of Physicians was eventually established in Florence. The situation differed from that in Southern Italy, where licenses to administer medicine or surgery had been granted by the royal administration, acting on advice from a commission of examining physicians. In 1421 CE, English physicians petitioned parliament, asking that nobody without appropriate qualifications be allowed to practice medicine. However, it was not until 1511 that a statute committed regulation of the English medical profession to the Bishops, with a financial reward offered for the reporting of unlicensed practitioners. In 1518 CE the College of Physicians received a royal charter from Henry VIII; Thomas Linacre was appointed as the first president of the College, and it took over responsibility for licensing from the Bishops, imposing standards of basic knowledge and competency upon those who sought to practice as physicians. It also regulated the composition of medicaments, publishing the first 10 editions of the London Pharmacopaeia, and through its “Censors,” it assured the College’s monopoly on standards of medical practice. English barber/surgeons had somewhat earlier regulation. Richard the Barber held the office of Master of the Worshipful Company of Barbers as early as 1308 CE. At this time, an important function of the barbers’ guild was to assist those monks who were charged with healing in the monasteries, since Papal decrees prohibited the monks themselves from performing such procedures as the drawing of blood. Among other duties, the barbers undertook blood-letting, leeching, neck manipulation, and the draining of cysts and boils.

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During the Renaissance, a number of surgeons began to tire of competing against the services offered by the ever-growing number of barbers, and in 1368 CE they formed their own guild, albeit under the general oversight of the Company of Barbers. In an effort to regulate competition between the two bodies, Henry VIII sponsored an amalgamation of the barbers and the exclusive guild of military surgeons; the outcome was the United Company of Barbers and Surgeons (1540 CE), with Thomas Vicary (Superintendent of St. Bartholomew’s Hospital and Royal Physician) as its first Master. The red and white striped barber’s pole symbolized the union of the two bodies. The act specified details of responsibilities for the two groups. No surgeon could cut hair or shave a client, and no barber could practice surgery, although both groups were allowed to extract teeth. Much professional jealousy remained between the 2 groups, and the barbers were scorned by many of the surgeons. Thus, the naval surgeon William Clowes (1544–1604  CE) viewed the barbers as: “tinkers, tooth-drawers, peddlers, ostlers, carters, porters, horse-gelders and horse-leeches, idiots, apple-squires, broom-men, bawds, witches, conjurors, soothsayers. and sow-gelders, rogues, rat-catchers, runagates, and proctors of spittle-houses.” In 1745  CE, the surgeons again broke away from the barbers, forming the Company of Surgeons, and as surgery became more a more prestigious profession. The Royal College of Surgeons was established in 1800 CE. In Scotland, surgeons and barber-surgeons received their charter of incorporation in 1505 CE. James I of England sought to establish a Scottish College in 1617 CE, but the process faltered because of dissent and jealousy from physicians who lived outside of Edinburgh, particularly when legislation envisaged giving the College the bodies of several malefactors each year for their practice of anatomy. Finally, after much haggling, the Scottish College received the Royal Seal in 1681 CE. It was given the power to inspect apothecaries shops, and to destroy any medicines that were thought inappropriate. The charter was not revised until 1861 CE.

Practical Implications for Current Policy During mediaeval times, medical practitioners were often strongly opposed to the activities of midwives, forcing referral of difficult deliveries to doctors who had less practical experience of obstetrics than the “sage femme.” This professional bias was dictated either by personal pride or a desire to conserve a large income. In the present century, we have witnessed a similar controversy, with many medical associations vigorously opposing home delivery of uncomplicated pregnancies by midwives, despite good evidence that obstetric outcomes were as good or better than those associated with medical supervision of labour. Some physicians have directed similar opposition against other health professionals such as exercise specialists. Although certified exercise physiologists typically have a much greater understanding of responses to physical activity and safe limits of exercise, some

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physicians have sought to maintain their primary role in the management of all exercise procedures. The legislation in mediaeval Arles specified that apothecaries were to keep out of medical affairs, and that doctors were forbidden to own or hold an interest in pharmacies. During the Post-Modern era, this lesson has to be relearned, particularly in the United States, where the content of many medical journals is heavily financed by the makers of specific and sometimes unproven remedies. It is vital that those reporting on the efficacy of drugs and other treatments have no financial interests leading them to emphasize positive factors when reporting their results. Currently, many general practitioners and hospital out-patient departments find their facilities over-whelmed by patients who are attending for the treatment of minor disorders that should have been amenable to treatment from the family medicine chest. In Victorian times, most families could not afford a medical consultation for such minor ailments, and the encyclopaedias of that era usually contained a section with simple medical advice allowing anxious mothers to diagnose and treat the minor complaints of their offspring. In more recent years, universal health care has removed the financial constraint on seeking professional advice, with a surge of unnecessary medical consultations. The Government of British Columbia has attempted to contain such unnecessary medical costs by establishing Health-Link BC, with a widely distributed hard-copy Household Guide to Health, and associated telephone and internet consultation services available to anxious parents.

Questions for Discussion 1. Mediaeval physicians often became very rich at the expense of their patients. Do you think that long training justifies the high salaries of many physicians today? 2. Errors in diagnosis and treatment led to severe penalties and sometimes death for mediaeval physicians. Do you think the medical errors made today are monitored adequately and punished appropriately by professional associations? 3. In mediaeval times, some of the most successful treatments were based upon herbal remedies. Do you think more use should be made of “natural” medications in the treatment of patients today? 4. Much of the treatment of the average person in mediaeval times was provided by the housewife or the intelligent lay-person. Do you think we should be encouraging a greater reliance upon home remedies today?

Conclusions Early societies saw illness as a punishment inflicted by an angry god, and thus sought treatment from a shaman or a priest. But classical Greek society moved progressively to a more material interpretation of health, with the emergence of

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physicians who sought to treat illness by logical measures. In the early part of the Middle Ages, there was a reversion to paganism is western Europe, with the treatment of illnesses by wizards and witches. Then, for a period, the church treated the sick, with a particular contribution from the healing herbs cultivated by the pharmacists of monastic communities. Edicts requiring clerics to confine themselves to religious issues led to the emergence of a variety of secular health professionals- not only doctors but also barber/surgeons, apothecaries, and midwives. However, responsibility for the treatment of many minor ailments fell upon female heads of households and intelligent lay-people. In Europe, the medical role of the “qualified” doctor had become dominant by the Enlightenment, and minimum qualifications had been defined and enforced. But on the frontiers of the New World there were still no medical schools, and health care commonly remained the responsibility of amateurs and lay people.

Further Reading Böck B. The healing Goddess Gula,. Towards an understanding of ancient Babylonian medicine. Leiden, Netherlands, Brill Publishing, 2013, 232 pp. Clark R. Sacred magic of ancient Egypt: The spiritual practice restored. St. Paul, MN, Llewellyn Worldwide, 2003, 383 pp. Cipolla C. Public health and the medical profession in the Renaissance. Cambridge, UK, Cambridge University Press, 1976, 136 pp. Dingwall HM. Physicians, surgeons and apothecaries in seventeenth century Edinburgh. Edinburgh, Scotland, Tuckwell Press, 1995, 262 pp. Eaton E. The shaman and the medicine wheel. Wheaton, IL, Quest Books, 1982, 212 pp. Elmer P. The healing arts: health, disease and society in Europe, 1500–1800. Manchester, UK, Manchester University Press, 2004, 408 pp. Engel CW. The Greek God of healing Ascelepius & Goddess of Health Hygeia. New Haven, Conn, Yale University Press, 144 pp. Garcia-Ballester L. Practical medicine from Salerno to the Black Death. Cambridge, UK, Cambridge University Press, 1994, 402 pp. Kutumbiah P. Ancient Indian medicine. New Delhi, India, Orient Longman, 1999, 233 pp. Magner LN. A history of medicine. Boca Raton, FL, CRC Press, 1992, 400 pp. Matthews LG. The Royal apothecaries. London, UK, Wellcome Historical Medical Library, 1967, 191 pp. Prioreschi P. Mediaeval medicine. Omaha, NE, Horatius Press, 804 pp. Storl WD.  The herbal lore of Wise Women and wortcunners. The healing power of medicinal plants. Berkeley, CA, Atlantic Books, 2012, 392 pp. Varner G. Sacred wells: A study in the history, meanings and mythology of holy wells and waters. New York, NY, Algora Publishing, 2009, 188 pp. Wallis F. Mediaeval medicine; A reader. Toronto, ON, University of Toronto Press, 2010, 563 pp. Wellcome HS. Medicine in ancient Erin: An historical sketch from Celtic to Mediaeval times. London, UK, Burroughs Welcome, 1909, 106 pp. Winkler G. Magic of the ordinary. Recovering the Shamanic in Judaism. Berkeley, CA, North Atlantic Books, 2003, 238 pp. Zysk KG. Medicine in the Veda: Religious healing in the Veda. New Delhi, India, Motilal Banarsidass Publishing, 1998, 311 pp.

Chapter 14

Herb Gardens, Naturopathy and Human Health

Learning Objectives 1. To recognize the large part played by herbal remedies in early attempts at health care. 2. To note the bizarre methods that were sometimes used to decide upon appropriate herbal treatments.

Introduction Herbal remedies have a long history, and some were among the more effective of early medical treatments. They were used with varying success by many traditional hunter-gatherer groups (Chap. 2), and there is a specific mention of numerous herbs in the written records of the Old Testament, and the Minoan culture. In mediaeval times, the wizards and witches continued a strong reliance on such natural remedies, often linking these to pagan rituals. A herbarium also became an important adjunct of a monastery or a well-ordered manor, and some early medical schools were located in association with specifically developed botanical gardens. Although a few of the herbs we shall consider were undoubtedly quite beneficial, a number of other were used for bizarre purposes. We will comment specifically upon the use of herbs in Israel, in the Minoan culture, and during the mediaeval era. Interest in herbal remedies subsequently declined, as advances in chemistry allowed the synthesis of the active ingredients of many plants, although we still had one herbalist in the Guy’s Hospital pharmacy when I was a student in the late 1940s.

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Israel Although many medicinal preparations are mentioned in the Bible, they are not always clearly identified. After the Babylonian exile, a guild of roquhim (apothecaries or perfume makers) was established in Jerusalem, one of their primary tasks being the preparation of myrrh and aloes for burials. The instructions for preparing holy oil and incense seems to have followed the accepted usage of apothecaries from that era. The Bible frequently mentions balm as a counter-irritant for local pain. Bitter herbs were also used not only as foods but also for their medicinal value. Cress was probably helpful as an astringent, and vinegar served to stop bleeding. Indian saffron and cummin were valued as carminatives and stimulants. Hyssop, which contains a high concentration of anti-fungal and anti-bacterial agents, was used by Moses as a purifying agent. Olive oil was also used as an unguent for wounds. A mixture of aloes, myrrh and cinnamon supposedly had aphrodisiac powers, as did mandrake. Juniper oil may have been used as an abortifacient. Nard, imported from India, was valued not only as an ointment, but also as a sedative. Wine laced with myrrh was a common analgaesic, and opium is also mentioned in the Talmud. As in Egypt, the fruit of date palms was claimed to cure many diseases and infections, to promote longevity and to act as a mild aphrodisiac. Pomegranate was sometimes added to wine as a prelude to coitus. In general, the Israeli knowledge of drugs seems to have matched that in neighbouring states, but for a long period there was a strong reluctance to use such remedies, as they were thought to be heathen practices (Chap. 13). When Hezekiah, king of Judah, fell mortally ill, and Isaiah warned him to prepare himself for death, he even decided to hide the “Book of Remedies” that summarized knowledge of healing herbs. He argued that if someone was sick, but followed what was written in the book and was healed, that person’s hearts was not humbled before Heaven because of the illness. By Talmudic times (70–500 CE), the fear of modifying divine punishment had waned, and the scope of Israeli medical practice had expanded; four main classes of drug were now recognized: sleeping draughts, abortifacients, poisonous drugs, and restoratives.

Minoans There was a strong reliance upon herbal remedies in the Minoan culture. The chest ailments of Minoans metal workers were treated with camphorated oils distilled from laurel, sage, and lavender. Other medicinal plants included coriander, cumin, dittany, rue, saffron, rosemary, safflower, anise, verbena, Aleppo pine, myrtle and fig. Opium was also known and used, at least as a soporific.

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Fig. 14.1  Example of a text inscribed with the Ogham alphabet on a pillar at Tralee, in County Derry, Ireland. Letters in the alphabet signified specific trees with sacred properties (Source: http://en. wikipedia.org/wiki/ Ogham)

Some of the herbs were used not only in treating illness, but also as cosmetics. These included such ingredients as anise, carnations, beeswax, honey, olive oil, resin and oil of iris! The value placed on this last substance can be judged from the number of jars decorated with pictures of the iris.

Mediaeval Era Celtic wizards and witches recognized sacred properties associated with 20 trees, as seen in the mysteries of the 20-letter Ogham tree alphabet (Fig.  14.1). Each tree represented a feeling, attribute or essence. For example, the first letter in the Ogham alphabet was Beithe, representing the birch tree; it signified youth, renewal and rebirth. Likewise, the letter Ngetal, or reed, symbolized health, harmony and growth. The main use of the Ogham language seems to have been to cloak mediaeval healers and their rites with a mysterious vocabulary not understood by the common people. The Celtic witches and Wise Women saw an important linkage between human life and creation as a whole. Thus, they focused their skills upon midwifery and the dispensing of what they perceived as appropriate herbal remedies and potions. An extension of their beliefs gave rise to the bizarre “doctrine of signatures,” which was also adopted by many mediaeval physicians. Protection against evil forces was said to be found in such remedies as a bracelet woven from senna, mint and rue, or a

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Fig. 14.2  King Alfred commissioned the Leechbook of Bald to summarize existing knowledge of herbs. One of the recommendations of this book was to use the rose-like herb agrimony as a remedy for male impotence. Its efficacy was enhanced by boiling in milk, but was decreased if it was heated with Welsh beer! (Source: http://en. wikipedia.org/wiki/ Agrimonia)

wreath of primrose and convolvulus, picked on May 1st. Likewise, fever was believed to be cured by an antidepressant (a preparation of St. John’s Wort, steeped in wine), particularly if the flower had been found accidentally on Midsummer’s Eve. If a person was bitten by a mad dog, he or she should eat some of the dog’s hair, boiled or fried with rosemary. The potency of many herbs was thought to be increased if spells and incantations were chanted while the witch was facing south and picking the leaves or blossoms at sunrise. Insight into Celtic folk remedies has been obtained through archaeological studies in the Orkneys. One important discovery at this World Heritage site was a large number of shriveled outer skins of puffball mushrooms. It is thought that the Celts used the inner tissue of the fungus as a styptic, and that the spores may have served as an early anaesthetic. According to the English parson-­naturalist John Lightfoot (1777), Scottish highlanders also used yarrow as a styptic, and sometimes sought to cure a nosebleed by thrusting a leaf up their nostrils. In mediaeval times, the general English population had more knowledge of herbs than did their continental contemporaries, and many householders maintained a small herb-yard. Between 900 and 950 CE, an English nobleman and “leech practitioner” named Bald persuaded King Alfred to commission a text (the Leechbook of Bald) as a part of the King’s programme of educational reform. A scribe by the name of Cild patiently transcribed the work, which discussed in the vernacular, some 500 herbal remedies and sacred rituals from Anglo-Saxon and Celtic traditions, supplemented by material gleaned from Greco-Roman and Arabic sources (Fig. 14.2). Many of Bald’s remedies were bizarre. For example, a headache was to be treated with a stalk of crosswort, bound to the head with a red kerchief. Agrimony was recommended for the treatment of male impotence; boiling this rose-like herb in milk enhanced its efficacy, but heating it in Welsh beer had the opposite effect! A second Anglo-Saxon collection of medical texts and prayers from the early eleventh century was given the Old English title Lacnunga (literally, “Remedies”) by Oswald Cockayne, who edited the book in the nineteenth century. It contains further information on the many charms that were supposed to enhance the efficacy

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of Anglo-Saxon herbal treatments. The most renowned of these remedies was the Nine Herbs Charm that invoked the help of the Saxon god Woden: “A snake came crawling, it bit a man. Then Woden took nine glory-twigs, Smote the serpent so that it flew into nine parts.” Other texts available to English mediaeval folk-healers were a translation of the Latin Herbarium Apuleii Platonici, probably written at Monte Casino between 1000 and 1050 CE, and the “Book of Nature” written by the German scholar Konrad von Megenberg (1309–1374 CE). The Herbarium, erroneously attributed to Plato, included on its frontispiece an image of the Greek Chiron the Centaur, who was supposedly given an understanding of the healing properties of plants by the goddess Diana. The treatments proposed in the Herbarium relied heavily upon a species known as Dutchman’s pipe or birthwort, a plant widely used in Egypt, Greece, Rome and China. Lucius Apuleius, a student of North African plants, maintained that no good doctor could afford to run short of this herb. It drove out demons, filled a peevish child with laughter, cured ulcers, chills, fever and cancer, and was a vital antidote against poisoning. The active ingredient (aristolochic acid) is itself potentially toxic, although in more recent years naturopaths have used it to speed healing, increase the production of white cells and treat arthritis. The Book of Nature covered many topics, but its fifth section discussed the properties of 89 plants, including sage, lilies, violets, onions, crocuses and hops. With the Norman conquest of 1066 CE, Latin became the language of English scholars, and the reference work for herbalists became the De Viribus Herbarum of Macer Floridus (a text derived from the observations of Pliny, but with pharmacological contributions from Arabic scholars, put together by Odo of Meung, a French scholar from the Loire valley). In Germany, the Abbess Hildegarde of Bingen prescribed feverfew, tansy and mullein for women who failed to menstruate, but given the Catholic context of her abbey, it is more likely that these preparations were seen as a treatment of malnutritional amenorrhoea than as abortifacients. Hildegarde certainly spoke out against abortion and contraception, although she also recognized that these three herbs “regulated” menstruation. For a case of poisoning, one of Hildegarde’s recommendations was to ingest a mixture of plantain, geranium and mallow. Another option was to grate beryl into spring water. If a person took a daily draught of this remedy: “the poison will either foam out through nausea, or pass through his posterior.” Her medical writings provide insight not only into the healing practices of the mediaeval church, but also into some of the earlier folk-lore of “Wise Women.” During the Mediaeval Era, many physicians based their choice of herbal remedies on the bizarre “Doctrine of Signatures.” In essence, this doctrine suggested that God had marked all of creation with specific “signs” (Fig. 14.3). The idea may have begun with the Swiss alchemist Paracelsus (1491–1541 CE), who wrote: “Nature marks each growth…according to its curative benefit” The concept moved into mainstream of medical thought when Jacob Boehme, a Christian mystic from Görlitz, Germany, wrote his “Signature of all things” (1621 CE), and the English botanist William Cole (1626–62 CE) argued in his “Art of Simpling” that: ‘the mercy

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Fig. 14.3 Physicians practicing the Doctrine of Signatures believed that God had marked all creation with specific signs. They used the Eyebright to treat ophthalmic conditions because of the supposed resemblance of this flower to the human eye (Source: http://en.wikipedia.org/ wiki/ Doctrine_of_signatures)

of God… maketh… Herbes for the use of men, and hath… given them particular Signatures, whereby a man may read even in legible characters the use of them.” In brief, the Doctrrine of Signatures drew a parallel between the colour of a flower and its usefulness in treating a particular disease. Plants that bore yellow flowers, such as dandelion and fennel, were linked to the yellow bile of the liver, and they were thus recommended to treat jaundice. In the same way, the Eyebright was prescribed for eye infections, because the appearance of the flower was thought to resemble that of the human eye. In Paradise Lost, John Milton (1608–1674 CE) had the Archangel follow this principle, clearing the vision of Adam with a preparation of Eyewort. An English botanical contemporary and herbalist, Nicholas Culpeper (1616–1664 CE), argued that a greater use of Eyebright would halve the trade of spectacle makers! The Christmas rose (Hellebore) was also considered a valuable medicinal flower; since it bloomed mid-winter, potions from this source were believed to have rejuvenating properties, and some mediaeval physicians recommended a daily dose of extracts from the Christmas Rose for all patients over the age of 50  years! The plant contains a number of cardiotoxins, and it is unclear whether such treatment boosted or shortened longevity.

Practical Implications for Current Policy The main practical lesson to be drawn from the use of herbal remedies in ancient times is that the choice of treatments was based on such specious reasoning as the doctrine of signatures, rather than on a clear understanding of pharmacology. Occasionally, cures were effected, but relatively few patients benefitted from their medication, and often their condition was worsened.

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Some patients today are attracted to herbal remedies because “they are natural.” But as in mediaeval times, the preparations dispensed by ill-informed naturopaths and herbalists must be used with great caution, and not at the expense of other more effective remedies. in a recent incident in British Columbia, a child died of meningitis, apparently because a herbalist recommended treating this simply with echinacea. Some plant preparations do indeed contain compounds that can be used for specific conditions, for example the digitoxin extracted from the purple foxglove. But in most cases, the herbal preparations have now been replaced by synthetic drugs, because the latter have consistent and known concentrations, and are not contaminated by unwanted compounds.

Questions for Discussion 1. Should there be more stringent regulation of naturopaths and herbalists today, including a specifying of the conditions that they can treat and the remedies that they can prescribe? 2. Is the modern exploration of remote eco-systems such as the Upper Amazon likely to provide leads to the introduction of new “miracle drugs?” 3. Do herbal medications have any advantages over preparations synthesized in a pharmaceutical laboratory?

Conclusions Early societies used a wide range of herbal preparations in their attempts to treat illness. In some cases, the choice of medication was based upon empirical knowledge of previous benefit, but often the rationale was bizarre, with the result that the condition of the patient was as likely to worsen as to improve. Although very popular in the Middle Ages, a logical use of herbs was impossible, given that herbalists had no clear knowledge of either the active chemicals that they contained, or their pharmacological effects upon the body.

Further Reading Bailey D. Magic and superstition in Europe. A concise history from antiquity to the present. Lanham, MD, Rowman & Littlefield, 2007, 275 pp. Berkel, K van, Vanderjagt AJ. The book of nature in early and modern history. Leuven, Belgium, Peeters Publishers, 2006, 336 pp. Blamires S. Celtic tree mysteries. Practical Druid magic and divination. Woodbury, MN, Llewellyn Worldwide Publications, 2013, 278 pp.

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Cameron ML. Anglo-Saxon Medicine. Cambridge, UK, Cambridge University Press, 1993, 211 pp. Dudgeon RE. Lectures on the theory and practice of homeopathy. London, UK, Henry Turner, 1853, 565 pp. Frisk G. A Middle English translation of Macer Floridus De Viribus Herbarum. Lund, Sweden, Lund University Press, 1949, 338 pp. Graves J.  The language of plants: A guide to the doctrine of signatures. Hemdon, VA, Steiner Books, 2012, 349 pp. Hatfield G. Encyclopaedia of folk medicine: Old world and new world traditions. Santa Barbara, CA, ABC-Clio, 2004, 392 pp. Keenan B. Irish folk medicine: An anthropological perspective. Galway, Ireland, National University of Ireland, 1996, 638 pp. Pollington S. Leechcraft: Early English charms, plant lore and healing. Cowley, OX, Anglo-Saxon Books, 2008, 539 pp. Rohde ES. Old English herbals. Sydney, NSW, Wentworth Press, 2016, 298 pp. Storl WD. The untold history of healing: Plant lore and medicinal magic from the Stone Age to the present. Berkeley, CA, North Atlantic Books, 2007, 344 pp. Wynn SG, Fougère B. Veterinary herbal medicine. Amsterdam, Netherlands, Elsevier Health Sciences, 2007, 714 pp.

Chapter 15

Bizarre By-ways in the Search for Good Health

Learning Objectives 1. To recognize that plausible charlatans have for many centuries made fortunes at the expense of wealthy hypochondriacs by the sale of bizarre and ineffective treatments for real or imagined disorders. 2. To appreciate that these bizarre procedures have at times endangered the user, and in some cases have also increased the susceptibility of the community to epidemics of infectious disease. 3. To observe that today appropriate medical treatment is still sometimes foregone, to be substituted by ineffective remedies such as homeopathic medicine or acupuncture. 4. To understand that in some instances the appearance of benefit has resulted from inadequate experimental blinding of observers, placebo effects exerted by strong personalities, and a bias for journals to publish positive findings.

Introduction During the Renaissance and the Enlightenment, the old legends surrounding herbal preparations (Chap. 14) were progressively eclipsed by the new discoveries of science, but people ranging from well-meaning amateurs to frank charlatans still proposed bizarre and ineffective treatments, particularly for conditions where there was as yet no widely accepted medical remedy. We will make specific note here of the King’s touch, the drinking of tar water, applications of static electricity and magnetic fields, the prescription of homeopathic doses of often toxic chemicals, the vigorous chemical stimulation of individuals with supposed asthenia, and hydrotherapy. In the mid-nineteenth century, the anti-elitism of Andrew Jackson encouraged a skepticism of often unwarranted medical authoritarianism in the United States, with © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_15

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Samuel Thomson and Sylvester Graham as leading figures in an egalitarian ­movement that promoted vegetarianism, high fibre bran bread and physical discipline (including a restriction of sexual intercourse). By the Modern Era, traditional medical care had provided appropriate remedies for many conditions, but despite this various forms of alternative and complementary medicine continued to flourish, including naturism, anthroposophical medicine, osteopathy, chiropraxis, and acupuncture; a survey conducted in 1990 suggested that during that year a third of Americans had chosen to seek a cure for their ailments through some form of “alternative medicine.” Indeed, the U.S. Congress decided in 1991 to establish an “Office of Alternative Medicine” at the National Institutes of Health, and a publicly-funded “Natural Medicine” clinic was opened in Kings County, Washington in 1996.

The King’s Touch King Charles II revived a popular belief that the “King’s touch” (a royal laying on of hands) could cure the King’s Evil (a tuberculous infection of the lymph nodes in the neck) along with certain other chronic diseases. The touching of supplicants had begun with Henry VII, and initially had involved only a handful of people per year. Elizabeth I had preferred to make the sign of a cross over a person’s head rather than touch a diseased body part, and James I had also been squeamish about handling overt lesions, but Charles II seemed to have no such inhibitions. If the infection was tuberculous, it often underwent spontaneous remission, thereby boosting belief in the efficacy of the King’s Touch. By 1633 CE, not only were there throngs of people crowding into the royal court in London, but over 100 people also demanded the King’s Touch when Charles II made a state visit to Holyrood Palace in Edinburgh. At its apogee, an average of 4600 Londoners crammed the court each year, hoping to obtain an admission ticket to the royal chambers. According to Samuel Pepys: “six or seven people were crushed to death by pressing at the churgeon’s door for tickets.” In England, the protestant House of Hanover abandoned what they regarded as a superstitious practice, but the exiled Stuarts continued the ceremony in France, hoping thereby to underline their legitimacy as monarchs of Great Britain.

Tar Water The Irish philosopher and Bishop of Cloyne, George Berkeley (1685–1753  CE), had no medical training, but he became an enthusiastic advocate of the health benefits of “tar water” (a mixture of pine tar and water that was then prescribed by some physicians). He recommended that it be combined with “light suppers, early hours, and gentle exercise.” The tar water likely contained a potent mix of carcinogens, but Berkeley’s recipe for good health at least had the merits of being inexpensive relative to many of the patent medicines that were being sold during the

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Enlightenment: “Pour a gallon of cold water on a quart of tar, and stir and mix them thoroughly...after which the vessel must stand eight and forty hours, that the tar may have time to subside...when the clear water is to be poured off and kept covered for use” Tar-water was soon seen as a universal remedy. In 1744 CE, a London apothecary told Horace Walpole: “Why, I sell nothing else.”

Static Electricity, Magnetism and Electrical Shock Treatments Proponents of the new electrical therapy included James Graham, Frank Mesmer and (somewhat surprisingly) John Wesley. James Graham  James Graham (1745–1794 CE) was a medical school drop-out. He began his working life as an apothecary in Doncaster, and then travelled to the United States. In the U.S., he came into contact with Ebenezer Kinnersley, a collaborator of Benjamin Franklin, and he thus became familiar with the basic principles of static electricity. Franklin had already speculated that an electrical shock might cure palsy. Graham became convinced that: “electricity invigorates the whole body and remedies all physical defects.” He returned to England, and in 1780 CE he opened a luxurious “Temple of Health” in London’s West-End, focusing upon the popular interest in magnetism and the electrical stimulation of the body as a means to cure sexual disorders (Fig. 15.1). The entrance fee of six guineas attracted only the wealthiest clients to the “Temple,” and at the peak of his career, Graham’s annual income was £30,000. “Imperial Pills” were prescribed for those suffering from a “want of exercise,” and jolts of static electricity were given to club members on demand. Shocks were applied through elegant metallic crowns. One well-attended feature of the spa was a course on sexual rejuvenation. Here, patrons were offered bottles of an ‘aethereal balm,’ sold by a scantily clad “Rosy Goddess of Health and Hymen.” One of the goddesses selling the balm later became Lady Hamilton, the mistress of Admiral Lord Nelson. For a further payment of ₤50, patrons had the option of renting a “celestial bed; for the night;” this bed boasted musical automatons, a canopied dome, live turtle-doves, and huge magnets that purported to correct any erectile dysfunction. However, within a year of its opening, the novelty of the spa had passed, and people began to realize that its promises were not always fulfilled. Graham found himself in financial difficulties, and he soon had to vacate the imposing Adelphi property in central London A final fad that he promoted was earth bathing; Graham himself was wont to give lectures while buried to his neck in mud. Frank Mesner  Franz Anton Mesmer (1734–1815 CE) studied medicine in Vienna, where his doctoral dissertation had the title “On the Influence of the Planets on the Human Body.” He became a proponent of electro-magnetic treatment, suggesting that movements of the sun and moon caused tides in the human body, and he purveyed a great deal of quackery based on his supposed ability to assure the proper flow of a mysterious magnetic fluid from inanimate objects onward throughout the

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Fig. 15.1  Electric shock treatments and exposure to strong magnetic fields were popular prescriptions by charlatans during the 18th and 19th centuries. This poster advertises a 10-lesson course of electromagnetism offered at the Lausanne Casino in 1857  CE (Source: http://en.wikipedia.org/ wiki/Animal_magnetism)

patient’s body. In 1774 CE, he claimed to have produced an “artificial tide” in a woman by having her swallow an iron preparation and then placing large magnets over key parts of her body; this treatment supposedly cured the woman’s symptoms for several hours. A year later, Mesmer was invited by the Munich Academy of Sciences to explain the exorcisms that were apparently being achieved by Johann Gassner, a local priest and healer. He suggested that Gassner’s power was due to a large store of animal magnetism. Mesmer himself claimed to mesmerize patients by remote control. The water basins, fountains, shrubs and even whole forests of private estates were magnetized, so that patients who touched the affected objects would be miraculously cured. The failure of animal magnetism to cure the blindness of a promising young musician forced Mesmer to leave Vienna rather hurriedly, but he quickly re-­ established himself with a substantial following in the salons of Paris. An English

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Fig. 15.2  A typical animal magnetism session, hosted in a fashionable drawing room. One man on a crutch has an iron band wrapped around his ankle; others in the group are holding bands similarly; to the left, a man has hypnotized a woman (Source: http://en.wikipedia.org/wiki/ Animal_magnetism)

physician described a typical session of animal magnetism (Fig. 15.2): “In the middle of the room is placed a vessel of about a foot and a half high... twenty people can easily sit round it; ...there are holes pierced corresponding to the number of persons... into these holes are introduced iron rods, bent at right angles outwards, and of different heights, so as to answer to the part of the body to which they are to be applied. Besides these rods, there is a rope which communicates between the baquet and one of the patients, and from him is carried to another, and so on the whole round. The most sensible effects are produced on the approach of Mesmer, who is said to convey the fluid by certain motions of his hands or eyes, without touching the person. I have talked with several... who have convulsions occasioned and removed by a movement of the hand...” At the request of Louis XVI, Mesmer’s methods were investigated by the Faculty of Medicine in Paris. Although controlled experiments appeared to show some benefit in a few patients, the panel concluded that belief and imagination rather than animal magnetism were responsible, and within a year Mesmer had to leave Paris. John Wesley  In England, the preacher John Wesley (1703–1791 CE) was a pioneer of electrical shock therapy (Fig. 15.3)., first trying it upon himself for lameness and neuralgia, and then applying it to his parishioners in treating 20 different illnesses that included blindness, gout, sprains, deafness, toothache, and stomach and back pain. In Primitive Physick, he declared it was “The nearest to an universal medicine of any yet known in the world.”

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Fig. 15.3  The machine used by John Wesley to apply electric shock treatments to those of his parishioners who were sick (Source: https://goo.gl/ images/GJoSlz)

Wesley believed that insanity was a manifestation of sin, and his cures for “lunacy” included the application of his electric shock machine, drinking herb tea 4 times a day, rubbing the scalp with vinegar, and drinking vinegar.

Homeopathy Samuel Hahnemann (1755–1843 CE) of Meissen, Germany, introduced the concept of homeopathy, another fad of the Enlightenment. Hahnemann studied medicine, and began medical practice quite humbly as an itinerant physician in the mining villages of Saxony. But later, he abandoned formal medical practice, recognizing the ignorance that he shared with most other practitioners: “My sense of duty would not easily allow me to treat the unknown pathological state of my suffering brethren with these unknown medicines...” One factor that had sparked his antipathy to traditional medical practice was a claim that cinchona bark would cure malaria because of its astringent properties; he concluded the claim must be false, since other astringents did not have any such effect. This caused him to look at all medication “under a different light.” He experimented on himself, finding that the ingestion of cinchona bark produced symptoms that were rather like those that were caused by malaria. Thus, he reasoned that any benefit from such treatment must arise because of the similarity of symptoms- like would cure like, one of the main principles of homeopathy. Hahnemann was worried by the toxicity of many of the medicaments used by his contemporaries, but he observed that their curative properties sometimes remained

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despite repeated dilution of a solution (presumably an expression of the strong placebo effect from a convinced protagonist). Thus, Hahnemann began to experiment with the ingestion of highly diluted solutions of substances such as belladonna, mercury and gold. However, his treatments quickly became as suspect as conventional medical wisdom, as claims were advanced that major epidemics of typhus and cholera had been halted by such therapy. As a schoolboy, Hahnemann had discovered that over-studying could make him physically ill. Thus, he included daily exercise (particularly walking) in his therapeutic recommendations, and this may have added to the effectiveness of his homeopathic preparations: “I did not quite forget to procure, by physical exercise and fresh air, that bodily energy and vigour which alone enable the body to stand successfully the strain of continued mental exertion...next to food, exercise is the most essential requirement of the animal mechanism” For a patient with scoliosis, the normal exercise regimen was supplemented by stretching, performed on a horizontal bar several times every day. The Leipzig homeopathic hospital opened in 1833 CE, and it included: “gravel pathways and spaces....where the patients might procure sufficient exercise and fresh air.” Despite demonstrations that any apparent effects were due to placebo effects and publication bias, belief in homeopathy continued through to the twentieth century, with the Nazi regime investing much effort in evaluating its claims. Despite condemnation by the World Health Organisation, sales of “over the counter” homeopathic remedies in the U.S. still totalled $2.7 billion in 2015, many of the purchasers being associated with the New Age movement.

Stimulation and Asthenia John Brown (1735–1788  CE) vigorously criticizing the medical teachings of his colleagues at the University of Edinburgh. He developed what has been termed the Brunonian system of medicine, with a central belief that all disease reflected an imbalance of excitability in the body. Many medical conditions were asthenic in type, due to inadequate excitation; they thus responded to strong stimulation, including a plentiful supply of beefsteaks, beef tea and brandy, supplemented by regular horseback riding and heroic doses of powerful drugs including opium. But a few disorders such as measles and small-pox were sthenic; these required the opposite type of treatment- a reduction of excitement by purging, bleeding and the use of debilitant and cathartic drugs. Some sthenic patients were even subjected to prolonged immersion: “in water as long as possible and kept under it for a long time till he is nearly killed.” Brown’s application of “remedies” are sometimes said to have killed more people than the Napoleonic wars. His ideas were highly controversial; in Germany university towns, students supporting and opposing his theories engaged in pitched street battles! Nevertheless, Brown was a convincing instructor, and some students

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continued to attend his lectures, even when he was finally consigned to a debtor’s prison.

Hydrotherapy Vincent Priessnitz (1799–1851) began life as a peasant farmer in Austrian Silesia. He was one of many entrepeneurs who made large profits from the Victorian taste for alternative forms of medicine. He had watched a roebuck bathe in cold water after a severe injury, and he applied the same treatment to himself successfully after a cart had injured his ribs. He then popularized the concept of hydropathy (now termed hydrotherapy). He insisted that for: “a complete cure, it is not only necessary to be out of doors, but to take a great deal of bodily exercises.” Fashionable European clients were supposedly restored to good health through a regimen that combined dietary restriction, regular sleep, fresh air, cold douches, massage, chopping wood, and other forms of vigorous exercise at his Graefenberg establishment. A Victorian ashphalt contractor, Richard Claridge (1799–1857), brought the hydrotherapy fad to England in 1842, with a book entitled Hydropathy; or The Cold Water Cure, as practiced by Vincent Priessnitz; this volume quickly went through five editions. An English physician, James Wilson, was also impressed with the apparent effectiveness of hydrotherapy, and he opened a water-cure spa at Malvern. Many well-known Victorians attended this facility, including Charles Darwin, Charles Dickens and Florence Nightingale, although the ideas of Claridge were strongly denounced in the Lancet. The author of the Lancet report noted contemptuously that Claridge had consulted him for mouth ulcers and bronchial complaints that had not responded to the cold water cure. Joel Shew also opened a hydropathic facility in New York City in 1843, and the idea was adopted by John Harvey Kellogg at the Battle Creek Sanatorium, operated by the Seventh Day Adventist Church, although the regimen adopted was much less strenuous than that originally proposed by Priessnitz.

Naturism Nacktkultur (Naturism or Nudism), was introduced in Vienna by the German painter and social reformer Karl Wilhelm Diefenbach (1851–193 CE) during the late 1890s. Diefenbach argued for living in harmony with nature, a vegetarian diet and the rejection of monogamy. He established a commune just outside of Vienna, and when this went bankrupt, he moved to Capri. Dr. Heinrich Pudor, a noted publisher of anti-Semitic writings, brought the Nacktkultur movement to German in 1902 CE. Pudor advocated vegetarianism and participation in sports without the impediment of clothing. He argued that physical fitness, sunlight, fresh air bathing, and a nudist philosophy brought mental and psy-

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chological fitness, good health, and an improved moral-life view. There were strong racial overtones to his programme: “If every German woman saw a naked Germanic man more often, so many would not run after exotic aliens.” During the Weimar Republic, nudist resorts were established along the northern coast of Germany, and by 1931, there were 40 naturist societies in Berlin. From the mid-twentieth century, a growing number of commercial vacation resorts also offered nudist facilities.

Anthroposophical Medicine Rudolph Steiner (1861–1925 CE), who initiated the Waldorf school system, promoted a combination of theosophy and homeopathy, the so-called “Anthroposophical medicine.” Among bizarre beliefs, Steiner’s system claims that the heart does not pump blood, and that a patient’s past lives may influence the course of an illness. Specially harvested mistletoe was also advocated for the cure of cancer. Waldorf schools have tended to follow Steiner’s doctrines, and it has been claimed that their pupils have a low incidence of allergies, possibly because the use of antibiotics, antipyretics and vaccines is actively discouraged. However, the anthroposophical system has no apparent scientific evidence-base, and the Waldorfians have not published any information on the deaths that are caused to their students and their immediate contacts because they have rejected modern medical remedies and immunization programmes!

Osteopathy The practice of osteopathy was begun by a Kansas physician, Andrew Taylor Still, in 1874, and medically qualified osteopaths have striven vigorously to distinguish themselves from chiropractors (below). Like many exponents of alternative forms of medicine, Still argued that the body naturally tended towards good health, and did not usually require the “heroic medicine” offered by many Victorian medical practitioners. Rather, the “harmony” of the body could be restored by massage and gentle manipulation. Colleges teaching 4-year courses in osteopathy became established over the Modern Era, and in several countries osteopathic physicians gained recognition as members of a legitimate profession, governed by parliamentary legislation. However, the manual practice of osteopathy by non-physicians has generally remained a non-regulated procedure. In 2011, a report to the British National Health Service indicated that although osteopathy might find some applications in the treatment of bone and muscle disorders, there was no justification for its use in many of the conditions where it had been advocated, such as headaches, migraines, painful periods, digestive disorders, depression and excessive crying in babies.

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Chiropractic The concept of chiropractic was introduced by Daniel David Palmer (1845–1913), a native of Pickering, Ontario who had been a teacher, a grocer and a magnetic healer (above) in Iowa, where he had styled himself “doctor.” His practice of chiropractic began when he noted that a vertebra of a deaf janitor appeared to be displaced, and after a spinal manipulation, it was claimed that the janitor’s hearing was restored. Among other bizarre beliefs, chiropractors were opposed to vaccination, on the basis that all diseases arose in the spine, and therefore were not susceptible to prevention by vaccination. Beginning in the 1970s, the National Institutes of Health in the U.S. attempted to evaluate the validity of chiropractic claims, and in reaction to their negative conclusions, some practitioners began to limit their practice to the treatment of musculo-skeletal disorders.

Acupuncture Acupuncture has had a long history in China (Fig. 15.4). Jesuit missionaries probably brought the concept to Europe during the seventeenth century. As one form of alternative medicine, it gained some credence in western society towards the end of Fig. 15.4  Old Chinese medical chart showing acupuncture meridionals (Source: http://en. wikipedia.org/wiki/ Acupuncture)

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the Modern era, with demonstrations of the technique to Henry Kissinger (1971) and Richard Nixon (1972) during their respective visits to Communist China. The U.S. National Acupuncture Association was formed in 1972 CE. Interestingly, Mao Tse Tsung had criticized acupuncture during the Chinese Civil War, declaring it a superstitious practice that was an obstacle to the Communist Party’s dedication to scientific thinking. However, he later reversed his position, declaring that: “Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level”. Acupuncture continues to find its advocates. But most scientists now consider that as with other bizarre remedies any apparent effects of acupuncture are too small to be of clinical relevance, and that the supposed benefits can be explained by a combination of the inadequate experimental blinding of observers, placebo effects, and a tendency of many journals to accept articles with positive results.

Practical Implications for Current Policy Over the centuries, wealthy hypochondriacs have invested much money in bizarre and bogus “cures;” sometimes marginal benefits were obtained, presumably because of placebo effects, and indeed the strength of the placebo response indicates the powerful effect that the mind can have upon the course of many diseases. Charlatans are still eager to exploit the anxious, the naive and the desperate, and in the course of my career I have had occasion to investigate many more recent scams for governmental consumer protection services. A favourite modern target is obesity, with rapid weight-loss remedies including impermeable suits that induce a transient water loss in a hot room, and an air-tight bag that was supposedly able to draw fat from the thighs when the suction from a vacuum cleaner was applied. Another unqualified charlatan in Toronto sought to treat persistent ragweed allergies by inviting sufferers to spend a couple of weeks in a house that was strongly impregnated with menthol vapour. The long-term solution seems to insist upon evidence-based medicine, with randomized controlled trials of all remedies, not only the ideas proposed by amateur fortune hunters, but also treatments not as yet convincingly tested by physicians and surgeons. Unfortunately, ill-founded beliefs such as loud-spoken and unfounded opposition to immunization continue to have adverse effects upon public health, not only causing concern for the immediately affected families, but sometimes also spawning epidemics of serious childhood illnesses such as measles.

Questions for Discussion 1. Why do you think that so many proponents of unusual methods of treatment quickly ended up in the bankruptcy courts?

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2. If a bizarre type of treatment is shown to have a beneficial placebo effect, should its use be sanctioned by health authorities? What circumstances might encourage such a policy? 3. If a parent holds an ill-founded belief that endangers either the individual patient or the general public (for example, opposition to immunization or blood transfusion), should the State or Province assume the responsibility of ensuring that appropriate health care is administered? 4. Is there any conceivable biological mechanism whereby acupuncture could have a beneficial effect in some forms of illness?

Conclusions Over the centuries, well-intentioned amateurs and greedy charlatans have proposed many bizarre and ineffective forms of treatment for chronic medical conditions. Some types of alternative and homeopathic medicine still have a substantial following, and the oddest types of “therapy” are still sold to many gullible individuals. There remains a need for stronger regulation of health claims by government, with randomized controlled assessment of all treatment options, including those advocated by licensed physicians and surgeons.

Further Reading Beatty HR. Nervous disease in late eighteenth century Britain. Abingdon, OX, Routledge, 2015, 256 pp. Booth ER. History of osteopathy. Paehl, Germany, Jolandos eK, 2005, 835 pp. Brogan S. The Royal Touch in early modern England. Martlesham, Suffolk, Boydell & Brewer, 2015, 285 pp. Brown J. The elements of medicine. London, UK, Johnson, 1788, 308 pp. Darnton R. Mesmerism and the end of the Enlightenment in France. Cambridge, MA, Harvard University Press, 1968, 218 pp. DelBourgo J. A most amazing scene of wonders: Electricity and Enlightenment in early America. Cambridge, MA, Harvard University Press, 2006, 367 pp. Fara P. Fatal attraction. Magnetic mysteries and the enlightenment. London, UK, Icon, 2005, 206 pp. Haller JS. The history of American homeopathy: From rational medicine to holistic health care. New Brunswick, NJ, Rutgers University Press, 2009, 191 pp. Inglis B. Natural Medicine. London, UK, Collins, 1980, 255 pp. Peters R. An early history of chiropractic: The Palmers and Australia. Asheville, NC, Integral Altitude, 2014, 531 pp. T. An authentick narrative of the success of tar water: in curing a great number and variety of distempers, with remarks and occasional papers relative to the subject. London, UK, W. Inys, 1746, 196 pp. Shaw J. Hydrotherapy or the water cure. Its principles, processes, and modes of treatment. 4th ed. New York, NY, Fowlers and Wells, 1851, 360 pp.

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Starr P. The social transformation of American medicine. New  York, NY, Basic Books, 1982, 514 pp. Whorton JC. Crusaders for fitness. The history of American health reformers. Princeton, NJ, Princeton University Press, 1942; 359 pp. Whorton JC. Nature Cures: The history of alternative medicine in America. Oxford, UK, Oxford University Press, 2002, 368 pp. Xiaofei JM. Acupuncture and moxibustion. Beijing, China, IOS Press, 2000, 414 pp. Wood M. Vitalism. The history of herbalism, homeopathy, and flower essences. Santa Barbara, CA, North Atlantic Books, 2000, 215 pp.

Chapter 16

Caring for the Sick: Hospitals and Hospices

Learning Objectives 1. To observe the progressive introduction of free or low-cost hospital care for the sick and the dying, beginning in Turkey and the Arab world, and progressing to mediaeval Europe. 2. To see the development of simple accommodation and sheltered workshops for those who have become too elderly to provide for their own survival. 3. To recognize the problems inherent in the provision of hospital and hospice services- a demand that exceeds capacity, fraudulent attempts to gain admission, and frequently a lack of endowment either to maintain the facilities or to provide adequate nutrition for the residents.

Introduction A number of Greek temples of healing had residential accommodation for the sick, as at the large healing establishment of Asclepion in Pergamon. This facility dealt mainly with psychiatric ailments (Fig. 16.1). Patients slept in an underground chamber, and reported their dreams to the priest-in-charge the next day. Often, the priest would prescribe a bath or a visit to the gymnasium. Sometimes, receptivity to his soothing suggestions was aided by enkoimesis, an opium-induced sleep or trance. Despite these Greek initiatives, credit for the first formal hospital open to all classes of society is generally attributed to Basil of Caesarea, the bishop of Cappadocia, in central Anatolia. We will discuss here opportunities available for care of the sick and the elderly in Cappadocia, Baghdad and Mediaeval Europe.

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Fig. 16.1  Artist’simpression of the Asclepion (a Greek temple of healing, primarily for the treatment of wealthy psychiatric patients) constructed at Pergamon, in Asia Minor (Source: https://goo. gl/images/1IxIxa)

Cappadocia Basil of Caesarea (330–379 CE), the bishop of Cappadocia, was active in offering direct medical care and help to the poor in his community (Fig. 16.2). He personally organized a soup kitchen when famine struck the region, and he oversaw the building of a large hospice and the first documented hospital just outside the gates of the city of Caesarea Mazaca, in Cappadocia. The entire complex was soon named the Basileias, in his honour. There were facilities for treating the sick, a hospice caring for lepers, a poorhouse for the indigent, orphans and the elderly, and a hostel for travellers and street people. Basil’s willingness to destigmatize illness and to care for dying lepers offered a powerful example to his community. It was at total variance with the attitudes of traditional Aesculapian medicine and many of his fellow churchmen. “[The sons of Aesculapius] thought that the life of a man constitutionally sickly...was of no use to himself or others, and that the art of medicine should not be for such, nor should they be given treatment even if richer than Midas.”

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Fig. 16.2  St. Basil, bishop of Cappadocia, built the first documented hospital at Caesarea Mazaca, (in what is now Turkey). In striking contråst with the normal practice of his day, this offered personal, hands-on treatment, even to moribund and indigent patients such as terminal cases of leprosy (Source: http://en.wikipedia.org/ wiki/Basil_of_Caesarea)

Baghdad With the eastward expulsion of medical scholars from Athens and Constantinople, impressive hospital facilities developed in the region around Baghdad. The medically qualified refugees were given a warm welcome in the Arab world, and health services in the region around Baghdad quickly moved far ahead of those available in Western Europe. The fifth century hospital in the Iranian city of Gondishapur not only provided treatment for the sick, but also accommodated the blind and lepers. In 762 CE, the Imperial capital was moved from Gondishapur to Baghdad, and the Caliph soon established a major hospital in the latter city. The medical director of the Gondishapur hospital relocated to the new facility, and his service was so effective that his son and his grandson were subsequently invited to serve as court physicians. The renown of Gondishapur graduates continued to impress hospital selection committees in Baghdad for generations, with 2 pharmacists from Gondishapur, both authors of important textbooks (Chap. 18), subsequently directing the Baghdad facility (Fig. 16.3). Two further hospitals were built in Baghdad in 918  CE, and in 981  CE the ­imposing Al Adudi hospital was constructed. This last facility was staffed by 24 physicians. There were separate sections for men and for women, with wards classified by the clinical condition that was being treated (for example, internal medicine, psychological disturbances, communicable diseases and cases of trauma). On admission, all patients were given clean clothes, and their possessions were put in

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Fig. 16.3  Hospital building attached to the Divirigi great mosque in the Anatolian region of Turkey, dating from thirteenth century (Source: https://en.wikipedia.org/wiki/Medicine_in_the_medieval_ Islamic_world)

trust. Regular governmental inspections evaluated not only the quality of the care that was provided by the attending physicians, but also the quality of the hospital food. Unfortunately, the Mongols destroyed this hospital in 1258 CE. But in the previous century, the health cåre budget was most impressive. In 1160 CE, an itinerant Jewish Rabbi commented that there were now 60 “medical warehouses” within the city of Baghdad. Moreover, a clinically appropriate level of service was provided without regard to a person’s wealth: “every patient who claims assistance is fed at the king’s expense until his cure is completed.” And on discharge from hospital: “each patient received five pieces of gold‚ so that he might not be obliged to return to work immediately.” The Arabs constructed other large and well-appointed hospitals in Damascus and in Cairo. The Cairo House of Wisdom boasted an extensive medical library that employed six librarians and was open to the public. Scholars were: “admitted without distinction. Some came to read, others to copy the books, others to attend the lectures of the different professors. They found there all the pens, ink, and paper they could require.” In addition to their service at formal hospitals, many Arabic doctors beg an to care for patients in annexes to their homes. For example, one wealthy Egyptian physician not only devoted much of the income he received from treating the Caliph, the military and other wealthy citizens to charitable purposes, but he also turned a

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portion of his dwelling into a sort of clinic, where the poor who could not be nursed by their families received free food, drugs and medical attendance.

Mediaeval Europe In Mediaeval Europe, monasteries set up limited facilities to care for the sick and dying within their walls, and a few spas were established around healing springs from the pagan era (Chap. 13). As the Middle Ages progressed, many hospices and homes for the elderly gained the support of the established church. However, during the latter part of the Middle-Ages, care for the sick increasingly passed to university-­ based teaching hospitals (Chap. 17), and sheltered workshops for the elderly were set up by wealthy private citizens. Monastic Healing Facilities  Despite the proclaimed benevolence of their Christian God, many in the Catholic Church did not support practical attempts to change the health of parishioners as imposed by divine fiat. This negative attitude imposed a major constraint upon medical practice in mediaeval Europe, since at least a half of educated physicians during the Middle Ages were members of the clergy. The general rule of thumb for a cleric was to treat only those living within the monastery to which he was attached. Nevertheless, various Church Councils urged priests to a greater care for the poor. Thus, Chapter VIII of the 25th session of the Council of Trent (1563  CE) specified: “The holy Synod admonishes all who hold any ­ecclesiastical benefices... to exercise with alacrity and kindliness the office of hospitality... the places commonly called hospitals, or other pious places instituted especially for the use of pilgrims, of the infirm, the aged or the poor.” It became the responsibility of the local bishop to administer specific funds for at least the passive care of the poor and the sick. By the end of the thirteenth century, monasteries across Europe had constructed as many as 19,000 leprosaria. Clerics were also directed to provide accommodation for the needy, and many almshouses caring for the poor and the elderly had also been built, usually adjacent to churches (Fig. 16.4). Healing Spas  Sometimes, the church built spa-like hospital facilities around healing springs that dated back to pagan times. Thus, in 1174  CE, Bishop Reginald founded St. John’s Hospital to accommodate the poor and infirm who were receiving extended treatment at the nearby Royal Baths in Bath, Somerset. However, as with many charitable organizations, the on-going funding of St. John’s became a problem, and by 1400 CE the Pope was offering to grant remission of sins to spa visitors who made a suitably large donation to the hospital. In the early 1530s, St. John’s was still active, and a local historian commented that: “Bath was much frequented by people diseased with lepre, pokkes, scabbes and great aches.” Unlike many similar establishments, the Bath hospital managed to escape the immediate turmoil surrounding the dissolution of the monasteries; nevertheless in 1536  CE Henry VIII ordered the facility to be closed because use of the baths

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Fig. 16.4 Almshouses adjacent to the parish church of St. John, Thaxted, Essex, providing accommodation for poor and elderly parishioners during the Middle Ages (Source: http://en. wikipedia.org/wiki/ Almshouse)

implied acceptance of a Catholic or even a pagan superstition of “holy” springs, rather than the new doctrines of his “Reformed” Church of England. The ban was relatively short-lived, and by 1590 CE, when Queen Elizabeth I granted a charter incorporating the city of Bath, she stipulated that “the thermal waters should be accessible to the public in perpetuity.” Many doctors settled in the streets immediately surrounding the public baths, and by 1609 CE, Bellot’s Hospital was another facility offering spa treatment not only to the rich, but also to poor people, Almshouses  “Almshouses” were built to ensure the provision of housing for elderly people during the Middle-Ages. Some of the earliest examples can be found in the English cities of Worcester, Canterbury, Winchester, Salisbury and London. A large proportion of such facilities were closely associated with a monastery or included a chapel or chantry for the residents, and because of these links to the Catholic Church, many were stripped of their support during the Reformation. The unfortunate occupants were left in penury: “Once they had scraps, now they have nothing. Then had they hospitals, and almshouses to be lodged in, but nowe they lye and storue in the stretes.” Wulfstan, a brutal pagan warlord who converted to Christianity and became the last surviving pre-Norman Bishop of Worcester, founded what became known as St. Wulfstan’s hospital as early as the eleventh century. Parts of the building can still be seen today. In 1141 CE the Archbishop of Canterbury solicited donations for a new Hospital House (Maison Dieu) in Dover that would receive the poor and strangers, particularly those making the pilgrimage to Canterbury. The constable of Dover Castle (Hubert de Burgh) lster donated 2 manors to provide for the on-going upkeep of this facility. St. John’s almshouse in Winchester traces its history back to St. Brinstan, Bishop of Winchester in 931 CE, but a new facility was built in 1085 CE specifically to ­accommodate: “sick and lame soldiers, poor pilgrims, and necessitous wayfaring men, to have diet and lodging thereto fit and convenient for one night or longer.” Because it was classed as a hospital, St. John’s escaped the immediate turmoil of the

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Reformation, and with a further endowment in 1558. St. John’s continues to provide accommodation for poor and elderly people in Winchester to the present day. In nearby Salisbury (1394  CE), the Dean of the Cathedral (John Chandler) received permission to construct Holy Trinity Hospital adjacent to the Church of St. Thomas, in the centre of the city. This facility offered 18 permanent and 12 temporary beds to the poor. It also escaped closure during the Reformation. The present building dates from 1702; it still provides accommodation and social events open to those over the age of 65 years. Around 1148  CE, St, Bartholomew’s (Smithfield, London) became a popular stopping place for sick pilgrims. Among those received were: “langwissyng men greuyd with uariant sorys”; one sought “remedie of his akynge hede,” another suffered from “bleriednes of yen” (eyes), and yet another from “ryngyng of his erys.” St. Bartholomew’s in London, and Holy Trinity in Salisbury also offered care to women following childbirth. Young mothers were allowed to remain at these hospices until such time as they had recovered and were “churched.” Soon, many other parishes were constructing facilities for the poor, weak and impotent, places where people could live until they died or departed healed. However, needs continued to outpace the available facilities, and the young Henry VIII lamented: “There be fewe at noon such commune Hosptialls within this our Reame, and that for lack of them, infinite nombre of pouer nedie people miserably dailly die, no man putting hande of helpe or remedie.” Although the almshouses offered a solid dwelling for the needy, the daily sustenance of the residents had to be found either by begging or by reliance upon an endowment from a generous benefactor. In 1390 CE, Alice de Bridford, a wealthy widow in the city of York, bequeathed one penny to every almshouse resident in York who was too infirm to beg. In Shaftesbury, Dorset, the poor men living at St. John’s Hospital were totally dependent upon the alms that they received from the town council. By the 1300s, some people were concerned that vagrants were usurping both the physical space and the alms intended for the deserving needy. In order to gain admission, some miscreants were simulating leprosy, and others were chewing soap to make them foam at the mouth. Able-bodied men found to be abusing the system were at first beaten with whips, and by the reign of Edward VI (1546 CE) they were being chastized with scorpions. The Statute of Westminster of 1383 CE included a public enquiry into vagrancy, and further laws against vagrancy were enacted in 1495 CE and 1503 CE. Seniors’ Housing and Sheltered Workshops  The concept of a Seniors’ housing complex made a first tentative appearance in mediaeval Germany. In 1388 CE, a prosperous Nürnberg brewer founded the “Guild of the 12 Brothers” to care for middle-class artisans after they had retired from their original employment. The guild provided lodging for: “12 old, sick, but not bedridden men of Nürnberg citizenship who could no longer feed themselves with their own work.” The facility included sheltered workshops where artisans could pursue their trades at a speed commensurate with their aging abilities. Nineteen of the group were book-binders, one of them being 77 years of age.

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More than a century later (1506 CE), a wealthy miner, Matthew Landauer, set up a similar centre for 12 elderly people in Nürnberg. Sheltered workshops continued throughout much of Europe into the twentieth century, often providing work for those with intellectual disabilities rather than the elderly. However, in recent times the emphasis has shifted (with varying success) to providing such individuals with meaningful work and opportunities for social integration into the community.

Practical Implications for Current Policy St. Basil demonstrated a willingness to interact closely with those who were sick, even those who had developed what appeared to be contagious illnesses such as leprosy. A few such as Father Damien have been willing to treat lepers in more modern times. But much of modern medicine has become impersonal, compartmentalized and reliant upon machine-based diagnoses rather than careful clinical examination, and health-care practitioners could profit from studying the attitudes of Basil of Caesarea. Currently, the demand for hospital beds is high, and there is a strong desire for early discharge, even if patients are unable to assume immediate responsibility for either personal care or the on-going support of their families. There remains a need for society to arrange generous post-hospital support and practical care of the type offered so freely in Cappadocia. In Mediaeval times, generous aid to the sick and the elderly was sometimes abused by unscrupulous vagrants, albeit with a rigorous punishment for those miscreants who were apprehended. This seems an inevitable consequence of a broad health care net. In current society, some opiate abusers have needed resuscitation from potentially fatal overdoses several times in the course of a single day. But such problems should not become an argument for curtailing or denying necessary services to the needy. Many elderly today suffer from a lack of meaning in their lives, and their morale could well be boosted if they were offered opportunities to continue plying and sharing their accumulated skills in some form of sheltered workshop, as in the mediaeval hospices of Nurnberg.

Questions for Discussion 1. Early hospital care seems to have provided not only free admission, but material support on leaving the hospital. Do you think this was good public policy? Should a similar system be implemented today?

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2. Sheltered housing for the elderly and the sick was abused by vagrants simulating illness during the thirteenth century. Is abuse of the system an inevitable consequence of comprehensive care, and if so, what should be done about this? 3. Could sheltered workshops where the elderly can continue to ply their accumulated skills be an important component of gerontotherapy in our present generation?

Conclusions The exodus of medical scholars from Europe following the collapse of Rome allowed the establishment of well-organized and generous hospital systems in the Arab world. In Mediaeval Europe, the church confined the medical care that it provided to those living within the monasteries, and facilities generally did little more than care for the sick and the dying. However, church authorities also recognized a need to provide practical assistance to the elderly; almshouses were built in ­association with parish churches, and prestigious hospitals eventually emerged in association with burgeoning secular medical schools. In Germany, helpful initiatives also allowed the elderly to continue to ply their traditional trades within sheltered workshops.

Further Reading Bailey BJ. Alms Houses. London, UK, Hale, 1988, 208 pp. Cicchetti J. Dreams, symbols and homeopathy: Archetypal dimensions of healing. Santa Barbara, CA, North Atlantic Books, 2003, 259 pp. Cooper E, Decker MJ. Life and society in Byzantine Cappadocia. New York, NY, Springer, 2012, 339 pp. Crislip AT. From monastery to hospital: Christian monasticism and the transformation of health care in late antiquity. Ann Arbor, MI, University of Michigan Press, 2005, 235 pp. Glick TF. Mediaeval science, technology and medicine: An encyclopaedia. Abingdon, OX, Routledge, 2014, 624 pp. Lyons J. The House of Wisdom: How the Arabs transformed western civilization. London, UK, Bloomsbury Publishing, 2011, 272 pp. Porterfield A. Healing in the history of Christianity. Oxford, UK, Oxford University Press, 2005, 240 pp. Ragab A. The mediaeval Islamic hospital: Medicine, religion and charity. Cambridge, UK, Cambridge University Press, 2015, 282 pp. Stapelberg M-M. Through the darkness: Glimpses into the history of western medicine. London, UK, Crux Publishing, 2016, 420 pp.

Chapter 17

The Emergence of Health Science Education

Learning Objectives 1. To recognize that the earliest attempts at formal education in the health sciences came not from Europe, but from the Middle East and the Arabic world. 2. To note that the earliest European medical schools were founded in Italy and France, with a much slower emergence of formal medical teaching in Britain. 3. To understand that for a long time, much of the available instruction was a reiteration of the views of classical scholars such as Galen and Hippocrates. 4. To see the importance of careful dissection of human cadavers to the challenging of traditional wisdom concerning the functioning of the human body in health and disease.

Introduction Egyptian and Greek temples of health undoubtedly had groups of apprentices, eager to gain an appreciation of medical practice from teachers such as Hippocrates. However, the first formal schools of medicine developed in the Eastern Mediterranean and the Arab world. The European move to the establishment of medical schools had its origins in Italy and in France during the late Middle Ages and early Renaissance. Major British teaching institutions in London and Edinburgh were founded much later, and in North America the first medical schools did not appear until towards the end of the eighteenth century.

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The Arab World and the Nestorian Connection The first medical school was established in the Turkish city of Nibisis in 350 CE, but 13 years later Nibisis fell to the Persians, and many of the faculty moved to Edessa, in northern Mesopotamia, where a School of Medicine and two hospitals were established by the Nestorians, under the direction of Ephrem. The Nestorians were a heretical sect of the Eastern Orthodox Church. Despite the suspect nature of their theology, the Byzantine court for a time gladly accepted treatment from Nestorian physicians. However, in 489  CE the Bishop of Edessa prevailed upon the Emperor Zeno to destroy the medical school as a heretical institution, and the accredited physicians were summarily expelled from the city. They fled back to the Turkish city of Nisibis, and there they established a medical centre, with a warm welcome from the liberal-minded Shah of Persia. The Shah was busily expanding an Academy at Gondishapur, in modern Iran, and resettlement of the Nestorian scholars contributed substantially to development of this new seat of learning. The eastward shift of knowledge was further strengthened as teachers fled from Plato’s Academy to the Arab world when the Emperor Justinian summarily closed the Athenian school in 529 CE. The new Academy in Gondishapur made maximum use of the knowledge of the refugees, and its scholarship was further expanded when Khosrau II (590–628 CE) sent his personal Physician to India to glean additional medical insights. The reputation of the school and the immigrant physicians became such that local Persian doctors became jealous. One complained he: “never had enough patients to make a living, even during an epidemic, because he lacked the three qualifications everyone sought: he was neither Syrian nor Christian and he was not from Jundishapur.” In the ninth century, the centre of Persian learning shifted to Baghdad (Chap. 16), and by 1000 CE, Gondishapur was reported as falling into ruins.

Europe By the twelfth century CE, Europeans had access to newly founded medical schools in Salerno, Montpellier, Paris, Bologna and Padua, and during the Renaissance and the Enlightenment, other important academically-oriented schools of health science emerged in Pisa, Pavia, Leiden, London and Edinburgh. In general, the faculty at these institutions was content to reiterate the ideas of Hippocrates and Galen, although occasional brave teachers undertook anatomical dissections, leading them to question established dogmas from the classical era. Before looking at the story of the individual schools, we will comment on their accreditation, typical class schedules, and sources of revenue. Accreditation  The term “studium generale” began to appear in the thirteenth century, to distinguish an upper tier of academic institutions, places where students

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were admitted on an international basis, such Schools had at least one faculty other than Arts (for example, Medicine), and professors had advanced degrees, with authorization to teach elsewhere in the world. The much desired cachet could be obtained not only by scholarly reputation, but also by means of a Papal Bull, and eventually the universities of Bologna, Paris, Padua and Cambridge all stooped to making such a request of the papacy. Oxford never received a Bull, and since this meant that European schools refused to recognize the Oxford Faculty, Oxford also refused to accept teachers from Bologna or Paris unless they took a local qualifying examination. Class Schedules  Lectures were usually timed by the chimes of a neighbouring church. A typical undergraduate routine included one 2-hour lecture in the morning, and two 90–120 minute lectures during the afternoon. Sources of Revenue  The awarding of a degree was sometimes a costly venture for the students, as candidates were expected to make substantial gifts to their examiners. In Bologna, where the students had in many respects assumed the balance of power (below), the remaining bastion of the administration was the awarding of the final certificate. Not only were students required to pay the university 30 shillings for the final examination, but the Archdeacon expected a bounty of 12 pounds 10 shillings from each candidate, and the other examiners each received a gift of 40 shillings. Sometimes, a large graduation dinner, enlivened by a tilting contest or tournament, was also expected. Universities found a second substantial source of revenue in the sale of parchments. In Paris, regulations governing such sales date back to 1291 CE. The parchment-makers brought their wares to the Hall of the Mathurines, where there quality was evaluated by four sworn parchmeniers, and the material was then sold to the students. Salerno  Salerno, in Southern Italy, guarded the purported remains of St. Matthew, and through the supposed efficacy of these relics it gained a substantial reputation in the healing arts. A medical school was founded during the tenth century CE, and by the eleventh century it had attained a status rivaling that of the medical school in Alexandria (Fig. 17.1). It emerged in a region of Italy with no previoius university tradition, but where many educated people retained some knowledge of Greek. Its origins were in the dispensary of the local monastery, but from the outset it developed as a multicultural, multi-faith institution, naming as its founding fathers the Jewish Helinus, the Greek Pontus, the Arab Adela, and the Latin Salernus. With the encouragement of the Archbishop of Salerno and the teaching efforts of an African immigrant, Constantinus Africanus, Salerno quickly gained renown as the “town of Hippocrates.” Famous texts written by the faculty included “Liber de Simplici Medicina,” and the twelfth or thirteenth century CE Regimen sanitatis Salernitanum. The latter book was in poetic form, with the well-known quotation: “Use three physicians still; first Doctor Quiet, Next Doctor Merry-man and Doctor Dyet.” The Saleerno school was officially founded in 1231 CE, and it received a formal statute in 1280 CE.

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Fig. 17.1  Depiction of what some regard as Europe’s first medical school, the Scuola Medica Salernitana in Salerno, Italy. from Avicenna’s Canons (Source: http://en.wikipedia.org/wiki/ Schola_Medica_Salernitana)

The students were taught anatomy based on the dissection of pigs and studied the writings of both Galen and Arabic scholars. Remarkably for this era, there was at least one female faculty member (Magistra Trotula). About 20 books are attributed to her, including a text on The Diseases of Women, which was written about 1100  CE.  Trotula risked the wrath of the Church by pointing out that infertility could arise from physiological problems in either men or women. The teaching facilities were severely damaged when the Holy Roman Emperor sacked Salerno (in 1194 CE). However, the medical school survived; indeed, it subsequently recovered some of its former glory, although by the thirteenth century CE it was beginning to be eclipsed by Montpellier and even by Naples (where a medical school had been established in 1224 CE). Teaching continued in Salerno for many years until the school was closed definitively by an edict of Napoleon in 1811 CE. Montpellier  Montpellier, in the south of France, claims to be the oldest continuing medical school in Europe. It dates from the middle of the eleventh Century, and it may have begun as an offshoot of the Salerno school. During the second half of the thirteenth Century, many political disturbances in Italy caused physicians to migrate from Salerno to the south of France, carrying with them their academic expertise. Montpellier university gained fame through its liberal policies: “anyone, no matter their religion or roots, could teach medicine in Montpellier.” The earliest teaching was in Arabic and Hebrew, but Latin quickly became the official language of the school. By the end of the twelfth century, teachers included monks, Jews and Islamic doctors. In 1220 CE, the staff established a “Universitas Medicorum.” Its official charter dates from 1289 CE, when Pope Nicholas IV granted the University a Papal Bull. During the 13th and 14th centuries, the Montpellier library held 16 required

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texts, 13 of which were Islamic. Galen and Hippocrates were quoted relatively rarely in Montpelllier, and even at the beginning of the seventeenth century CE, tutorials still focussed heavily on the works of Arabic scholars such as Avicenna and Rhazes. Problems in gynaecology and obstetrics received short shrift in Montpellier, as in most teaching centres of that era. In the Breviarum Practicae, Arnaldus of Villa Nova, a physician and alchemist from Montpellier linked the topic of gynaecology to a discussion of vipers, on the basis that: “women are for the most part poisonous creatures.” During the fourteenth Century CE, the Montpellier school espoused the idea that the Black Death was caused by a miasma entering the body pores. Rather unwisely, the Faculty thus advised against bathing, in case this opened up the pores. The resulting growth in the local flea population substantially increased vulnerability to the plague. Famous Montpellier alumni included Gilbert the Englishman (c. 1180–1250 CE), Guy de Chauliac (1300–1368), Rabelais (1494–1553), Nostradamus (1503– 1566 CE), and Thomas Sydenham (1624–1689). The school became progressively more elitist as its reputation grew. In 1529  CE, it expelled Nostradamus when it discovered that he had plied the “manual” trade of apothecary before beginning his medical studies. Nevertheless, Nostradamus continued to work as an apothecary, claiming that his rose pills could protect people against the plague. Unfortunately, his first wife and two children died of this infection, greatly reducing the confidence of customers in his medication. In 1556, a lecture theatre was built in Montpellier for the public dissection of corpses, and in 1593 the university saw opening of a Botanical Garden devoted exclusively to a collection of medicinal plants. The reputation of the Montpellier school suffered during the Enlightenment, when it chose to embrace the unpopular doctrine of vitalism (the concept that the functions of living organisms are based on an élan vital, something quite distinct from normal chemical and biochemical reactions). In the 1760s, the revolutionary government forcibly moved an extensive medical library from the church-run Hôpital St Eloi to the secular medical school in Montpellier. The professors’ salaries were also greatly increased, and even medical students were offered a small annual stipend. However, financial difficulties quickly arose, as the responsible governmental department had failed to provide the university with adequate funding to cover these innovations. Paris  The University of Paris had its origins in the middle of the twelfth Century CE. There were four founding faculties, one of which was medicine (Fig. 17.2). The Parisian medical school was firmly under the control of the Church, and students acknowledged this by shaving their heads in tonsure. Because of strict Church supervision, the school chose to spurn the services of an outstanding (but married) Milanese Surgeon-in-exile (Lanfranc, c1250–1306 CE); Lanfranc had promoted cleanliness in surgery, as opposed to encouraging accumulation of a supposedly “healing” pus in wounds.

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Fig. 17.2  A meeting of doctors at the church-­ controlled University of Paris, as pictured in a mediaeval manuscript (Source: http://en. wikipedia.org/wiki/ University_of_Paris)

After studying in Montpellier and Bologna, Guy de Chauliac brought a wealth of new anatomical knowledge to Paris. Later, he moved to Avignon. There, he served as personal physician to the Papal Court, surviving the Black Death, distinguishing Bubonic and Pneumonic forms of the Plague, and successfully fighting the rumour that Jews had caused the Black Death by poisoning local wells. The first clash between the Parisian students and the university administration came on Shrove Tuesday, 1229 CE, when a riot by a mob that had been enjoying pre-Lenten celebrations led to the death of several students. University courses were boycotted for 2 years, and many of the disaffected students enrolled at other universities such as Reims or even Oxford. Pope Gregory IX finally restored harmony by a Bull (Parens scientiarum), that honoured the University of Paris as the “Mother of Sciences,” and for many years, the Paris school continued to outdraw its French rivals in terms of student enrolment. Bologna  The University of Bologna received its official charter in 1158 CE, and the medical school began operations around 1288. It was a secular institution, with a guild-like structure. The initial impetus to organization of the students came from mutual aid societies (universitas) of foreign scholars who resented the collective punishments that were being imposed on them for the misdemeanours of a few of their fellow nationals. The students thus grouped themselves into what they termed “nations” and established a system of collective bargaining with the City and with the faculty (Fig. 17.3). Over the course of these negotiations, the students gained considerable power, setting course content, determining the salaries of professors,

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Fig. 17.3  German students attending the University of Bologna grouped themselves into a mutual self-aid society, termed a “nation,” one of a number of student collectives (universitas) that sought better terms from the city and the Faculty. From a miniature painted in 1497 CE (Source: http:// en.wikipedia.org/wiki/University_of_Bologna)

and levying fines if teachers did not finish courses on schedule. The professors reacted by establishing a College of Teachers that determined tuition fees and graduation requirements. Eventually, a Charter made Bologna a public university, with faculty salaries paid by the city. Although an Edict of the Council of Tours (1163  CE) and a Bull from Pope Boniface VIII (1300  CE) had been interpreted as proscribing the dissection of human bodies, during the fourteenth century the Bologna school began to undertake human dissections for the first time in almost 1000  years. The resulting findings challenged many of the classical concepts of anatomy and physiology. Beginning in 1595  CE, an Anatomical theatre was constructed in Bologna, and here criminals were publicly dissected, particularly during the season of Carnival. During the 1700s, the Anatomy department gained further renown from its collection of waxwork models, prepared initially by an Abbot from Syracuse. However, the overall reputation of the Bologna school began to wane when many of the faculty positions were awarded on a hereditary basis. Padua  The School of Medicine in Padua is first mentioned in a document from 1222 CE, although its origin may have been somewhat earlier (Fig. 17.4). The student body was at first divided into two “Nations,” the “Italians” and the “ultramontanes,” the latter being students who had crossed the Alps from other parts of Europe. Because the University of Padua was not under direct Papal control, a number of Jewish students were accepted. Like Bologna, Padua had an Anatomy theatre where public dissections were performed. But contrary to the practice in Bologna, the anatomists began to carry out the dissections themselves, rather than leaving this

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Fig. 17.4  The Bo Palace, one of the historic buildings of the University n of Padua, as seen in a woodcut from 1654 CE (Source: http://en.wikipedia.org/wiki/University_of_Padua)

task to their technicians, and in consequence they discovered much more about the structure of the human body. Local patricians were barred from accepting lectureships. Unlike the hereditary and aristocratic system in Bologna the emphasis in appointing Paduan faculty was that of a meritocracy. Moreover, tenure was by no means guaranteed. Students voted every 4 years on the renewal of individual faculty appointments. One of the most famous Paduan scholars in Anatomy and Surgery was Andreas Vesalius (1514– 1564 CE). In 1543 CE, he published “De Humani Corporis Fabrica,” and in the second edition of this book he questioned the classical doctrine of the existence of pores in the ventricular septum of the heart, thus opening the way for an accurate description of the circulation of the blood. Other well-respected graduates from the Paduan school were Thomas Linacre (who founded the British Royal College of Surgeons) and William Harvey. Pisa  An edict of Pope Clement VI had founded the University of Pisa in 1343 CE, with medicine as one of its four faculties. Pisa was one of the first universities to have its degrees attested by the Papacy. The institution suffered temporary closure during the Florentine conquest of Pisa, but there was a ceremonial re-inauguration of the university in 1543. Notable faculty members from this era included Gabriele Falloppio, Marcello Malphigi and Galileo Galilei. An early initiative of the reopened institution was to establish Europe’s oldest academic botanical garden. This was begun in 1544 CE, and it moved to its present location in 1591, serving as an important source of rare medicinal plants (Fig. 17.5). An intense rivalry developed between the Universities of Pisa and Pavia, both academic and athletic. One element in this continuing competition was the Pisa-­

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Fig. 17.5  The first botanical garden, established at the medical school in Pisa in 1544 CE, provided an important reserve of rare medicinal herbs. Other universities such as Pavia and Montpellier subsequently developed botanical gardens (Source: https://goo.gl/images/QOXlJR)

Pavia regatta, which seems to have developed from the boat races of Venetian peasants held at the end of the fifteenth century. Pavia  The University of Pavia was founded by the Holy Roman Emperor Charles IV in 1361 CE. It developed a botanical garden, beginning in 1773 CE. Pavia was particularly renowned for its Faculty of Law, but its alumni also included some celebrated medical scientists, including Alessandro Volta (1769–1804  CE) and Camillo Golgi (1843–1926 CE). The University of Pavia fell into serious decline during the Italian civil wars that marked the second half of the sixteenth century. Leiden  William of Orange had founded the medical school in Leiden in 1575 CE, apparently in recognition of the bravery of local citizens during a prolonged siege of their city by the Spanish army. At this time, the only other university in the low countries was Leuven; this had been founded in 1425 CE, with Vesalius as an alumnus, but it was now firmly under Spanish control. The Leiden anatomist Johannes Walaeus concluded that Harvey’s theory of the circulation of the blood was sound, and he frequently debated this question with his European colleagues. By the early seventeenth century, Leiden had become one of the dominant forces in European medical education. It was recognized particularly for the efforts that Herman Boerhaave (1668–1738 CE) made to apply new scientific knowledge to the healing arts as a careful bedside teacher.

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London  Within the city of London, much of early teaching in the health sciences was undertaken by the Guild of Surgeons (an organization dating from 1368 CE), and by the College of Physicians (Chap. 13). The College of Physicians provided a forum for distinguished lecturers such as William Harvey, who in 1616 CE gave his noted discourse on the circulation of the blood. The College of Physicians became the licensing body for medical texts, and through its examinations set clear minimum standards of knowledge for medical practitioners. It also established a “Nomenclature of Diseases” in 1869 CE, and this invaluable epidemiological tool held sway until the World Health Organization Manual of International Classification of Diseases was introduced in 1967 CE. The first British medical schools developed around religious institutions. Until 1900, they also remained aloof from formal university governing structures. I remember that at least one bishop still served on the Board of Governors at Guy’s Hospital during the late 1940s, and most of the leading teachers at Guy’s held no formal rank within the University of London. The front quadrangle at Guy’s Hospital marked its religious origin by the incorporation of a fine Georgian Church, and across the street, the Church of St. Thomas bore witness to the original site of St. Thomas’s Hospital. The first hospital initiatives in London came from Rahere (died 1144 CE), variously described as a clergyman, courtier, minstrel and jester. He founded a small hospital at St. Bartholomew’s Priory in 1123 CE. His primary intention was to treat poor people. The initial endowment was so small that the Hospitaller (the equivalent of our modern hospital administrator) had to visit the adjacent meat shambles each day, begging for food, and in a parody of modern hospital over-crowding, several patients slept in each single bed. But St. Bartholmew’s did not become a formal medical school until around 1550 CE. William Harvey was one of the distinguished early alumni of the school. Formal medical teaching did not begin at “Bart’s” until 1730  CE, when Eric Nourse inserted a brief announcement in the London Evening Post: “I shall begin a course of anatomy, chirurgical operations and bandages on Monday, November 11th..” St. Thomas’s Hospital began formal teaching operations as early as 1173 CE. Records of a student being apprenticed to a surgeon date back to 1561 CE, and by 1713 CE there were complaints that one surgeon was being attended by three or more apprenticed students. In 1724 CE, an entente with the neighbouring Guy’s Hospital enabled students to pursue their studies of medicine and chemistry at Guy’s. St. Thomas’s is remembered particularly for its nursing school, which was established by Florence Nightingale in 1860 CE. Guy’s Hospital was established in 1721 CE by Thomas Guy, a financier of somewhat dubious reputation. He had made a substantial fortune by offering sailors “loans till pay-day,” coupling this source of income with the illegal importation of Bibles that had been printed off-shore. He multiplied his ill-gotten capital tenfold during the “South Sea Bubble,” and some historians suspect that his endowment of Guy’s Hospital may have been a “conscience money” project. Initially, the hospital served as a chronic, long-term care facility for patients who had been discharged from St. Thomas’s hospital, immediately across the street. However, the physicians

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accredited to Guy’s were unhappy to continue in this subordinate role, and undertook legal manoeuvres to change the interpretation of the hospital endowment, so that acute cases could be admitted to Guy’s Hospital. From 1769 onwards, medicine and chemistry were taught at Guy’s, while courses in surgery were offered either at St. Thomas’s, or at private clinics in London’s West End. The extent to which eighteenth century anatomy departments were involved in grave-robbing and murder remains a controversial topic. Guy’s reputedly resorted to dealings with the local “Resurrectionists” in order to provide students with an adequate number of cadavers for their dissecting room: “Returned to Vestry Clerk of Newington, by order of the Treasurer, one male and two females, purchased of Page, &c., on the 25th, who had broken open the dead-house to obtain them.” Edinburgh  The Faculty of Medicine in Edinburgh did not open its doors until 1726 CE. It was modeled on the schools in Bologna, Padua and Leiden. The associated Royal Infirmary initially had only four beds, and the admission of students to clinical seminars was thus closely regulated, using a ticket system. Edinburgh quickly became renowned for its excellent understanding of Human Anatomy. The officially sanctioned dissection allowance of one criminal per year proved woefully inadequate, and a brisk trade in body-snatching emerged, supplemented by the occasional murder. The distinguished anatomist Robert Knox is reputed to have paid the local Mafia a fee of 7 pounds 10 shillings per corpse. Despite the criminal conviction of the original miscreants, the gruesome trade of the body-snatchers persisted until the Anatomy Act of 1832 CE gave British teaching institutions a more adequate supply of cadavers. Oxford and Cambridge  Some Oxford scholars claim that their university was established as early as 1096 CE. However, those interested in medicine had to move to a London teaching hospital after obtaining their baccalaureate. A medical teaching facility was eventually established in Oxford in 1936, with an endowment from the Nuffield Foundation, but the teaching of medical students did not begin until World War II, with the evacuation of London teaching hospitals to Oxford and other provincial cities. The University of Cambridge was founded in 1209 CE, following a dispute with Oxford University over the little matter of the execution of two under-graduates. However, facilities for clinical instruction did not become available at Cambridge until 1976 CE, with the enlargement of Addenbrooke’s Hospital, on the outskirts of Cambridge.

North America In North America, students had little or no possibility of studying medicine or the health sciences until the late eighteenth century. In 1765  CE, the University of Pennsylvania (Philadelphia) decided to offer: “anatomical lectures and a course on the theory and practice of physik,” drawing upon three professors who had recently

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returned from European medical schools. Bedside teaching was provided nearby, at the Pennsylvania Hospital, founded by Benjamin Franklin. A second medical school was established at Columbia University, New York, in 1768 CE. The New York institution, like its British counterparts, faced accusations of grave robbing, and in 1788 a mob surged into the New York Hospital, seizing the school’s four anatomists. Despite these North American initiatives, the surgeon John Collins Warren found no official medical school or accredited hospital in Boston when he began his studies in 1799  CE, so he travelled to Guy’s Hospital in London, to profit from the expertise of Sir Astley Cooper, one of the leading surgeons of that era. Rather than paying the standard fee of £25 that would entitle him to become a “walker,” merely following Cooper on his ward rounds, Warren elected to pay the premium fee of £50. This entitled him to become a “dresser,” a student who was permitted to undertake minor surgery such as the suturing of wounds sustained in a fight at the local gin palace. Warren greatly appreciated the excellence of the anatomical models that he discovered in the school’s Gordon Museum, but he had a much less favourable opinion of the hospital’s environs just to the south of London Bridge: “The air is thickened with smoke and vapors so that it is scarcely respirable, and as for the sun, no one can tell you when he was seen.” The thick winter smogs persisted around Guy’s Hospital until the domestic consumption of coal was banned in the 1950s. Early Canadian health care professionals were trained primarily in France, and indeed even today in some parts of Quebec, physicians find it advantageous to flaunt a French medical qualification on their office door-plates. The McGill Medical School began life as the proprietary “Montreal Medical Institution” in 1823 CE, and 6  years later it officially affiliated with McGill University. Queen’s University Medical School (Kingston, Ontario) gained its Royal Charter in 1841 CE, and the University of Toronto opened a Medical School in 1843  CE, However, 10  years later, the Toronto school transferred its students to Trinity Medical College, the Toronto School of Medicine and the Woman’s Medical College. The University of Toronto did not reopen its Medical School until 1887 CE. The French-language medical school at Laval University did not commence operations until 1878 CE.

Practical Implications for Current Policy For much of its history, medical teaching has been extremely conservative, with a focus upon classical texts and instruction in anatomy, surgery, the symptoms and signs of illness, and treatment by herbal preparations. Only in the past few years have teachers begun to consider the efficacy of proposed treatments in terms of costs and benefits to the patient and to society, and the quality of life-years added by any proposed treatments. Many long-standing procedures have now undergone critical evaluation, but there still remains a need to reassess much of traditional practice through objective, double-blind trials, and to move beyond a focus on the treatment

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of established disease to a consideration of prevention and the optimization of human health. The best method of medical teaching still remains open to debate. Currently, students spend a large part of their time in large lecture theatres covering the pathology and treatment of exotic diseases, and there is perhaps a need to restore some of the apprenticeship and simple clinical responsibility that was the lot of the “dresser” 50 years ago. Medical teaching currently receives a large fraction of university budgets; in Toronto, per capita funding is about 16 times as great as that provided for students of Kinesiology. Given that after qualification, the likely earnings of medical students exceed that of students in other faculties, it may be questioned whether medical students should contribute more to the costs of their instruction. Another issue raised by mediaeval history is the extent of the influence that students should have upon the appointment of university faculty. Currently, student evaluations of faculty play a significant role in considerations such as tenure and the award of merit pay. Careful evaluations can indeed help to improve instruction, but there also seems a real danger that teachers who give light course loads and award high marks are likely to receive inappropriately favourable evaluations.

Questions for Discussion 1. How far should students control the appointment, salary and tenure of teaching professors? 2. How important is long tradition to the success of a medical school? 3. Do Anatomy departments treat the bodies of the deceased with adequate respect? 4. How far should medical students be allowed to gain experience by performing largely unsupervised minor surgery and other simple clinical procedures and laboratory tests?

Conclusions In part because of the forced displacement of skilled professionals from Western Europe, the earliest attempts at formal medical education began in the Middle East and the Arabic world. The earliest European medical schools were established in Italy and in France, with patterns of teaching and governance differing between institutions under religious and secular control. Formal medical teaching began much later in Britain, typically based on hospitals that had been established by religious orders. For a long period, much of the available teaching of medical schools was a reiteration of the views of classical scholars such as Galen and Hippocrates. However, careful dissection of human cadavers enabled a few courageous teachers to chal-

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lenge traditional wisdom concerning human anatomy and physiology, leading to the new discoveries of the Renaissance and the Enlightenment.

Further Reading Carlino A. Books of the body. Anatomical ritual and Renaissance learning. Chicago, IL, Chicago University Press, 1999, 266 pp. Haller JS. American medicine in transition, 1840–1910. Chicago, IL, University of Illinois Press, 1981, 457 pp. Klestinic C. Theaters of anatomy. Students, teachers and traditions in Renaissance Venice. Baltimore, MD, Johns Hopkins University Press, 2011, 257 pp. McPhedran NT. Canadian medical schools: Two centuries of medical history, 1822–1992. Eugene, OR, Harvest House, 1993, 294 pp. Mitchell P. Anatomical dissection in Enlightenment England and beyond. Farnham, Surrey, Ashgate Publishing, 2013, 198 pp. Mukherjee PK. Evidence-based validation of herbal medicine. Amsterdam, Netherlands, Elsevier, 2015, 556 pp. Persaud VN, Loukas M, Tubbs RS. A history of human anatomy. Springfield, IL, C.C. Thomas, 2014, 390 pp. Ridder-Symoens H. A history of the university in Europe. Vol. 1. Universities in the Middle Ages. Cambride, UK, Cambridge University Press, 2003, 536 pp. Ripman HA. Guy’s Hospital 1725–1948. London, UK, Guy’s Hospital Gazette Committee, 1951, 175 pp. Rothstein WG. American medical schools and the practice of medicine: A history. Oxford, UK, Oxford University Press, 1987, 430 pp. Shultz SM. Body snatching: The robbing of graves for the education of physicians in early nineteenth century America. Jefferson, NC, McFarland, 2005, 144 pp. Wilks S. A biographical history of Guy’s Hospital. London, UK, Ward, Lock, Bowden, 1892, 500 pp. Wise S. The Italian boy: Murder and grave robbery in 1830s London. New York, NY, Random House, ™012, 368 pp. Withington ET. Medical history from the earliest of times: A popular history of the healing art. Cambridge, MA, Scientific Press, 1894, 424 pp. Wood M. Vitalism. The history of herbalism, homeopathy and flower essences. Santa Barbara CA, North Atlantic Books, 2000, 215 pp.

Chapter 18

Literature in the Search for Health and Fitness

Learning Objectives 1. To appreciate the importance of the printing press and the widespread distribution of published texts to the conservation and consolidation of existing knowledge. 2. To understand how scientific progress has been impeded by the uncritical inclusion of untested ideas and opinions into comprehensive works of reference. 3. To recognize that many early books in the health sciences focused upon minor surgical procedures or provided compendia of herbs that could be used in the treatment of common medical conditions. 4. To observe that beginning in the 1830s, texts began to appear that were specific to individual medical conditions, and a progressive availability of books on sports medicine, health maintenance and the enhancement of physical fitness.

Introduction As in other areas of human understanding, knowledge concerning health and fitness has developed through the transmission of insights from one generation to the next. At first, such wisdom was passed on orally, with accuracy limited by the memory and the personality of the story-teller. The introduction of manuscripts increased the fidelity of transmission, but hand-copied texts remained susceptible to both unwitting and deliberate errors of transcription. Translation of books into the vernacular, and the invention of the printing press made multiple and consistent copies of books available to a much broader audience. In recent years, communication of the written word has undergone a further advance, with most major texts now available on line. In this chapter, we will trace the development of general medical literature, with all its bizarre and erroneous theories, through the civilizations of Egypt, India, China, Greece, Rome and Mesopotamia, along with early Middle-Age Europe, © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_18

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before commenting briefly on the appearance of specific books on sports medicine, health and fitness during the nineteenth and twentieth centuries, and the important innovation of consensus texts.

Development of General Medical Literature Egypt  Early Egyptian medical papyri covered anatomical principles, the treatment of injuries and other issues confronting the practicing physician. Noteworthy documents were the Hearst, Ebers, Smith, and Kahun papyri (all named after their discoverers rather than their authors). Hearst Papyrus  The Hearst papyrus (~2000  BCE) was one of the oldest of the Egyptian medical documents. In addition to proposing remedies for headaches, digestive problems, and a tooth that falls out, it focused on urinary problems, issues with blood and hair, and the treatment of bites from humans, pigs and hippopotami. Ebers Papyrus  The Ebers papyrus (Fig. 18.1) was found at Luxor; it dates back to about 1550  BCE, and it offers remedies for over 700 conditions, ranging from a crocodile bite to a painful toe. Castor oil and dates were used as laxatives, mother’s milk was administered for viral infections, cumin was thought to relieve flatulence and arthritic joints, pomegranate root was prescribed for tapeworms, and frankinFig. 18.1 Recommen dations for the treatment of a patient with cancer, as found in the Egyptian Ebers Papyrus. The main advice was expectant- to “watch and see” (Source: http://en.wikipedia.org/ wiki/ Ancient_Egyptian_ medicine)

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cense was proposed for the relief of pain. Some prescriptions were quite complex, containing as many as 37 ingredients. Wounds were treated by binding with raw meat and white linen, and swabs were treated with honey and grease to counter infection. Edwin Smith Papyrus  The Edwin Smith papyrus is the oldest known surgical treatise, dating from about 1600  BCE.  It describes 48 cases of injuries, fractures, wounds, dislocations and tumors. It may have been a military surgeon’s manual, but it is often attributed to Imhotep, the Egyptian Chancellor and high priest of the sun god. There is an interesting anonymous note scribbled on the back of the text, marking a first tentative step towards the rational explanation of disease; this note suggests that sometimes disease might be caused by windborne pests rather than supernatural causes. In contrast to the practice of some later “experts,” the papyrus shows that Egyptian surgeons emphasized the removal of post-operative pus, and at least some early Egyptian patients survived major operations such as amputations. Kahun Papyri  The Kahun Papyri (c. 1800 BCE) included a document that was one of the earliest treatises on women’s health. Its remedies (almost all herbal) covered fertility, pregnancy, contraception and protection of the newborn. India  Much of the earliest Indian medical writing is intertwined with Hindu philosophy. We will examine the ideas of the Atharva-Veda, the Suṥrutha Samhita, the Charaka Samhita, and modern continuations of Ayurvedic medicine. Atharva-Veda  The Atharva-Veda (one of the four sacred texts of Hinduism) offers a collection of medically important spells and incantations that were once thought relevant to the treatment of disease, injuries, fertility, in sanity, and poor health. The core information probably dates from the second millennium BCE, although mention of iron places a part of the text in the early Indian Iron Age, about 1000 BCE. More than 100 hymns cover the use of medicinal herbs, the injection of solutions, the treatment of snake-bites, hydropathy, fevers, food poisoning and the use of surgical instruments. At one point, there is apparently a description of the symptoms of diabetes mellitus: “the appetite is so morbidly increased that a person… will consume four times the quantity of his accustomed food and yet will not feel satisfied.” Diseases such as leprosy were attributed to living organisms, to be killed either by appropriate incantations or the administration of herbs and drugs: “The medicinal herbs of the motherland… render numerous benefits and bring health and strength to sick patients.” However, medicine was not seen as a universal remedy for ill-health: “medicine &c, are powerless to remove the pain accompanying a disease in every instance… pain…. is apt to reappear after it has once been stopped.” Sometimes, the remedy was the correction of personal ignorance, with the attainment of release through knowledge of Brahma, the divine.

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Suṥrutha Samhita  The Suṥrutha Samhita added to this groundwork of medical ideas, offering the views of Suṥrutha, an Indian physician from around 600 BCE. The text discusses the aetiology, signs and symptoms of important surgical conditions, with rudimentary accounts of embryology and anatomy, venesection, obstetrics, geriatrics, and the management of poisoning. It also describes specific surgical procedures, including the incision and excision of tissues, the probing of sinuses, blood-letting and suturing. The book was translated into Arabic during the eighth century CE. Charaka  The word Charaka means literally a wandering religious ascetic. The Charaka Samhita (~300 BCE) was compiled by another influential Indian medical writer, born c. 300  BCE.  It speaks of some 500 herbal preparations, including Rauwolfia. It also contains more than 100 comments about exercise and physical activity, in particular attributing sexual dysfunction to a lack of exercise. Continuation of Ayurvedic Medicine  The Ayurvedic approach to medicine survives today as one form of holistic, “alternative medicine.” The basic hypothesis of Ayurveda is that the body comprises dhatus (tissues), malas (waste products) and 3 doshas or energetic forces: the vata dosha (derived from air), the pitta dosha (related to bile) and the kapha dosha (related to phlegm). The task of the Ayurvedic practitioner is to balance these several elements. Some 100 Indian schools now offer courses in Ayurvedic medicine, but in the west, concerns are often raised about the quality of the herbs that are prescribed; sometimes, they contain toxic quantities of heavy metals. China  Traditional Chinese medicine can be traced to two important books: the Yellow Emperor’s Inner Cannon and the Treatise on Cold Damage. Inner Cannon  The Inner Cannon was compiled in the first century BCE. It emphasized the essential unity between humans, the environment and the cosmos, and it discussed the symptoms of illness and how to make a diagnosis. It propounded the doctrine of opposing female and male forces, the yin and the yang (Fig. 18.2), and it argued that an even, balanced temperament promoted health and longevity. The human body was seen as subject to the same forces of yin and yang that governed the universe. Disease reflected a blockage in the circulation of the Qi, which had allowed an imbalance to develop between the yin and the yang. An illness due to an excess of yin was associated with the lower back and internal organs, whereas a yang-based illness had external causes, and was associated with the upper regions of the body. Disharmony between the two opposing forces could be detected by examining the pulse, inspecting the tongue, skin, and eyes and by looking at eating and sleeping habits. The pulse was described in great detail: its rhythm, strength, and volume, and qualities like “floating, slippery, bolstering-like, feeble, thready and quick.” If the pulse was “surging, large and dissipated,” then the heart was overwhelming the liver, and if it was “deep, soggy, and slithering” the kidneys were overwhelming the liver. Some 29 different types of pulse were recognized.

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Fig. 18.2  The I-Ching, or Book of Changes, a Chinese book of divination that also discusses the opposing female and male forces, the yin and the yang. Parts of the book may date back to 1000 BCE. A silk manuscript copy of the text that escaped a book burning was found in the Mawangdui tomb in China (Source: http://en. wikipedia. org/wiki/I_Ching)

Treatments of the imbalance between the yin and the yang included moxibustion (Fig. 18.3), acupuncture, applications of pressure at critical pressure points, tao yin exercises and herbal medicine. Moxibustion involved scalding the skin with burning mugwort fluff; the resulting inflammation increased the flow of qi to the treated region, and was supposedly a very effective method of treating weakness and old age. Acupuncture opened up blocked circulatory pathways, and breathing exercises also facilitated this process. Tao yin comprised a series of light exercises, performed lying or sitting, and accompanied by slow respiration and meditation. The idea of balancing the yin and the yang remains deeply imbedded in Chinese concepts of health promotion even today. Treatise on Cold Damage  The Treatise on Cold Damage was collated by Zhāng Zhòngjǐng (150–219 CE). The first part of this work dealt with epidemic diseases, with treatments ranging from warming (to increase the yang) to cooling (to increase the yin). The second part, Essential Treasures of the Golden Chamber, focused on herbal remedies. Greece and Rome  Noteworthy medical authors from classsical Greece and Rome included Hippocrates, Diocles, Titus Aifidius and Dioscorides.

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Fig. 18.3  The technique of moxibustion involved the scalding of the skin by burning mugwort fluff, a procedure that was supposed to increase the flow of Qi to the treated region. From Sketches of Japanese Manners and Customs, 1867 CE (Source: http://en. wikipedia.org/wiki/ Moxibustion)

Corpus Hippocraticus  The Corpus Hippocraticus is a collection of 60–76 volumes, attributed to Hippocrates; it may be the remnants of a library from Cos, or more likely a compilation of the main ideas of Hippocrates and his followers put together by third century BCE Egyptian physicians in Alexandria. The scribes undertaking this Herculean task were apparently paid by the kilo for their efforts. This had at least one beneficial effect: they sought out very heavy paper of exceptional quality, imported from China. This ensured that the manuscripts that they prepared survived for many centuries! Hippocrates was the first to describe many medical conditions and their associated clinical signs. One interesting example was the clubbing of the fingers associated with cyanotic heart disease. An important element in Hippocratic teaching, relevant to many of the controversies of modern medicine, was the duty of the physician to avoid harming the patient. Diocles  Diocles (c.240–180 BCE) practiced in Athens, and he wrote the first medical treatise in the Attic (as opposed to the Ionic) language, thus offering much practical advice on diet and nutrition in a form that could be understood and appreciated by his contemporaries in Athens. He also provided the first systematic text on animal anatomy, and invented a technique for the extraction of missiles from the tissues. Titus Aufidius  In the first century BCE, Titus Aufidius, a native of Sicily, the Roman praetor of Asia, and a pupil of Asclepiades, wrote a text on Chronic Diseases that remained popular for almost eighteen centuries.

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Dioscorides  Dioscorides (c. 40–90 CE) was a Greek surgeon with the Roman army with intersts in pharmacology and botany. He accumulated a wealth of information on herbal remedies, and his De Materia Medica was used extensively by pharmacists for the next 1500 years. Mesopotamia  Some medical documents from the region of Mesopotamia are very ancient, as for example the tablets found in Nineveh; during the Mediaeval period, the Arab world was the source of most new medical writing, with contributions from the Zoroastrians and scholars centred in Baghdad, and a spreading of this new knowledge to Alexandria and Cordoba. Nineveh  Much of the history of Sumerian and Babylonian medicine was conserved in the Royal library of Ashurbanipal in Nineveh, the oldest surviving library in the world. Some 660 cuneiform medical tablets from this library (some dating back as far as 2000 BCE), were translated by scholars during the early 1920s. These tablets offered prescriptions for specific problems such as diseases of the head and bruises, together with prognoses for some clinical disorders; interestingly, conditions were described on the tablets in head-to-toe order. Zoroastrian Contributions  The Zoroastrian holy book, the Zend-Avesta, dates from the Sasanian Empire (224–661 CE). Many of the 21 constituent volumes relate to worship and prayer, but the book also provides information about medicine and health, including hygiene, cleansing, and the dignity of physical effort. The volume known as the Vendidad, for example, deals with care of the dead, disease, and spells to fight it. Babylon  During the “Golden Age” (c. 750–1258 CE) of Arabian scholarship, the Islamic community accumulated considerable wealth, because of its location astride important trade routes. A defeated Byzantine emperor was surprised to learn that one of the terms of the peace treaty exacted by the Muslim “barbarians” was the right to purchase Greek manuscripts. An early Islamic court physician translated the entire works of Galen into Arabic. Islamic libraries were further enriched as a second wave of scholars set about the task of translating many other classical Greek and Roman medical texts. Hunayn ibn Ishâq not only coordinated the massive task of translation, but also served as physician to the reigning Caliph. He refused the Potentate’s request to formulate poisons to use against his enemies, even for an enormous fee, arguing that such action would run counter to his Hippocratic medical oath. The hospitals and universities that sprang up in and around Baghdad (Chap. 17) stimulated much medical enquiry. The most extensive medical text from the Babylonian era was the Diagnostic Handbook, written by Esagil-kin-apli of Borsippa, a suburb of Baghdad. The author was chief scholar to the Babylonian King Adad-apla-iddina (1069–1046 BCE). The text was summarized on 40 tablets dedicated to Ea, the Babylonian god of wisdom, water, healing and creation. Esagilkin-apli argued that a careful patient history and examination would lead to an appropriate diagnosis, treatment and prognosis, and he gave clear descriptions of various medical problems, particularly epilepsy. He maintained that it was impor-

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tant to identify not only the nature of an illness, but also its cause, and he believed that one of the gods might have turned against a person, placing the disease inside of him because of a crime or broken taboo. In his view, finding out which God was at the bottom of the illness was thus a key first step in the healing process. Another contributor to the “Arab Spring” was ibn Masawaih (~777–857 CE), one of the Nestorian physician who had been exiled to Baghdad (Chap. 17). He authored widely read texts on such issues as “Adjusting of Laxative Medicines,” “Treatment of Headaches,” and “Treatment of Women Who Do Not Become Pregnant.” A further important medical author from Baghdad was the pharmacist, Sabur ibn Sahl (d. 869.). He compiled the Great Pharmacopoeia. Even the abbreviated version of his magnum opus covered 22-volumes, and it became the standard reference work for Iranian pharmacists until well into the seventeenth century. Alexandria  Arab scholars gave an important stimulus to enquiry at the major university in Alexandria, Egypt. One notable contributor was Aëtius (mid fifth-mid sixth century CE); he came from Amida, now in Turkey, but studied in Alexandria, and later served as physician to the Byzantine Emperor. He complied a 16-volume medical compendium that others arranged as the 4 volume Medicinae Tetrabiblos. This included some early Christian spells, such as those associated with the cult of St. Blaise and the curing of throat ailments. He drew heavily upon the teachings of Galen and Oribasius, but performed an important service in offering a judicious compilation of many classical writings that since have been lost. Aetius is particularly remembered for recommending the addition of cloves and camphor to ointments. Cordoba  The region around Cordoba, in Spain, was captured by the Muslims in 711 CE, and it was held by them until the late fifteenth century; this region thus profited from the new Arabic learning. Albucasis of Cordoba (936–1013 CE) was a Muslim physician and surgeon. In 1000 CE he completed an encyclopedic 30-volume text of medical practice (Kitasb al-Tasrif). Much of this was devoted to surgery. 200 surgical instruments were described (Fig. 18.4), and the text discussed such practical facets of technique as the need for obstetric forceps and the choice of catgut for suturing. In the twelfth Century CE, the book was translated into Latin, and it remained an influential surgical text until the eighteenth century CE. Middle Age Europe  In Middle Age Europe, noteworthy contributions of original writing and translations of existing texts were made by Isidore of Seville, Rabanus Maurus and Hildegard of Bingen in Germany, Constantinus Africanus and the Salerno Medical School in Itasly, Nicholas Myrepsos of Nicaea, and Gilbert the Englishman, among others. Isidore of Seville  The scholar Isidore of Seville (560–636 CE) became archbishop of thåt city for three decades. His Etymologia provided an encyclopaedic compilation of all existing knowledge in 20-volumes. Sections discussing health and fitness included volume IV (De medicina) and volume XVIII (De bello et ludis, On war and games). Ambrose (c 337–397  CE), Archbishop of Milan, had previously

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Fig. 18.4  Surgical instruments illustrated in a Latin translation of the text Kitab al-Tasrif, by the Cordoban physician Albucasis (~ 1000 CE) (Source: http://en.wikipedia.org/wiki/Abu_al-Qasim_ al-Zahrawi)

described a pulse with “windy” characteristics in sick patients, and Isidore supported the view that the quality of the pulse was a potent indicator of a person’s overall health status. Isidore embraced Galen’s concept of curing illness by balancing the body’s “four humours.” He distinguished dietary, pharmaceutical and surgical treatments. Diet was seen as “observance of the law of life.” However, Christians should not despise pharmaceuticals, the second arm of treatment. Moreover, treatment was not always to be based on antidotes, or “opposites;” sometimes, there was a need to apply “likes.” Thus, a circular bandage was appropriate for a round wound, and the bitterness of disease could be countered by administering bitters. Further, good health required attention to lifestyle. The very term medicine came from the word modus, or moderation.

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Rabanus Maurus  Rabanus Maurus (775–856  CE), Abbott of the Benedictine Abbey of Fulda, in Germany, compiled an Encyclopedic De rerum naturis (On the nature of things) during the ninth century CE. However, for some reason the book was not published until 1025 CE, and then by the Monte Cassino monastery rather than by Fulda abbey. Book 18 of this text contains a chapter entitled De medicina et morbis. In it, Maurus discusses the fundamental principles underlying studies of the human body, illness and the principal medicinal herbs. Hildegard of Bingen  Hildegard of Bingen (1098–1179 CE) was a notable Abbess of a Benedictine convent in the German Rhineland. Two important medical books (Physica and Causae et Curae) appeared under her authorship. Contrary to some church scholars of her era, she maintained that humans had the right to exploit the healing properties of plants, animals and stones, and she maintained that God had commanded her in various visions both to treat the sick and to compile herbal formulae gleaned from folk healers. Constantinus Africanus  The merchant Constantinus Africanus (died c. 1099 CE) emigrated from Sicily to Italy, and when he became sick, he noticed with concern that the local doctor failed to examine his urine (Fig. 18.5). He concluded that the standard of medicine in Italy was poorer than what he had experienced in his native Carthage, and he asked his physician whether any good medical texts were currently available to him. The physician replied “no.” Constantinus thus decided to fill this void. His returned to Carthage, where he gained a grounding in medicine, and collected many valuable texts. On returning to Italy, he took up residence as a Benedictine monk in the Monte Cassino monastery, 160 km to the north of Salerno. There, he led several scholars in a systematic translation of classical and arabic medical texts. Fig. 18.5 Constantinus Africanus (died 1099 CE) examining a specimen of urine in his medical practice. Failure of a local Italian medical practitioner to look at his urine had spurred Constantinus to become a physician and a Benedictine monk He translated many Arabic medical texts (Source: http://en.wikipedia.org/ wiki/ Constantine_the_African)

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Salerno Medical School  The medical school in Salerno was the first of such instiution, and for long held a top international ranking (Chap. 17). The Regimen sanitatis Salernitanum, probably written in the twelfth or thirteenth centuries CE, is one of the most famous of mediaeval medical writings. It is generally attributed to faculty from the Salerno Medical School, although some scholars believe the contents were derived from an Arabic source. The text takes the form of a poem, offering 362 pieces of cogent lifestyle advice such as: “Joy, temperance, and repose, slam the door on the doctor’s nose” and “Use three physicians still; first Doctor Quiet, Next Doctor Merry-man and Doctor Dyet. “Although not always approved by the Roman Church, the text was widely respected until at least the eighteenth century,. A commentary, prepared by Arnald of Villa Nova (1230–1300 CE) was publicly burned, and for a while the Regimen itself was placed on the Papal codex of “forbidden books”. Nicholas Myrepsos  Another important resource from this period was the Dynameron, a compendium of medical knowledge written by Nicholas Myrepsos, a Byzantine physician who lived in Nicaea during the late thirteenth century. His text contained over 2500 formulae, including many superstitious remedies. It also ­identified 293 plants, including 39 used by present day herbalists. The book was adopted by the Faculty of Pharmacy in Paris until 1651 CE. Gilbert the Englishman  A final respected text from the latter part of the Middle-­ Ages was the Compendium of Medicine compiled by Gilbert the Englishman (~1180–1250 CE). Gilbert was included by Chaucer on a “short list” of the greatest physicians of all time. Gilbert had gained much of his knowledge by studying at the Salerno Medical School in Italy, under Roger Parma. He subsequently became physician to the Archbishop of Canterbury. In one consultation, he recognized that the Archbishop’s death was close at hand, and simply advised him to set his affairs in order, rather than proceeding with the usual ritual of examining the pulse and urine. His Compendium was probably finalized while Gilbert was studying at Montpellier university. The text, which was translated from Latin to Middle English in the early fifteenth century, provided not only therapeutic recipes but also guides to diagnosis and prognosis. Like the works of his teachers in Salerno, Gilbert’s book began with a long discussion of fevers and then presented in logical sequence the treatment of all known conditions from the head (headaches) to the tail (haemorrhoids). The book had a very practical orientation. Gilbert insisted doctors did not need to know philosophical truths; what they required was an understanding of a treatment that would heal the patient.

Texts of Sports Medicine, Health and Fitness Although many classical texts had made passing reference to exercise and sport, the first books focussing upon sports medicine, health and did not appear until the twentieth century.

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In Germany, Herxheimer’s Grundriss der Sportmedizin (1933) was the first text to incorporate the words “Sports Medicine” into its title. Credit for the first English language text on sports medicine has sometimes been attributed to C.B.Heald. In 1931  CE, he published Injuries and Sport: a general guide for the practitioner. However, Heald focused uniquely upon injuries, and did not venture into the health and fitness consequences of sport participation. John Williams (1932–1995  CE) published two books (Sports Medicine and Medical aspects of sport and physical fitness) that went substantially beyond the treatment of sports injuries. Williams stimulated considerable controversy with his contention that many athletes were not particularly fit, and he staunchly maintained the conservative position that sports medicine was the prerogative of physicians rather than kinesiologists. He resisted proposals to include health professionals other than physicians in the ranks of the British Association for Sports Medicine, and his intransigence contributed largely to formation of the rival British Association of Sports Sciences. Walter Meanweel was an early American writer on Sports Medicine. He was team physician at the University of Wisconsin; and in 1931  CE, he collaborated with Notre Dame football coach Knute Rockne to publish Training, Conditioning and the Care of Injuries. As suggested by the title, this book focussed mainly on sports injuries. More broadly based texts included Physical fitness appraisal and guidance (Tom Cureton, 1947), Foundations of Physical Activity (Adams, 1968), Foundations of Physical Activity: Applications as Disciplines and Professions (Larson, 1976), and Sports Medicine (Ryan and Allman, 1974). The Canadian, physician Tait McKenzie published Exercise in Education and Medicine in 1915. This book discussed the physiology of exercise and physical conditioning, and presented recommendations based on experience that McKenzie had gained while rehabilitating soldiers who had been injured in World War I.  I published the first edition of Endurance Fitness, a detailed discussion of the physiology of cardio-respiratory fitness and its implications for health in 1969. Health Policy is now essentially evidence-based, and in recent years, several major international conferences have accumulated agreed information on the relationships between physical activity, health and the prevention and treatment of chronic disease, with publication of consensus texts based on the conference proceedings. Methodologies underlying these initiatives have included the use of Citation Indices to select the most knowledgeable panel of invitees and the employment of professional facilitators to develop a consensus from world experts, who often have arrived at the conferences with quite disparate views. The published conclusions are found in Exercise, Fitness and Health (1990), Physical Activity, Fitness and Health (1994), and a supplement to Medicine & Science in Sports & Exercise (2001). These three consensus conferences have proven very helpful in clarifying the current ideas of exercise scientists, and a “translation” of the findings into a format accessible to front-line workers is now available in the published version of a 2001 CE Whistler conference entitled “Communicating physical activity and health messages: science into practice.” The definition of dose-response relationships remains critical to appropriate exercise recommendations, and over the past 10 years Canadian investigators led by

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Norm Gledhill and Darren Warburton have held further international conferences, carefully weighing the evidence on safety and the appropriate doses of exercise to prescribe both for healthy individuals and for those with a wide variety of clinical conditions. This has allowed them to develop electronic tools for exercise prescription in a variety of clinical conditions (the new PAR-Q+ and the e-PARmed-X+), and they have also accumulated the necessary information to publish consensus reports on the safety and effectiveness of exercise in treating various clinical conditions.

Practical Implications for Current Policy In early history, it was common practice to prepare comprehensive multi-volume medical texts that summarized the work of classical scholars, emphasizing unproven ideas and personal opinion. This approach was slow to disappear. As late as the 1950s, John Conybeare’s widely used Textbook of Medicine still offered many unproven remedies for common medical ailments. A willingness to rely on classical scholarship, and a lack of critical review of the evidence undoubtedly slowed the progress of medical knowledge over the centuries. The material published in medical journals is now critically reviewed by the author’s peers, who look for proof of assertions by well-designed double-blinded experiments. Increasingly, comprehensive textbooks reflect this new evidence-­ based approach to medicine. Further, electronic publishing and translation now allow the wide dissemination of current knowledge around the globe. However, a new threat to knowledge is posed by the emergence of aggressive commercial publishers, who will (for a large fee) rapidly publish material with minimal peer review and little regard for its accuracy. In future, those writing medical texts and review articles will need to ensure that their sources are limited to scientific journals with a sound reputation and a high citation index.

Questions for Discussion 1. How do you think a scribe might modify the content of a medical text during its transcription? Is there any such danger in the presentation of modern research on health and fitness? 2. What would be your major criticism of the medical texts available during the mediaeval era? 3. Why do you think that were there no texts dealing with the health and fitness benefits of sport participation until the 1930s?

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Conclusions Although medical knowledge was at first transmitted orally, the early civilizations of Egypt, India, China, Greece and Rome all prepared exhaustive accounts of their accumulated medical beliefs, often interwoven with religious superstition and complicated by a poor understanding of human physiology. The texts provided some useful information on surgical techniques and potent herbs, and despite their limitations some of these volumes were accepted uncritically as reference works well into the seventeenth and eighteenth centuries. Although earlier narratives made occasional references to exercise and health, books dealing specifically with sports medicine and the health benefits arising from regular physical activity did not make their appearance until the 1930s.

Further Reading Biller P, Ziegler J. Religion and medicine in the Middle Ages. Woodbridge, ON, Boydell & Brewer, 2001, 253 pp. Carter N. Medicine, sport and the body: A historical perspective. London, UK, A.C. Black, 2012, 304 pp. Chattopadhyaya D. Science and society in ancient India. Amsterdam, Netherlands. John Benjamins Publishing, 1978, 441 pp. Dendle P, Touwaide A. Health and healing from the mediaeval garden. Mertlesham, Suffolk, Boydell & Brewer, 2015, 270 pp. Getz F. Medicine in the English Middle Ages. Princeton, NJ, Princeton University Press, 1998, 192 pp. Hildegarde. Selected writings. London, UK, Penguin Books, 2005, 320 pp. Hinrichs TJ, Barnes LL. Chinese medicine and healing. Cambridge, MA, Harvard University Press, 2013, 464 pp. Ho PY, Lisowski FP. A brief history of Chinese medicine. Hackensak, NJ, World Scientific, 1997, 103 pp. Lagerkvist U. The enigma of ferment: From the Philosopher’s stone to the first Biochemical Nobel Prize. Hackensak, NJ, World Scientific, 2005, 172 pp. Longrigg J. Greek medicine: From the heroic to the Hellenistic age. Abingdon, OX, Routledge, 256 pp. Miles SH.The Hippocratic oath. Oxford, UK, Oxford University Press, 2005, 232 pp. Nunn, 1997, JF. Ancient Egyptian medicine. Norman, OK, University of Oklahoma Press, 2002, 240 pp. Nutton V. Ancient medicine. Abingdon, OX, Routledge, 2013, 488 pp. Sezgin F. Constantinus Africanus and Arabic medicine. The School of Salerno. Frankfurt, Germany, Institute for the history of Arabic-Islamic Science, 2006, Catalogue IV, Chapter 7, 1–34. Sigerist HE. A history of medicine: Early Greek, Hindu and Persian medicine. Oxford, UK, Oxford University Press, 1987, 352 pp. Strouhal E, Vachala B, Vynazalova H. The medicine of the ancient Egyptians, Vol. 1. Cairo, Egypt, American University in Cairo Press, 2014, 272 pp. von Staden H. Herophilus: The art of medicine in early Alexandria. Cambridge, UK, Cambridge University Press, 1989, 666 pp. Wallis F. Mediaeval medicine: a reader. Toronto, ON, University of Toronto Press, 2010, 563 pp. Wujastyk D. The roots of Ayurveda. Delhi, India, Penguin Books, 1998, 389 pp.

Chapter 19

Teaching Health and Fitness to the Growing Child: The Physical Educator

Learning Objectives 1. To note the wide range of physical education programmes that have been developed at various times and in various countries. 2. To observe how individual physical education programmes have been shaped to meet such objectives as military preparedness, excellence in sport, a team spirit, beauty of movement, and the development of health and fitness. 3. To understand how governmental support of physical education has often been stimulated by military concerns, and curtailed once the immediate threat of armed conflict appeared to have passed.. 4. To support the current emphasis upon enjoyable conditioning programmes that have sufficient intensity to enhance a child’s physical condition, but which create long-term positive attitudes towards physical activity, health and fitness.

Introduction Until recently, physical education has been conceived largely in terms of learning the skills needed for successful hunting and gathering, preparing the individual for armed combat, and/or ensuring success in a particular athletic discipline; however, the emphasis has now shifted to teaching the growing child a lifestyle that can sustain lifelong health and fitness. In the earliest societies, children were taught activity skills by their grandparents, and from an early age they accompanied their parents on hunting and foraging expeditions (Chap. 10). More formal physical activity instruction was given in both Persia and India, and systematic programmes of physical education reached their apogee in ancient Athens and Sparts. Subsequent initiatives in Europe have followed a wide range of differing philosophies; we will trace these ideas briefly from the Middle Ages through the Renaissance, the Enlightenment, the Victorian and the © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_19

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Modern Eras through to the present day, sketching brief portraits of some of the main protagonists of various approaches. The specific issue of the co-option of sport and physical education programmes for political ends is deferred to Chap. 20.

Physical Education in Ancient Persia Early leaders in the Persian Empire of the sixth century BC ensured the physical fitness of male children through mandatory training programmes that began at the age of 6 years. The regimen included hunting, marching, riding, and javelin throwing, with the primary objective of providing well-trained recruits for expansionist wars.

Physical Education in Ancient India During the Vedic period of Indian history (1500–500  BCE), physical educators were appointed to instruct the sons of twealthy Hindus. Teaching included chest pushes, full-squats, and a wide range of sports. Buddhist seats of higher learning also established facilities for the teaching of physical education and corrective physical activity from about 700 BCE, and Janists also established a gymnastic institute with a strong interest in the teaching of yoga around 500 BCE.

Physical Education in Classical Athens and Sparta The Athenians placed a high premium on physical education, with a strong cadre of professional teachers providing a combination of physical education and academic learning in the Palaestrae and Gymnasia. Spartan society placed an even greater emphasis upon physical education, although their focus was almost entirely upon physical rather than mental development. Athenians recognized important linkages between physical and mental skills, as we can see in the views of scholars such as Solon, Aristotle, Quintilian, and Galen. The palaestrae thus taught not only athletic skills, but also literature, mathematics and music. Solon  Solon (c. 638–559 BCE), an early Athenian statesman, explained that students engaged in all of the rigorous demands of the gymnasium in order to: “develop manly perfection, physical beauty, wonderful condition, mighty skill, irresistible strength, daring rivalry, indomitable resolution and inexpressible ardor for victory.”

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Fig. 19.1  The Greek palaestrae taught children both physical and mental skills. The ruins of the palaestra at Olympia cover an area of 60 m2 (Source: http://en.wikipedia.org/wiki/Palaestra_at_ Olympia)

Aristotle  Aristotle (384–322  BCE) recommended that instruction of the child should include play, physical activities and morals to the age of 14 years, with physical education preceding education of the mind. Quintilian  Quintilian (c. 35–100 CE) was a Roma rhetorician, and teacher of Pliny the Younger. He appreciated the value of physical activity to the development of a graceful body, but also favoured the inclusion of play in the teaching of young children. However, he cautioned that exercise for older children should be purposeful, and warned that over-attention to the body could dull the mind. Galen  Galen (130–216 CE), the physician of Pergamon, conceived the idea that there was an activity centre in the brain. He stressed that nature compelled young children to engage in active play, and this fact should influence patterns of teaching of the young. Palaestrae  The palaestrae were physically quite large complexes (Fig. 19.1). The school at Olympia dates from the end of the third century BCE; it covered an area of 60 m2. Facilities included changing rooms, rooms for the teaching of gymnastics, wrestling and boxing, and areas set aside for punch-bag practice, cold and hot baths, the application of oils and dusting powders, as well as space for academic study. An open central court allowed running, jumping, discus and javelin throwing. The palaestra at Delphi also boasted 2 ball courts and a 9.7 m diameter bathing tank. The staff of the palaestrae included paidotribes (somewhat analogous to the modern trainer), grammatistes (who taught writing, arithmetic and literature), kitharistes (who taught singing and the lyre), and the paidagogos, slave-guardian/ monitors who supervised the morals of the students while they were in residence. Tuition fees were high, and although wealthy children attended school until they graduated to the gymnasia, the offspring of poorer citizens probably received no more than 3–4 years of instruction at the palaestrae (Fig. 19.2). Gymnasia  Around 16 years of age, wealthy Athenian youths graduated from the palaestra to the gymnasion. The latter provided training for participation in the public games, and opportunities for socializing and philosophic discussion. A

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Fig. 19.2  At the age of 16, Athenian children graduated from palaestrae to gymnasia. Substantial ruins of the gymnasion at Pompeii remain to this day (Source: http://en.wikipedia.org/wiki/ Gymnasium_(ancient_Greece))

s­ tadium for athletic events was often built adjacent to the gymnasion. By the second century CE, major cities in Greece all boasted at least one gymnasion. The word gymnasion literally means a school for naked exercise. In the time of Homer, Greek athletes had worn clothing when they were exercising. Explanations for the subsequent change of policy include a winner who lost his shorts en-route to the finishing-line, a poorly coordinated runner who tripped over his clothing, an attempt to alleviate heat stress and (most plausibly) an opportunity for spectators to appreciate the aesthetics of a well-trained body. Although the Paidotribes continued to supervise the immediate physical activities of an adolescent attending the gymnasion, their instruction was overseen by the gymnastes, highly paid exercise trainers who purported to understand not only the mechanics of athletic performance, but also what a given type of movement could do for the body. The gymnastes monitored the progress of their charges, and prescribed any necessary remedies. Sometimes, they were as aggressive as modern coaches. One urged: “What a wonderful inscription on your grave. He did not give up at Olympia” Much as in some Universities today, the gymnastes also had police powers in order to maintain discipline within the confines of the gymnasion. Other staff of the gymnasion included the aleipte. They anointed the athletes’ bodies with oil, performed massages, administered herbs and carried out any necessary minor surgery. Attitudes in Sparta  The Spartan teaching of physical education showed some differences from that in Athens. The Spartan gymnastes were expected to have a thorough understanding of military manoeuvres, and the primary intent of their instruction was to: “maintain an army of experts who were ready and able at any moment to suppress sedition within the state or repel invasion from without.” Education was seen as a disciplined undertaking from a very early age. The mother instructed the young infant, and the father quickly began to supplement this with moral training. Mothers soon gave their sons a military shield, with the instruction that they should return: “Either with this or upon this.” At the age of 6 or 7, all Spartan male children entered a special fitness programme, and thereafter the government assumed responsibility for the child’s

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upbringing until adulthood. Rigorous training began with 5  years of gymnastics. The subsequent regimen increased pain tolerance, as the adolescent faced walking barefoot, sleeping on an ox-hide, eating a meagre diet, and bathing in cold mountain streams. Scourging was frequent, but whimpering was not allowed. Recreational boxing was a common pastime, and other sports included wrestling, running, ball games, archery, dancing, hunting, bare-back riding and javelin throwing. Successful graduation from the programme was a condition of being granted Spartan citizenship. Spartan girls also underwent mandatory physical training from the age of 6 or 7 years. The girls programme included wrestling, running, playing ball, throwing the javelin and discus, swimming, riding horseback, and light combat, with the primary goal of producing women who would bear healthy children. Although the physical results of Spartan education were outstanding, in the view of the Athenians, their academic attainments left something to be desired. Aristotle maintained: “Parents who devote their children to gymnastics while they neglect their necessary education in reality vulgarize them, for they make them useful to the State in one quality only.”

Physical Education in Mediaeval Europe In mediaeval Europe, formal education was only available to children of the nobility and upper middle class. Instruction of the Nobility  Between the ages of 7 and 14 years, the sons of the nobility served as pages to powerful barons, mastering the very physical aristocratic curriculum of riding, swimming, diving, use of the crossbow, arm- and hand-bow, the climbing of ladders, poles and ropes, titling and jousting, wrestling, fencing, and courtly dancing. At the age of 14, they became squires, attending to their master’s horse, and at 21 years they were admitted to the knighthood. Many youth who followed this regimen became extremely fit. One page of Charles VI could turn a somersault wearing full armour, and could pull himself up a ladder using only his hands while equipped in full harness. Unfortunately little attention was paid to the inclusion of any academic instruction, and many knights were obliged to hire a secretary because they could neither read nor write. Instruction of the Middle Class  Middle-class children were mainly taught in monasteries and cathedral schools. The curriculum offered by these institutions had no component of physical education, although the rapid succession of mediaeval “holy days” gave the boys some opportunities for play. Parish priests were sometimes more tolerant of physical activity than the monks. Enea Piccolomini (1405–1464  CE) was a Sienna-trained schoolteacher. He proposed a regimen of “natural education” that included archery, hammer and spear throwing, riding, swimming, hunting and ball-playing, with exercise for girls as well as boys: “we aim at implanting habits which will prove beneficial throughout

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life….Games and exercises which develop the muscular activities and the general carriage of the person should be encouraged by every teacher.” Building upon the informal type of schooling available at the parish church, choristers’ schools were attached to most English cathedrals in the latter part of the Mediaeval Era, and almonry schools became associated with large monasteries.

Physical Education During the Renaissance In England, the Renaissance saw the emergence of guild schools and grammar schools. The Bishop of Winchester founded Winchester College in 1394 CE, and in 1440  CE Henry VI opened “The King’s College of Our Lady of Eton besides Wyndsor.” The original intent of the Eton college was to educate 70 poor children, rather than future Prime Ministers of England, but this objective was soon lost. Curricula with a commitment to physical activity were the exception rather than the rule during the Renaissance. The Dutch teacher Erasmus (1446–1536 CE) saw no place for sport or physical education when instructing children over the age of 6 years. When schoolboys begged for a holiday for games, Erasmus replied: “they that labour hard had need of some relaxation; but you that study idly and play laboriously had more need of a curb than a snaffle.” However, there were some scholars who appreciated the importance of developing both the body and the mind of the growing child. We will look at the contributions of da Feltra, Alberti, Vegio, Mulcaster, and de Montaigne. da Feltre  In the Talian region of Lombardy, Vittorino da Feltre (1378–1446 CE) was invited by the Marquis of Mantua to tutor his children. da Feltre set up a Spartan boarding school away from the court, with little artificial heat in the building even during the cold of winter. An enrolment of some 70 pupils included the children of the Marquis, the offspring of other wealthy Mantuans, but also a leavening of poor children. Hearing two young boys earnestly discussing the morning’s academic lessons, da Feltre declared “That is not a good sign in a young boy,” and he sent the students off to join the other pupils in their games. Ample room was found for ball games, riding, running, leaping, fencing and other forms of exercise in the grounds surrounding his school. Feltre avoided physical punishment, and lessons were individually adapted to the students’ abilities. Greek and Roman literature formed the basis of the academic curriculum, but da Feltre also taught history, philosophy, arithmetic, geometry, music, and astronomy. Moreover, he combined this mental training with individually prescribed exercise and games in order to encourage the physical development of his pupils. Alberti  Leon Battista Alberti (1404–1472 CE) was an Italian perhaps best known as an architect, but he was also interested in educational philosophy, and some have considered him the archetype of the Renaissance scholar. He advocated beginning exercise in early infancy, to strengthen the muscles, boost the circulation and adapt

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the nervous system. Moreover, he emphasized that such exercise became even more important with increasing age. He himself excelled in all types of bodily exercise. He amused himself by taming wild horses and climbing mountains, and he could leap over a standing man while his feet were tied. Vegio  Maffeo Vegio (1407–1458 CE) was a professor at the University of Pavia, in Lombardy. He wrote a 6 volume treatise on the education of children. The first 3 volumes dealt with the responsibilities of parents and teachers, and volumes 4–6 covered the duties and good manners of children. Unlike many of his contemporaries, Vegio approved the education of girls, and he believed that exercise should become an integral part of normal pedagogy. Mulcaster  Richard Mulcaster (1531–1611  CE) was a notable teacher in Renaissance England. He was appointed as the first headmaster of the Merchant Taylor’s Guild School, in London, but after a dispute over his salary he set up a private school, before becoming headmaster of the rival St. Paul’s School. Unlike many of his contemporaries, Mulcaster was as interested in educating the children of burghers as those of the nobility. He also approved the education of girls (although he thought that this should be undertaken at home rather than at school). In his “Positions concerning the training up of children” the chapter on exercise covered such topics as: “How necessarie a thing exercise is… What health is, and how it is maintained… what sickness is, how it commeth, and how it is prevented…. What a parte exercise playeth in the maintenance of health.” Mulcaster argued that fitness enhanced intellectual learning, and he rounded out the elementary curriculum for his school with exercise as an important sixth principle. He listed what he considered the best exercises for children: walking, running, leaping, martial arts, wrestling and fencing, swimming, riding and ball exercises. He coined the term footeball, and organized something approaching the modern form of this game. He asked referees to guard against any rough play, and argued that if it was played appropriately, football not only maintained health and promoted strength, but also had educational value. However, he also recognized the vagaries of the English climate, and recommended exercises that could be practiced indoors as well as outdoors. Montaigne  Michel de Montaigne (1533–1592 CE) was an early French humanist who is said to have influenced the thinking of both Shakespeare and Rousseau. Montaigne’s father was a great believer in exercise, and had sufficient strength to turn his body around on a table while supporting himself on his thumb. Montaigne himself lacked this formidable strength; he could neither swim nor fence, but he became a fair runner and an excellent horseman. Like Mulcaster, he argued that the physical and moral education of the child were closely linked: “It is not enough to toughen his spirit, his muscles also must be toughened.” An appropriate physical education programme should include running, wrestling, dancing, hunting, riding and fencing.

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The Enlightenment By the seventeenth century, English children from wealthy homes began their education at what was termed a “petty school.” The boys then progressed to a grammar school, and the girls were educated further by personal tutors (or their mothers, in the case of poorer families). In most of Europe, lower class children still did not attend schools beyond the age 10 or 11  years, although a few of the “brightest” students might continue their education by winning a scholarship or finding a wealthy benefactor. Many of the available schools were staffed by indifferently educated minor clergy. Others were privately operated by even more ignorant instructors. Often, teachers maintained order by a combination of bullying, beating, and ridicule (Fig. 19.3). Classes (usually all boys!) could have a roster of 100 pupils. The school day was sometimes as long as 13 hours, with short breaks for meals, and neither time nor space for physical activity. Often, the only activity open to the pupils was to perform minor chores around the schoolroom. However, the Age of Reason spurred new thinking, and for some European scholars there was a growing nationalism, with a sense of the moral value of physical activity. In North America, the Pilgrim Fathers brought with them a tradition of scholarship, and they introduced a programme of formal education soon after their arrival. In 1642 CE, the State of Massachusetts passed a law requiring both parents and apprentice-masters to ensure that every child in their care was taught to read.

Fig. 19.3  The Dickensian character Nicholas Nickleby tackles Mr. Squeers, a schoolmaster who has been beating one of the boys at Dotheboys Hall, a small fictional private school in England. (Source: http://en.wikipedia.org/wiki/Nicholas_Nickleby)

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We will comment specifically on the contributions of Comenius, Rousseau, and Catherine the Great to education of the Enlightenment child. Comenius  Johann Amos Comenius (1592–1670, Fig.  19.4) came from a poor Czech family, and did not to begin his education until the age of 16 years. However, he was subsequently able to attend the University of Heidelberg. He was forced into exile because of his views as a Moravian, and took refuge in Poland. There, he led a “gymnasium,” and is considered by many as the father of modern education. Comenius urged educators to make learning a pleasure rather than something instilled by corporal punishment. He wrote that understanding comes “not in the mere learning of the names of things, but in the actual perception of the things themselves.” One of his six educational principles was: “Education should be physical as well as mental and moral; children should be trained in health and vigor through outdoor life and sports.” He argued that, just as the soul was nourished by books, so the body was nourished by movement. Thus, 30 minutes of exercise should be provided for every hour of academic study. He also commended light exercise for pregnant women, in order that they might bear vigorous offspring. Rousseau  Jean-Jacques Rousseau (1712–1778) was the son of a watchmaker in Geneva. His mother unfortunately died 9 days after his birth. After a chequered up-­ bringing, he moved to Paris, and became a friend of Diderot, contributing to his vast “Encyclopaedia.” Rousseau returned to Geneva in 1754, and reconverted to Calvinism, but unwisely expressed his view that all religions were equally worthy. Thus he was forced to flee to England, where he took refuge with the Scottish philosopher David Hume. Fig. 19.4 Johann Comenius (1592– 1670 CE), pioneer Moravian educator who encouraged the integration of physical and academic learning (Source: http:// en.wikipedia.org/wiki/ John_Amos_ Comenius#cite_ note-eb1911-12)

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Rousseau argued strongly against the interference of either Church or State in matters of education. He placed a strong emphasis on health, and the unity of mind and body. In his view, outdoor games and sports played an important role in maintaining good health and predisposing to longevity. Until the age of 12  years, the emphasis of schooling should be on cultivation of the body and the senses, rather than the intellect. In acquiring physical skills, the pupil would learn about the mechanics of the world and about himself. Physical activity also contributed to character training: “The training of the body…. is…the most important part of education not only for making children healthy and robust, but even more for the moral effect.” Finally, Rousseau appreciated that physical training could serve nationalistic ends. As policy adviser to the newly reconstituted state of Poland, he suggested that games would make children’s hearts: “glow and create a deep love for the fatherland and its laws…” Catherine the Great  At the other end of the Enlightenment spectrum in terms of attitudes to exercise, Catherine the Great of Russia (1729–1796 CE) wrote a book on education, and opened the Smolny Institute in St. Petersburg. At first, this offered schooling for girls of the nobility, but later it was opened to the petit bourgeoisie. Students were taught impeccable French, music and dancing, but running and games were strictly forbidden and the rooms were kept bitterly cold, because it was thought that exercise and an excess of warmth impaired development of the girls’ bodies.

Physical Education in the Victorian and Modern Eras The Victorian Era saw a growing emphasis upon gymnastics in the better European schools. There was a strong rivalry between German, Danish and Swedish systems of instruction. Czechoslovakia, Switzerland and France all added their particular contributions to systems of teaching, and by the final two decades of the nineteenth century, English “Public” School athletic programmes also began to attract attention across Europe. We will look at each of these various perspectives, noting also how immigrants carried interest in German and Swedish gymnastics to specific ethnic communities in the U.S. and Canada, with Canadian efforts to enhance physical education being stimulated by fears of imminent invasion from the United States. During the Modern era, British “Public” schools continued the traditions of the nineteenth century, whereas State grammar and secondary Schools emphasized traditional gymnastics. At state primary schools, rhythmic gymnastics were often performed outdoors, with shivering boys stripped to the waist even in the snows of winter. The grammar school that I attended had a relatively well-equipped gymnasium with wall-bars, parallel bars, rope ladders, ropes, boxes and jumping horses. Sex-segregated gymnastics classes were scheduled for 40 minutes twice per week, supplemented by 40 minutes of games. In the summer, there was cricket for the boys and tennis for the girls, and in the winter field hockey for the girls and soccer for the

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boys. Male students also had opportunity to play “drop-in” cricket and soccer for 15–20  minutes before morning and afternoon academic classes. Most cycled or walked 2–3 km to and from their homes twice a day. Germany  During the Victorian Era, German interest in physical education can be traced to the enthusiastic efforts of Basedow, Guts-Muths, Vieth and Jahn. The average time allocated for gymnastic instruction rose to a substantial 2 hours per week. One teaching guide from 1871 was entitled “Gymnastic rides, hikes and school trips,” and a more general Handbook of School Hygiene, published in 1900, included a substantial section on gymnastics. The militaristic nature of most programmes appealed mainly to male students, and from the age of puberty girls tended to play truant from required physical education classes. Basedow  Johann Bernhard Basedow (1723–1790 CE) was born in Hamburg. He studied at the University of Leipzig, and becoming an enthusiastic disciple of Rousseau, he decided to reform the Prussian educational system. He began as a private tutor to the rather difficult son of a Holstein nobleman, and wrote his M.A. thesis “On the best and hitherto unknown method of teaching children of noblemen.” He next taught at Academies in SorØe, Denmark and Altona, but was dismissed for a combination of unorthodox theology and riotous living. He then moved to Dessau in North Germany, where he established a model school or Philanthropinum (Fig. 19.5). The daily schedule of this establishment comprised 5 hours of academic learning, 3 hours of games and physical exercise and 2 hours of physical labour and handicrafts. The emphasis throughout was upon playful pursuits and self-directed learning. Items from the SorØe programme in Sweden (horseback riding, dancing and ball games) were adapted to the Baroque taste, with development of the Dessau pentathlon (running, jumping, throwing, carrying and balancing).

Fig. 19.5  In Basedow’s model school (the Philanthropinum), the emphasis was upon a playful approach to education (Source: http://en.wikipedia.org/wiki/Johann_Bernhard_Basedow)

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Guts-Muths  Johann Christian Friedrich Guts-Muths (1759–1839) also lived in North Germany, and he was greatly influenced by the educational views of Basedow. Guts-Muths is often regarded as the grandfather of gymnastics. He joined the beauty of Greek gymnastics to the militaristic exercises of Jahn (below), and he included women in his vision, writing: “woman is not destined to move sickly through this world, but to live.” Guts-Muths and Salzmann published the first systematic text of gymnastics for schools (1793), arguing that moral health and mental robustness often depended upon bodily strength. Guts-Muths wrote other influential books including: an analysis of the skills developed by 105 different sports, gymnastics for the young; and gymnastics for the sons of the Fatherland. He believed that all physical activity should take place out of doors, and that by the age of 7 years, a child should accumulate 10 hours of physical activity per day, including gardening and social play. His programmes included running, jumping, lifting, carrying, dancing, balancing, vaulting, fencing, shooting, and military drill. However, the necessary facilities remained simple. Typically, class needs were met by little more than a 6 m wooden frame fitted with ropes, a rope ladder and a climbing pole. Vieth  Gerhard Ulrich Anton Vieth (1763–1836) was a gymnastic pedagogue who spent much of his career in the city of Dessau. He published an encyclopaedia of physical education (1792) that included among other things information on the lifestyle of extinct ethnic groups, and ideal characteristics for vaulting horses. He concluded: “Physical exercises were driven without a doubt even in the earliest times, this is the nature of the thing.” Jahn  Friedrich Ludwig Jahn (1778–1852  CE) was born in Brandenburg. His University days were marked by clashes with both students and academic authority. He reached Jena in time to witness defeat of the Prussians by Napoleon, and became a voluntary fugitive. He spent much time brooding on the humiliation of the German people by Napoleon, and joined a contingent of the Prussian army committed to continuing the fight against France. He saw enhanced physical development through outdoor gymnastics as a tool in the rebuilding of his country: “Only when all men of military age have become capable through physical education of bearing arms….. can a people be called militarily prepared.” He established the first gymnastics club, or Turnverein, in Berlin in 1811, and soon upwards of 1000 young enthusiasts were meeting for exercise twice weekly outside the gates of the city. Permanent grounds for the Turnverein were next found; these included facilities for running, jumping, balancing, climbing, and vaulting. The stated aims of the club included not only the development of physical health, but also the promotion of “German-ness” During the French occupation, he declared: “Poles, French, priests, aristocrats and Jews are Germany’s misfortune,” thus leading some to consider him as one of the precursors of the Nazi movement. By 1819, the authorities recognized that the Turners had an unwelcome political agenda. Jahn was at first kept under house arrest, then imprisoned for 2 years, and

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finally told he must live 10  miles outside of Berlin. The Turnplatz was officially closed, but exercise programmes appear to have continued behind closed doors. Following their unsuccessful participation in a revolutionary uprising, many Turners were forced into exile, thus spreading the Turner movement to Britain, the United States and Canada. The humiliations of the Treaty of Versailles (1919) gave renewed impetus to the political ideas of Jahn, and his style of gymnastics became a part of German physical education in 1935. His ideas can also be seen in some of Hitler’s speeches. Denmark and Sweden  In Scandinavia, gymnastics was viewed largely as an educational tool, but it did also include a military component. Swedish instructors emphasized free movement and the perfection of rhythmic activities rather than deliberate muscle building. Important figures in the Scandinavian story have included Christiani, Nachtegall, Bukh, Salzmann and Ling. Christiani and Nachtegall  Christiani, chaplain to Frederik VI of Denmark, opened a private school in Vesterbro, near Copenhagen in 1795. The curriculum placed a strong emphasis upon bodily exercises, active games and the ideals of Basedow. Franz Nachtegall (1777–1847) was appointed as teacher of physical education at this school in 1799 CE. By 1805, nine private and public schools in the region were offering similar gymnastics courses. Following some military disasters, Frederik VI decided to create a Danish Institute of Military Gymnastics, and appointed Nachtegall as its first Director. He developed a detailed gymnastics manual for the military course. In 1807, he was also appointed professor of gymnastics at the University of Copenhagen, and he was awarded an honorarium of 300 Rix-dollars (about 5 pounds sterling) for the instruction of civilians who showed an interest in the teaching of physical education, An ordinance of November 7th, 1809 required Danish secondary schools to offer a daily hour of gymnastics “when and where it was possible,” and in 1814 gymnastics became an integral curricular component for boys attending State elementary schools, with every school providing at least 300–450 m2 of outdoor space for the teaching of gymnastics. Bukh  Niels Ebbesen Bukh (1880–1950) was born in Jutland. He built on the tradition of Nachtegall. Although a vigorous proponent of sport for all, Bukh focussed particularly on elite male aesthetics. Tightly clad gymnasts engaged in gracious and suggestive touching, followed by powerful, dynamic movements performed at a frantic tempo. Bukh boosted the national image by international trips with his acclaimed gymnastic teams. But later he became fascinated with the German Nazi party, a strange choice given his apparent homosexual orientation. During the 1930s his form of gymnastics was popular in German and Japanese schools. Salzmann  Christian Gotthilf Salzmann (1744–1811) founded a boarding school with Natural Law and Enlightement as its watchwords. He had taught previously at Basedow’s philanthropinum in Dessau, and was heavily influenced by the ideas of Rousseau. In his text on Gymnastics for Youth, written jointly with Guts-Muths

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(above), Salzmann suggested:“We are weak because it never enters our thoughts that we might be strong.” Ling and Zander  Pehr Henrik Ling (1776–1839) dominated Swedish physical education during the early part of the nineteenth century. He was appointed fencing master at the University of Uppsala in 1805, and was active in fencing, riding and swimming. He observed that daily exercise had cured his rheumatism and overuse injuries, and he thus became interested in developing gymnastics as a therapeutic measure. In 1813, he was appointed Principal of the newly constituted Royal Central Gymnastic Institute in Stockholm, well known tin recent times for such scholars as P-O Åstrand and Bengt Saltin. Here, Ling developed a system that emphasized: (1) pedagogic gymnastics, (2) military gymnastics, (3) medical gymnastics and (4) aesthetic gymnastics. His programme gained the respect of local doctors, and in 1831 he was elected an honorary member of the Swedish General Medical Association. Swedish massage became widely accepted across Europe, with its characteristic components of stroking, kneading, friction, and vibration. Ling recognized that exercise was essential for everyone, although he maintained that it should be tailored to respect individual differences. He also insisted that physical educators acquire a sound knowledge of physiology, and probably for this reason, the Royal Central Gymnastic Institute has continued to play a dominant role in clinical exercise physiology for some two centuries. The demand for Swedish massage quickly exceeded teaching capacity, stimulating a call for machines that could provide active, assisted and resisted exercise. A medico-mechanical system was thus elaborated by a Swedish physician, Gustaf Zander (1835–1929). By strapping patients to a variety of machines, he was able to exercise many muscles, adjusting weights as the individual’s strength improved. By 1876, Zander had a roster of 900 patients attending various Institutes across Europe. In the 1970s, an American entrepreneut (Arthur Jones) marketed very similar machines under the trade name of Nautilus. Czechoslovakia  Czechoslovakian gymnastics closely followed the lines of the German Turners. As in Germany, gymnasts reacted against industrialization and urbanization; their urge was to get exercise out into the open air. The movement took the name of Sokol (falcon), and was led by Miroslav Tyrš (1832–1884). Ostensibly, it was “above politics,” aiming to provide physical, moral, and intellectual training for the working classes, but de facto it played an important role in fostering Czech Nationalism. The physical activity component of the Sokol movement focused on marching, fencing, weight-lifting and rhythmic gymnastics. In the first decade of the twentieth century, alignment with the Czech National Socialist party brought about an unfortunate “ethnic cleansing,” with elimination of Germans and Jews from its classes. At this point, some Sokol members shifted their allegiance to the rival Workers’ Gymnastic Club. Switzerland  Important contributors to physical education in Switzerland included Pestalozzi and Piaget.

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Pestalozzi  The pedagogue Johann Heinrich Pestalozzi (1746–1827, Fig.  19.6). enthusiastically endorsed the concept that children should receive schooling irrespective of the wealth of their parents. His grandfather was a Pastor, and by accompanying him on parish visits, Johann learned the poverty of the peasants and the problems of children who entered factories with little education. After some fruitless ventures, he established a successful school at Yverdon, in the Vaudois region of Switzerland, and in 1802 he travelled to Paris, hoping to interest Napoleon in his system that combined physical education and academic teaching. However, Napoleon told him that he was “not interested in the alphabet.” Pestalozzi vigorously opposed rote learning and corporal punishment, embracing as his motto “learning by head, had and heart.” In his view, education should be child-centred, based on individual differences, sensory perception and the student’s own activity, with a strong emphasis upon outdoor activity. By 1830, his efforts had largely abolished illiteracy in Switzerland. Piaget  Jean Piaget (1896–1980) was a developmental psychologist from Neuchatel, in Switzerland. In the context of health and fitness, he is best known for the sensori-­ motor model of intellectual development, which postulates that children develop brain structures through adaptation to appropriate programmes of exercise. France  Napoleon levied most of his troops abroad, and thus was not greatly interested in the military potential of physical education. But attitudes changed following the defeat of France by Prussia in 1870 CE. Subsequently, militaristic physical education became compulsory for both boys and girls. Controversy over the merits of rhythmic versus militaristic gymnastics continued for several decades, with Delsarte promoting the rhythmic approach, and Amorós arguing for military drills. Fig. 19.6  Johann Heinrich Pestalozzi (1746–1827 CE) was a Swiss national who had an important influence upon both physical education and academic instruction (Source: http:// en.wikipedia.org/wiki/ Johann_Heinrich_ Pestalozzi)

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Other noteworthy scholars on the French scene included Demenÿ, Hébert, Triat, and (in the Modern Era) Tissié. Delsarte  François Delsarte (1811–1871) taught relaxing exercises and breath control for actors, and he believed that certain rhythmic physical exercises contributed to poise, grace, beauty and health. Towards the end of the nineteenth century, a vogue for what was erroneously termed Delsarte “gymnastics” developed in North America, and this was perpetuated into the twentieth century through the teachings of Rudolf von Laban (1879–1858) and Frederick Matthias Alexander (1869–1955). Amorós  Francisco Amorós (1769–1848) was born in Valencia, Spain, and became a leading exponent of militåry gymanstics. He founded the Military Gymnastics School in Madrid, but after the defeat of Napoleon, political considerations forced him to migrate to France. In 1819, he organized the Normal Gymnastic Civil and Military School in Paris, and in 1831 CE he became the French National Director of Gymnastics. He brought a scientific attitude to his task, collating physiological data on each recruit, including dynamometric measures of their muscular performance. He defined gymnastics as: “the rational science of our movements and their relationship to our senses, our intelligence, our mores, and the development of all our faculties.” Problems with the Bourgeois Revolution caused Amorós to lose his office in 1830, but the army continued to follow his plan of physical education, establishing a permanent military gymnastics school at Joinville-le-Pont in 1852. After his dismissal from the military, Amorós opened a commercial gymnasium in Paris. His pattern of gymnastics included many elements found in a Turnverein. Demenÿ  George Demenÿ (1850–1917) was a physiologist and physical educator interested in chronophotography and biomechanics, and he collaborated closaely with Etienne-Jules Marey, inventor of the sphygmograph. In 1898, Demenÿ returned to physical education, founding the Cour Supérieur d’Education Physique in Paris. Demenÿ had initially favoured the Swedish system of gymnastics, but later he concluded that these exercises were too static; training should develop the cardio-respiratory system rather than the muscles. Hébert  Georges Hébert (1875–1957) was a naval officer. He was impressed by the physique of some of the indigenous people that he had seen during his voyages, and he urged a return to primitive natural movement, with the slogan:“Be strong to be useful.” He stripped his gymnasium of all equipment. A presentation on the improvement in performance of 350 seamen, given at the 1913 International Congress of Physical Education, was well received, and soon afterwards Hébert was appointed Director of the Athletes’ Secondary School in Reims. He also assumed responsibility for the physical training of French troops during World War I, and his ideas form the basis of the present Parkour.

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Triat  French-speaking countries enjoyed an enthusiasm for public gymnasia, thanks largely to the influence of Hippolyte Triat (1812–1881). He opened his first commercial gymnasium in Liège in 1833, followed by a larger establishment in Brussels in 1840. Ten years later he built a grandiose gymnasium in Paris, with spectator galleries on the second and third floors; this facility attracted many of Paris’s distinguished citizens. Tissié  Some French experts such as PhilippeTissié (1852–1935) criticized the teaching of sport following World War I, pointing to a lack of progression, a cultivation of the ego, an antidemocratic division into winners and average performers, excessive specialization, and the temptations of professionalism. England  In reviewing British contributions to physical education in the Victorian and Modern Eras, some have focussed on the sports programme introduced by Thomas Arnold at the “Public” school in Rugby. The Catholic theologian Cardinal Newman also had much to say in favour of sports at elitist schools. However, English “Public” schools never served more than a privileged minority of the population. The great majority of students attended State schools, sometimes only for a few years. School attendance first became compulsory between 1876 and 1880, but most state schools remained poorly equipped, whether for teaching academic material or physical activity. Often, they had no more than a small tarmac or gravel courtyard for gymnastics, and the instructors were commonly retired War-Office drill sergeants. Later, some graduates from the Ling Institute were also recruited. They introduced musical drill, gymnastics, dancing, swimming and games. But most children continued to follow military style gymnastic programmes. We will comment here on the contributions of Walker, Arnold, MacLaren, Newman, Arnold, and the Sports Control Board of the British Army. Walker  Experience gained during the colonization of India led the British army to be impressed with the fitness of those who engaged in the swinging of Indian clubs, and this form of physical activity gained a following in Victorian Britain. Donald Walker (1784–1836), a British magistrate, specifically recommended such activity in his catalogue of “British Manly Exercises:” He followed up with a text for women, where the weight of the clubs was reduced to 2 pounds (0.9 kg); many of the exercises for women were performed seated, doing little to increase respiration. Walker seemed to imply a social barrier to the participation of “proper” ladies in serious exertion; certain physical tasks were best left to lower class women. Indian club swinging subsequently became sufficiently popular that it was even featured in the 1904 and 1932 Olympic Games. Thomas Arnold  At the beginning of the nineteenth century, headmasters of the more reputable “Public” Schools in Britain seemed united in their opposition to sport. Eton had vetoed cricket matches, Westminster School had objected to rowing contests and Shrewsbury School had stated that football was “only fit for butcher boys.” Thomas Arnold (1785–1842), headmaster of Rugby School, changed this negative attitude to sport. He introduced a routine that comprised academic study in the

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mornings and evenings, with the afternoons set aside for sports, particularly rugby football and cricket. MacLaren  Archibald MacLaren (1820–1884) was a physician who operated a preparatory school in Oxford, and ran a commercial gymnasium on Oriel Lane in that city. His text entitled “A system of physical education” recognized that children needed regular and appropriately graded physical exercise, and he argued that the best cure for weariness or stress was physical action. He noted that the intensity of exercise in many school programmes was insufficient to attain adequate fitness, and he maintained that frequent practice of a single game would not produce a well-­ balanced physical development. MacLaren had occasion to train 12 army sergeants, and they applied his concepts of training throughout the British army. Newman  Cardinal John Henry Newman (1801–1890) established the Birmingham Oratory, an elitist “Public” School for Catholic boys. He had much to say in favour of sport, and did not think it needed to be justified by its utility. In his view, sport only lost its “liberal” character when it was motivated by a search for personal gain, as by gamblers. Matthew Arnold  Matthew Arnold (1822–1888) was the son of Thomas Arnold. During the period 1851–1886, he became a British school inspector, criss-crossing England to look at a wide range of schools. He did not agree that sport should be an end in itself, writing: “Bodily health and vigour are things which are nowhere treated in such an unintelligent, misleading and exaggerated way as in England.” In his view, if a boy had to work long hours, gymnastics was the best type of physical activity to choose, since it did the most to improve health in a short time. Army Sport Control Board  The British Army remained relatively elitist during the Modern Era, establishing a “Sport Control Board” to regulate 9 Synopsis Sports, 28 Recognised Sports and 5 Approved Sports for officers. Following the Dunkirk evacuation, the Board remained busy publishing a substantial Sports Manual. Senior officers recognized that mechanization was leading to a loss of fitness in their troops, and one or two afternoons per week were thus allocated to participation in vigoeous sports programmes. United States  Physical education was lacking from the public educational system in the U.S. until towards the end of the nineteenth century. At this point, some far-­ sghted educators firmly believed in the value of German or Swedish gymnastics, but in many schools the focus shifted progressively to the development of sports such as American football. After World War I, statistics from the military draft showed that 1 of every 3 potential recruits was unfit for combat and many other recruits had a low level of physical fitness when they first enlisted. Legislation was thus enacted to improve physical education in State schools. Unfortunately, the great depression quickly choked governmental interest; funding was progressively cut and was eventually eliminated. During World War II, recruits thus showed even poorer levels of fitness

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than in World War I, with nearly a half of draftees rejected or given ­non-­combatant roles. Specific individuals contributing to the development of fitness-­related programming during the Victorian and Modern Eras included Beck, Lewis, Hitchcock, Anderson, Sargent, Cureton and Kraus. Beck  In 1751, Benjamin Franklin helped to found an “English school” that was open to poor children aged 8–13 years. It placed a strong emphasis upon physical education. Unfortunately, local School Boards quickly rejected Franklin’s ideas, and the English schools were absorbed into the main school system, where there was still little interest in physical education. One North American school that chose to emphasize gymnastics was the Round Hill School in Northampton, MA. There, the programme was taught by Karl Beck (1798–1866), an immigrant Turner who was a keen disciple of Jahn, and had translated the book Deutsche Turnkunst into English. Beck persuaded the school to construct a gymnasium, and students received 3  hours of gymnastics per week, supplemented by horse-back riding, baseball, hockey, football and gardening. The Round Hill school closed in 1834 but Beck moved on to found his own school, again with a strong emphasis upon gymnastics. Lewis  Following the American civil war, Swedish and German gymnastics enjoyed some popularity in North America, but the most trendy approach was “The New Gymnastics” of Diocletian Lewis (1823–1886). Despite little formal education, Lewis had established a small school in Ohio at the age of 15, with enthusiastic support from the local townsfolk. He then went into medicine, and despite not completing his studies, he practiced as a physician in Port Byron, NY, becoming interested in homeopathy. In Lewis’s view, the feats required by Jahn’s gymnastics were not suited to those most needing regular exercise: boys; old, fat or feeble men; and girls and women. Visitors to the average gymnasium: “witness the wonderful performances of accomplished gymnasts and acrobats, admire the brilliant feats; but… see no opportunity for themselves..” Nevertheless, Lewis advocated an active life for women as well as men, and in 1861 he founded the Normal Institute for Physical Education in Boston. The exercises he proposed were applicable to the poorest of schools, and could be performed without even moving the pupils’ desks. Hitchcock  Edward Hitchcock (1828–1911) was the son of the President of Amherst College. He graduated from Harvard Medical School, and became the first university-­level physical educator in North America, teaching classes in Hygiene and Physical Education at Amherst. He believed strongly in developing the physical health of college students, and integrated a physical education programme into the student health service. Students were required to complete schedules of physical education, recording gains in their physical performance. Hitchcock preferred light gymnastics, and made extensive use of marching and light wooden dumb-bells. He wrote an undergraduate anatomy and physiology text, and ventured into physical anthropometry, measuring all of his students for 6 segmental heights, 23 girths, 6 breadths, 8 lengths, 8 muscular strengths, lung capacity,

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and pilosity. His anthropometry manual described how to make the relevant ­measurements, and to use them in assessing the development of fitness. In 1885, Hitchcock became the first President of the Association for the Advancement of Physical Education. Anderson  William Gilbert Anderson (1860–1947) studied at Amherst and the University of Wisconsin, and in 1881 he became superintendent of the Cleveland YMCA.  He is best known for founding the American Association for Health, Physical Education and Recreation in 1885. In 1892, he moved to Yale, and 2 years later he became Director of the renamed Anderson School of Normal Gymnastics. He wrote several texts on physical education. Some of his titles point to an aesthetic viewpoint: “Physical education: health and strength, grace and symmetry” (1897) and “The making of a perfect man” (1901). Sargent  Dudley Allen Sargent (1849–1924) is best known for his Jump Test. In 1869, he was invited to direct the gymnasium at Bowden College, Maine, where he was also studying. He moved to Yale, teaching gymnastics while enrolled in medicine, and then moved to New York, where he opened a commercial gymnasium. He subsequently taught Swedish and German gymnastics at various universities, becoming the first Director of the Hemenway Gymnasium at Harvard. He published texts describing apparatus such as a stadiometer and a girth-­ measuring device, together with simple tests of strength, endurance and power for each of six major muscle groups. In Health, Strength and Power, he presented fitness-­enhancing exercises for children and adults of all ages. Perhaps his greatest contribution was in forwarding the development of physical education as a professional occupation. Cureton  Thomas K. Cureton (1901–1992) was a noted fitness protagonist during the inter-war years. He was himself a champion swimmer, and served as research director of the YMCA Aquatic Institute. When studying engineering at Yale, he had become fascinated by the physiological research carried out on the Yale rowing team. He thus transferred to the physical education programme at Springfield College, where he produced a monograph entitled Physical Fitness. He then moved to the University of Illinois (Urbana-Champaign), where he trained a multitude of graduate students in physical education. He focused on simple tests of cardio-­ respiratory endurance, muscular strength, and flexibility, and on the forms of exercise that improved physical condition. Kraus  Hans Kraus (1905–1995) developed the Kraus Minimum Muscular Fitness Tests, which were applied widely to U.S. and European schoolchildren. There was deep concern when it seemed that 58% of American children had failed at least one of the six tests (usually the measure of forward flexion). In striking contrast, it was initially reported that only 8% of children from Italy, Austria and Switzerland had failed the same test battery. Kraus thus warned Americans that their children were watching too much television and getting too little physical exercise.

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Canada  In seventeenth century New France, most immigrant children were occupied with the tasks of land clearing, gardening and spinning, and only one Canadian in seven could sign his or her name. In the larger towns, Catholic religious orders provided elementary instruction (but no physical education). After the British Conquest (1759–60), attempts to establish secular schools in Québec were consistently out-manoeuvred by the Catholic Church. However, in Upper Canada, formal education began in the mid 1840s, through the efforts of Egerton Ryerson. By 1862, a “Normal” School (teacher training college) had been equipped with a gymnasium, and in 1865 Provincially supported schools were offered a grant of $50 if they were willing to teach “drill and gymnastics” (usually with instruction from a retired army sergeant). After World War I, there was a movement of physical education from “drill” towards “fitness,” with an emphasis upon the performance of natural, spontaneous and enjoyable activities. Full-time professional physical educators began training at the Hamilton School of Physical Culture in 1889, and 3 years later, physical education became compulsory in all Ontario Provincial Schools. In 1891 calisthenics was also placed on a list of optional subjects for Provincial Schools in British Columbia, with an emphasis on drill and gymnastics. McGill University in Montreal prepared elementary teachers for schools in Lower Canada, and their Faculty of Education began with the McGill Normal School (1857). During the 1920s and the 1930s, some Canadian universities required all students to complete a minimum number of hours of physical education or athletics. Canadian degree programmes in physical education were finally established during the 1940s, beginning with the University of Toronto. The National Physical Fitness Act was an important stimulant, offering Universities in each Canadian Province $250,000 (contingent on matching provincial funds) for the development of physical education programmes. By 1960, Canada boasted 12 degree-granting Schools of Physical Education & Health, and there was growing recognition of the subject as an appropriate University discipline. We will comment in a little more detail on the contributions of Ryerson, the Strathcona Trust, Scott, Lamb and Cartwright, and Tait McKenzie. Ryerson  Egerton Ryerson (1803–1882) was a Methodist Episcopal minister. He was appointed Chief Superintendent of Education for Upper Canada in 1844. A rapid tour of Europe and the United States impressed him with the ideas of Pestalozzi, Guts-Muth and Ling (above). Among many educational reforms introduced in a succession of three School Acts, Ryerson planned that during the winter months, Canadian students should engage in gymnastics, calisthenics and work with dumb-bells and Indian clubs, and in the warmer months they should replace their indoor physical activities by walking, skipping, dancing and lawn bowling. One less positive legacy of Ryerson’s administration was the Native Education Commission, which foreshadowed the enforced attendance of Canada’s aboriginal children at “Residential Schools,” where they would be “civilized” through “instruction and industry.”

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Strathcona Trust  Lord Strathcona (1820–1914) was Canada’s High Commissioner to Great Britain in the early nineteenth century. He was very impressed with the syllabus of physical training that had recently been introduced into British ­elementary schools, and he established the Strathcona Trust with a view to implanting a similar regimen in Canadian schools. An endowment of $500,000 had the stated objective of encouraging: “physical and military training in the public schools of Canada.” Thirty-five per cent of this funding was allocated to cadet training, 15% to rifle shooting, and 50% to physical education. The Strathcona programme continued with little change until World War II. Scott  In Quebec, Henri-Thomas Scott (1880–1925) received his first physical education lessons at the age of 15. He later enlisted in a Canadian regiment, and was sent to the Royal Military College at St. Jean-sur-Richelieu, Quebec, where he was trained as an infantry instructor. The Canadian government was at that time offering instruction in physical education to one representative from each military district, and in 1903 Scott profited from this provision, attending the Royal Military College in Kingston. In 1905, Scott began teaching Swedish drill at various schools in Montreal. This approach was popular because it required a minimum of equipment. Scott also organized gymnastics clubs in many schools, and on Saturdays, students had the opportunity to attend gymnastic classes that he taught at the Catholic Commercial Academy of Montreal. His influence soon extended beyond the classroom. In 1905, he established the Société Nationale de Gymnastique. Gymnasts began performing at the Quebecois National Fete (St Jean Baptiste Day), and a Montreal newspaper (La Presse) assigned a columnist the specific responsibility of promoting physical activity. In 1908, La Presse sponsored the travel of Scott’s gymnastic team to an international gymnastics congress. The Canadians were declared the winners of this competition, and emboldened by this victory, Scott quickly moved to establish a gymnastics school for women. He also offered home lessons in riding, tennis and snow-shoeing to young ladies who remained a little shy of exercising in public. Lamb and Cartwright  The martial format of physical education typical of Canadian government policy was vigorously opposed by Arthur Lamb (1886–1958), Mary Cartwright (Physical Education Director at McGill University and subsequently at the University of Saskatchewan) and teachers at the Margaret Eaton School in Toronto (Chap. 25). All pleaded for an emphasis upon play rather than military drill, with instruction from physical education specialists rather than retired army NCOs. Lamb graduated from Springfield College in 1912, serving as Instructor in the newly founded Department of Physical Education at McGill University from 1912– 1916, and after service with the Canadian Army Medical Corp, in 1920, he was appointed Professor of Physical Education and Director of the Department of Physical Education at McGill.

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He founded the Canadian Physical Education Association in 1933; this became the Canadian Association of Physical Health Education and Recreation in 1948 CE, Dance was added to this title in 1994, and it is now known as PHE Canada. Tait McKenzie  Robert Tait McKenzie (1867–1938) was an outstanding exponent of physical activity during the Modern Era. As a child, he was considered rather delicate, but this changed during his studies at McGill University, where he became involved in acrobatics and gymnastics, set a high jump record, ran hurdles, boxed, played football, and joined the tug-of-war team. Nevertheless, he continued to favour activities that required skill and coordination, rather than strength or stamina. After completion of his medical training, he became personal family physician to the then Governor General of Canada. He asked McGill University to establish a School of Physical Education; the University governors decided that this would be too costly, but in 1898 he was appointed Medical Director of Physical Training, with responsibility for the physical examination of incoming students. In 1905, McKenzie accepted a post as Director of Physical Education at the newly formed University of Pennsylvania, giving him a chance to develop, test and implement his theories on health and athletics. During World War I, he enlisted in the British Royal Army Medical Corps, assuming responsibility for the physical training of recruits, developed physiotherapy programmes and designing prosthetics for the injured. After the first world war, McKenzie resumed teaching at the University of Pennsylvania, and remained at this post until his retirement in 1930, when he purchased the Almonte mill, near Ottawa, ON. The Mill served as his summer home, and it provided an excellent backdrop for his very realistic sculptures that reflected a deep understanding of both medicine and physical education.

Physical Education in the Post-modern Era During the Post-Modern Era, perhaps the largest changes in physical education have occurred in North America. Here, physical education instructors have replaced the rote instruction of earlier times by classes that include information about health and nutrition. There is also now much less emphasis on the coaching of sports teams, and greater interest in teaching students a broad range of activities. The new approach seems likely to satisfy children with differing abilities, to create long-­ lasting positive attitudes towards physical activity, and to teach recreational skills that can be carried forward into adult life. Sophisticated path analyses have recently made a close examination of psycho-social factors contributing to the child’s interest in physical activity, and this has allowed health promotional efforts to focus upon the primary motivators. The last 40 years has also seen a unique evaluation of both the short and long-term impact of physical education, with Hugues Lavallée and his colleagues in French Canada playing a leading role in this enquiry (Fig. 19.7). Their research has brought new insights into physiological responses, the impact of

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Fig. 19.7  Hugues Lavallée and his colleagues have made a quasi-experimental study of the short and long-term effects of daily physical education upon the fitness and academic attainments of primary school students in the Trois Rivières region of Quebec

physical activity upon academic performance, and long-term influences upon adult lifestyle. Physiological Responses  During the 1960s, it was widely believed that preadolescent children did not respond to either aerobic or resistance training. However, the Trois Rivières study showed that both the aerobic power and the muscular strength of young children could be increased relative to that of their peers by participation in a daily one-hour programme of vigorous physical education. Impact Upon Academic Performance  For many years, another area of controversy had been whether devoting a substantial fraction of class-time to physical education would have a negative impact on academic performance. A study in Vanves, France, had suggested that children who spent mornings in the classroom and afternoons performing physical activities actually had a better academic performance than their peers who devoted little time devoted to physical activity, but this study had been poorly controlled. In Trois Rivières, a well-controlled investigation demonstrated clearly that the levels of academic attainment for experimental students were at least as good as those of control subjects, even though they spent 14 percent less time learning academic material than did their peers. It remains to be determined whether the added physical education had a direct positive effect upon the learning of academic material, whether it stimulated the production of neutrotrophins, or whether the observed benefits arose less directly (through such mechanisms as enhancement of a child’s self-image, greater attention and better classroom behaviour on the part of the active pupils, or a shortening of teaching time and thus less exhaustion of the academic teachers following introduction of the new programme).

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Long-Term Influence Upon Lifestyle  Until recently, little has been known about the impact of school physical education upon adult attitudes and lifestyle. Some authors have even suggested that demanding programmes have a negative influence upon the activity levels of adults. However, the Trois Rivières study was able to collect data 3 and 4 decades after completion of the initial controlled primary school study. Participants showed a modest persistence into adulthood of health benefits derived from the enhanced primary school physical education programme, including a greater continuing involvement in physical activity and a lower prevalence of cigarette smoking than their peers from the control group.

Practical Implications for Current Policy The need for military recruits with a high level of physical fitness was the primary stimulus for governmental support of physical education programmes over many centuries. In a few cases (such as in Sparta), the objective of military preparedness may have been realized, but from the poor physical state of enlistees seen during many major conflicts, such preparation for battle seems generally to have been ineffective. Moreover, the future of combat lies increasingly in automated warfare, thus diminishing the imperative for the physical conditioning of recruits. Governments thus need to be persuaded of other and more important long-term benefits of a welldesigned physical education programme, including greater fitness and health of the adult population, and a resulting decrease in health care expenditures. As the overall body of knowledge grows, competition for curricular time among the various school departments becomes ever more intensive. Replication of the Trois Rivières findings of enhanced academic performance among the more active students is thus important in ensuring that adequate class-time is allotted to physical activity. There is a continuing need to explore the idea that physical education enhances receptivity to other forms of learning, and to explore the underlying mechanisms. The content of physical education programming has undergone major changes in recent years, and there is a need to design studies exploring whether these changes have succeeded in increasing life-time interest in a physically active lifestyle. Is the new approach more effective than an emphasis on sport? What activities have a strong “carry over” from the classroom in to adult life? How useful is the idea of combining physical education with the teaching on health maintenance? And are there other potential dividends of physical education that need to be exploited, such as the greater social integration of the child?

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Questions for Discussion 1. What do you think should be the primary focus of a good physical education programme in today’s environment? 2. Can you remember your early school experiences of physical education? Do you have good or bad memories? What aspects of instruction would you change? 3. Do you have any suggestions for the more stable funding of physical education initiatives, both at school and in the community? 4. What tactics would you suggest to gain more curricular time for physical education in what others may claim is an over-filled school timetable?

Conclusions At various times over the centuries, school programmes of physical education have been advocated to develop military fitness, to enhance the excellence of school sport programmes, to develop graceful body movement, and to enhance health and fitness. For much of the past, military objectives have been dominant, with classes repeating rigid drills, often under the supervision of former army sergeants. However, currently the need is seen for programmes that will not only ensure fitness and health as a child, but will develop long-term positive attitudes towards health and fitness as an adult. These objective seem best achieved by flexible and enjoyable school programmes, adapted to the talents of the student, and involving activities with a proven potential for carry-over into adult life.

Further Reading Cosentino F, Howell M. A history of physical education in Canada. Don Mills, ON, General Publishing Company, 1971, 154 pp. De Molen RL. Richard Mulcaster (c. 1531–1611) and educational reform in the Renaissance. Leiden, Netherlands, De Graaf Publishers, 1991, 222 pp. Deshpande SH. Physical education in ancient India. Delhi, India, Bharatiya Vidya Prakashan, 1992, 325 pp. Gutek GL. Pestalozzi and education. Long Grove, IL,Waveland Press, 1999, 178 pp. Kirk D, Vertinsky P.  The female tradition in physical education. Women first reconsidered. Abingdon, OX, Routledge, 2016, 240 pp. McIntosh PC. Physical education in England since 1800. London, UK, G. Bell, 1968, 320 pp. McIntosh PC. Landmarks in the history of physical education. Abingdon, OX, Routledge, 2013, 240 pp. Mechikoff RA, Estes S. A history and philosophy of sport and physical education. New York, NY, McGraw Hill, 2002, 379 pp. Moss M. Manliness and militarism. Educating young boys in Ontario for war. Toronto, ON, University of Toronto Press, 2015, 227 pp.

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Naul R, Hardman K. Sport and physical education in Germany. Abingdon, OX, Routledge, 2002, 224 pp. Nolte C. The Sokol in the Czech lands to 1914; Training for the nation. New York, NY, Springer, 2002, 258 pp. Patrick JP. Aristotle’s school: a study of a Greek educational institution. Berkeley, CA, University of California Press, 1972, 247 pp. Rajagopalan K. A brief history of physical education in India. Delhi, India, Army Publishers, 1962, 206 pp. Rao VK. History of education. Delhi, India, APH publishing, 2008, 273 pp. Rice EA, Hutchinson JL, Lee M. A Brief History of Physical Education. New  York, NY, The Ronald Press Co., 1958, 430 pp. Rousseau JJ. Rousseau on education. New York, NY, Collier-Macmillan, 1969, 147 pp. Sadler JE. Comenius and the concept of universal education. Abingdon, OX, Routledge, 2013, 336 pp. Tait McKenzie R. Exercise in education and medicine. Philadelphia, PA, Saunders, 1923, 601 pp. Tiwari SR. History of physical education. New Delhi, India, APH Publishing, 2006, 280 pp. Welch PD. History of American Physical Education and Sport (2nd ed.). Springfield, IL, C.C. Thomas, 2004, 415 pp. Ziegler E. A history of sport and physical education to 1900. Champaign, IL, Rao VKStipes Publishing, 1973, 3787 pp.

Chapter 20

Co-opting Fitness and Sport for Political Objectives

Learning Objectives 1. To recognize that governments of various types have often co-opted major sports events and fitness organizations to serve their political objectives. 2. To evaluate the effectiveness of government sponsored fitness awards as a tool in motivating people to engage in greater habitual physical activity. 3. To see the growing interest of governments in encouraging physical activity in order to increase the health of their populations, and thus reduce medical costs. 4. To understand that strong governmental interest in excellence at international competitions may have a negative effect upon sport participation rates in the general population.

Introduction In many societies from the earliest of times, physical education programmes have been viewed as useful in preparing youth for military service. Some proponents of group gymnastics such as Jahn and Tyrš (Chap. 19) also saw their movements as enhancing national identity. In this chapter, we will focus upon the Modern and Post-Modern Eras, looking at how the co-option of fitness and sport for nationalist ends reached its apogee in policies of the totalitarian regimes of Mussolini, Hitler, Stalin and Pétain. We will also note how in recent years, the governments of the U.S., Canada, and to a lesser extent Britain have become involved in the promotion of fitness with the dual objectives of enhancing national health and increasing the “take” of Gold medals in Olympic competition.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_20

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Italy The Fascist government of Mussolini controlled Italy from 1922 to 1943. The futurist Filippo Tommaso Emilio Marinetti (1876–1944) was an ardent supporter of and adviser to Mussolini. Marinetti’s attitudes to physical education have parallels with subsequent Nazi ideas. As early as 1909, he expressed scorn for many aspects of traditional education, demanding the destruction of “museums, libraries, and every type of academy,” and in 1919 he called for: “a school for physical courage and patriotism… a merciless system of physical exercise in all our schools….teaching… physical courage and scorn for danger.” After some comments on Mussolini himself, we will comment on Fascist views on physical education, higher education, and doctrinaire programmes for youth and adults. Mussolini  Benito Mussolini (1883–1945, Fig. 20.1) was born in Italy, but moved to Switzerland, in part to avoid Italian military service requirements He became an admirer of Nietzsche, campaigning against such Christian virtues as humility, resignation, charity, and goodness. He also became convinced of the need to overthrow the liberal democracies of Europe, which he regarded as decadent. He returned to Italy in 1904 CE, under an amnesty accorded to Army deserters. By 1921, he was asserting his views on racial superiority, seeing Italy as the Mediterranean branch of an Aryan race. Faced by a crowd of about 30,000 Black-­ shirts, in 1922 King Victor Emmanuel III decided to ask Mussolini to form a new government. This at first took the form of a right-wing coalition, but progressively Fig. 20.1  Under Benito Mussolini (1883–1945), Italian physical education and all sports and youth groups were placed under close Fascist control (Source: http://en. wikipedia.org/wiki/ Benito_Mussolini#cite_ note-Mediterranean4-26)

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morphed into a fascist police state. A sophisticated propaganda machine emphasized Mussolini’s view that liberalism was passé and that fascism was the wave of the future. Mussolini himself adopted a frenetic lifestyle, never spending more than 3 minutes on a meal. Until middle age, he was obsessed with enhancing his fitness by riding, swimming, running, tennis, fencing and football. Physical Education  Theoretically, all Italian schools had included physical education in their curriculum since 1878, and in 1909 physical education had become compulsory at all levels of education. However, instruction had often been nominal, since facilities and equipment in many schools were extremely limited. Under Mussolini, new playing fields were constructed and new equipment was delivered, but if children wanted to use the facilities after school, they had to join the Fascist Youth Organization. For younger children, physical education programmes continued to focus on play, but a military emphasis was introduced into activities for older children. In addition to exercise and team sports, there were classes in fencing, boxing and shooting, together with 20 km marches and obstacle races. Successful completion of the physical education course soon became a requirement for completing an academic grade. Higher Education  The Fascist regime quickly assumed a tight control over sports groups in universities and colleges, and from 1927 onwards, all local and provincial sports associations were required to appoint representatives of the Fascist Party to their Boards. The Academy of Physical Education became the centre for sport and political education, combining the traditional curriculum of physical educators with political indoctrination. From 1929 onwards, all faculty had to be accredited members of the Italian Fascist Party. The Academy was initially housed with the Military Academy, but in 1932 it moved to the Foro Mussolini, with the objective of training physical education teachers and those working with the Fascist Youth Organization. The school comprised four sections: political, military, biological-scientific and sport, and its degrees were awarded by Mussolini himself. The impressive Academy building now serves as the headquarters of the Italian National Olympic Committee. Youth Groups  Much effort was expended to indoctrinate the youth of fascist Italy with National Socialist objectives. A youth Action Squadron was formed in 1919, and this quickly gave birth to Fascist Youth Vanguards and Fascist University Groups. The Vanguard served youth aged 15–18 years; it was soon supplemented by a Balilla, for boys aged 8–14 years, with corresponding groups for girls (Young Italians and Little Italians), and infants aged 6–8  years (“Children of the She-Wolf”). Initially, none of these groups attracted a large membership. However, the Fascists assumed direct control of these organizations in 1926, with a strong Nazi sympathizer (Renato Ricci, 1896–1956) as Director. Ricci was charged with “reorganizing the youth from a moral and physical point of view.” He sought inspiration

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from Robert Baden-Powell (1857–1941), the right-wing founder of the British Scout movement who was a strong anti-communist and initially expressed admiration for both Mussolini and Hitler. Local leaders of the youth groups were commonly schoolteachers who had joined the Fascist Teachers’ Association. The boys wore a scaled-down version of the “Blackshirt” uniform, and they engaged in massive gymnastic displays, with the singing of Fascist anthems, and an award of medals by Mussolini himself. Groups also placed a strong emphasis upon vigorous outdoor activities that prepared boys for the Army. In 1924, Mussolini’s official newspaper underlined the view that sport was not an end in itself. Rather, it was a “national necessity for the progress and prosperity of the race.” Other Italian youth movements were banned, with the exception of one closely circumscribed Catholic group, and in 1939 membership of the official youth groups became mandatory for all Italian children. Programmes for Adults  Top-level athletes became a part of the party propaganda machine. They were required to wear Fascist uniforms, and when opponents offered to shake hands, this gesture was returned with the official party salute. Adult programmes for the general population were organized through an “After Work” group (the OND). This was established in 1925, at the request of Fascist trade unions that wished to compete with “socialist” cultural organizations. It was initially an “apolitical” and “productivist” group, modelled after the YMCA to promote: “the healthy and profitable occupation of workers’ leisure hours by ….. developing their physical, intellectual and moral capacities.” It was argued that if properly managed, the OND could increase worker output by restoring the vigour of those who were fatigued after a day of heavy physical labour. However, within 2 years, the OND was transformed into a mechanism of Fascist indoctrination. During the 1930s, the OND focused on organizing sports events and constructing recreation rooms in factories. Moreover, it reinforced traditional female stereotypes by organizing sewing, cooking and home economics classes for women members. By the end of the decade it had recruited some 80% of white collar and 40% of blue-collar workers, and 60% of companies employing over 100 workers had established special facilities for the OND.

Germany As in Italy, the state assumed total control of all health and fitness initiatives in Nazi Germany. After some comments on Hitler himself, we will examine the totalitarian control of physical education, sport and leisure organization for youth and adults, finally looking at the aftermath of this social control in the post-war era. Hitler  Adolf Hitler (1888–1945) was born in Austria, but he moved to Germany at the age of three. In 1905, he returned to Vienna, where anti-Semitism was already rampant. There, he supported himself by the sale of an occasional water-colour and

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generous subsidies from his mother He moved from Vienna to Munich in 1913, apparently because he did not wish to serve in the racially-mixed Austro-Hungarian army. However, in World War I he served in the Bavarian Army, and was awarded the Iron Cross. Subsequently, he returned to Munich, where his vitriolic beer-hall speeches attracted a growing audience. After an attempted Putsch (1923), he had a short spell in prison, but the ban on the National Socialist Party was lifted in 1927. He was appointed German Chancellor in 1932, and assumed total power of the country in 1933. A speech in Nuremberg (1938) summarized Hitler’s attitudes towards building a fit, warrior nation: “German boys of the future must be slim and lithe, swift as greyhounds, tough as leather and hard as Krupp’s steel.” Physical Education  Physical education had long been important in German schools (Chap. 19), and it was a major emphasis at the German school conference of 1920, with Prussian State boarding schools continuing to emphasize a militaristic form of gymnastics. Experimental schools that integrated physical activity and learning such as a Eurhythmics School of the Dalcroze type were also instituted, and the first Waldorf School was founded by Rudolf Steiner, with the strong financial support of the Waldorf-Astoria cigarette company. Under the Nazis, school physical education was drastically increased, from 2 hours per week to 2 hours per day, and a child’s performance as graded by fitness tests became an important item on student report cards. The standard physical education programme included athletics, gymnastics, swimming, boxing, and various forms of play. Boxing classes were compulsory for boys unless a medical certificate was provided. Sometimes, students who failed a fitness test were expelled from their school, and any evidence of physical weakness was despised. Hitler wrote: “A violent, masterful, dauntless, cruel younger generation- that is my aim.. I want them to learn to conquer the fear of death by undergoing the severest ordeals.” Sports  Hitler ruthlessly exploited the Berlin Olympic Games of 1936 to advance his cause. Details of this event have been given in Chap. 12. Nazi Youth Organizations  The Reich Youth Badge and the Reich Youth Sports Competitions had been initiated under the Weimar Regime. On Hitler’s orders, existing youth organizations were abolished, and von Schirach, who had been named Youth Leader of the new German Reich, appropriated all of their assets. A “Year of Physical Training” was proclaimed in 1935, and medals were awarded to youth who performed rigorous athletic drills and achieved strict physical fitness standards. The German Youngfolk was established for boys aged 10–14 years, and the Hitler Youth was for those who were older. There were parallel groups for girls. These organizations had superficial similarities to Scouting, with an emphasis upon clean living, competition, drill, teamwork, and sport. However, their primary goal was Nazi indoctrination; other activities included singing both patriotic and anti-Semitic songs, camping, field trips and attendance at large rallies (Fig. 20.2). Before each

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Fig. 20.2  Mass rallies were organized for the Hitler Youth movement (Source: http://en. wikipedia.org/wiki/ Hitleer_Youth)

meal, members were required to recite a prayer praising Hitler. Moreover, the boys spent much time in military pursuits (marching, map reading, bayonet drill, grenade throwing, trench digging, crossing barbed wire and pistol shooting). Rigid fitness standards included a medical examination, running 60 metres in 12 seconds or less, completing a 36-hour hike, and undertaking a test of courage (Muttprobe) such as jumping from a second-storey ledge onto a canvas. The programmes had some positive influence upon the lives of teenager girls, permitting them to engage in camping and sports that had previously been denied to females. However, they also had to meet challenging standards; they were expected to run 60 metres in 14 seconds, throw a ball 12 metres, complete a 2-hour march, swim 100 metres and know how to make a bed. By 1936, membership of the Nazi Youth Organization was made compulsory for all “Aryans,” and in 1939 attendance at meetings of the organization became mandatory, although parents complained that the weekend activities were so exhausting that their children’s schoolwork was suffering. The public schools theoretically remained independent of the Nazi Youth Organization, but the elderly Minister of Education was frequently out-manoeuvred by Schirach. Teachers who were Jews or who had expressed social democratic leanings were dismissed as “unreliable.” By 1938, Schirach was sufficiently entrenched to launch a massive attack on the entire school system. He described it as hopelessly

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out of date and counter-revolutionary. Often, leaders in the Hitler Youth assisted Schirach by denouncing teachers who were not sufficiently enthusiastic Nazi supporters, and at the Nuremberg hearings, the prosecutor noted that von Schirach had proclaimed the idea that schools should become mirrors of the State. Nazi Programmes for Adults  The fitness of adults was addressed through the “Strength through Joy” programme of the Nazi Labour Front. This programme organized worksite military fitness training and rhythmic dancing, as well as lectures on “racial improvement” and other Nazi doctrines. The DAF (the Nazi replacement for trade unions) also organized exercise programmes in factories, and large open-air swimming pools were constructed across the country. In 1931, 6.5 million German adults were members of various sports organizations, but by 1939, the Strength though Joy movement employed 7000 workers and had 135,000 volunteers, with 54.6 million programme participants. The Gestapo Chief insisted that the public image of the SS Officer (and by extension, the good male citizen in Nazi Germany) must be one of masculinity and strength, with moderation in drinking and smoking. Strict exercise schedules were established for all State Security employees, with men attending sport classes twice per week, and women undertaking additional sessions from 8–10 a.m. on Saturdays. Hitler had a strong belief in the importance of physical rather than mental development, writing: “A man of little scientific education but physically healthy, with a good, firm character, imbued with the joy of determination and will-power, is more valuable for the national community than a clever weakling.” Post-war Reactions  Following World War II, reactions to the Nazi system were very different in West and East Germany. In the West, a German Sports Federation was established in 1950, and it proclaimed complete freedom from political, religious, racial and military influences. Nevertheless, in 1960, the German Olympic Association promulgated a 15-year “Golden Plan for Health, Sport and Recreation,” with the West German government providing a budget of $6315 M Deutsche marks to achieve this objective. In East Germany, sport moved from the Nazi system to a new system of State control, much as in communist Russia. Participants were required to belong to the communist youth organization (the Free German Youth) or to the communist Free German Trade Union Federation. A highly political German Sports Committee was established in 1948, followed in 1952 by a State Committee for Sport and Physical Culture. The Russian influence was further underlined by the introduction of a Ready for Work and Detence medal, and the construction of a College for Physical Culture in Leipzig (an Institution that later became notorious for the doping of East German athletes).

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Russia The Russian Tsar was ousted in 1917, and the war between Bolshevik and anti-­ Bolshevik factions ended in 1922, with establishment of the Union of Soviet Socialist Republics, a form of government that held sway until 1991. Stalin and his successors Khrushchev and Brezhnev ruled the population with an iron-fist, controlling physical education programmes, establishing politically motivated organizations to promote fitness for both youth and adults, and investing heavily to achieve success in international sports competitions. Physical Education  The biologist Peter Franzevich Lesgaft (1837–1909) had developed an indigenous approach to Russian physical education during the Victorian era. The St. Petersburg Institute of Physical Culture is named after him. In the 1870s, Lesgaft took the forward-looking step of admitting women to the Imperial Medico-Surgical Academy. He became a consultant in therapeutic gymnastics, and wrote a History of Sport. He was also assigned responsibility for the physical training of military cadets. Prior to the 1917 revolution, Russian schools had adopted German gymnastics, Swedish calisthenics or British sports. Military service had become compulsory in 1918, and with the new regime responsibility for physical education was initially assigned to the Red Army, under a Department of Physical Development and Sport. In the first decade of Soviet rule, the main objective was to help in overcoming the aftermath of civil war. The first All Russia Congress of Workers in Physical Culture, Sport and Pre-military Training was convened in 1919. This advocated the promotion of general health, military preparedness and all-round physical development within the framework of communist educational objectives. Subsequently, there was a protracted power struggle for the control of physical education, with the Red Army, the Communist Youth Organization and the Trade Unions as the main protagonists. A communist party resolution of 1959 placed a new emphasis on sport, with the aim of achieving world dominance in international competition. It was hoped that the achievements of top athletes would motivate the general population to greater physical activity. A further reorganization occurred in 1966, with an attempt to organize activities that were appropriate not only for children, but also for middle-aged and elderly citizens. In 1975, it was estimated that 29% of the population between the ages of 10 and 60 years was engaged in some form of regular physical activity. Youth Programmes  The first meeting of the Young Communist League (for those aged 14–28  years) was held in 1918. Younger children (aged 10–15  years) were encouraged to join the Young Pioneers. The Young Communist League fought hard to eliminate any remaining influence of the previously established Scouting movement, replacing it with an organization committed to communist indoctrination. Most Russian children still lived in the countryside during the early 1920s, and many had to endure the hardships ­associated

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Fig. 20.3  Pioneer Palace in Sevastopol; the Pioneer Palaces provided places for youth to undertake sports training and to engage in other types of creative activity under close communist supervision (Source: http://en. wikipedia.org/wiki/ Pioneers_Palace)

with the enforced collectivization of farms. Early activities assigned to the Young Pioneers were designed to help struggling farmers in the back-country: We are patrons of the colts and piglets, and the girls are patrons of the poultry farm…we guarded the harvest and helped with the mowing and the weeding…

The first summer youth camp was built in 1925, and by 1973 there were 40,000 such camps across Russia. Some focused on sport, but others were for those interested in geology, nature study and other potential career paths. Often, the fee for attendance was paid by the parent’s place of employment. Typical mornings began with physical exercise under the supervision of a physician, and there was a ceremonial parade each morning and evening with orchestral accompaniment. Young Pioneers who excelled in their academic study, work, sports or social activity were sent as delegates to Young Pioneer gatherings in other parts of Russia, with the most notable members recognized in the organization’s Book of Honour. As economic conditions improved, Pioneer Palaces for sports training, creative work and extracurricular activities were opened in many cities (Fig. 20.3). The first such Palace occupied the former House of Noble Assembly in Kharkov (1935) and other early Palaces were residences of the former nobility. Imposing purpose-built Palaces were constructed after World War II, but sadly, with the dissolution of the Soviet Union, many of these facilities were quickly converted into casinos and/or strip-clubs.

Soviet Physical Activity and Sports Programmes for Adults The opinion of Soviet experts was divided on the intensity of physical effort that was appropriate for adult workers. Proponents of “Normal Gymnastics” focused upon free and corrective gymnastics, running and jumping. They argued that in many industries workers already undertook adequate amounts of physical activity

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during their employment, and they did not need to supplement this with heavy exercise in the gymnasium. The rival “Spartak” system criticized the restriction of exercise intensity by the Normal Gymnasts, arguing that sports and vigorous competition were essential to optimal physical development of the Soviet labour force. The Moscow Central Institute for Physical Culture proposed a third option of “Industrialized Calisthenics.” This approach included improved personal hygiene, exposure to sun, air and water, the development of motor skills applicable to industry, and participation in games, gymnastics, sport, tourism and dancing. In 1925, the Soviet Central Committee argued that physical education was important to the working population, serving to draw the masses into social and political activity. The GTO (Ready for Labour and Defence of the USSR) programme was introduced during the 1930s, with badges for personal attainments in 21 skills such as running, jumping, grenade-throwing, swimming, and cross-country skiing. Initially, 3 age categories were distinguished, with appropriate levels of achievement specified for each age group. A second level of attainment was introduced in 1932, and in 1934 further levels were added for children aged 13–14 and 15–16 years. As war threatened in 1939, additional military skills were added to the test battery, including crawling over barbed wire, a fast foot-march, grenade-throwing, rope and tree climbing, the ability to carry a cartridge box, and various martial arts. In 1946, it became necessary to revise the GTO norms downwards, because the physical health of the population had deteriorated. However, the programme continued until the end of the Soviet regime, and in 1976, 220 million citizens were awarded badges. Soviet Interest in Sports  Spectator sports, particularly soccer, flourished in Soviet Russia during the mid-1930s, and large new stadia were constructed. Branches of State and Federal government and individual factories sponsored teams; thus, Dinamo teams were sponsored by the the People’s Commissariat for Internal Affairs, and Lokomotiv teams by the Ministry of Transportation. Beginning in the 1950s, the Soviet Union also invested ever-increasing resources into producing athletes who could excel on the international stage. One quantitative measure of governmental interest in high performance sport was a growing output of stamps commemorating the feats of Soviet athletes. The athletes themselves became entirely subservient to state coaches, and often submitted to dangerous doping practices in an attempt to win gold medals for their country.

France France ended World War I financially bankrupt and severely traumatized by massive losses of its soldiers in conflict. The inter-war years were marked by a rapid succession of unstable governments, with Paté and LaGrange being the politicians who showed the greatest interest in augmenting physical activity. Policies saw a drastic change in 1940 CE, with the fall of France and installation of the pro-Nazi Vichy regime. Following World War II, Charles de Gaulle strove vigorously to restore

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French prestige on the international stage, but he did not introduce any striking new policies in physical education or health care. Paté  Henri Paté (1878–1942 CE) was initially Commissaire for physical education and military training (his title indicates the military orientation of French thinking in regard to physical education). Subsequently, he became Under-Secretary for physical education, making this mandatory in French State schools. He also introduced courses on eugenics, dietetics and industrial hygiene at the Musée pedagogique. He was associated with the Paris World Fair of 1937, which emphasized physical fitness, virility, social hygiene and eugenics. He had a strong interest in sport for the deaf, and found the necessary funds for the first International Silent Sports, which was held in Paris in 1924. Lagrange  Regional Institutes of Physical Education were attached to French medical schools in 1927, and a teachers’ training college was established in 1933. With the victory of Léon Blum and the Popular Front in1936, Lagrange was appointed Under-Secretary of State for sports and for the organization of leisure. Before the Popular Front came to power, sport had been considered as “bourgeois” and “reactionary,” connected with social privilege. Now, it was viewed for the first time as a health issue. Leo LaGrange and the Popular Front instituted a programme of 5  hours of physical education per week in 29 Departments of France. Unfortunately, the effects of this initiative upon health and fitness do not seem to have been documented, although a positive effect upon academic achievement was reported from one trial in a suburb of Paris (Chap. 19). The Blum government also mandated a 2-week paid holiday, and Lagrange arranged cheap rail fares so that workers could enjoy vacations at the ski and coastal resorts that had previously been the preserve of the wealthy. Vichy France  Following the defeat of France in 1940, Marshall Pétain, an elderly but respected General from the first world war established a puppet government in the small spa town of Vichy (Fig. 20.4). Policies of his government included anti-­ Fig. 20.4  Marshall Pétain meeting with Hitler; Pétain controlled French sports and physical activity programmes along Nazi lines (Source: http:// en.wikipedia.org/wiki/ Vichy_France)

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parliamentarianism, xenophobia, anti-Semitism, and restoration of the glory days of France through a return to “traditional family values.” The attitudes of the Vichy regime towards physical education and personal physical activity were relatively favourable. The Vichy government denounced professional competition and sought to revive traditional forms of activity, with the aim of “rebuilding the nation.” The Vichy leaders also encouraged involvement of the nation’s youth in Pro-­ German youth associations. Sport policies were initially determined by a three-person Commissariat Général à l’Education Générale et Sportive. Beginning in 1941, a “sportsman’s pledge” was exacted from all athletes. It stated (with a De Coubertin-like reference to honour rather than swearing): “I promise on my honour to practice sport with disinterested discipline and loyalty in order to become better and to serve my country better.” Vichy showed a particularly strong opposition to sports of British origin. By October 1940, professionalism was prohibited in tennis and wrestling, but a 3-year delay was accorded to football, cycling, boxing and Basque pelota. Female participation in cycling and football was also prohibited, and (much as in Nazi Germany), the assets of several Sports Federations were forcibly transferred to a “National Council of Sports.” Efforts were made to increase physical education instruction for women, and the French Air Force initiated a youth programme that encouraged young boys to engage in virile outdoor pursuits at high altitudes (cutting timber, rebuilding chalets and footpaths and helping small farmers, with occasional bouts of recreational skiing and climbing). The Germans became suspicious of the loyalty of this group, and in 1943 they demanded that it be disbanded, but closure proceeded sufficiently slowly that many of the participants had time to join the Maquis resistance forces in their mountain hide-outs. Reactions After World-War II  After World War II, leading figures in French physical education were R. Marchand (who maintained a traditional programme) and Pierre Seurin, President of the International Physical Education Federation, who adopted an Existentialist approach to Swedish style gymnastics.

United States During the latter phases of the Modern Era, an increased involvement of the U.S. government in fitness and health programmes was manifested through the formation of Presidential Councils, Presidential fitness awards, and the funding of training programmes for top athletes. Presidential Councils  Beginning in the 1950s, the American presidency became closely involved in the promotion of fitness for children. At a White House luncheon in July 1955, Hans Kraus had stated that “the U.S. is becoming the softest nation on earth.” President Eisenhower showed apparent alarm, and instructed Vice-President

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Nixon to convene a “Conference on the Fitness of American Youth.” This led to formation of the President’s Citizens Advisory Committee on the Fitness of American Youth (July 1956), with the ill-defined objective of “serving as a catalytic agent.” A further conference in 1957 attempted to develop an appropriate action plan, and the President’s Council on Fitness was established in 1965. However, Kraus remained concerned that the Council had a limited budget and little real authority. Moreover, his campaign met with strong opposition from both the American Medical Association and gym teachers. The two groups reacted vigorously to what they perceived as a criticism of their leadership, and they claimed that the Kraus-Weber test scores were largely worthless, because physical fitness could not be quantified. Moreover, they argued: “calisthenics and gymnastics are totalitarian, and the proper physical activity in a democracy is team sports. Calisthenics and gymnastics would Hitlerize youth…” Attitudes shifted under President John Kennedy, who was a major proponent of physical fitness and its health-related benefits. He stated: “Physical fitness is the basis for all other forms of excellence.” Presidential Fitness Awards  A system of Presidential fitness awards was initiated in 1966, with the objective of motivating children to a greater involvement in physical activity. Awards were initially given to students for meeting empirical standards on 6 criteria (a 50-yard dash, a 600 yard walk-run, a standing broad jump, pull-ups, sit-ups and a soft-ball throw). Recognizing that test failure was having a negative impact on some students, a percentile-based award system was substituted in 1991, and in 2012–2013 this in turn was replaced by a FITNESSGRAM® assessment. Relatively low standards are now set for the physical performance of U.S. children, on the hypothesis that children gain substantial benefit from even modest increases in their habitual physical activity. In 1997, a Presidential Active Lifestyle Award was added, based on reported physical activity participation. Adult recipients were required to undertake physical activity for 30 minutes a day, at least 5 days a week, during 6 out of 8 weeks, or to reach a pedometer count >8500 steps/day, as well as attaining a healthy eating goal. For children and adolescents (8–17 years of age) the requirements were more rigorous: 60 minutes of physical activity a day, for at least 5 days a week, during 6 out of 8  weeks, or a pedometer count >12,000 steps/day, plus attaining healthy eating goals. Finally, a Presidential Champions’ Award was introduced for those who claimed to be successful in raising their level of physical activity. Government Funding of Sports Training  The U.S. opened an Olympic training centre at Colorado Springs in 1978. It offers facilities to competitors in 15 disciplines, including a state of the art sports medicine and sports science laboratory, and space for more than 500 athletes at any one time. In all, the U.S. now operates 3 Olympic training centers and 15 Olympic training sites, established at a total cost of “millions of dollars,” in the hope of providing American athletes with the best available training.

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Britain In Britain, there has been relatively little government involvement in fitness and sport. However, what previously had been termed a “Sport for All” programme was transformed into the UK Sports Council in 1997, with the objective of offering enhanced training to competitors in some 30 sports where there seemed a prospect of winning Olympic medals for Britain. Funding for this initiative came from a National lottery. Since 2002, the Council has funded the U.K.  Institute of Sport, which provides services to elite Olympic and Paralympic athletes through 15 high performance centres.

Canada The Dominion-Provincial Youth Training Act of 1939 provided funding to support various Provincial physical recreation projects. The National Physical Fitness Act (1943) was also intended to promote physical fitness through various physical education, sports and athletic programmes. However, the Act was repealed in 1954. The Federal Government was then absolved of any responsibility for either sport or physical fitness until 1961, when Bill C-131 (An act to encourage fitness and amateur sport”) was enacted. This last piece of legislation established a Federal Directorate of Fitness & Amateur Sport; under successive ministers, the emphasis of the Directorate lurched between the promotion of fitness and the encouragement of sport. We will comment on three specific initiatives: the Fitness Awards, the mnotivational agency ParticipACTION, and government involvement in sport. Fitness Awards  The Canada Fitness Award Programme (1970) was similar to that developed in the U.S. (above). In order to win the highest award (Excellence), a child had to excel in all of six test events. By 1986, more than 16 million Canadian children had participated in the Canada Fitness Awards programme. However, it was discontinued in 1992. As in the U.S., critics argued that the Awards discouraged those who failed to achieve even the minimum grade. ParticipACTION  The Canadian Crown Corporation ParticipACTION is relatively unique in undertaking a long-term nation-wide motivational programme designed to increase physical activity. The organization was formed as a not-for-profit company in 1971, with former prime minister Lester B. Pearson as its first Chairman, and Philippe de Gaspé Beaubien, the Chair of the Canadian Council for Physical Fitness & Amateur Sport, as its first President. The name of the organization, ParticipACTION, skated diplomatically around the connotations of hard work and inconvenience that some people found in the words “exercise” and “fitness.” In discussion with Prime Minister Pierre Trudeau, Beaubien pointed out that it would cost at least $5 M to launch a new design of automobile, and that a publicity campaign intended to increase the physical activity

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of the population could hardly be expected to cost any less. Pierre Trudeau agreed to contribute $2.5 M to the project, provided that Beaubien could raise $2.5 M from the private sector. In 1972, Russ Kisby (1940–2007 CE) was hired as its Director-General. The job advertisement read: “Wanted: A Chief Executive Officer to whip Canada into shape. Reward- a generous salary and the thanks of future generations.” During 1972 CE, the first “public service” notices appeared, and a pilot fitness project was launched in the city of Saskatoon. ParticipACTION’s controversial “60-year-old Swede” television advertisement appeared in 1973; a 15-second film showed a 60-year-old Swede jogging effortlessly beside a puffing 30-year-old Canadian. Other memorable slogans in buses included: “Jog to the rear of the bus. If you’re like most Canadians, it’s the only real exercise you’ll get today,” and “Canada, the true north, soft and free.” In 1974, ParticipACTION launched its own newspaper, and two years later activity trails (Participarks) were built in 100 Canadian communities. In 1979, the booklet “What’s the Matter with Kids?” high-lighted the growing lack of fitness and obesity among Canadian children, and in 1980–81 an employee fitness booklet was directed to 100,000 workers and their families. In 1982, PartcipACTION Saskatoon challenged the residents of 100 towns across Canada to exceed the level of physical activity found in neighbouring communities. Other diverse initiatives included a programme that focussed upon improved eating and increased exercise in elementary schools, Exprès (a training plan developed for the Canadian Forces), and the distribution of “Health Saver” pamphlets to family physicians. In 1992, the emphasis shifted to encouraging active living, and in 1998, ParticipACTION joined with Health Canada to launch Canada’s Physical Activity Guide to Healthy Living. By the turn of the twenty-first century, government funding of ParticipACTION had shrunk to a level where it was difficult to maintain an effective national publicity campaign. Moreover, the initial mainstay of publicity, free “public service announcements,” had become a rarity. Thus, with the retirement of Russ Kisby in the year 2000, ParticipACTION officially ceased operations. However, it was revived in 2007, and now is placing increased emphasis upon social media as a means of raising the public’s awareness of the need for regular physical activity. Government Involvement in Sport  Involvement of the Canadian Federal government in sport was renewed during the 1960s, in part because of political embarrassment about the poor showing of Canadian athletes at recent international competitions. A Task Force on Sport for Canadians (1969) made numerous recommendations. One important consequence was the establishment of a National Centre for Sport and Recreation (1974). All of Canada’s sporting organizations were encouraged to establish their national offices in a single building in suburban Ottawa, and in return they were offered technical, executive and programme staff, office expenses, secretarial help, and use of core services at a low cost. Loto Canada was established as a crown corporation in 1973. They reported to the Minister of State for Fitness, and Amateur Sport, and revenues were applied to

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the funding of public events such as the Commonwealth Games, and specific projects in Fitness & Amateur Sport. The minting of Olympic coins and postage stamps carrying an Olympic surcharge provided further sources of revenue for governmental support of sport. The Provincial and Territorial governments of Canada became involved in sports development in the late 1960s, partnering in programmes such as the Canada Games and the National Coaching Certification Programme. A key concern in many regional and national consultations was the continuing limited participation of school students in physical education and sports programmes. A Canadian Sports Policy emerged in 2002, with 4 goals: enhanced participation; enhanced excellence; enhanced capacity; and enhanced interaction between the 2 senior levels of government. In 2003, a new Physical Activity and Sport Act replaced the federal legislation of 1961. Sport participation was passed from the Minister of National Health and Welfare to the Minister of National Heritage, with an assistant who was designated in a series of cabinet reshuffles as a Minister of State for Sport, Minister for Sport or Minister for Amateur Sport. Objectives for the new agency were increased participation in sport, support for the pursuit of excellence and building capacity in the Canadian Sports system. Stimulated by the award of the Winter Olympic Games to Vancouver in 2012, a governmental initiative was entitled “Own the podium.” Its objective was to provide sufficient support for Canadian athletes that they would contend for the number one spot in the Olympic Winter Games. Unfortunately, the diversion of governmental interest from programmes for the general public to a search for international medals was associated with a decline in overall sports participation; among Canadians >15  years of age, participation dropped from 45% cent of the population in 1992 to 34% in 1998 and only 28% in 2005. Population aging might explain some of this change, but even in youth aged 15 to 18 years, participation declined from 77% in 1992 to 59% in 2005.

Practical Implications for Current Policy Totalitarian governments have apparently been successful in winning international competition through the ruthless control, exploitation, and systematic doping of their athletes. However, the support of sport by governmental interventions of the type acceptable to liberal democracies has apparently had little effect upon performance in international competitions. It is debatable whether a systematic increase in the national medal count is an important and worthy goal for governments to pursue; but if this is seen as important to national prestige, then a new approach would seem necessary. Equally, totalitarian governments have seemingly been successful in involving people of all ages in movements dedicated to improving health and fitness, but the more gentle persuasion of motivational organizations such as ParticipACTION has had little success in augmenting the habitual physical activity of the general

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p­ opulation. Possibly, one reason for this failure has been that the amounts of money invested in government supported advertizing campaigns have been dwarfed by commercial voices preaching a more indolent lifestyle. But again, there may be a need to consider new ways of influencing popular opinion, particularly a determined use of social media.

Questions for Discussion 1. Are there ever situations where governments should use sports events for political purposes? 2. Can governmental organizations increase population involvement in physical activity by such means as advertizing, the award of fitness medals, and the building of sports facilities? 3. What is the most effective way of transmitting information about health and fitness in today’s society? 4. Does compulsory membership and/or attendance at meetings of a youth sports organization ever have a positive effect upon a person’s health or well-being?

Conclusions In earlier generations, enthusiasts frequently promoted physical education with patriotic objectives, but in the modern era totalitarian regimes, particularly in Italy, Germany and Russia exploited every facet of sport and physical activity programming to promote their causes. In more recent years, the United States and Canada have also seen substantial involvement of government in both the training of top athletes and in attempts to promote greater physical activity among the general population. In North America, the prime objectives have been to increasing standings in international competition and to counter a growing prevalence of obesity and chronic disease. But whereas the ruthless totalitarian interventions appear to have achieved the outcomes desired by their proponents, there is as yet scant evidence of benefit from governmental health promotion initiatives that are acceptable to modern liberal democracies.

Further Reading Ainsworth BE, Macera C. Physical activity and public health practice. Boca Raton FL, CRC Press, 2012, 356 pp. Baker WJ. Sports in the western world. Chicago, IL, University of Chicago Press, 1988, 359 pp.

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Blamires C.  World Fascism: A historical encyclopaedia. Santa Barbara, CA, ABC-Clio, 2006, 750 pp. Cardoza AL. Benito Mussolini. The first fascist. New York, NY, Pearson-Longman, 2006, 188 pp. Cyr NM. Health promotion, disease prevention, and exercise epidemiology. University Press of America, 2003, 202 pp. Clumpner RA. American Federal government involvement in sport, 1888–1973. Edmonton, AL, University of SAlberta Ph.D. thesis, 1976, 848 pp. D’Agati P. The cold war and the 1984 Olympic Games: A Soviet-American surrogate war. New York, NY, Springer, 2013, 197 pp. Dvorson A. The Hitler youth. Marching towards madness. New  York, NY, Rosen Publishing Group, 1999, 64 pp. Houlihan B. Sport, policy and politics; a comparative analysis. Abingdon, OX, Routledge, 2002, 336 pp. Kirk T. The architecture of modern Italy. Visions of Utopia. 1900-Present. New York, NY, Princeton Architectural Press, 2005, 280 pp. Lackerstein D. National regeneration in Vichy France. Ideas and policies 1930–1944. Abingdon, OX, Routledge, 2016, 278 pp. Lewis PH. Latin fascist elites. The Mussolini, Franco and Salazar regimes. Santa Barbara, CA, ABC-Clio, 2002, 210 pp. Macintosh D. Sport and politics in Canada. Montreal, QC, Mcgill/Queen’s University Press, 1987, 224 pp. Manley AF, U.S. Surgeon General. Physical activity and health: A report of the Surgeon General. Collingdale, PA, Diane Publishing, 1996, 276 pp. McKenzie S. Getting physical: The rise of fitness culture in America. Lawrence, KS, University of Kansas Press, 2013, 254 pp. Morow D. A concise history of sport in Canada. Oxford, UK, Oxford University Press, 1989, 393 pp. Musich S. The association of health promotion participation with health risks and medical costs. Ann Arbor, MI, University of Michigan, Ph.D. Thesis, 1998, https://deepblue.lib.umich.edu/ handle/2027.42/131059?show=full. O’Mahony M. Sport in the USSR: Physical culture, visual culture. Islington, UK, Reaktion Books, 2006, 221 pp. President’s Council on Youth Fitness. Fitness of American Youth. Washington, DC, US Government Printing Office, 1956, 52 pp. President’s Council on Youth Fitness. Physical fitness elements in recreation. Washington, DC, US Government Printing Office, 1962, 58 pp. Redman G. Sport and Politics. Champaign, IL, Human Kinetics, 1986, 214 pp. Rempel G. Hitler’s children: The Hitler Youth and the SS. Chapel Hill, NC, UNC Books, 2015, 368 pp. Riordan J. Sport in Soviet society: development of sport and physical education. Cambridge, UK, Cambridge Univeristy Press, 1980, 446 pp. Tedor R. Hitler’s revolution: ideology, social programs, foreign affairs. Pennsauken, NJ, BookBaby, 2013, 531 pp. Thibault L, Harvey J.  Sport policy in Canada. Ottawa, ON, University of Ottawa Press, 2013, 450 pp. Tumblety J. Remaking the male body: Masculinity and the uses of physical culture in inter-war and Vichy France. Oxford, UK, Oxford University Press, 2012, 257 pp. Victor JL. Sport in the Soviet Union. Amsterdam, Netherlands, Elsevier, 2013, 154 pp. Zilberman V. Physical education and sport in the Soviet Union. Montreal, QC, McGill University, Doctoral Thesis, 1979, 132 pp.

Chapter 21

Governmental Involvement in Health Care and Health Promotion

Learning Objectives 1. To see how medical ethics can be subverted by totalitarian regimes for nefarious purposes such as “racial cleansing.” 2. To recognize that for many centuries, governments have provided some medical care for the poor, but that the widespread drive to provide universal, free health care did not blossom until after World War II. 3. To note that an aging population and the overuse of ever-more sophisticated medical technology is currently leading to an unsustainable increase in governmental health-care expenditures in many nations. 4. To understand that good outcomes such as a long and healthy life expectancy can be achieved at relatively low cost through a well-planned health-care system with an emphasis upon prevention rather than high-cost hospital treatment.

Introduction Governments have at various points in history been involved not only in the promotion of fitness and sport (Chap. 20), but also in the management and delivery of health services. In the Arab world and in Mediaeval Europe, medical fees were seen as a barrier to treatment for poorer people, and various mechanisms were developed that provided limited medical services to the poorest members of the community. But a blossoming of comprehensive free health care for all citizens did not occur until the Post-Modern Era, as nations recovered from the devastation of World War II. Benefits of the extended health care were seen in substantial increases of average longevity. But one dark stain upon government intervention occurred in Nazi

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Germany, where state-controlled medicine was used with sinister objectives such as “racial cleansing.”

Health Care in the Arabic World Health care was tightly regulated by government in the Arabic world. Al Ma’mum (768–833 CE), the Caliph of Baghdad, officially appointed Islamic physicians and paid their salaries. Doctors were not allowed to practice until they had passed a state-administered qualifying examination, and they were legally required to keep peer-audited medical records. Evidence of malpractice led to decertification and even execution. Generous provision for the sick was made through Arabic hospitals (Chap. 16), covering not only care within the hospitals, but also the period of convalescence following discharge.

Health Care in Mediaeval Europe In mediaeval Europe, the provision of health care for the poor was less systematic, but some services were provided by the state. In Britain, the Crown made some provision for the poor. Thus John of Essex received a penny a day from the Royal Exchequer to cover his services as phlebotomist, medic and toothdrawer over the period 1156 to 1171 CE. This type of public office seems to have persisted for several centuries, and in 1400  CE, the crown reimbursed Matthew Flynt 6d per day for his services as toothdrawer. Other facilities for the indigent sick and dying were provided through monasteries and hospices (Chap. 13). In Bologna, Hugh of Lucca was appointed State Surgeon in 1214  CE, at an annual salary of 600 Bologni. In return for this stipend, he spent 6 months per year attending the poor. Likewise, in the City of Nuremberg, Magister Petrus was appointed city physician in 1377 CE. Wismar, Strasburg, Cologne and Frankfurt followed suit by naming city physicians between 1281 and 1384 CE, and in 1426 CE the Holy Roman Emperor Sigismund decreed that every City within the Holy Roman Empire must hire a town physician at an annual salary of at least 100 guilders. Zűrich had appointed its city physician by the fifteenth century, and Geneva, Berne and Basel soon followed this example. In addition to treating the poor, many city physicians had responsibilities akin to that of a modern Medical Officer of Health- visiting food markets to examine the condition of meat and fruit, testing for the contamination of well-water, checking on the disposal of diseased animals, and conducting forensic examinations.

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Health Care in the Post-modern Era During the Post-Modern Era, health care in much of the western world evolved from an earlier tradition of spotty governmental assistance and mutual aid societies to state systems for the delivery of health-care. As a part of this process, both ­occupational health and rehabilitation attracted increasing interest. Other consequences of governmental involvement included recognition of the toxicity of cigarette smoke, increased regulation of automotive emissions, measures to control the HIV epidemic, and a facing of challenges from the global spread of disease associated with international air travel. Over the Post-Modern Era, the emphasis of many government programmes shifted progressively from traditional treatment to the ­prevention of disease and the optimization of health. We will comment on the role of the World Health Organisation in this process, and discuss how health-care delivery has evolved in Britain, Canada, the United States, France and Germany. World Health Organisation  As early as 1948, the World Heålth Organisation recognized that good health was “A state of complete physical, mental and social well-­ being and not merely the absence of disease and infirmity,” and in subsequent years it focussed heavily on preventive measures, under the rubric “Not merely the absence of disease.” An International Conference on Primary Health Care was hosted by the WHO in Kazakhstan in 1978; it set the goal of “Health for All.” In 1986 CE, the WHO also participated in the Ottawa Charter. One important preventive initiative of the WHO has been its efforts to reduce cigarette smoking. A convention on tobacco control envisaged taxation measures that would reduce consumption, control passive smoking, packaging and labelling, provide education, and control advertising and sponsorship schemes. In 1997, the WHO Jakarta Declaration on Leading Health Promotion into the twenty-first Century identified poverty as the greatest threat to health, and it warned of various dangers posed by globalization and environmental degradation. In 2004, the WHO established a global strategy on diet, physical activity and health. A first ministerial conference on healthy lifestyles and the control of non-­ communicable diseases was held in Moscow in 2011 CE. That same year, the Rio Political Declaration on the Social Determinants of Health expressed global interest in adopting a “social determinants of health” approach. Britain  David Lloyd George (1863–1945) (Fig. 21.1) was head of the British wartime coalition government from 1916 until 1922. At this early date, he initiated many of the reforms that foreshadowed the modern Welfare State in Britain, including State support for the sick and the infirm. He had campaigned vigorously against those leading the second Boer War (1899–1902), complaining that the British Generals made little provision for sick and injured soldiers, and that Boer women and children were starving to death in British concentration camps.

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Fig. 21.1  David Lloyd George (1863–1945) laid the groundwork for the Welfare State in England as early as 1916–1922 (Source: http://en. wikipedia.org/wiki/ David_Lloyd_ George)

This initiative was followed by the Beveridge Report of 1942, which highlighted the five giant social evils of squalor, ignorance, want, idleness and ill health. Immediately following World War II, with Aneurin Bevan (1897–1960) as Minister of Health, Clement Attlee introduced the National Health Service (1946). This provided all British citizens access to free medical and dental services, with general practitioners receiving an annual lump-sum payment for each patient under their care. Canada  In Canada, as in the U.S. (below), the medical profession was initially strongly opposed to medicare. A government-sponsored scheme was first introduced in Saskatchewan in 1962, by the socialist-leaning (Cooperative Commonwealth Federation) provincial government of Tommy Douglas. This provoked a bitter labour action by the Province’s doctors, but the protest only lasted 23 days, as the provincial government began to replace the striking physicians by replacements recruited from Great Britain. The government of Lester Pearson introduced universal pre-paid health care for Canadians in 1965; participant physicians were paid on a fee-for-service basis. Recognition of the importance of preventive medicine came early to Canada, with publication of the landmark Lalonde Report (1974), appointment of the Romanow Commission, and promulgation of the Ottawa Charter. The Health Promotion Directorate (1978) was the first bureaucratic structure in the world devoted to health promotion. A report entitled “A new perspective on the Health of Canadians” was published by Marc Lalonde, Minister of National Health and Welfare, in 1974. This document recognized the heavy financial demands imposed by universal and unrestricted health care, and it identified twin health objectives: improvement of the health care system itself and the prevention of health problems through the promotion of good health.

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During the last decade, the Canadian Federal and Provincial governments have shown ever-increasing concern about large annual increases in the costs of health care. In fact, Canadian health care expenditures peaked at 11.9% of the Gross Domestic Product (GDP) in 2010, and have since fallen marginally to 11.6–11.7% of GDP. The Romanow Commission on The Future of Health Care in Canada was appointed in 2005; it looked at some of the causes underlying the rising expenditures. Among other important findings, it estimated that in 1999, physical inactivity was costing the Canadian health care system $2.1 B per year, and that a 10% reduction in physical inactivity would save $150 million per year in direct health care costs. In 1986, the Canadian Public Health Association, Health Canada and the World Health Organization launched the Ottawa Charter for Health Promotion, and at an international meeting held in Victoria, BC, Health Canada released “Achieving Health for all: A framework for health promotion.” The latter document underlined the concept that much of the physical activity needed to maintain health could be incorporated into the daily routine (for example, through active transportation). United States  During the twentieth century, the medical profession recovered from the opprobrium of the nineteenth century (Chap. 15), gaining new prestige and authority in society, and in company with private insurance companies it formed a powerful lobby opposing the establishment of any government-sponsored system of universal health-care coverage. President Lyndon Johnson was able to set in motion the Medicare and Medicaid programmes which had been proposed by the Kennedy administration, but it encountered fierce opposition. Opponents, especially the AMA and medical insurance companies, argued it was compulsory, represented socialized medicine, would reduce the quality of health care, and was un-American. Nevertheless, the proposal was enacted in 1965, offering low cost medical services to tens of millions of elderly Americans. In 1971 CE, Senator Edward Kennedy proposed a universal, federally-run health insurance scheme. Nixon responded with a health care plan that provided Medicaid for low-income families with dependent children, and required that all employees be provided with health care. However, the Nixon plan still left some forty million people without coverage, and for this reason the Democratic party refused to support it. Until the initiatives of President Obama, health care in the United States was thus provided largely by private insurance plans (although unionized companies often paid the necessary insurance premiums for their workers). Costs of the U.S. system were high (17.2% of GDP by 2011), and currently the Republican party under Donald Trump is seeking ways to dismantle the system. U.S. research on population health is well-served by a series of Institutes in the Bethesda/Washington area, and health promotion is increasingly fostered through the Centers for Disease Control and Prevention in Atlanta. The Atlanta institution opened its doors in 1946, and focussed initially on malaria prevention in the southern United States. Its mandate has since expanded to include health surveillance,

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with the resultant data shaping U.S. public health policy. Current strategic areas are: supporting state and local health departments; improving global health; implementing measures to decrease the leading causes of death; strengthening health surveillance and epidemiology; and reforming health policies. France  With de Gaulle’s retirement, the French medical system became aligned with that of other nations in the European Community, and a cross-fertilization of ideas led to a communality of health care programmes. Not all medical expenses were covered when the French National Health Insurance plan was introduced in 1945, and up to 90% of the population thus opted to purchase supplementary health insurance. Nevertheless, in 2000, the WHO rated the French programme as “close to best overall health care in the world.” Germany  The German State health care system had its beginnings under Bismark, and during the Weimar Republic (1919–1933), doctors cooperated with the government to provide health care services to all citizens. The emphasis of services shifted progressively towards prevention, with new measures against tuberculosis, venereal disease and substance abuse. Following World War II, Western Germany reverted essentially to the Weimar system of decentralized health care, with input from management and labour. Some 77% of funds are now provided by the government, and 23% comes from private sources. The system is lauded for its lack of restrictions and consumer orientation. The rebuilding of sports facilities was not initially a high post-war priority in what was a ruined country, but as reconstruction progressed, the West German Olympic Committee developed a “Golden plan for health, play and recreation,” with an emphasis upon providing access to physical activity for all. East Germany introduced a Soviet style medical service under the rigid control of the central government. The sport infrastructure was focussed on the development of elite international competitors (Chap. 20), with consequent neglect of the physical activity needs of the average citizen.

Improved Health Services and Life Expectancy The practical success of state-sponsored health care services can be assessed in terms of life expectancy, and particularly the quality-adjusted or disease-free life expectancy. Despite some narrowing of the gap, in general people from developed societies continue to live 20 years longer than people from the poorest countries in the world. A typical Canadian born in 2014 can now expect to live a total of 81.96 years [nearly 11 years longer than in 1961], and despite the snide remarks that Americans sometimes make about the quality of “socialized medicine” north of the border, a Canadian child currently lives 3  years longer than its American counterpart, for roughly half as great a health care expenditure.

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Nevertheless, there remains a substantial discrepancy between the life expectancy in Canadian urban centres and that of indigenous populations in the northern territories, where it is difficult to provide the full range of medical services; the average life expectancy of the Inuit in 2017 was still only 64  years for men and 73 years for women. More than a half of the increase in urban life expectancy in Canada over the past 20 years has been due to an increased life expectancy at the age of 65  years. Important factors influencing these statistics include a reduced prevalence of smoking (in southern Canada, but not Nunavut), and many medical and surgical advances, offset by an increase in obesity and associated metabolic diseases. Life expectancy in most developing societies remains poor because of a continuing high maternal and perinatal mortality, the persistence of controllable infections such as malaria, limited access to hospital and nursing care, and the widespread HIV/AIDS epidemic. In 2013, one of the lowest life expectancies was in Angola (185th of 191 nations, 52.3 years at birth). However, a low Gross National Product is not necessarily synonymous with a poor life expectancy; much depends on the wisdom with which available funds are spent. In Cuba, limited but well-distributed health care expenditures that emphasize prevention have given a life expectancy (78.5 years) in 2015, slightly greater than that achieved by massive medical expenditures in the United States.

Nazi Subversion of Medical Expertise The Nazis sought to improve conditions in industry, with slogans such as “Clean men in a clean factory” and “Good lighting means good work,” but their subversion of accepted medical practice was seen in policies of eugenics, racial categorization, and the use of “non-A ryans” for gruesome human experimentation. Eugenics  During the Modern Era, a number of physicians and philosophers in various countries had been attracted by the ideas of eugenics. Enforced sterilization was particularly active in parts of the U.S. such as California, and German eugenicists working in North America received strong financial support from the Rockefeller Foundation. In Nazi Germany, the government ordered euthanasia for thousands of immigrants, elderly, weak, mentally ill and institutionalized patients (Fig. 21.2), with the aim of reducing government expenditures in supporting such individuals. Racial Categorization  Accurate racial categorization was a key plank of Nazi administrative policy. The Hitler regime began racial instruction at 6 years of age, and Hitler decreed: ”no boy or girl should leave school without complete knowledge of the necessity and meaning of blood purity.” German scientists exploited facial anthropometry in an attempt to determine which citizens were not of “pure Aryan descent” (Fig. 21.3).

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Fig. 21.2  Poster from 1938, promoting the practice of euthanasia in Nazi Germany; the text reads “This person costs the community Dm 60,000 over his lifespan.” (Source: http://en.wikipedia.org/ wiki/Action_T4)

Fig. 21.3  Otmar Freiherr von Verschuer (1896– 1969) and his assistants engaged in facial anthropometry in their attempts to decide which German citizens were of “pure Aryan descent.” (Source: http://en. wikipedia.org/wiki/ Otmar_Freiherr_von_ Verschuer)

Human Experimentation  Beginning in 1940, Josef Mengele was appointed as physician to the Auschwitz concentration camp, where he carried out gruesome human experiments on such topics as cold survival, as well as genetic experiments on twins that he found amongst the internees.

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Following World War II, Mengele managed to escape to the Argentine, where he has remained in hiding. However, his associate (Otmar von Verschuer) was never punished for his war crimes, and perhaps because of support from powerful members of the American eugenics movement, he was eventually rehabilitated as a prestigious Professor of Human Genetics at the University of Münster. Governmental subversion of medical expertise to nefarious ends continues in a number of countries through such practices as the synthesis of ever-more toxic nerve gases, and the systematic doping of Olympic athletes.

Practical Implications for Current Policy The introduction of state-sponsored medical care initially did much to improve health, particularly for the poorer segment of the population. However, in many countries, a combination of an aging population and advances in medical technology are now creating unsustainable annual increases in the costs of State (or indeed privately insured) medical services. Thus, there is an urgent need to examine how far these costs can be contained, both by emphasizing the prevention of ill-health rather than by relying upon high-cost hospital treatment, and by changing traditional patterns of treatment (for instance, substituting home for hospital care of the elderly). In countries such as Canada, there remains a need to ensure that the medical services available in urban centres are also open to those living in geographically remote regions. Developments in tele-diagnosis and robotics may in the future address some of the current disparities in health care. Given that most individuals currently incur a large fraction of their total medical costs during their final year of life, and the proportion of elderly people is increasing in most countries, there may be a need to consider some age restrictions on the governmental provision of expensive forms of medical treatment. The eugenic policies of Nazi Germany have generally been considered as repulsive, and some of their perpetrators were successfully prosecuted at the Nuremberg War Crimes Tribunal. However, there may be a small role for eugenic planning and counselling in future medical care. There are a number of inherited disorders with devastating consequences for the individual’s future health. Many of these disorders can now be detected by genetic testing during pregnancy. This raises questions as to how far the perpetuation of such conditions should be prevented by termination of pregnancy or genetic manipulation of affected foetuses. The gruesome human “experiments” conducted in a number of German concentration camps brought to the fore the issue of personal consent for human experimentation, and prior to the publication of reports, all reputable scientific journal now require the clear approval of studies by institutional committees on the ethics of human experimentation. Questions continue on the employment of physicians in some countries on the development of agents of mass destruction, including chemical and biological weapons.

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Questions for Discussion 1 . Does eugenics have any place in an ethical health care system? 2. What is a reasonable proportion of the gross national product to allocate to the provision of universal health care? 3. How would you accelerate the transition from traditional medical treatment to health promotion? 4. Are there any advantages of privately funded relative to State-sponsored health care?

Conclusions Governmental involvement in the provision of health services has generally had a positive effect upon populations, assuring adequate medical care for the poorer members of society, and yielding substantial increases in human longevity. The one problem with State medical services has been an unsustainable annual escalation of costs. Currently, governments hope to curtail these rising expenditures by focusing increasingly upon prevention and health promotion rather than traditional high-cost hospital care. However, the example of Cuba shows that an excellent outcome (in terms of quality-adjusted life expectancy) can be achieved at an acceptable cost by the adoption of a simple but well-planned public health care system. One potential negative aspect of governmental control is illustrated by the Nazi regime, where doctors were co-opted to carry out “experiments” that were later condemned as heinous war crimes, and were also involved in massive “eugenic” exterminations of “non-­Aryans” in the infamous concentration camps.

Further Reading Beveridge J. Beveridge and his plan. London, UK, Hodder & Stoughton, 1954, 239 pp. Bryant T. Health policy in Canada, 2nd ed. Toronto, ON, Canadian Scholars, 2016, 430 pp. Ernst D. The social policies of David Lloyd George. Madison WI, University of Wisconsin, Madison, 1942, 498 pp. Kevies DJ. In the name of eugenics. Genetics and the uses of human heredity. Berkeley, CA, University of California Press, 1985, 426 pp. Kuhl S. The Nazi connection. Eugenics, American racism and German National Socialism. Oxford, UK, Oxfoed University Press, 2002, 185 pp. Leichter HM. A comparative approach to policy analysis: Health care politics in four nations. Cambridge, UK, Cambridge University Press, 1979, 326 pp. Marchildon GP. Making medicare: New perspectives on the history of Medicare in Canada. Toronto, ON, University of Toronto Press, 2012, 321 pp. McNeill PM. The ethics and politics of human experimentation. Cambridge, UK, Cambridge University Press, 1993, 316 pp.

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Rodwin V. The health planning predicament. France, Quebec, England and the United States. Berkeley, CA, University of California Press, 1984, 303 pp. Roemer MI. National health systems of the world. Oxford, UK, Oxford University Press, 1993, 368 pp. Russell AW. The town and city physician in Europe from the Middle Ages to the Enlightenment. Wolfenbüttel, Germany, Herzog August Bibliotek, 1981, 156 pp. Schmidt U, Frewer A. History and theory of human experimentation: the Declaration of Helsinki and modern medical ethics. Hendon, VA, Steiner, 2007, 364 pp. Siddiqi J. World Health and world politics. The World Health Organisation and the United Nations system. Columbia, SC, University of South Carolina Press, 1995, 272 pp. Starr P. The social transformation of American medicine. New  York, NY, Basic Books, 1982, 514 pp.

Chapter 22

Building the Infrastructure and Regulations Needed for Public Health and Fitness

Learning Objectives 1. To recognize the importance to the maintenance of good health of adequate public health regulations and an infrastructure that provides clean water and appropriate waste management 2. To see the lack of such amenities over many centuries, but the progressive development of public health bureaucracies dedicated to provision of an appropriate infrastructure, beginning during the Victorian Era. 3. To observe how responsibility for the provision of adequate housing for poorer city dwellers has been shared between government, benevolent entrepreneurs and charities. 4. To note the new challenges to public health presented by such issues as the abuse of tobacco and mood-altering drugs, continuing toxic auto-emissions, the epidemic of HIV/AIDS, a decreased acceptance of MMR vaccinations, and the ready spread of infectious diseases by air travel.

Introduction Opportunities for the spread of communicable diseases have increased with the growth in size of cities. The success of urban living has depended in great part on governmental ability to maintain population health through the building of an adequate infrastructure to provide clean water and to dispose of waste, as well as the enactment of appropriate regulations to control the prevent the spread of infectious diseases. In this chapter, we will look at success in meeting these objectives in various communities from early history through the Classical Era, the Arab World, Mediaeval Europe, the Renaissance, and the Enlightenment to the Victorian Era, concluding with some comments on current challenges to public health.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_22

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Early History Some early civilizations enacted quite specific health regulations, and some also developed an impressive health infrastructure, at least for their wealthier citizens. We will cite briefly examples from the Harrapan region of the Punjab, Egypt and Israel. The Harrapan Culture  The Harrapan cities date back 2 millennia BCE, The Harrapan people were perhaps the first to pay significant attention to a healthy urban infrastructure. Multi-storied brick houses boasted wells and an effective covered sewage system. Public baths facilitated personal, hygiene, and dykes protected the region against flooding. Laws also protected the community against the adulteration of grain and fats. Egypt  In Egypt, pigs were regarded as unclean animals, and were avoided as sources of protein; further, the eating of other meat products was prohibited during the hotter parts of the year. The wealthier citizens used natron, a paste of ash or clay, to clean their hands, and for upper-class Egyptians the laundry supervisor was an important member of the domestic staff. There are ruins of a few public bath-­houses built during the period of Greek domination, but most Egyptians were content to wash their bodies by a quick dip in a canal or river. Israel  Moses (1391–1271  BCE) imported some early Egyptian regulations into Israel, and the priestly class elaborated 213 of 613 Biblical commandments that focussed upon health and personal hygiene. Items covered in these discourses of the Torah include rigid quarantine regulations, a variety of dietary restrictions, and a regular weekly Sabbath period of relaxation. Water, usually drawn from wells, was a precious commodity in ancient Israel, and excreta accumulated in cess-pits.

Classical Civilizations Minoans  The Minoan culture (2000–1500 BCE) seems to have had some knowledge of the principles of public health. Networks of clay pipes provided upper class houses with water and sewage facilities, and aqueducts brought fresh water to the palace fountains and spigots from springs that were some 10  km away. Separate pipes cleared waste-water and the run-off from heavy rains, and the Minoan palace even had a footbath for weary travellers. However, provision for the lower echelons of society was less satisfactory. People still had to carry water from a local spring, and dysentery and typhoid fever were likely frequent problems for poorer Minoans. Greece  Classical Athens viewed hygiene as the management of 6 non-natural things (air, exercise, diet, sleep, excretion and retention, and passions of the mind).

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However, the city also made major public investments in infrastructure to provide clean water and treat sewage. There are reports of groundwater exploitation and water transportation from distant sources, together with storm water and wastewater systems, flood protection and drainage, and the construction of fountains, baths and other sanitary and purgatory facilities. Laws also required the inspection of wines to ensure the purity and soundness of these products. Rome  The ideas of classical Greece were further developed in Rome, where good health was seen as dependent upon a combination of bathing, wise eating, massage and exercise. Infrastructure included public and private baths, aqueducts as long as 350  km, and city-wide sewage systems. The private villas of wealthy citizens boasted indoor plumbing, with flush toilets, and baths were often included in their dream homes, sometimes staffed by one or more athletes. Ordinary citizens made wide use of public baths. A water commissioner named Frontinus (40–103  CE) reported that under his jurisdiction there were 856 baths in Rome alone. Visitors to the baths gave their belongings to slaves, and then entered the cold-plunge-bath. After exercising in this pool, they moved into a warm and humid room where they sweated and were massaged. They could then progress to a yet warmer room with a mosaic floor immediately above the furnace, finishing with a brief spell of dry sweating in the hottest room of the facility. Women used an adjoining, smaller set of baths. There were rigid state laws to guard the purity of food products and protect the public against bad quality and fraud. Documentation describes the watering of wine and the adulteration of olive oil. It was once suggested that lead piping had caused a widespread poisoning of the Roman population. However, Vitruvius (c. 75–15 BCE) seemed aware of this danger: “Water conducted through earthen pipes is more wholesome than that through lead; indeed that conveyed in lead must be injurious, because from it white lead…. is obtained, and this is said to be injurious to the human system.” If indeed there was chronic lead poisoning in Rome, it more likely arose from syrups prepared by concentrating grape juice in lead kettles. The return of the Roman legions from foreign expeditions exposed the population to many micro-organisms for which they had little natural immunity. The Antonine plague (165–180 CE) was probably smallpox. It quickly decimated the ranks of the legions, with a clinical picture of fever, diarrhoea, inflammation of the pharynx, and a pustular skin eruption on the 9th day. A similar plague raged under Cyprian, between 251 and 270  CE.  One charlatan (Alexander the Paphlagonian, second century CE) made much money selling a protective oracle to hang over front doors; however, it did little to stem the infection!

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The Arab World In the hey-day of the Persian Empire, heat, cold, dirt, stench, old age and anxiety were all thought to contribute to ill-health. Cyrus the Great (590–530 BCE) thus taught his soldiers not to urinate or spit into running water. Dead matter was also carefully removed from water-courses, and the clothing of dead people was systematically burnt. During the mediaeval era, interest in public health was much more advanced in the Islamic world than in Northern and Western Europe. Ali Ibn-Rabban (838– 870 CE), a well-respected physician living on the south coast of the Caspian Sea, wrote in his seven-part medical work Paradise of Wisdom that: “No one should live in any country which does not have four things: a just government, useful medicaments, flowing water and an educated physician.” In the eleventh century, the Arabic biographer Al-Mussawir emphasized that the main duty of a monarch was the preservation of health and well-being in his subjects. Thus, Islamic legislation required physicians to pay regular visits to army units, prisons and people living in outlying areas. The practice of medicine was regulated through a religious office, the Hisba, headed by an official called the Muhtasib with some of the powers of a modern ombudsperson. One function of the Muhtasib was to act as the city medical officer of health. He prevented people with elephantiasis from using the public baths, regulated the cleanliness of public places such as markets, and ensured that garbage collectors did not handle food. One interesting example of applied hygiene was the method used to determine an appropriate location for construction of the main hospital in Baghdad (Chap. 16). The merits of various sites were compared by hanging up pieces of meat, and noting the location where decomposition proceeded the most slowly. The city of Córdoba under Moorish rule further illustrates the infrastructure typical of the Arab world during the tenth century CE. Among other facilities, the city boasted 300 public baths.

Mediaeval Europe In Northern and Western Europe, public health infra-structure such as aqueducts and sewers fell into disrepair following departure of the Roman garrisons, and during the Mediaeval Era the sanitary conditions in most cities were appalling. Positive developments were the development of quarantine procedures and the re-emergence of a few public baths. Food inspectors were appointed, and some cities also introduced zoning regulations, requiring malodorous trades such as tanning to be undertaken outside the city walls. Water Supply and Sewage Disposal  Untreated waste was thrown directly into the rivers of London and Paris, and travellers were advised: “wise men go over bridges, and fools go under them.” In 1349  CE, King Edward III ordered the Mayor of

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London to: “cause the human faeces and other filth lying in the streets and lanes in the city top be removed with all speed to places far distant, so that no greater cause of mortality may arise…” A fourteenth century ordinance prohibiting the emptying of latrines into a creek near London’s City Wall remained largely ignored, so that in the fifteenth Century the stream was buried underground. Substantial populations of hogs and cattle roamed the streets of many large cities, adding to the urban stench. Uncontaminated water was a rarity, and a lack of refuse disposal encouraged rat infestations. Infrequent bathing and unwashed woolen clothing led to a proliferation of fleas and other insect vectors of infection. During the mid-fourteenth century, two thirds of the European population was killed by the flea-borne bubonic plague (the “Black Death”, 1340–1348 CE). Many doctors deserted their patients during this epidemic, and others proposed preposterous remedies. Guy de Chauliac wrote: “so contagious was the disease…. that no one could see or approach the patient without taking the disease…For self-preservation, there was nothing better than to flee the region… to purge oneself with pills of aloes, to diminish the blood by phlebotomy and to purify the air by fire and to comfort the heart with senna and things of good odor and to soothe the humours with Armenian bole and resist putrefaction by means of acid things.” Chauliac unwittingly kept the rats and fleas away from Pope Clement VI, by surrounding his bedside with charcoal burners. Development of Quarantine Procedures  A few years following the Black Death, observant physicians hypothesized that ships arriving from overseas were contributing to the recurring epidemics of plague. At first, hostels for sick townsfolk and newly arrived visitors were set up outside the city, but this was not entirely effective in containing infection. Thus in 1377 CE, a trentino (30 days) of isolation on an uninhabited island was required at many European ports of entry. Subsequently, the isolation period was extended to 40 days, perhaps because of an ancient Greek doctrine that a contagious disease became manifest within 40 days. In Britain, recently arriving travellers were quarantined on guardships, anchored in the Thames Estuary (Fig. 22.1). Revival of Public Baths  Most of the Roman baths in Northern Europe had been abandoned by the Mediaeval Era, in part because of the high cost of heating the bath water, and in part because the church considered public bathing as a common prelude to venal sins. The church also had concerns about reinforcing belief in the supposed healing powers of Celtic water deities (Chap. 14). Nevertheless, as prosperity increased in the latter part of the Middle Ages, public baths were built or reopened in various parts of Europe. In Britain, the King’s bath was built over the Sulis Minerva temple in the city of Bath, and Paris had established 26 public baths by the thirteenth century. In Germany, the tradition of river bathing had persisted from Celtic times, and a growing number of new public bath-houses were constructed during the 14th and 15th Centuries. Admission to a bath-house was expensive, and poorer Germans considered the payment of “bath money” a great blessing. The full luxury package of a spa treatment included washing, scouring and slapping of the body with a sheaf of twigs, a steam bath, rubbing to induce perspiration, swatting the skin with wet rags,

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Fig. 22.1  In the years following the Black Death, many Nations quarantined newly arrived immigrants on an island for 40 days. In Britain, incoming travellers were held on guardships such as the Rhin, anchored in the Thames Estuary (Source: http://en.wikipedia.org/wiki/File:Quarantine_ guardship_Rhin_1830.jpg)

scratching, hair washing, cutting and combing, lavendering, and blood letting. Unfortunately, some of the baths subsequently became the scene of debauchery, prostitution and infection, and by the sixteenth Century, many were closed for fears of spreading syphilis, leprosy and plague (Fig. 22.2). Personal Hygiene  Substantial quantities of soap were traded during the Mediaeval Era, but this was used more for the washing of wool than for cleansing of the skin. Monasteries boasted laundry rooms, and many women listed their trade as “laundry woman.” However, the laundering of clothes was an infrequent luxury for poorer people, and indeed many had no spare set of clothing, so that fleas flourished in the poorer households. Food Inspection  Basic foodstuffs such as wine, beer, bread, meat, fish and salt were frequently adulterated in Mediaeval times. To counter such abuses, several European governments appointed food inspectors. In Britain, in 1266, the Assize of Bread and Ale regulated the price of these staples in relation to the price of corn.

The Renaissance Occasional Renaissance scholars expressed some interest in health promotion. The English diplomat and scholar Thomas Elyot (c. 1420–1546) wrote a book entitle the “Castell of Health,” summarizing the latest medical knowledge for those unfamiliar

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Fig. 22.2.  Woodcut of the women’s bath-house at an early German spa, as seen in a woodcut by Albrecht Dürer. By the sixteenth century, many bath-houses had been closed because they had become scenes of debauchery (Source: http://commons.wikimedia.org/wiki/File:Albrecht_ Durer,_%22Womans_Bath%22.jpg)

with Greek, and the Venetian nobleman Luigi Cornaro (1464–1566) wrote a book on the art of living a long life. Santo Santorio (Chap. 27) also sought to put hygiene on a mathematical basis. Most of Renaissance society showed little interest in public health or hygiene, as shown by the outbreak and management of the Great Plague. However, Boards of Public Health were set up in some cities. Two small advances in personal hygiene were the introduction of cotton clothing and a growing use of toothbrushes. Diligent housewives adopted a few other simple changes in household management to preserve the health of their families, and Cambridge University insisted on a direct control of its food supply, The Great Plague  The London “Plague” of 1665  CE was one in a series of European epidemics of bubonic plague dating back to the “Black Death.” The Great Plague claimed at least 70,000 lives in central London, this being about a half of the population who had not fled from the city. Indeed, the death count was probably underestimated, since publically appointed street monitors were open to bribery by those who did not wish to disclose that their house had become infected. Samuel Pepys commented that the prevalence of the disease was such that corpses could not removed during the hours of darkness (Fig. 22.3). People were confined to their homes if one family member was infected, thus virtually ensured the death of the entire household. Two watchmen were posted at the doors of infected homes for 40 days, at a cost of 16d per house per day, and the

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Fig. 22.3  Collecting the dead for burial during the Great Plague of London, in 1665 CE. At the peak of the epidemic, the number of corpses was such that collection could not be completed during the hours of darkness (Source: http:// en.wikipedia.org/wiki/ Great_Plague_of_ London#cite_note-­ Leasor42-­12)

victims received a public stipend of 8d per day to pay for food, fuel and medicaments. Believing that the disease was conveyed by miasmata, the College of Physicians recommended using bonfires to displace the infected air. There was probably some incidental benefit from these fires, since the smoke tended to drive away the flea-ridden rats that were vectors of the disease. The epidemic was eventually checked by the Great Fire, which consumed both the rats and the plague-­ infested slum dwellings. Boards of Public Health  In Europe, local Boards of Public Health were established; they adopted various measures for the containment of epidemics and the provision of social support to the community. In some cases, they designated specific physicians to attend plague victims, and in Florence, local doctors prepared a public information booklet that summarized current knowledge on plague prevention. A further responsibility of these Boards was to deal with doctors who failed to report communicable diseases in wealthy patients. One Roman doctor who was arrested for this offence was ordered to serve as resident physician at the local pest-house. Outbreaks of the plague placed a severe financial stress upon some municipalities. In Milan, extra funding was needed to hire physicians and grave-diggers, to pay for operating a quarantine “pest-house,” and to reimburse the infected for two-thirds of the estimated value of their possessions, which were summarily burned. Some

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municipalities set up immigration offices on mountain passes to control the arrival of infected travelers, and others restricted imports, exports, market trading, travel and funerals, although it was unclear how far these costly measures were successful in reducing the toll of disease and mortality. Personal Hygiene and Household Management  One positive development during the Renaissance was the introduction of washable cotton clothing and sheets. This greatly curtailed the spread of insect-borne diseases, particularly among those with sufficient wealth to own several changes of clothing. Another innovation was popularization of the bristle toothbrush. This device had been invented by the Chinese in the thirteenth century, but did not become popular in England until the late seventeenth century, beginning with the aristocracy. Without necessarily knowing why, Tudor housewives achieved some sterilization of their dairy equipment by scouring with salt and hot water, and then exposing utensils to bright sunlight. Infestation of houses by fleas was also countered by sprinkling appropriate herbs beneath the rush mats that covered their floors. Control of Food Supply  The Renaissance saw further occasional attempts to control the quality of food, particularly for the wealthy. Cambridge University insisted that the direct supervision of their refectories was important to preserving the health and well-being of their students.

The Enlightenment One of those promoting hygiene during the Enlightenment was the physician James MacKenzie, who in 1758 wrote a text on “the history of health and the art of preserving it.” The Enlightenment saw some improvement of health infra-structure Many dwellings for the poorer citizens of Europe.were now constructed of brick and boasted glass windows. And Samuel Johnson (1709–1784) was urging a pro-active response to the prevention of disease:“we must consider how many diseases proceed from our own laziness, intemperance or negligence… and beware of imputing to God, the consequences of luxury, riot and debauchery.” The Diderot Encyclopédie, first published in 1751, included a section on hygiene, which wss defined as: “the things which mankind uses or handles… and their influence on our constitution and organs.” Gottfried Wilhelm Leibniz (1646–1716) was perhaps the greatest enthusiast for public health during this era. He strove to establish a pattern of medical training that was oriented towards public health and preventive medicine rather than the treatment of disease. He reminded his colleagues that Hippocrates had registered every successful cure, and he urged a similar meticulous recording of outcomes in order to provide a modern preventive medicine data-base. He proposed that standardized questionnaires should be developed to examine eating habits, and that careful mor-

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Fig. 22.4  Ruins of an aqueduct, built by Philippe de la Hire to improve the water supply to the city of Versailles and its royal palace (Source: http://en. wikipedia.org/wiki/ Canal_de_l’Eure)

tality statistics should be collected so that findings could be correlated with the local climate, air conditions and the nature of the soil. A few other scientists such as Hales (who improved the water supply for his village of Teddington), and Bernouilli (with authored a probability study demonstrating the merits of vaccination) were also interested in public health. But concern about the provision of clean drinking water, adequate treatment of sewage and garbage, and protection against communicable diseases remained the exception rather than the rule, with most countries making a poor showing on indices of population health. Clean Drinking Water  Francis Bacon published studies on the percolation, filtration, distillation and coagulation of water as early as 1627. Anton van Leeuenhoek described the microscopic animalicules that he had seen in Dutch drinking water in 1680, and the French scientist Joseph Amy patented a water filter in 1746. However, the quality of water in most large cities left much to be desired. Philippe de la Hire (1640–1718) mapped the area around Paris, seeking to improve the water supply to Versailles, probably as much to service the palace ornamental fountains as to provide clean drinking water in the town, and he built a massive aqueduct for this purpose (Fig. 22.4). He further suggested that householders should install a sand filter to purify the water collected from the roofs of their dwellings, although he noted that one alternative source of water, from underground aquifers, was rarely polluted. In 1804, Paisley, Scotland became the first British city to establish a municipal water treatment plant. It used a sand filter that had been developed by Robert Thom. In 1806, Paris also constructed a large water treatment facility on the Seine; here, river water was allowed to settle for 12 hours, and was then passed through sponge pre-filters and main filters that contained sand and charcoal. Despite these advances, the residents of Broad St., in Central London, faced a massive outbreak of cholera as late as 1854, because they were drawing water from a shallow well that was located close to a cholera-contaminated cess-pit. Treatment of Sewage and Garbage  Too often, the city dwellers of the Enlightenment continued to pass sewage into open gullies or cess-pits that were

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close to wells, and garbage was thrown directly onto the street. However, in 1706, the Conseil Supérieur of New France ruled that in order to reduce infection, the houses in Quebec City must have latrines, and that garbage must be carried to the River St. Lawrence, rather than simply thrown out of the door. Populatiion Health during the Enlightenment  Vital statistics provide simple objective indices of overall population health during the Enlightenment. At birth, the average European could expect to live no more than 35 years. A third to a half of the population died before reaching the age of 16 years. Those who survived to their mid-teens lived into their 50s or even their early 60s, and at the age of 21 the aristocracy could expect to live a further 43–50 years; this was an improvement over the 25 years of adult survival typical of the fourteenth century. Survival prospects were much worse in North America than in Europe during the Enlightenment. Many of the population succumbed to fevers, intestinal diseases, and, in the case of the African slaves, to harsh working conditions. A quarter of European immigrant children did not survive until their first birthday, and half of all marriages ended in the death of one partner before their seventh wedding anniversary. Epidemics of beri-beri, smallpox, malaria and yellow fever wreaked havoc among early colonists. Two of every three deaths were attributed to typhoid, dysentery or salt poisoning. In an attempt to reduce this terrible toll, newly arrived immigrants were initially isolated in “guest houses.” Replacement of contaminated water by wine, beer or cider, a reduced consumption of infected clams, and a scattering of the population to areas where there were copious fresh water springs reduced deaths from typhoid and dysentery, but progress in reducing overall mortality was slow. In early Canada, dispersal of the population along the major rivers made major epidemics less likely than in the urban settlements of the United States, but isolation, accidents and harsh winters made Canadian life expectancy worse than those in either Europe or the U.S. Only a small fraction of the population lived beyond 40 years, and many of the children suffered from rickets and anaemia. Typhus and smallpox were also recurrent problems.

The Victorian Era The Victorian era was marked by growing government responsibility for the health of the public in large European cities. There was a gradual improvement in the ­quality of housing, and demographics showed a burgeoning birth rate. Social reformers also succeeded in abolishing child labour and slavery from Western Society (Chap. 23). In this section, we will discuss the role of Boards of Health, continued deaths from poisoning, and improvements in housing conditions. Boards of Health  Major epidemics of influenza, cholera, typhus, typhoid fever and scarlet fever sparked a deep concern about population health in Victorian England. In London, England, cholera killed 14,137 people in 1848–49 and

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10,738 in 1853 (Chap. 24). However, leaders of a new sanitary movement such as Edwin Chadwick (1800–1890) and Thomas Southwood Smith (1788–1861) began to recognize that ill-health of the individual soon became ill-health of the population. They thus made urgent calls for the provision of clean drinking water, proper removal of refuse and sewage treatment. Chadwick and Smith sat as commissioners on London’s General Board of Health that regulated the water supply and sewer connections for all new housing in the city, and provided adequate burial grounds for those who died. The quality of London’s drinking water was rapidly upgraded, and money was spent on methods of preventing death during childbirth. The Public Health Acts of 1848 and 1875 also established public baths and wash-houses, and by the 1870s, health-conscious municipalities were building public swimming pools. In Lower Canada (Quebec), a physician was appointed as Health Officer in 1816, with the primary responsibility of monitoring the sick and starving people who were arriving on immigrant ships from Europe. By 1823, a strengthened five-member Board of Health was supervising quarantine arrangements on Grosse Isle, in the St. Lawrence River near to Quebec City. Nevertheless, the number of immigrants was such that this holding facility was at times overwhelmed, and cholera periodically reached Quebec and Montreal, killing between 10–15% of the population. In 1847, 5424 people also died of typhus while they were quarantined at Grosse Isle. A Central Board of Health for both Upper and Lower Canada was created in 1849. Compulsory vaccination against smallpox was introduced in the early 1860s. In the United States, organization of sanitary reform began rather later than in Canada. The city of New York enacted the Metropolitan Health Bill in 1866, creating a 9-person Board of Health. Immigrants were processed on Ellis Island, just outside New York City. The original wooden structure was quickly destroyed by a catastrophic fire, but a stone replacement building opened in 1900. Many immigrants spent only a few hours in the facility, but those with contagious disease were summarily denied admission to the United States. Continued Deaths from Poisoning  Many Victorians died from eating adulterated or diseased food. One report to the British Privy Council (1863) estimated that 20% of meat came from diseased cattle. Flour was expensive, and bakers frequently adulterated it with chalk (to whiten it) and alum; often, the bakers also kneaded the mixture with their bare feet. An act prohibiting the adulteration of food was passed in 1860, but its enforcement was an option for local authorities, so that it was not very effective. Cooking was typically done in tin-lined copper pans; wealthier citizens replaced the pots when the tin had worn away, but the poor could not afford to do this, and in consequence they sometimes developed copper poisoning. Other sources of poisoning in the Victorian home were leaking gas pipes, lead used in white paint, and arsenic used to colour wallpapers. Improvements in Housing Conditions  In the early nineteenth century, the sudden influx of country folk into the major cities of Europe created hideous slums: “In big, once handsome houses, thirty or more people of all ages may inhabit a single room.”

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Fig. 22.5  Charitable foundations such as the Peabody Trust replaced the worst of British slums by solidly built if Spartan apartments (Source: http://en.wikipedia.org/wiki/Peabody_Trust)

Housing gradually improved over the Victorian era, as many workers accumulated sufficient funds to purchase modest but well-built homes. Enlightened industrialists also constructed model housing estates for their employees. Robert Owen (1771–1858) organized a Model Community for his workers at the New Lanark mills, in Scotland, complete with a nursery school. He envisaged an even more ambitious employee housing project in New Harmony, IN, but this project failed within two years. The Quaker chocolate manufacturer George Cadbury (1839–1922) built a model village for his employees around his factory at Bournville, near Birmingham, and in the U.S. George Pullman, the railway carriage czar, built a model town at Pullman, IL, in 1885. Charitable foundations such as the Peabody Trust began to replace the worst of London’s slums with solidly-built if Spartan apartments (Fig.  22.5). The first Peabody block, at Spitalfields, included 57 dwellings for the poor, 9 shops complete with accommodation for the shopkeepers, and on the top floor baths and laundry facilities for a total cost of £22,000. In the United States, building codes were improved during the Victorian era, and a National Housing Association was founded in 1910, under the aegis of the Commission on the Congestion of Population in New  York. There were also attempts to persuade philanthropists to build model tenements at low rents; buildings were bought, renovated, and then rented to relocated slum dwellers who were given “friendly instruction” on management of their new households.

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Current Challenges to Public Health Despite substantial progress in the delivery of public health, there remain a number of continuing challenges in the twenty-first century. Current issues include the definitive control of the sales of tobacco and mood-altering drugs, the regulation of automotive emissions and other source of urban air pollution, management of the HIV/AIDS epidemic, concern over a growing reluctance to accept childhood vaccinations, and the management of infections spread by international air travel. Control of Cigarettes and Mood-Altering Drugs  In the Edwardian era, cigarette manufacturers had promoted their wares as the cure for various respiratory conditions such as asthma and hay fever. But in 1912, the American physician Isaac Adler pointed to a growing incidence of lung cancer, and he speculated that the abuse of tobacco and alcohol might be responsible. Anti-smoking groups developed in Germany following World War I, and a magazine (German Tobacco Opponents) was published from 1919 to 1935. The Nazi regime was opposed to smoking, with Hitler declaring it a waste of money. In particular, women who smoked were considered as unsuitable to be German wives and mothers. During World War II, the axis powers made much propaganda from the fact that Hitler, Franco and Mussolini were non-smokers, whereas Churchill, Roosevelt and Stalin were all heavy users of tobacco. Evidence of the toxicity of tobacco steadily accumulated during the Modern era. In 1929, Fritz Linkint Dresden demonstrated an increased prevalence of lung cancers in smokers. His research was confirmed in 1939, with a case-control study by Franz Hermann Muller of Cologne. During the 1950s, Ernst Wynder at the Sloan-­ Kettering Institute in New  York and Richard Peto and Bradford Hill at Oxford University advanced even more compelling evidence that cigarettes were carcinogenic. Hill concluded that consuming 35 cigarettes per day increased the odds of dying from lung cancer as much as forty-fold. Other damning evidence came from cellular pathology, animal experimentation and the demonstration of toxic chemicals in cigarette smoke. However, for a substantial part of the Post-Modern era, public health workers had to combat a deliberate campaign by the cigarette manufacturers to confuse and deceive the general public. The manufacturers were well aware of the damning facts by the early 1950s, but their misleading propaganda was able to increase U.S. cigarette sales to a peak of 630 billion units in 1982. As late as 1960, only a third of U.S. doctors considered smoking as “a major cause of cancer,” and 43% of physicians were still smoking on a regular basis. Beginning in the mid 1970s, there was a dramatic decrease in the social acceptability of cigarette smoking, and growing restrictions were placed on public areas where smoking was permitted. This resulted from demonstrations that passive exposure to cigarette smoke gave rise to small but significant increases in the risks of chronic respiratory disease and asthma in childhood, and carcinoma of the lungs and cardiovascular disease in adults. Public polls showed a growing acceptance of public health measures to control smoking in public spaces. Cigarette manufactur-

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ers went to particularly great pains to obfuscate the risks of passive exposure to cigarette smoke, but adverse effects were clearly demonstrated during the 1980s, not only by epidemiological research, but also by the exposure of volunteers to machine-generated cigarette smoke while they exercised in closed chambers. Public health workers continue to face many challenges in reducing the sales of tobacco products, as manufacturers doggedly resist measures to reduce consumption through increased taxation, prohibition of sponsorships, and plain packaging. They constantly seek methods of creating new addicts, both through extensive advertising in third world countries and through such tactics as the marketing of electronic cigarettes. As recently as 2015, cigarette smoking still accounted for 11.5% of deaths world-wide. The toll from cigarettes is now compounded by the effects of mood-altering drugs. Several countries (including Canada) have abandoned attempts to prohibit the marketing of marijuana, with as yet no clear standards of dosages compatible with worker and road safety, and an ever growing segment of the North American population is becoming addicted to powerful opiates, with a high risk of deaths from overdoses. British Columbia alone had 914 deaths from opiate overdoses in 2016, despite providing emergency workers with supplies of the antidote naloxone. Control of Urban air Pollution  The Modern era saw a dramatic drop in the sulphurdioxide/large particulate smog associated with coal fires in many developed societies, but air pollution problems have continued from coal-fired power station and sautomotive emissions, particularly during thermal inversions. The exposure of cyclists and pedestrians to carbon monoxide was studied during the 1970s. Substantial concentrations of carbon monoxide were recorded on congested city streets, particularly if air movement was impeded by tall buildings, but any build-up of carboxyhaemoglobin in the blood stream was reversed quite quickly when the individual moved to a less polluted area. The only adverse clinical effect from carbon monoxide exposure was a somewhat earlier onset of angina if a person with coronary atherosclerosis exercised on a heavily polluted street. Chamber experiments by Steve Horvath in Santa Barbara, CA, and Larry Folinsbee in Toronto documented acceptable ceilings of exposures to the ozone that was formed by the action of sunlight upon the nitrogen oxides from vehicle and aircraft exhaust. The threshold concentration causing a minor disturbance of respiratory function in healthy exercisers was around 0.75 p.p.m., a level that was exceeded in some North American cities on heavily polluted days. To date, in many cities improved automotive emission controls have done little more than match the increase in vehicle registrations, and places such as Paris and Beijing have needed to forbid the access of drivers to the centre of cities on alternating days in order to reduce pollution levels. Since ozone levels show a marked diurnal cycle, one immediate remedy for the active individual is to exercise at less heavily polluted times of the day (early morning or late at night). The ultimate

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s­ olution to the problem of automotive exhaust probably lies in the replacement of gasoline-driven by electric or hydrogen-powered vehicles. The Epidemic of HIV/AIDS  The HIV/AIDS epidemic officially began in the U.S. in 1981, when the Centers for Disease Control reported a clustering of cases of Pneumocystis pneumonia among homosexual men in Los Angeles. It was quickly realized that the condition was not limited to homosexual individuals, but was seen also in intravenous drug users, haemophiliacs and others receiving blood transfusions. Thus, in August 1982, the CDC coined the new term AIDS. A year later, Luc Montagnier and his associates at the Pasteur Institute in Paris discovered the virus responsible for this disease. Much effort has since been devoted not only to finding highly effective anti-­ retroviral agents, but also in devising measures to reduce transmission of the disease. Particular emphasis has been placed upon the wearing of condoms during sexual intercourse, in providing sterile needles for intravenous drug users through programmes of needle exchange and supervised injection sites, in closer control of blood banks and in ensuring sterility during drug injection treatments of tropical diseases. Nevertheless, success in controlling the epidemic has as yet been only partial. In the U.S. the disease had already claimed 575,000 lives by 2006; a further million were living with the disease, and 56,000 fresh cases were diagnosed in that year. In rural Africa, the situation remains even worse, with as many as a third of young adults currently infected. Decreasing Acceptance of Childhood MMR Vaccinations  During the early part of the Post-Modern Era, successful childhood vaccination campaigns brought the incidence of mumps, measles and rubella to a very low level in most developed countries, and the WHO set the year 2015 CE for the total elimination of measles and rubella from the European region. However, the percentage of children receiving vaccination has decreased in recent years, with parents weighing the low current risk of infections relative to the supposed dangers of developing meningo-encephalitis and autism. Fears that vaccination would cause autism stemmed from a paper published by the British physician Andrew Wakefield, in 1998. Extensive research found no evidence to support his claims, and the British Medical Journal recently declared that the original article was fraudulent. Further, the British General Medical Council found Wakefield had been guilty of serious professional misconduct, and he was struck from the Medical Register. There have since been small outbreaks of measles consequent upon the decreased proportion of vaccinations in Britain and in Canada, and unfortunately many of the general public remain convinced that vaccination can cause autism. Spread of Infections Through Air Travel  Infectious diseases can now spread very rapidly, due to the ever-growing number of people who engage in global air travel. This problem is well exemplified by an epidemic of SARS (severe acute respiratory syndrome). This began in mainland China in November of 2002, and due to delayed reporting by the Chinese authorities it spread rapidly around the world. The WHO issued a global health alert on April 11th 2003. Fortunately,

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a­ pplication of rigid quarantine measures contained the epidemic, with relatively few deaths in North America, and by July 5th 2003, the WHO was able to declare that the SARS epidemic was over.

Practical Implications for Current Policy Many of the major epidemics of earlier eras were due largely to poor hygiene- a lack of clean water, poor sewage treatment, and an inadequate control of people who were already infected. Although we often assume that these issues have now been resolved, it is important to recognize that in many third world countries supplies of clean water and adequate supplies of food are still lacking, with shortages often exacerbated by ethnic conflicts. The same issues of clean water, waste disposal and burial of the dead could still arise in wealthier countries today if there were to be an earthquake, a typhoon or a Tsunami, and emergency services must be prepared to give the highest priority to an early re-establishment of the basic health infrastructure following any natural disaster. Issues in the adulteration of food have now been largely overcome in developed society, but the current obesity epidemic underlines that problems still have to be resolved in terms of persuading food processors to avoid tactics designed to persuade consumers to overeat. For those who can afford housing, the modern single-family home is generally well-equiped to optimize the health of those who are living in it. Massive tower blocks are less suited to a healthy and active life-style, particularly for families with young children. Moreover, ever-increasing minimum specifications for housing, a growing world population and a lack of land is presenting public health agencies with the issue of a growing proportion of homeless individuals in many large cities. Globalization is presenting new challenges to public health, not only with the rapid spread of infections, but also with the international enforcement of regulations on issues ranging from emission controls on cars to the quality of foods and medications. The ideal forum for developing appropriate preventive measures would seem the World Health Organisation, but unfortunately (as with many international bodies) its effectiveness is often limited by political considerations, including threats from some nations to slash funding unless criticism of their practices is shelved.

Questions for Discussion 1. Are the infrastructure constraints of an earlier era still compromising public health in third world countries?

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2. Does the provision of a healthy residential community for workers make good business sense to an entrepreneur? 3. Is there ever justification for a parent not immunizing a young child against measles, mumps and rubella? 4. What will be the likely new challenges to public health agencies over the next 20 years?

Conclusions Some early societies had an infrastructure that provided clean water and the removal of sewage, but since this was usually available only to wealthy citizens, its impact upon the course of epidemics was limited. Major cities such as London did not build a comprehensive infrastructure until the middle of the Victorian Era, when appropriate initiatives were taken by newly formed Boards of Public Health. Although the traditional concerns of public health have now been largely met in developed societies, new challenges are constantly arising. These include the control of tobacco products and mood-altering drugs, the reduction of automotive emissions and other forms of urban pollution, management of the HIV/AIDS epidemic, overcoming a growing reluctance to vaccinate infants, and countering the rapid spread of infections by air travel.

Further Reading Andresen E, Bouldin E deF. Public health foundations: Concepts and practices. Chichester, Sussex, John Wiley, 2010, 500 pp. Bahamondes ME, Ness K. Cigarette smoking: health effects and challenges for tobacco control. Hauppauge, NY, Nova Science Publishers, 2016, 215 pp. Carmichael AG. Plague and the poor in Renaissance Florence. Cambridge, UK, Cambridge University Press, 2014, 198 pp. Cech TV. Principles of water resources. Chichester, Suffolk, John Wiley, 210, 546 pp. Fagan GG. Bathing in public in the Roman world. Ann Arbor, MI, University of Michigan Press, 2002, 437 pp. Fowler AE, LeBerge F. Mission and method: the early nineteenth century French public health movement. Cambridge, UK, Cambridge University Press, 2002, 400 pp. Kawakita Y, Otsuka Y, Sakai S. History of Hygiene. Proceedings of the 13th International symposium of the comparitive history of medicine. Tokyo: Ishiyaku EuroAmerica,1991, 269 pp. Leslie CM. Asian medical systems: A comparative study. Berkeley, CA, University of California, 1976, 419 pp. Mikkeli H. Hygiene in the early medical tradition. Helsinki, Finland, Finnish Academy of Science and Letters, 1999, 195 pp. Orton E. Public health. New York, NY, John Alden, 1984, 365 pp. Penner L. Victorian medicine and popular culture. Abingdon, OX, Routledge, 2015, 256 pp.

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Philipson TJ, Posner RA. Private choices and public health. The AIDS epidemic in an economic perspective. Cambridge, MA, Harvard University Press, 1993, 264 pp. Porter D. Health, civilization and the state; a history of public health from ancient to modern times. Abingdon, OX, Routledge, 2005, 384 pp. Proctor RN, Proctor R. The Nazi war on cancer. Princeton, NJ, Princeton University Press, 2000, 380 pp. Rodger R. Housing in urban Britain, 1780–1914. Cambridge, UK, Cambridge University Press, 1995, 100 pp. Rom WN. Environmental policy and public health: air pollution, global climate change and wilderness. Chichester, Suffolk, John Wiley, 2011, 500 pp. Rosen G. A history of public health. Baltimore, MD, Johns Hopkins University Press, 2015, 370 pp. Shephard RJ. Carbon monoxide: The silent killer. Springfield, IL, C.C. Thomas, 1983, 220 pp. Shephard RJ. The risks of passive smoking. London, UK, Croom Helm, 1982, 195 pp. Snow J. On the mode of communication of cholera. Churchill, London, UK, 1849, 162 pp. Tulchinsky TH, Varavikova EA. The new public health. New York, NY, Academic Press, 2014, 912 pp. Woods ME. The establishment of a Board of Health for New York City in 1866. New York, NY, Cornell University, 1981, 402 pp.

Chapter 23

Health and Fitness in Industry: The Development of Occupational Health

Learning Objectives 1 . To trace elimination of the scourges of slavery and child labour. 2. To see the role of occupational physicians in enhancing safety in health and industry. 3. To consider methods of health-care delivery in industry. 4. To understand the challenges associated with equal opportunity employment legislation. 5. To consider special issues in the provision of health care to the armed services.

Introduction Most adults spend a substantial fraction of their week at the workplace, so that provision of a safe working environment makes an important contribution to overall population health and fitness. The place of employment also provides a convenient stage on which to launch more general health and fitness initiatives, and finally health is best served by matching the physical demands of heavy work to the abilities of the worker. After a brief survey of the early history of occupational medicine, we will comment on removal of the scourges of slavery and child labour, and will consider the training of occupational physicians and methods of health care delivery in industry. The chapter concludes with a recognition of the challenges presented by equal opportunity legislation, and the provision of medical services to the armed forces.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_23

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Early History The early history of occupational health embraces the miners of Minoa, and pioneer physicians of the Enlightenment such as Ramazzini, Pott and Virchow. Minoa  The Minoan people engaged in both mining and smelting. Herbal medications were prescribed for those with chronic cough, but there was little appreciation of the long-term dangers that such occupations posed to health. Ores found around the city of Chrysokamino in Eastern Crete, for example, contained substantial amounts of arsenic, and many of those working in the foundries would likely have developed heavy metal poisoning and/or silicosis. Bernardo Ramazzini  Bernardo Ramazzini (1633–1714) was Professor of Medicine, firstly in Modena and then in Padua. He is today best known for initiating systematic studies of health and fitness in the work-place. In his text Diseases of Workers, he noted that messenger runners avoided many of the health problems that were encountered by those who worked in sedentary occupations: “Those who sit at their work…. such as cobblers and tailors, become bent and hump-backed and hold their heads down like people looking for something on the ground...These workers, then, suffer from general ill health caused by their sedentary life … they should be advised to take physical exercise…. and so to some extent counteract the harm done by many days of sedentary life.” Ramazzini was an early proponent of “exercise breaks:” “whenever occasion offers…. interrupt…. that too prolonged posture by sitting or walking about….” He also commented that millers were prone to herniae because they carried excessive loads. Prophylactic measures recommended to increase the health of workers included bathing, frequent changes of clothing, adoption of a correct posture, physical exercise and covering the mouth when working in dusty trades. His credo continues to challenge both employers and industrial hygienists: “tis a sordid profit that’s accompany’d with the destruction of health.” Percival Pott  Occasionally, other voices were raised against such prevalent industrial hazards as the “black spittle” of mine workers, grinder’s rot and potter’s asthma. In 1775, the English orthopaedic surgeon Percival Pott described the first occupational cancer, that found in chimney sweeps. Rudolph Virchow  In 1848, Rudolph Virchow (Fig. 23.1) was sent to investigate an epidemic of typhus in Silesian coal-miners. He wrote a scathing report on conditions in that industry which cost him his job as a government physician at the Charité Hospital in Berlin. He wrote: “Medicine, as a social science….has the obligation to point out problems and to attempt their theoretical solution…. physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” In part as a result of Virchow’s concerns, the Chancellor of Germany, Otto von Bismark, introduced a form of workmen’s compensation as early as 1884. Similar

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Fig. 23.1 Rudolph Virchow lost his post as a government physician for advocating the rights of Silesian coal miners too strongly in 1848 CE (Source: http://en. wikipedia.org/wiki/ Rudolf_Virchow)

legislation was not enacted in New York until 1910 CE, and Mississippi was the final U.S. State to make such provision in 1948 CE.

The Twin Scourges of Slavery and Child Labour Much of the commercial success of Britain and the United States during the Enlightenment was attributable to the economic surplus generated by a ruthless exploitation of slaves and child labour, and the eventual abolition of both slavery and the exploitation of young children had a major impact upon the health of a large segment of the labour force both in Britain and in North America. Slavery  By the year 1772, an English Court had refused to enforce slavery. A further critical event in the emancipation of slaves was the Zong trial of 1783. The captain of the Zong had thrown 133 live slaves into the Atlantic in order to claim £30  in insurance for each of his captives. Stimulated by this horrific event, the English abolitionist Thomas Clarkson (1760–1846) quickly established a committee to put an end to slavery. In 1807 CE, through the further efforts of William Pitt the younger, William Wilberforce and John Newton, slave trading became illegal throughout the British Empire, and parliament passed the Slavery Abolition Act in 1833. An estimated 12 million slaves had been transported to the Americas between the 16th and the 19th centuries. The importing of slaves into the United States became illegal in 1808, but existing slaves were still not emancipated. There were also some slaves attached to households in Canada until the practice was prohibited in 1833;

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most had been brought to Canada as farm and domestic workers during the seventeenth century. After abolition in British North America, Canada became a haven for fugitive slaves from the United States, where slavery was not prohibited until 1865. Child Labour  In the early part of the industrial revolution, poor European children were expected to work long hours at dangerous jobs in order to balance the family budget. In 1840, only 20% of the children in London were receiving any formal education. Agile boys served as sweeps, climbing dangerous and smoke-filled chimneys. They also scrambled under dangerous machinery to retrieve cotton bobbins, and crawled through mine shafts that were too narrow to admit adults. Charles Dickens worked in a boot-blacking factory from the age of 12, because his father had been confined to a Debtors’ Prison. Nevertheless, conditions in British industry were progressively improved through the efforts of social reformers such as Robert Owen (1771–1858) and the Earl of Shaftesbury (1801–1885). Beginning with the Factory Act of 1802, legislation progressively reduced the permitted role of young children in industry, and the Education Act of 1870 required universal school attendance, initially for a total of five years, but rising to 9 years by 1914. The 1902 Factory Act led to appointment of the first factory inspectors. Among other duties, they were required to ensure that industrial premises had sufficient windows to ensure adequate ventilation, and that walls were whitewashed at least twice per year. All pauper children employed in factories were also to be provided with at least two sets of clothing, with the girls being housed separately from the boys, and not more than two children were permitted to sleep in any one bed. Progress in reducing the exploitation of children was much slower in the United States (Fig.  23.2). The National Child Labor Committee of 1904 had the aim of abolishing child labor, but it took the surplus labour of the 1930s to see a Nationwide campaign against child labour. Even today, American children of 12 can work in industry for up to 3 hours per day on school days, and in agriculture, they can still work an unlimited number of hours, often with exposure to dangerous pesticides and other hazards.

Occupational Physicians and Workplace Safety As legislation established the role of occupational physicians in Europe and North America, attention was focused upon hours of employment, the physical loading of employees, and the delivery of health care in the workplace. Occupational Physicians  Beginning in the 1920s, the London School of Hygiene in England, the School of Hygiene in Toronto (Fig. 23.3), and counterpart institutions in the United States began to graduate specifically trained occupational ­physicians. The responsibilities of these individuals have included watching that company practices complied with labour legislation, ensuring workplace safety, providing employee assistance to those with addictions and psychological ­problems,

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Fig. 23.2  Twelve-year old girl working at a cotton mill in the United States, 1912 CE (Source: http:// en.wikipedia.org/wiki/ Child_labor_laws_in_the_ United_States)

Fig. 23.3  John Fitzgerald, first Director of The University of Toronto’s School of Hygiene trained occupational physicians and public health workers. Fitzgerald recommended that staff spend 45 minutes each day playing deck tennis on the roof of the building (Source: http://en.wikipedia. org/wiki/Dalla_Lana_School_of_Public_Health)

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and (more recently) having general oversight of work-site fitness and wellness programmes. In North America, a professional organization (the American College of Occupational and Environmental Medicine) had its beginnings in 1916, and a corresponding journal (Industrial Health, since renamed Occupational Health & Safety) was founded in 1932 CE. One adverse aspect of occupational health in the U.S. was that corporations often exerted a close control over research findings (particularly if they were critical of a company). A typical letter sent from management to a prominent Industrial researcher in 1955 read in part: “It is our understanding that the results obtained will be considered the property of those who are advancing the required funds, who will determine whether, to what extent, and in what manner they shall be made public.” The task of reducing industrial injuries was at first difficult. In Ontario, a Factory Act enacted in 1884 had defined such things as a child, young girl and factory, but the legislation was slanted in favour of the employer and the maximization of production; in practice, it did little to reduce injuries on the job. The Meredith Report of 1913 addressed the issue of injury compensation for Canadian workers. But effective legislation ensuring safe working conditions was not enacted in Canada until the Post-Modern era. An incident that killed five workers during the construction of a subway tunnel in Toronto spurred passage of the Industrial Safety Act in 1964; this legislation defined safety as “freedom from injury to the body and freedom from damage to health.” Concern continued about the hazards associated with work in uranium and asbestos mines and exposure to lead and mercury, and the Occupational Health and Safety Act of 1980 gave Canadian workers the right to participate in discussions of occupational health, to know the risks, and to refuse work that they believed to be unsafe. The legislation was further strengthened in 1991, with a requirement for a Joint Health and Safety Committee that included management and worker representatives certified by the Workplace Safety and Insurance Board. Progress in establishing an effective industrial health service was in some respects even slower in the Unites States than in Canada. Three women activists organized a worker directed health service between 1921 and 1928. This initiative had its own staff (physician, dentist, nurse and other employees) and its own laboratories and x-ray service, but in the end its operation was thwarted by opposition from the American Federation of Labor. During the 1940s, a few of the more powerful U.S. unions were also able to negotiate comprehensive health insurance plans with their employers. President Kennedy had planned a Conference on Occupational Safety in 1964, but his assassination led to abortion of this plan. President Nixon established the Occupational Safety & Health Administration in 1970. Nevertheless, in 1990, there were still 1200 worker compensation awards involving children in New York State alone, with 42% of these cases reflecting permanent disability. And as late as 1991, 25 workers died in a fire at a food processing plant because 8 of 9 exit doors were either locked or blocked.

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Hours of Employment  Health and fitness can quickly be compromised by working excessively long hours, Discussions have focused largely around the maximum hours of work per day, but other topics of concern have included half-holidays and paid vacations, and more recently the adoption of a compressed work-week and tele-working from a home office. From 1975 to the present day, the participation of women in the U.S. labour force has increased from 47% to 78%, and this has created new stresses for those charged with child or elder care. A growing proportion of women with dependents have found relief in either flexible working hours or tele-work. Hours of Work  An 8-h day was declared for U.S. Federal workers as early as 1868, but this did not become general policy in the U.S. until the Fair Labor Standards Act of 1938. In Europe, the working day decreased from 10 to 12 h and then to around 8 h during the late Victorian era. However, long hours of overtime were reinstituted in British armament factories during World War I, in the hope of boosting overall output. Such policies proved counter-productive; with poorer overall health and an increased rate of industrial injuries actually reducing output. A “Health of Munition Workers’ Committee” was thus established. After the conclusion of hostilities, this morphed into the British Industrial Fatigue Board, and in 1929 CE the Industrial Health Research Board. This organization monitored many facets of working conditions, making recommendations on posture, load carriage, physique, rest pauses, lighting, heating and ventilation. In the U.S, the Harvard Fatigue Laboratory began to explore similar issues during the 1930s. Half-Holidays and Paid Vacations  The idea of giving English employees a Saturday half-holiday had originated during the 1860s with the Quaker chocolate manufacturer George Cadbury, and by the mid-1870s most workers enjoyed a free Saturday afternoon; this gave opportunities for active recreation which often had not been possible on Sundays. Paid 1–2  week vacations were also introduced in Britain and other European countries during the 1930s (Chap. 9), although U.S. unions often preferred to seek wage increases rather than paid vacations. Compressed Working Week  A number of companies have experimented with compressed working weeks in recent years. The Mobile and Gulf Oil Companies moved to a four-day, 40-hour week in 1940. This proved popular with some employees, since it offered them a longer weekend. One meta-analysis concluded that absenteeism, productivity and job satisfaction were all favourably influenced by the change, and this type of schedule was adopted by a growing number of companies. However, many studies found that the compressed week resulted in greater employee fatigue, not only because of the greater length of the working day, but also because people took advantage of their increased “free” time to engage in demanding domestic “do it yourself” projects, or even to find a second job. Tele-Working  Teleworking is popular with some companies, because it saves large real estate costs. It has also proven popular with employees, with reports of greater

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well-being, less stress and enhanced health. It spares workers from ever-longer commutes, and in some cases allows parents to combine paid work with the care of infants. Physical Loading of Employees  Ill health can result if the physical demands of a job are excessive, and occupational physicians should evaluate loads relative to the fitness of employees. During the inter-war years, time-and-motion and work-study experts tended to treat employees as robots, prescribing standard times and movement patterns that employees should for meet for each action that was required on an assembly line. This left little opportunity for employee initiative. However, one favourable consequence of such a close examination of work practices was that it sometimes suggested changes in the design of machinery and task performance that could reduce the energy cost of heavy industrial jobs. In Western Europe, the typical attitude of industrial physicians and physiologists was to determine the intensity of effort required by a physically demanding task, to set an upper limit to the permitted duration of such activity, and then either to seek workers with a physique that would enable them to undertake the job, or to hire an ergonomist to redesign the task and reduce physical demands to a more acceptable level.

Health-Care Delivery in the Workplace Occasional far-sighted employers instituted work-site fitness breaks and built work-­ place athletic facilities many years ago, but work-site fitness programmes first became common-place during the 1970s. Assessments of their efficacy in terms of employee health remain controversial, and in recent years many programmes have moved from simple fitness programming to addressing a broad spectrum of work-­ place wellness. Fitness Breaks  John G. Fitzgerald (1882–1940) the first Director of the University of Toronto’s School of Hygiene was an early proponent of work-site fitness breaks. He urged his staff to spend 45 minutes each lunch-time playing deck tennis on the roof of the school. In the period before World-War II, many jobs required hard physical labour, and the attitude of Russian occupational hygienists was typical. They argued that the demands of daily physical labour already imposed a dangerously heavy physiological load on a large proportion of employees, and any added exercise might cause irreparable damage to health. After World War II, studies from Europe began to suggest that brief “relaxation breaks” could reduce sickness and absenteeism and enhance industrial output, particularly for those engaged in heavy physical work. In stressful management positions, deliberate relaxation was also beneficial. In sedentary occupations such as telephone operators, the problem was boredom rather than physical fatigue, and in

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such situations work performance was restored more readily by 5–10 min of exercise than by a corresponding period of passive relaxation. During the 1970s, Fitness Canada encouraged companies to replace the traditional mid-morning break for coffee and donuts by a formal 8-min fitness break. This was taken at the employee’s immediate work-station, with a volunteer leading a scripted programme of exercises to the rhythm of taped music. However, it was recognized that the total volume of physical activity was insuffient to have any substantial effect upon fitness; the main goal of the intervention was to increase the worker’s awareness of the need for regular exercise, rather than to provide the volume of daily physical activity that was required to maintain good health. Work-Site Health and Fitness Programmes  Although there were some much earlier initiatives, worksite fitness programmes did not reach their hey-day until the 1970s. There remain questions about the suitability of programmes for blue-­collar employees, and a lack of convincing evidence on programme efficacy. Early Initiatives  A few major corporations have for long recognized the benefits of comprehensive work-site health and fitness programming. In 1893 CE, the Quaker chocolate manufacturer George Cadbury bought a very pleasant 120-acre tract of land some 6 km outside of Birmingham. There, he developed a model village for his employees (Fig. 23.4), with recreation areas to maintain the health and fitness of his work force. The company encouraged swimming, walking and outdoor sports, and laid out football and hockey pitches together with a running track.

Fig. 23.4  A pleasant recreational area in the model village developed by George Cadbury, the English chocolate manufacturer, beginning in 1893  CE (Source: http://en.wikipedia.org/wiki/ Bournville)

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Likewise, in the U.S., the Pullman railcar company, established an athletic association for its employees in 1879, and in the 1880s, the president of National Cash Register (NCR) was reputed to meet with his employees for horseback rides before work; later, the NCR instituted twice-daily exercise breaks, built an employee gym, and constructed a 325-acre recreation park for its workers. Hershey Foods also built a recreation complex, complete with a swimming pool, in the 1930s, and in the 1950s and 1960s Texas Instruments, Rockwell and Xerox Corporations all instituted employee fitness programmes. The Hey-Day of Worksite Fitness  During the 1970s, many larger companies in the United States and Canada introduced comprehensive work-site fitness programmes, hoping for substantial gains in productivity. Russian reports from this period had suggested that “worker-athletes” had a higher level of productivity than their sedentary peers, and the high productivity of Japanese industry was attributed in part to massed work-site exercise programmes. In Canada, a community-wide fitness programme was conducted by ParticipACTION in the city of Saskatoon in 1972 CE had proven both expensive and relatively ineffective in augmenting the physical activity of the local population (Chap. 20). The Canadian government thus welcomed the potential of work-site fitness initiatives as a low-cost and focused alternative that could address the fitness needs of the working population. A key stimulus to this new governmental initiative was a conference on Employee Fitness, convened in Ottawa in 1974. Papers presented at this meeting suggested that the costs of such work-site programmes would usually be borne by the employer and/or the worker rather than the government, and that the sponsoring companies might reap such dividends as an enhanced corporate image, the recruitment of premium employees, greater productivity, less absenteeism, and reduced health insurance costs. One expression of the surging interest in employee fitness programmes during the 1970s was formation of the American Association of Fitness Directors in Business and Industry. This organization was subsequently renamed the Association for Worksite Health Promotion (AWHP), reflecting a shift of its objectives from simple fitness programming to more broadly-based wellness initiatives addressing such issues as work-place stress, low back-problems, obesity and addictions (below). By the early 1990s, the U.S. group was boasting a membership of some 2500. Around this time, many companies undertook a critical reappraisal of the loudly touted fiscal benefits of worksite wellness programmes (below). They found only limited evidence for their efficacy, so that their funding was slashed, and this led to a rapid demise of the AWHP. Nevertheless, a worksite health promotion “interest group” continued at the American College of Sports Medicine, and in 2009 an International Association for Worksite Health Promotion made its début. The U.S. Centers for Disease Control and the National Institute for Occupational Safety and Health have also continued their support of worksite health promotion. The Issue of Blue-Collar Employees  One major criticism of most work-site fitness programmes has been their failure to attract blue-collar workers; indeed, some fit-

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ness facilities have only been open to upper echelon employees. The Canadian Public Health Association thus initiated a project with a specific focus on blue-­ collar employees, and in the U.S. the American Heart Association also convened a meeting to examine the needs of hourly workers. One suggestion emerging from the latter conference was that the blue-collar group might be attracted more by team sports than by light aerobic-type gymnastics. Assessing Programme Efficacy  It has proven difficult to provide either health scientists or industrial management with convincing evidence of the postulated economic benefits from work-site fitness programmes, in part because of problems in organizing appropriate controlled studies in an industrial setting, and in part because the person charged with collecting subjective data on employee attitudes has usually been the individual hired to run the fitness programme. Most “investigations” have been simple “before and after” comparisons, devoid of any control groups. Even when findings were reported dispassionately, the responses of workers were thus vulnerable to a fallacious “Hawthorne” effect (a favourable response kindled by a perception of greater management interest in their welfare). But often the observers, anxious to keep their own jobs, made over-­ optimistic assessments of programme success. During the 1980s, I recall visiting one factory in Holland with supposedly the best work-site fitness programme in that country. I was shown a beautiful gymnasium, but at what I supposed was the peak hour for exercise (around 12 noon), there were just two exercisers in the facility! In 1977–78 CE, a controlled, quasi-experimental study of work-site fitness programming was undertaken in downtown Toronto, with the enthusiastic support of Art Salmon and his colleagues at Fitness Ontario. Findings at the experimental site (the head office of the Canada Life Company, Fig. 23.5) before and in the year following initiation of the work-site fitness programme were compared with those at a well-matched control site (the nearby North American Life Assurance Company). Minor economic benefits were documented at the experimental site: increased productivity, reduced absenteeism, and reduced employee turnover relative to the control site. But the unique feature of the Canada Life Study was a direct comparison of Ontario Health Insurance Plan (OHIP) Medicare billings (both the nature of diagnoses and the dollar payments disbursed to hospitals and physicians) for employees at experimental and control companies. Some sceptics had argued that a fitness programme would increase immediate medical costs, particularly for the treatment of musculo-skeletal injuries and for cardiac problems. However, the OHIP data showed small decreases in doctor and hospital visits by employees at the experimental work-site once the programme was in operation. Not only was the overall number of medical consultations reduced, but there were also fewer claims for such specific diagnoses as musculo-skeletal injuries and cardiac problems. The Canada Life head office payroll of over 1000 employees was sufficiently large to make an objective assessment of the overall success of a work-site fitness programme in a white/pink collar environment. Despite the vigorous publicity that one would anticipate with an experimental study, only about a third of employees were initially recruited to the programme, and the participation of many of these

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Fig. 23.5  A quasi-­ experimental evaluation of an employee fitness programme was conducted at the Canada Life Assurance Company in downtown Toronto, beginning in 1977–1978 CE

individuals flagged over the first year of observation. We were also able to obtain information on long-term adherence, and 12 years after initiation of the programme only a very small group of employees were actively using the exercise facility. One major problem, probably generic to large cities, was that long commuting distances limited the involvement of many employees in exercise programmes either before or after work. From the viewpoint of population health, the downtown exercise facility also did not cater either to the families of employees or to the growing number of people who worked from home. In terms of enhancing national fitness, a further limitation of worksite fitness programmes is that for logistic reasons, they are largely restricted to companies with more than 100 employees, and companies of this size are in the minority, particularly in Canada. One potential alternative recently adopted by some small organizations has been to subsidize membership of a commercial fitness club. During the 1980s, careful economic analyses at several companies suggested that many of the supposed gains from work-site programmes were at best marginal. In many operations, productivity has indeed become a function of advanced technology rather than human physical input, so that the potential for greater fitness of the individual to augment output is now necessarily limited. Overall Work-Place Wellness  Partly because economic evaluation of worksite fitness programmes has been disappointing, the emphasis of many programmes has

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now shifted from the development of physical abilities to the enhancement of overall workplace wellness, including the enhancement of mental and psychological health. Some altruistic companies have seen the provision of a broadly-based health service of this type as a worthy goal in its own right, and in the U.S., other companies have hoped that such an emphasis might counter ever-rising medical insurance premiums, a management cost that is still included in many union contracts. A second option has been to seek less costly alternatives than the construction of large gymnasia. New low cost initiatives to improve fitness have included poster campaigns to encourage use of the staircase rather than the elevator at work, and the provision of bicycle lockers and showers to promote active commuting.

Equal Opportunity Employment Occupational physicians now face many complex problems in relating the fitness of employees in physically demanding work to the requirements of the Equal Opportunity Commission in the U.S., and the Human Rights Commission in Canada. After sketching the historical background, we will look at how the legal framework has developed, and consider the issues that have arisen in testing occupational fitness. Historical Background  Many professions, particularly those concerned with public safety, have historically demanded certain minimum standards of physical fitness from their employees. As early as 1893, a recruiting poster for the North-West Mounted Police specified the need for: “applicants between the ages of 22–40, active, able-bodied men of thoroughly sound constitution.” In a less formal sense, the hiring of a day worker outside the dock-gates or at the local labour exchange during the 1930s was often determined by the apparent strength and stamina of a candidate. However, in recent years, the issue of denying employment on the basis of inadequate physical fitness has become a concern for the Equal Employment Opportunity Commission or the Human Rights Commission, and a trend to elimination of mandatory retirement has highlighted the inherent conflict between the age-related decline in fitness and the unchanging physical requirements of demanding employment. Legal Framework  John Kennedy established the President’s Committee on Equal Opportunity in 1961  CE, to ensure that people were employed without regard to their race, creed, color, or national origin. In 1965 CE, this body was renamed the Equal Employment Opportunity Commission, with the broader mandate to investigate any apparent discrimination in employment based upon an individual’s race, color, national origin, religion, sex, age, disability, genetic information, or retaliation for reporting, participating in, and/or opposing a discriminatory practice.

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Occupations that have now received detailed physiological scrutiny under this legislation include not only the military, the police, and jail workers, but also postal carriers, bus drivers, and marine surveyors. The Canadian Human Rights Commission was established in 1977  CE.  In 1982 CE, two Etobicoke, ON, firefighters fought what was then their mandatory retirement age of 60 years. They argued that Section 4(1) of the Ontario Human Rights Code prohibited their employer from discriminating in the hiring or firing of workers, based on their age. However, the Borough of Etobicoke pointed out that Section 4(1) of the legislation does not apply if the age of the individual can be considered as a bona fide occupational requirement (BFOR). In other words, if age is affecting your ability to be a capable firefighter, then you can indeed lose your job because of your age. The issue was appealed to the Canadian Supreme Court. In 1999  CE, this body ruled that a BFOR must be “objectively reasonable,” and it set specific guidelines for tests and standards. The judgment prompted extensive research by occupational physiologists, particularly a group at York University led by Norman Gledhill. Their mission was to determine the physical demands of various occupations where public safety was at stake, and to design appropriate, job-­related tests to determine the physical competence of employees who wished to continue working beyond the normal retirement age. The legislation still only regulates employment for those between the ages of 18 and 65 years. The Equity in Employment Act also became law in 1986 CE; it forced an equally careful consideration of the fitness capabilities of female employees who wished to undertake what had traditionally been male jobs. Designing Occupational Fitness Tests  Much of the discussion of methodology in occupational fitness assessment has centred around the use of criterion-based testing, which sometimes has had the effect of selectively excluding women and ­minority populations with a short average stature. In a 1999 decision (Meiorin), the Canadian Supreme Court called upon employers to ensure that any fitness standards that were applied accommodated individual and group differences to the extent that was reasonably possible. Another hotly debated question has concerned the relative merits of task simulation vs. the use of laboratory fitness tests. In the Canadian Armed Forces, minimum criteria have shifted frequently, suggesting that no test is entirely satisfactory. Normative referencing prevailed during the 1960s, firstly with an emphasis upon performance of the 5BX and 10 BX tests (1960s and 1970s), then on achievements in the 2.1 km run (1972–1980 CE), the BFOR (1978 CE), and a fitness test battery (1984 CE). An Occupational Physical Selection Standard was adopted from 1980 to 1984 CE, followed by the Battle Efficiency Test (1985 CE), an indoor obstacle course (1986 CE), the Land Force Command Physical Fitness Standard (1991  CE) and the Basic Military Qualification (2002  CE). Specific additional qualifications are now required for tasks such as parachuting or diving.

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Health and Fitness of the Armed Forces A substantial proportion of adults in most countries are employed by the armed services, a group that has long had special health and fitness needs. We will comment briefly on some health initiatives in the army and the navy, military environmental laboratories and interventions of the Red Cross. The Army  The Scottish physician Sir John Pringle Pringle authored a treatise “Observations on diseases of the army” in 1707. He recommended making stronger attempts to ensure an adequate diet, clean water and the personal cleanliness of military personnel, and he did much to emphasize the vital role of prevention in Military Medicine. In Pringle’s view, sources of ill-health included exposure to an excess of heat or cold, moisture, or putrid air, a poor diet, a lack of cleanliness, and for much of a military campaign an excess of rest and inactivity. A second person contributing substantially to healthy of the military was Frances Nightingale (Chap. 25). In recent years, much discussion has centred around the fitness of women for combat roles, with heated debate on appropriate measures to determine if recruits had the required levels of physical fitness (above). A further concern has been the high proportion of soldiers leaving the military with post-traumatic stress disorder. The Navy  The British Naval Surgeon James Lind (1716–1794 CE) was appalled to find that during a long voyage of HMS Salisbury in 1747, 80 of the 350 ship’s crew fell victim to scurvy. Lind confined the affected sailors to the forepeak of the vessel, and there he carried out an early controlled dietary study. He quickly discovered that scurvy was entirely preventable if the sailors were given a sufficient quantity of fresh fruit such as oranges, but he persisted in the belief that scurvy was caused by an accumulation of ill-digested and putrefying food, bad water, excessive work and living in the damp atmosphere of the ship’s hold. Lind pressed for higher standards of hygiene on British naval vessels, insisting on greater cleanliness of the sailors’ bodies, clothing and bedding, increased ventilation of the hold, and periodic fumigation of the crew’s quarters with sulphur and arsenic. He discovered that steam obtained from sea water was salt-free, and he thus proposed developing a solar still to prepare fresh water for use during long voyages. Military Environmental Laboratories  Beginning in World War I, and gathering pace during World War II, the armed forces of many countries developed large environmental laboratories where scientists could focus upon the challenges to health and operational fitness posed by military operations in extreme environments (Chap. 28). Issues included survival at sea, physiological responses to extremes of heat and cold, very high altitudes, vast ocean depths, and high gravitational accelerations, the potential of combatants to carry heavy loads, and the design of protective equipment to minimize the effects of exposure to toxic environments.

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The Red Cross  The birth of the Red Cross is credited to a Swiss investment banker Henri Dunant (1828–1910). He halted a business trip to Algeria because he was distressed by the neglect of wounded soldiers that he observed during the war between Austria and Sardinia. He saw that more than 40,000 wounded men were left to die on the battlefield during a single day, and he published an account of this suffering at his own expense. Thereafter, he sought to establish a permanent agency that would provide humanitarian relief in times of war. His proposals led to the First Geneva Convention and establishment of the International Red Cross.

Practical Implications for Current Policy While we may condemn the entrepreneurs of the Enlightenment and early Victorian periods for the vast profits they made from slave and child labour, it is all too easy to forget that today many companies are still boosting their profits by employing third world women and children at starvation wages under unsafe working conditions. The fact that Virchow lost his hospital appointment through a criticism of working conditions in the German mines underlines the importance of tenure for medical officers of health and factory inspectors. Those inspecting factories, mines and other places of work need total freedom to report their findings. At times, this freedom has been compromised when a company has addressed a health or safety issue by itself hiring experts to examine workplace hazards, with the constraint of confidentiality clauses limiting the publicizing of their findings. Comapnies currently have many options for the arrangement of working hours, and demands for new time schedules seem likely to increase. In a high proportion of families both parents now work outside of the home, and face long and increasingly congested commuting. There is also a growing concern about non-renewable energy expended in rush-hour travel to and from the workplace. There is thus a need to explore the health and fitness implications of alternative work schedules, including the compressed working week, shift work and the use of home offices. Initial optimism regarding the economic dividends of worksite health and fitness programmes has now abated, with recognition that long-term programme adherence is limited to a small proportion of employees, many of whom were previously active elsewhere. However, the pendulum of appraisal may have swung too far in a negative direction, and there remains a need for an unbiased assessment of the potential of comprehensive workplace health initiatives to enhance the organizational effectiveness of white-, pink- and blue-collar workers. Many jurisdictions have now removed all age limits for most categories of employment, but there remains an urgent need to develop occupation-specific measures that can be applied to test physical abilities when a worker no longer appears to be offering safe and/or effective service.

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Questions for Discussion 1. Are there still major health concerns facing occupational physicians? What areas of working life still require attention? 2. What would you consider as the optimal length of working day for the average worker? Would you favour the institution of a compressed work-week, and if so, why? 3. Have the early promises of work-site fitness programmes been realized? 4. If not, is there justification for continued management support of such initiatives? What changes might make them more effective?

Conclusions Physician efforts to enhance employee health date back at least to Ramazzini, during the Enlightenment. However, even in Europe and North America it has taken several centuries to remove the scourges of slavery, child labour and exposure to toxic environments and unsafe working conditions. Moreover, many of these problems persist in the third world. There has been growing recognition of the need for paid holidays and a regulation of the length of the working day; shorter and more appropriate arrangement of work schedules generally seem to enhance rather than reduce productivity. During the 1970s, experts in health promotion began to see the workplace as an ideal place for the introduction of fitness and health programmes, with potential benefits to both the employer and the individual worker. However, initial enthusiasm for such initiatives has been dampened by poor adherence, with as yet only limited objective evidence of either financial benefits to corporations or gains in the health status of the average worker. The recent abolition of mandatory age-based retirement in many types of employment has posed new challenges to occupational physicians and physiologists, with a need to develop reliable and valid methods of assessing the continued physical ability, competence and safety of individual workers.

Further Reading Connolly WB, Connolly MJ, Feinstein J.  A practical guide to equal employment opportunity. New York, NY, Law Journal Press, 2016, 2588 pp. Corn JK. Response to occupational health hazards: a historical perspective. New York, NY, Van Nostrand Reinhold, 1992, 182 pp. Cusman BC. The human factor: The Harvard fatigue laboratory and the transformation of Taylorism. Cambridge, MA, Harvard University Press, 1983, 122 pp. Department for Work and Pensions, UK. Fitness for work: Governmental response to Health at Work, an independent review of sickness absence. London, UK, HM Stationery Office, 2013, 78 pp.

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Dobbin F. Inventing equal opportunity. Princeton, NJ, Princeton University Press, 2009, 360 pp. Fee E, Acheson RM. A history of education in public health: health that mocks the doctors’ rules. Oxford, UK, Oxford University Press, 1991, 349 pp. Gillespie R. Manufacturing knowledge. A history of the Hawthorne experiments. Cmabridge, UK, Cambridge University Press, 1993, 282 pp. Horvath SM, Horvath EC. The Harvard Fatigue Laboratory. Its history and contributions. Englewood Cliffs, NJ, Prentice-Hall, 1973, 122 pp. Kirby P. Child labour in Britain, 1750–1870. New York, NY, Palgrave-Macmillan, 2003, 184 pp. McCarthy EJ, McGaughey W. Nonfinancial economics: The case for shorter hours of work. New York, NY, Praeger Publications, 1989, 232 pp. Moorehead C. Dunant’s dream: War, Switzerland and the history of the Red Cross. New York, NY, Harper-Collins, 1999, 780 pp. Palmer KT, Brown I, Hobson J. Fitness for work. Oxford, UK, Oxford University Press, 2013, 736 pp. Ramazzini B. Diseases of workers. New York, NY, Hafner Publishing, 1964, 549 pp. Reddie RS. Abolition! The struggle to abolish slavery in the British Colonies. Oxford, UK, Lion, 2007, 254 pp. Rom WN, Markowitz SB. Environmental and occupational medicine. Philadelphia, PA, Lippincott, Williams & Wilkins, 2007, 1800 pp. Shephard RJ. Fitness and health in industry. Basel, Switzerland, Karger Publications, 1986, 316 pp. Spender J-C, Kijne H. Scientific management: Frederick Winslow Taylor’s gift to the world? New York, NY, Springer, 2012, 192 pp. Thackrah C. The effects of the principal arts, trades and professions and of civic states and habits of living on health and longevity. With a particular reference to the trades and manufacturers of Leeds, and suggestions for removal of many of the agents which produce diseases, and shorten the duration of life. London, UK, Porter, 1832., 180 pp.

Chapter 24

Understanding the Root Causes of Ill-Health: The Emergence of Epidemiology, Bacteriology and Immunology

Learning Objectives 1. To recognize the role that epidemiology has played in understanding epidemics of both acute and chronic disease. 2. To observe how advances in microbiology have contributed to methods for the control of infectious disease. 3. To follow the development of effective remedies for bacterial and viral infections such as sulphonamides, antibiotics and vaccines. 4. To note the global replacement of acute disease by epidemics of chronic conditions such as cardiovascular disease, obesity, and the metabolic syndrome. 5. To see how technological advances in immunology are helping to define appropriate ceilings of physical activity for people of differing age and physical condition.

Introduction Many of the early city-states were beset by disastrous epidemics, and (as during the Black Death) a substantial fraction of the population in entire continents succumbed to acute infections. Deep mystery surrounded the spread of disease until the nineteenth century, when the discipline of epidemiology began through the efforts of Snow and Louis. In this chapter, we will review the growing understanding of mechanisms for the spread of infections as seen in classical civilizations, the Renaissance, the Enlightenment, and the Victorian Era, the growing understanding of microbiology that emerged in Victorian times, and the development of appropriate remedies such as chemotherapy, antibiotics and vaccines that emerged in the Modern Era. Unfortunately, benefits from the countering of acute disease have been offset recently by world-wide epidemics of chronic disease, attributable to overeating and a lack of adequate daily physical activity. Finally, we will explore © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_24

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knowledge of the immune system that has accumulated during the Post-Modern Era, including a growing appreciation of interactions between physical activity and the immune defenses of the body. Advances in each of these areas of knowledge have made important contributions to the control of acute disease and the growth of preventive medicine.

Epidemics Affecting Classical Civilizations The great plague (probably typhus, but possibly typhoid fever or even Ebola) was a critical event in early Athenian history. The epidemic began in the second year of the Peloponnesian war (430 BCE), and it killed about a third of the citizens living within the walls of Athens. An oracle interpreted the episode as evidence that Apollo, the god of medicine and disease, favoured Sparta rather than Athens. However, the historian Thucydides (c. 460–395 BCE) was skeptical of such supernatural explanations. He observed that the birds and animals that ate plague-infected carcasses soon died themselves. Thus, he suspected that there was a natural cause for the epidemic. The Romans also suffered through many epidemics. In their view, diseases stemmed from fumes emanating from the swamps around their city, and the word malaria (bad air) reflects this belief.

The Renaissance Understanding of Epidemics The concept of disease being transmitted by bad air persisted from classical Rome into early Renaissance Italy. The Florentians found it necessary to: “reduce the army.... as it was extremely stressed by disease and bad air...” Amid continuing poorly-based speculation, the Italian doctor Girolamo Fracastoria (1478–1553) is noteworthy for advancing the hypothesis that epidemics were caused not only by pathogens from outside the body, but also by direct or indirect human-to-human contact. He wrote: “such things as clothes, linen.... although not themselves corrupt, can nevertheless foster the essential seeds of the contagion and thus cause infection.” The Mongols may have been aware of this concept, as in 1346 they catapulted dead bodies over the city walls during the siege of Kaffa, Ethiopia, in what was the first known act of biological warfare. Renaissance explorers such as Christopher Columbus caused an unwitting ­genocide, decimating the population in the “new world” by introducing European diseases such as smallpox to which the indigenous peoples had no immunity. The Great Plague of London (1665–1666) was a resurgence of the infection that had caused the Black Death two centuries before. Its origins remained a mystery to everyone living at the time. Popular hypotheses included pestilential effluviums

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from local marshes and creeks, unusual weather, sickness in livestock, abnormal behaviour of animals, or an increase in the numbers of moles, frogs, mice or flies.

Epidemics During the Enlightenment Sydenham and Hume are names that stand out for epidemiologists during the era of the Enlightenment. Following an extensive study of fevers in his Westminster practice, Thomas Sydenham (1624–1689) wrote “Observationes medicae,” noting the link between the presence of fleas and typhus infections. David Hume (1711–1776) developed an important series of “rules by which to judge of causes and effects,” a scheme that closely foreshadows the epidemiological precepts of Sir Alexander Bradford Hill. Hume stressed the need for a probabilistic approach to disease, based on the study of populations and inter-group comparisons, and above all upon an acceptance of the idea that the most likely event was the one most apt to happen.

 eginnings of Epidemiology and Bacteriology B During the Victorian Era During the Victorian era, the mystery of epidemics began to be clarified through the epidemiological efforts of men such as Snow and Louis, and the bacteriological research of Semmelweiss, Pasteur, Koch and Lister. John Snow  At the age of 19, an apprentice physician John Snow (1813–1858) became medical officer to a Tyneside Colliery; here, he was soon confronted by an outbreak of cholera which he traced to a lack of sanitation in the mine. After completing his formal medical qualification, he began working at the Westminster Hospital, in central London. He quickly confronted further cases of cholera, and became skeptical of the prevailing wisdom that the disease was spread by a noxious miasma emanating from the stinking creeks that surrounded the city. He studied several cholera outbreaks, and published a treatise On the Mode of Communication of Cholera. After carefully mapping the distribution of cases in the 1854 outbreak around the Broad Street pump in Soho (Fig. 24.1), he noted the infection of a woman who had moved to suburban Hampstead, but chose to continue to import her water from the Broad St. pump. He also observed that most of the local brewers (who rarely drank water of any type) were spared from infection. He commented:“there has been no particular outbreak or prevalence of cholera in this part of London except among the persons who were in the habit of drinking the water of the above-mentioned pump well.” Snow soon stopped the epidemic by removing the handle from the Broad St. pump. Based on his Broad Street investigation, and his correlation of other cholera

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Fig. 24.1  Map drawn by John Snow (1813–1858), illustrating the clustering of cases of cholera around the Broad Street pump in Soho. The epidemic was halted when he removed the handle from this pump (Source: http://en.wikipedia.org/wiki/1854_Broad_Street_cholera_outbreak)

epidemics with water that was being pumped from the polluted lower reaches of the River Thames, Snow is now regarded as the father of epidemiology. Louis  The French physician and pathologist Pierre Charles Alexandre Louis (1787–1872) was a second major contributor to the birthing of clinical epidemiology. He introduced clinicians to the idea of “numeric reasoning,” making a quantitative analysis of the outcome of various medical procedures on the assumption that inter-individual differences in the manifestations of disease would disappear if results were averaged. Most notably, Louis established that the practice of applying leeches to a feverish patient had no beneficial effect. Indeed, it often increased the risk of death in patients with inflammatory disease. Applying the same numerical approach to children with tuberculosis, he concluded: “play and sports is more favorable than injurious to health.”

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Semmelweiss  The Hungarian obstetrician Ignatz Semmelweiss (1818–1865 CE) introduced a doctrine of rigorous hand cleansing with chlorinated lime water to his skeptical colleagues in Vienna. By insisting on the adoption of this simple hygienic precaution, he quickly reduced the incidence of puerperal fever at his institution from 12.4 to 1.27% (Fig. 24.2). However, the medical colleagues of Semmelweiss soon took umbrage at his unvarnished condemnation of the prevailing squalor in the local obstetric units. Semmelweiss was stripped of his hospital accreditation and summarily “run out of town.” The ideas of Semmelweiss did not gain traction until Pasteur had established the germ theory of disease transmission. Pasteur  The career path of the French biologist and microbiologist Louis Pasteur (1822–1895) was strongly influenced by the deaths of 3 of his 5 children from typhoid fever. He is now regarded as one of the founders of modern microbiology. He demonstrated that fermentation was due to the growth of microorganisms rather than some mysterious process of “spontaneous generation,” and he introduced a method to prevent the spoiling of wine or milk by killing the responsible microorganisms. The liquid was heated to a specified temperature for a specified time, and then cooled rapidly (the process of “Pasteurization”). Pasteur supported the emerging germ theory of disease, and he was a strong advocate of preventive medicine: “When meditating over a disease, I never think of finding a remedy for it, but instead, a means of preventing it.” Pasteur thus developed vaccines for rabies and anthrax, and his insistence on the Semmelweiss dictum of cleanliness did much to reduce puerperal fever in Parisian maternity wards.

Fig. 24.2  Decrease in the rate of puerperal infections at the Vienna Maternity Institution following the introduction of compulsory hand-washing at the instigation of Semmelweiss, in mid-May 1847 (Source: http://en.wikipedia.org/wiki/Ignaz_Semmelweis)

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Koch  Robert Koch (1843–1910) was another pioneer in microbiology. Working as a district medical officer in Prussian Poland, he had quite limited laboratory resources, but nevertheless he studied the transmission of anthrax, and isolated the micro-organisms responsible for tuberculosis and cholera. Koch also discovered tuberculin in 1890. It proved helpful in the diagnosis of tuberculosis, but Koch’s hopes that it might cure the disease were soon dashed. Epidemiologists remember Koch for his four postulates that link the genesis of a disease to specific microorganisms. Lister and Malloch  Joseph Lister (1827–1912) was a Glasgow surgeon. He built upon the germ theory by routinely using phenol to sterilize surgical instruments and clean infected wounds. He believed that there were dangerous bacteria in the atmosphere of operating theatres, and he thus carried out his surgery under a continuous spray of carbolic acid. However, towards the end of his career, his emphasis shifted from antisepsis to asepsis in operating theatres. An Ontario surgeon (Archibald E. Malloch. 1844–1919) served as an intern with Lister in Glasgow. Malloch tried to teach the concept of asepsis to colleagues in the Toronto area, but had difficulty in persuading local surgeons to abandon such practices as holding knives in their mouths, wiping bloody scalpels on dirty rags, and feeding post-operative sutures through the button-holes of their jackets. Wright  Sir Almroth Wright (1861–1947) was a bacteriologist and immunologist at St. Mary’s Hospital, in London. He was a strong advocate of preventive medicine, and had been concerned by the high death rate among injured troops in the second Boer War (1898–1902), Thus, during World War I, he worked with the Allied Forces to ensure the vaccination of Allied troops before they left for the battlefields.

I ntroduction of Chemotherapy, Antibiotics and Vaccines During the Modern Era During the 1920s and 1930s, acute illnesses were still major causes of death and children often died of such infections before reaching maturity. Viral pneumonia could kill in a night, and outbreaks of tuberculosis and poliomyelitis brought panic to many communities. Sanatoria were filled with young people who remained in care for years because their cardiac valves were being eaten away by rheumatic fever, or their lungs were being destroyed by tuberculosis. But as the Modern Era progressed, the introduction of sulphonamides, antibiotics, and vaccines allowed resolution of many of these acute health problems. Sulphonamides  The first ray of hope in the treatment of catastrophic infections came in the mid-1930s, when Gerhard Domagk (1895–1964), a physician at the Bayer laboratories in Germany, had the novel idea that coal tar dyes might bind preferentially to microorganisms, killing them but not the patient. He found a red dye that protected mice against lethal doses of streptococci and staphlococci, and in

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1935 the drug was marketed as Prontosil Rubrum. It proved particularly effective against rheumatic fever and puerperal fever, and it also played a major role in reducing wound infections at military hospitals during World War II. Antibiotics  The treatment of superficial infections by a local application of moulds had first been suggested in ancient Greece. In 1640  CE, the apothecary to King Charles I (John Parkington) had also advocated applying mould to wounds, and in 1871 Sir John Scott Burdon-Sanderson noticed that if a culture was covered with mould, the bacteria were unable to grow. Lister later observed that if urine samples were contaminated with mould, this checked bacterial growth, and that a form of penicillium had an anti-bacterial action on human tissue. Pasteur also reported that anthrax cultures were inhibited by penicillin. However, credit for the discovery of antibiotics is generally attributed to Alexander Fleming. Working in Almoth Wright’s laboratory in 1928, he observed a halo of inhibited staphylococcal growth near a spot of blue-green mould in a Petri dish that had rather carelessly been left near an open window. He concluded that the mould was secreting an inhibitory chemical, and he isolated the penicillin that was responsible for this effect. By the early 1940s, Walter Florey had discovered a form of penicillin that was stable enough to allow its mass production, and it became widely used in the treatment of streptococcal and staphylococcal infections. Despite its immediate efficacy against these micro-organisms, Wright warned physicians that the overuse of antibiotics would create strains of resistant bacteria. Unfortunately, too few members of the medical community have heeded his advice over the following 70 years, and many resistant types of bacteria have emerged. In 1946–47, another important antibiotic (streptomycin) was discovered. It was initially very effective in the treatment of tuberculosis. Selman Waksman of Rutgers University, NJ, received a Nobel prize for this discovery, although it has since been suggested that he fraudulently excluded evidence of major research contributions from Albert Schatz, his graduate student. The use of streptomycin has now been abandoned because of the widespread development of resistant bacteria. Anti-polio Vaccines  Anterior poliomyelitis had been recognized for several millennia, but major epidemics were still occurring during the twentieth Century. Indeed, during the 1940s and 1950s, half a million people in North America were either paralyzed or killed by poliomyelitis each year. Epidemiological studies suggested that the disease was spread in part through the contamination of swimming pools, and in part along railway lines, due to faeces dropped from open toilets. Jonas Edward Salk developed an inactivated polio virus, and as mass vaccinations began in 1967, there was a ten-fold decrease in the incidence of poliomyelitis in the United States. Some 8  years later, Albert Bruce Sabin introduced an oral attenuated poliovirus. This was much easier to administer, and its effects lasted longer than the Salk vaccine. Within a few years of the introduction of these 2 antidotes, no new cases of anterior poliomyelitis were being reported in the U.S.

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Epidemics of Chronic Disease As techniques of countering acute disease were perfected, those concerned with population health became concerned about new epidemics of chronic disease. Sophisticated epidemiological techniques were thus introduced to study relationships between objectively quantitated habitual physical inactivity, cardiac disease and obesity. Objective Quantification of Habitual Physical Activity  Until recently, epidemiologists relied almost exclusively upon subjective questionnaires responses to determine an individual’s habitual physical activity. Such estimates provided a simple 2–3 level classification of people into “active” or “inactive” categories, but major systematic errors precluded the examination of dose-response relationships or the interpretation of questionnaire responses in terms of optimal absolute amounts of physical activity. Relatively inexpensive pedometers and accelerometers now provide epidemiologists with objective data on physical activity patterns. This has allowed them to repeat earlier questionnaire-based studies, and to define minimum daily levels of physical activity associated with protection against conditions such as arteriosclerosis, osteoporosis and sarcopenia. Leonardo da Vinci developed an early form of pedometer for military purposes. Perrelet (1729–1826 CE) perfected this type of device in Enlightenment France, and President Jefferson used a pedometer to monitor his personal exercise routine. However, the widespread use of pedometers by epidemiologists awaited the introduction of accurate and inexpensive electronic monitors. Hatano marketed the first reliable electronic pedometer in 1965; he encouraged Japanese wearers to take a minimum of 10,000 steps/day. The best of currently available pedometers can record 500 paces taken on a track with an accuracy of −0.2 ± 1.5 steps. Performance is necessarily less precise when measuring the activities of daily living, but a reasonably accurate assessment of activity patterns can be monitored continuously for up to 60 days. The Epidemic of Cardiac Disease  The epidemic of cardiovascular disease and deaths noted by Morris and his associates in Great Britain during the early 1950s has been replicated in Canada and the U.S. Physical inactivity has undoubtedly been one important underlying factor, but it does not seem to have been the sole cause of the epidemic; cigarette smoking has also played a major role. The incidence of coronary deaths in North America declined from the 1960s through the 1990s, as smoking became less prevalent and hypertension was better controlled, although there was little evidence that many of the population increased their habitual physical activity over this period. Unfortunately, partial control of the cardiac epidemic in the western world during recent years has been offset by a growing prevalence of cardiac disease in developing nations, as their populations move to large cities and adopt the adverse lifestyle previously typical of western society.

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Fig. 24.3  Illustrating the soaring prevalence of overweight and obesity (as defined by body mass index) in the United States over the period 1960–2004 (Source: http://en.wikipedia.org/wiki/ Epidemiology_of_obesity#cite_note-Caballero-4)

The Obesity Epidemic  An increasing prevalence of obesity became a major health concern towards the end of the twentieth century. This was most evident in the U.S.(Fig. 24.3); less than 15% of U.S. adults were obese in 1990  CE, but by 2012 CE, 36 States had a prevalence of obesity greater than 25%, and in 13 States, the figure was greater than 30%. In Canada, there were few overweight and obese people during the 1950s. However, by 2004, obesity rates among Canadians aged 18 and over had increased to 23%, and among those aged 2 to 17 years the obesity rate had risen to 8%. The WHO has now recognized obesity as a world-wide epidemic, with 2.1 billion obese people in 2013, compared with 857 million in 1980.

Immunology in the Post-modern Era The post-modern era has brought rapid advances to the science of Immunology. Noteworthy developments include the introduction of cell-sorting and cell-counting equipment, reverse transcription methods to detect messenger RNAs, and increased sensitivity of methods to determine circulating cytokines. This has allowed a detailed exploration of how immune defenses are modulated by exercise, and the breakdown of immune function as seen in sepsis reactions. Cell Sorting and Counting Equipment  Progress in all branches of immunology was slow while investigators had to complete painstaking differential white cell

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counts, using a light microscope and a graticule to enumerate the various types of leukocyte. Maxwell Wintrobe introduced the modern haematocrit and concepts of mean cell volume, mean cell haemoglobin and mean cell haemoglobin concentration in 1929. One important application of his studies was the development of a standard method to estimate changes of plasma volume during prolonged exercise. In 1947, Wallace Coulter developed a device that could detect the number and size of particles suspended in a fluid. In essence, changes in electrical conductance were detected as a cell-containing fluid was drawn through a small aperture. Automated sorting of cell sub-types became possible with development of the fluorescence-­activated cell sorter, the synthesis of appropriate monoclonal antibodies, and the introduction of devices that could sort cells in terms of their volume. Reverse Transcription Technique  Determinations of plasma cytokines are challenging, since circulating concentrations are very low; most cytokines also bind strongly to receptor molecules, have a short half-life, and are readily neutralized by circulating inhibitors. But recently, determination of the quantities of cytokines secreted by immune cells has been facilitated by the transcription of cytokine messenger RNAs, using the reverse transcription polymerase chain reaction technique. Enhanced Sensitivity of Cytokine Detection  The new sensitivity of methods for cytokine detection has led to a realization that circulating cytokines may be derived from sites other than circulating leukocytes, and that a bout of strenuous exercise typically unleashes a complex cascade response, with the sequential appearance of various interacting cytokines. Modulation of Immune Responses by Exercise  These new techniques have allowed a detailed exploration of how the body’s immune system is modulated by physical activity. Over the past 3 decades there has been an increased study of interactions between exercise and leukocyte demargination, the secretion of immunoglobulins, resistance to respiratory infections, the metabolic role of cytokines, and the potential role of excessive exercise in causing septic reactions. Leukocyte Demargination  The adherence of leukocytes to the walls of blood vessels, and their subsequent migration into the extravascular space was first described by Henri Durochet in 1824. In 1938, Vejlens further demonstrated an association between such margination and erythrocyte aggregation. In 1983, Crary added the important discovery that leukocyte adherence to the vascular wall was decreased by an action of catecholamines upon adhesion molecules, with a resulting release of immune cells from storage sites during exercise and other forms of adrenogenic stimulation. As early as 1893, Schulte had noted that a bout of vigorous exercise induced a leukocytosis, and in 1902, Larrabee reported a 3–5 fold increase in leukocyte count following participation in a marathon run. Mucosal Immunoglobulins  In recent years, it has been shown that immunoglobulins offer the primary barriers to infection by most hostile micro-organisms. The first observations on immunoglobulin responses to heavy exercise were made by

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Tomasi and colleagues in the early 1980s. They reported decreased concentrations of immunoglobulin A in saliva following a bout of strenuous cross-country skiing. Others soon confirmed these findings, and noted that there was also a chronic suppression of salivary immunoglobulin secretion with heavy training. Further, Laurel Mackinnon was able to relate these decreases in immunoglobulin levels to episodes of upper respiratory infection. Resistance to Infections  During the 1920s, studies in rabbits and guinea pigs suggested that exercise could increase susceptibility to experimental pneumococcal infections, particularly if heavy physical activity had been undertaken during the infectious stage of the disease. Other research showed that heavy exercise had an adverse effect on the course of viral infections. Fatiguing exercise increased the severity of paralysis in monkeys inoculated with poliomyelitis virus, and retrospective questioning of human victims suggested that exercise influenced both the course of poliomyelitis and the location of paralysis. However, it was not until the late 1980s that David Nieman and his colleagues demonstrated an increased vulnerability to upper respiratory infections following participation in extreme endurance events such as a marathon race. Proof of the relationship remained somewhat tenuous, since most studies were based on reports of respiratory symptoms rather than clinically diagnosed and virologically proven episodes of rhinovirus infection. Metabolic Role of Cytokines  Bente Klarlund-Pedersen opened up a new line of enquiry in 2001 when she discovered that exercise activated the IL-6 gene in skeletal muscle. This caused a progressive release of the cytokine IL-6 into the blood stream as intramuscular glycogen stores were depleted. It thus appears that in addition to controlling responses to infection and injury, cytokine secretions may contribute to metabolic regulation. Exercise and Sepsis  In 1994, Camus drew attention to a possible parallel between clinical sepsis and the immune reactions seen following very heavy exercise; this led to suggestions that physical activity might prove a useful experimental model for those interested in countering problems of surgical sepsis, and that there was some danger that excessive exercise might induce a septic reaction. Three years later, an international symposium in Toronto agreed with the concept of Camus and encouraged further animal experimentation, but decided it was unethical for human volunteers to undertake exercise of sufficient intensity to cause a long-term suppression of their immune function.

Practical Implications for Current Policy It is 170  years since Semmelweiss first demonstrated the importance of hand-­ washing following the clinical examination of patients, but there are still hospitals today where the spread of C.  Difficilis infections has been traced to a failure of

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medical personnel to observe this simple act of hygiene. Plainly, hospital administrators need to take such lapses in protocol more seriously than they are currently doing. Soon after its discovery in his laboratory, Sir Almoth Wright was warning that over-prescription of antibiotics would lead to drug resistance. However, this message has yet to be heard by many physicians and veterinarians, who prescribe antibiotics without testing the sensitivity of the micro-organisms causing a given infection. The consequence of excessive and ineffective prescription of such medications is that a large proportion of available antibiotics have now lost their therapeutic effectiveness. Although vaccination at one point had led to the almost total elimination of poliomyelitis world-wide, sporadic cases are now being reported from central Africa, Pakistan and Afghanistan. This points to the need to continue efforts at eradication of the disease, particularly in areas where access to vaccination is limited by poverty and continuing ethnic violence. David Nieman has frequently alluded to a j-shaped relationship between habitual physical activity and resistance to infection. This is an important concept that needs clearer definition. If exercise is indeed beneficial in moderate amounts, but becomes less beneficial or even harmful in large doses, then health workers need to establish appropriate upper limits of exercise intensity and volume for men and women in various age groups and at various levels of physical condition.

Questions for Discussion 1. What are some of the current limitations of epidemiological methodology when studying relationships between physical activity and chronic disease? 2. Upper respiratory infections are frequently incurred following participation in a marathon run. Does this imply that such exercise is excessive for the average well-trained runner? 3. The efficacy of penicillin was discovered through careful checking of an aberrant laboratory outcome. What other major discoveries have been made by seeking the cause of aberrant results?

Conclusions For many centuries, epidemics of acute disease were attributed to bizarre and improbable causes, limiting the likelihood of finding effective remedies. In the Victorian era, painstaking epidemiology demonstrated the connection between exposure to vectors such as contaminated water and the development of diseases such as cholera. Moreover, the growing expertise of microbiologists demonstrated the actual micro-organisms responsible for various infections. This in turn allowed the development of potent methods of treatment and prevention- sulphonamides,

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antibiotics, and vaccines. New techniques of immunological research have also allowed exploration of the relationships between participation in vigorous exercise and resistance to infection. Unfortunately, the relatively complete elimination of many acute diseases has given place to epidemics of chronic disease, apparently related largely to over-eating and a decrease in habitual physical activity by much of the world’s population.

Further Reading Brock TD. Robert Koch, a life in medicine and bacteriology. Berlin, Germany, Science Tech Publishers, 1988, 364 pp. Céline LF. Semmelweiss, 1818–1865. Paris, France, Gallimard, 1952, 132 pp. Cliff A, Haggett P, Smallman-Raynor M. Deciphering global epidemics: Analytical approaches the disease records of world cities, 1888–1912. Cambridge, UK, Cambridge University Press, 1998, 489 pp. Crelin J, Worthen DB. A social history of medicines in the twentieth century. Boca Raton, FL, CRC Press, 2004, 340 pp. Debra P. Louis Pasteur. Baltimore, MD, Johns Hopkins University Press, 2000, 600 pp. French RK, Wear A. The medical revolution of the seventeenth century. Cambridge, UK, Cambridge University Press, 1989, 328 pp. Gard M, Wright J.  The obesity epidemic. Science, morality and ideology. Abingdon, OX, Routledge, 2005, 232 pp. Hempel S. The strange case of the Broad Street pump: John Snow and the mystery of cholera. Berkeley, CA, University of California Press, 2006, 321 pp. Lax E. The mold in Dr. Florey’s coat: The story of the penicillin miracle. New York, NY, Henry Holt, 2015, 320 pp. Magner LN. A history of infectious diseases and the microbial world. Sanra Barbara CA, ABC-­ Clio, 2009, 225 pp. Oshinsky DM. Polio: An American story, New York, NY, Oxford University Press, 2005, 342 pp. Rosenberg CE. Explaining epidemics. Cambridge, UK, Cambridge University Press, 1992, 357 pp. Shephard RJ. The immune system. In: History of exercise physiology, ed. C. Tipton,Champaign, IL, Human Kinetics, 2013, pp. 525–556. Shephard RJ, Tudor-Locke C. The objective monitoring of physical activity: Contributions of accelerometry to epidemiology, exercise science and rehabilitation. Cham, Switzerland, Springer, 2016, 383 pp. Worboys M. Spreading germs. Disease theories and medical practice in Britain 1865–1900. Cambridge, UK, Cambridge University Press, 2000, 327 pp.

Chapter 25

The Feminine Touch in Health and Fitness

Learning Objectives 1. To admit the long-standing exclusion of women, from medical training, from many types of sport and physical activity enjoyed by men, and indeed from many research projects. 2. To observe the ways in which these barriers have been progressively overcome in recent years. 3. To determine whether there is still a demand for sex-specific types of physical activity programming. 4. To decide whether there remain barriers to equitable treatment of women with respect to entry into health professions, maintenance of personal health and fitness, and the conduct of research.

Introduction During the middle ages, the female head of household was expected to provide front-line health services to her family and neighbours (Chap. 13). There had been at least one female professor in the Salerno medical school during the Mediaeval Era (Chap. 17). But through into Victorian times, women were firmly excluded from most medical schools, and in consequence many health and fitness research projects failed to include women among their test subjetcts. Nevertheless, women found opportunity to make an important formal contribution to health and fitness through the organization of effective nursing services, beginning with Florence Nightingale. In the Modern era, the political voice of women was also heard increasingly, and there were growing demands for equal access to exercise and sport programmes. Participation in vigorous physical activities was facilitated by changing dress codes and less rigorous chaperoning, coupled with a reduction of family size that was made possible through free access to birth control information. Nevertheless, even © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_25

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into Modern times, some forms of exercise remained the prerogative of men, and their were lighter forms of physical activity designed specifically for women. This chapter explores the sustained male gender bias in many of these areas of health and fitness.

The Systematic Exclusion of Women from Medical Schools Earlier generations had offered girls less schooling than boys, with fewer opportunities for instruction in physical education (Chap. 19). As the number of medical schools expanded in Victorian times, there was a reluctance to admit that women had the intellect demanded by comprehension of the medical curriculum. The author of one American obstetrics text described the Venus de Milo in these terms: “She had a head almost too small for intellect, but just big enough for love.” Thus, few women were allowed to become physicians during the nineteenth century. It is rumoured that during the Victorian Era one well-known military surgeon (Sir James Barrie, 1799–1865) was born a female (Margaret Ann Bulkley), but chose to live as a man in order to pursue a career in medicine. Also, a Russian woman with an intense interest in medicine (Nadezhda Suslova (1843–1918) overcame the prevailing prejudice, travelling to Zürich to pursue her studies and become the first female Russian M.D. The secret of her educational programme was kept from the Tsarist bureaucracy until after she had graduated in 1869, but when the authorities discovered what had happened, they took stern measures to exclude other women from Russian medical schools. During this period, Elizabeth Blackwell (1821–1910) managed to enroll in the small medical school at Geneva, NY by the expedient of signing her application form as E.  Blackwell Esq., but when she graduated in 1849, she was obliged to travel to Paris in order to complete her internship and residency. In Britain, the prejudice against female physicians was, if anything, even stronger than in other countries. A letter to the Lancet concluded: “women are sexually, constitutionally, and mentally unfitted for the heavy responsibilities of general medical and surgical practise. Women might become midwives, but in an inferior position of responsibility as a rule. I know of no great discovery changing the boundaries of scientific knowledge that owes its existence to a woman. What right have woman to claim mental equality to men?” All attempts by Sophia Jex-Blake to enter a medical school in England were rebuffed. In 1869, she was admitted to the medical school in Edinburgh, but when she and 6 other women presented themselves at the Surgeons’ Hall for their anatomy examination a year later, this provoked what was termed the Surgeon’s Hall Riot. As the women approached the building (Fig. 25.1), the outer gate was slammed in their faces, and they were verbally abused and pelted with refuse. The candidates eventually gained access to the building via a side door, and several noisy male students were ejected from the hall, but conduct of the anatomy examination was further disrupted when a live sheep was led to one of the examination desks. Sophia named the student who had incited the riot, and claimed

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Fig. 25.1  Sophia Jex-Blake and six other women were admitted to the Edinburgh medical school in 1869, but when they attended their anatomy examination at the Surgeons’ Hall one year later, the gate was slammed in their face. This event provoked the Surgeon’rs Hall riot (Source: https:// en.wikipedia.org/wiki/Surgeons’_Hall_riot)

that he was supported by one or more of the medical faculty. A writ of defamation was found in favour of the male student, but he was awarded only one fartbing of the £1000 in damages that he had claimed. Sophie never graduated as a physician, but by 1876 she had succeeded in encouraging the passage of legislation that gave women the right to practice medicine. Even during the modern era, women’s medical education in Britain was limited to a few segregated institutions. When I became a medical student at Guy’s Hospital, London, in 1946, women who wished to practice medicine pursued a programme of segregated instruction at the Royal Free Hospital, and no other London teaching hospitals had places allocated for female students. Until recently, opportunities for women to enter medical school were also very limited in North America. In 1883, the Women’s Medical College in Kingston, ON, an affiliate of Queen’s University, became the first Canadian academic establishment to receive female students. However, it was not allowed to become a part of the Royal College of Physicians and Surgeons (an early incarnation of the Queen’s Faculty of Medicine), because of adverse reactions from the male students in Kingston. The Women’s Medical College continued its operations until 1894, when it closed because of a lack of students. Females were not readmitted to the Queen’s University medical programme until 1943. Maude Abbott was one early female physician in Canada. She overcame many practical difficulties, and was finally allowed to graduate from Bishop’s University, a small college in the Eastern Townships of Quebec in 1894.

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Gender Bias in Health and Fitness Research Until recently, much health and fitness research was based on small convenience samples, often students and colleagues in medical schools, and partly for this reason data involving women were rarely collected. The resulting conclusions showed an inevitable gender bias, ignoring such factors as the sex disparities in average body size and shape, and the inevitable differences in responses to training associated with an altered hormonal milieu. Granting agencies are now trying to rectify this situation, and support is generally denied unless female subjects are included in the investigation. Since the 1970s, there has also been a growing volume of research examining the influence of the menstrual cycle and pregnancy upon the responses to exercise, and the athletic triad of eating disorders, disturbed menstruation and osteoporosis found among competitors in sports usually won by athletes with a petite figure.

Opportunities for Women in Nursing Since few Victorian women had the opportunity to become physicians, the only educational option for those who were interested to pursue a career in the Health Sciences was to become a nurse-probationer. During an onerous apprenticeship of making beds and emptying bed pans, many women contented themselves with seeking out and marrying a good-looking male medical student, but some went on to become Registered Nurses and Hospital Matrons. Florence Nightingale (1820– 1910) is a prime example of the women who completed such training (Fig. 25.2). During the Crimean War of 1853–1856, she is said to have accomplished more for health than the entire (male) military medical establishment. “Such a head” said Queen Victoria to Prince Albert. “I wish we had her at the war office.” At the Skautari hospital, she cut the death rate of soldiers from 42% to 2% by a judicious use of soap, water, clean linen and humane care. When she returned to England, she established the first School for Nurses, at St. Thomas’s Hospital in London. Nevertheless, Nightingale did not accept the “germ theory,” and she still believed that miasmata and dirty bed linen were the prime causes of disease. Some authors have suggested that although she did much to improve the health of the soldiers in her care, she was also guilty of manipulation, evasions and lies, with some of her more devious actions being all too evident in official record books. According to one historian: “Florence Nightingale, like Mr. Richard Nixon and his tapes, was so possessed of the habit of deceit and the conviction that the full record would compel posterity to vindicate her actions, that she could not bring herself to destroy material...Having brazened out lies in life, she would brazen them out in death.”

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Fig. 25.2  Nursing was the only career option for most Victorian women interested in the health sciences. Florence Nightingale (1820–1910) revolutionized military nursing care during the Crimean war (Source: http://en. wikipedia.org/wiki/ Florence_Nightingale)

The Growing Political Voice of Women Throughout most of the Victorian era, women remained politically disenfranchised, and had little voice in public policy. Their views on issues such as the enhancement of health and fitness generally had to be voiced through the mouths of their husbands or male relatives. Nevertheless, population health was enhanced more directly through the advocacy of outspoken individuals such as Florence Nightingale (above). A few women attained dominant leadership roles in small Christian sects. Mary Eddy Baker (1821–1910) founded the Church of Christian Science, giving full bent to her singular views on the causes of illness and the efficacy of faith healing. The Salvation Army, from its foundation in 1865, accorded equal rights to women and men, and it did much to enhance the personal lifestyle of both sexes in the poorer areas of large cities. And the Quaker movement insisted on the equality of men and women, profoundly influencing the thinking of such feminist advocates as Lucretia Mott, Elizabeth Cady Stanton, and Susan B. Anthony. Some women became entitled to vote in Britain, Sweden, and western U.S. States in the 1860s, but universal suffrage did not arrive until much later: New Zealand (1893), South Australia (1895), Finland (1907), Norway (1913), Denmark (1915), Canada (1917/18), Great Britain (1918) and the U.S. (1920). In Britain, Sylvia Pankhurst (1882–1960) was confined to Holloway Prison in 1906, following suffragette demonstrations. However, her jailors noted with respect that she did not neglect her exercise routine while behind bars, marching silently but resolutely around the bare prison yard for 30  minutes on the two mornings each

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week when she was allowed to do this. When not in prison, Pankhurst also ventured into health care, opening a maternity clinic for poor women of London’s East End, and writing a book entitled “Save the Mothers” where she pleaded eloquently for measures to prevent the annual loss of 3000 child-bearing mothers and 20,000 infant lives in England and Wales. Canada’s best-known advocate of women’s rights, Nellie McClung (1873–1951), was also a defender of both physical and mental eugenics. She called for the enforced sterilization of children with limited intelligence, contributing to the pressure for passage of a Eugenics Act in the Province of Alberta. However, she also championed more praiseworthy pieces of health legislation during the early 1900s, including the provision of medical and dental services for schoolchildren, mothers’ allowances and factory safety requirements.

Range of Opportunities for Women to Exercise In the Victorian era, women were often seen merely as a hostess, or a tasteful parlour ornament; many wealthy women even thought it unfashionable to be healthy and spent their days lying on a sofa! The American educator Catharine Beecher (1800–1878) and a few far-sighted male physicians fought against this stereotype. Catherine Beecher  Catherine Beecher actively promotied the idea that women should be more active. She was a sister of the abolitionist Harriett Beecher Stowe, and was reputed to have begun life with a “delicate and scrofulous constitution,” not walking until she was 2 years old. She was home educated to the age of 10, and was then sent to a private school where for 6 years she experienced the limited tuition that was offered to many Victorian women. As she grew, she became quite active: “up to eighteen was one long play spell out of doors.” Following the death of her mother, she returned home to manage the household. However, she managed to study mathematics, latin and philosophy, and by the age of 21 she was herself teaching in New Haven, CT. She went on to establish schools for women in Hartford and Cincinnati, OH, and on the advice of her brother, she continued to exercise regularly for 1–2 hours per day, often on horseback. Catherine developed a detailed educational plan that included a fitness programme designed to meet the specific needs of girls and women. Her ideas on physical education were gleaned from several sources, including: Sarah Pierce, her teacher at the Litchfield Female Academy in Connecticut (who had insisted that her pupils take regular daily physical exercise); Dr. Elizabeth Blackwell (the first female physician in America) who had provided scientific evidence in favour of regular exercise; George Taylor, who had brought Swedish therapeutic gymnastics to the U.S.; and an “English lady of fine person” who claimed to have cured herself of a hump-back by participating in a gymnastic programme. Catherine objected that the new exercise regimen proposed by Diocletian Lewis (Chap. 19) was: “so vigorous and ungraceful as to be more suitable for boys than

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for young ladies.” In its place, she recommended that girls undertake daily calisthenics, preferably performed to music and aimed at securing graceful movements. Her insistence upon musical accompaniment proved a problem in some frontier schools, where no piano was available. She continued to regard calisthenics mainly as a means of remedying postural problems, and she recommended that in addition the girls set aside 2 h per day for more utilitarian physical tasks such as cleaning, gardening and laundering. Where this was not possible, two daily 30-min sessions of calisthenics were to be substituted as the next best thing. In 1856, 2 books appeared in a single binding: “Physiology and calisthenics for schools and families” and “Calisthenic exercises for schools, families and health establishments.” Catherine certainly wrote the first of these, and probably the second. Her 50 calisthenic exercises included no movements that would induce any substantial increases in strength; much class time was spent tossing light corn bags, and marching steps were limited to the length of the child’s foot. Catherine also carried out dietetic experiments on her pupils, weighing their food intake, and insisting that recipes based upon Graham flour were better for children than a richer diet. Male Supporters.  In Victorian times, most male physicians had negative attitudes towards exercise by women, but there were some exceptions who supported the idea of greater physical activity for women. In 1830, the distinguished English physiologist and gynaecologist Marshall Hall (1790–1857) lamented that: “Instead of having their health invigorated.....by a regular plan of vigorous exercise, young persons in the present day are enfeebled and disordered by a system of sedentary studies.” Likewise, on moving to London, the French physician Antoine Martin Bureaud-­ Riofrey (born 1801) wrote a text entitled “Physical education: specially adapted to young ladies.” This argued against the low intensity exercise that Thomas Walker had been advocating for English women (the rhythmic manipulation of 0.9  kg clubs). In his view, calisthenics should not be restricted to: “Mere mechanical movements of going backwards and forwards with a wand or Indian sceptre..”

 he Impact of Altered Dress Codes and Greater Female T Emancipation Female participation in active recreation during the Victorian era had been greatly hampered by social conventions and the requirement to wear restrictive clothing; tennis, for example, was played while making little movement around the court. However, feminist leaders clamoured for greater opportunities to engage in vigorous exercise. In her “Discourse on Women” (1849), the American Quaker and women’s rights leader Lucretia Mott (1793–1880) demanded that a woman: “receive encouragement for the cultivation of all her powers... strengthening her physical being by

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proper exercise and observance of all the laws of health.” And in the opinion of the another American Quaker and social reformer Susan Anthony (1820–1906): “In the battle for equality, women need strong bodies as well as quick minds.” Elizabeth Stanton (1815–1902) was a regular contributor to the New York Journal, and she often advocated that women should shorten their skirts so that they could increase their physical activity, arguing that: “mental discipline and physical activity produce mental health.” Towards the end of the nineteenth century, changing dress codes brought women new opportunities to adopt an active lifestyle. During the 1880s, introduction of the rear-driven safety bicycle with pneumatic tyres had opened up cycling to the general population. Female participation was facilitated by the design of athletic bloomers and knickerbockers (Fig. 25.3). These “scandalous” garments reached the Canadian

Fig. 25.3  Invention of the safety bicycle and changes in dress codes for women allowed them to participate in unchaperoned cycling expeditions and to engage in ordinary travel around town without male help (Source: http://en.wikipedia.org/wiki/History_of_the_bicycle/)

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market around 1895. Women could now use their bicycles to leave home without a chaperone and become involved in public life. Susan B. Anthony commented on the importance of cycling to female emancipation: “I think it has done a great deal to emancipate women. I stand and rejoice every time I see a woman ride by on a wheel.” Multi-layered petticoats had been a major hindrance to female participation in Victorian pedestrian events, but this problem was also resolved in the 1850s, as Amelia Bloomer popularized baggy pants, cuffed at the ankle and worn beneath a skirt. Nevertheless, pundits proclaimed pedestrianism was both immoral and excessively strenuous for such frail creatures as women. Many Victorians viewed the pedestriennes as brazen entertainers, ready to violate moral standards, and some argued that they had a negative impact on the involvement of decent women in any type of sport. Despite these criticisms, some women undertook outstanding pedestrian feats during the Enlightenment and the Victorian era. In England, a woman named Mary Wilkinson walked from Yorkshire to London (402 km) in less than 4 days. In 1764 (at an age of 90) she strapped provisions including a keg of gin onto her back, and repeated the same journey in 5 days and 3 hours. She did not die until the age of 109  years. And in 1899 women and 8 children completed a winter trek from Montreal to Albany NY (402 km) in 1 month. The long battle for equal participation of women in Olympic sport continued far into the twentieth century, and is only now drawing to a close (Chap. 12). However, beginning in the 1920s, female athletes demonstrated exceptional prowess in some events, particularly in marathon and synchronized swimming.

Birth Control Until recently, responsibility for families of 10–20 offspring offered most working-­ class women opportunity for little other activity than extended child-care. However, effective family planning became progressively more readily available during the Modern Era. Marie Stopes opened the first birth-control clinic in England in 1921 CE. Her teachings were well-received by the middle class, but despite free distribution of an abbreviated version of her book Married Love (Fig. 25.4), she was viewed as a meddler by many poor slum dwellers, where too often the only method of birth control was resort to a back-street abortionist. In the U.S., the Comstock Act had made the distribution of contraceptive information illegal from the 1870s. A nurse named Margaret Sanger was charged under this legislation in 1918, and the policy was only overturned in 1965. In Canada, birth control was ruled as “obscene” in 1892, but by the 1920s feminists were beginning to question this legislation, and family size was shrinking fast in the upper strata of society. The first Canadian birth control clinic opened in Hamilton, ON, in 1932. In 1936, a field-nurse working in a poor and mainly Catholic

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Fig. 25.4  For most of history, responsibility for the care of large families limited the activities of many women largely to the tasks of child-care. Marie Stopes opened the first birth control clinic in Britain in 1921 (Source: http://en.wikipedia.org/wiki/Marie_Stopes)

suburb of Ottawa was charged with breaking the 1892 obscenity law, but she was acquitted on the grounds that her actions had been for the public good. There were no further prosecutions under this legislation, and the fertility rate decreased rapidly in Anglophone Provinces. In Quebec, fertility did not decline until the 1960s, when many of the population rejected the traditional teachings of the Catholic Church on contraception. In France, birth control did not become legal until 1965, and in Italy the circulation of birth control information was not permitted until 1970.

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Exercise Initiatives Addressed Specifically to Women In the early part of the twentieth century, several new exercise programmes had a particular appeal to women. We have noted already some of the initiatives directed to women by Mussolini and Hitler (Chap. 20). Dalcroze, Laban, Alexander and Pilates attempted to meld physical education for women with the teaching of musical and dance rhythms and the dramatic concepts of the stage. This approach became particularly popular in schools for “young ladies,” where physical education was seen as but one facet in the process of enhancing a woman’s natural graces so that she could attract a suitable husband. The stage was thus set for foundation of the Women’s League of Health and Beauty. and institutions such as the Margaret Eaton School of Literature and Expression. Dalcroze  Emile-Jacques Dalcroze (1865–1950) was a Swiss educator and musician. He developed what became known as the eurhythmics system of gymnastics. His primary objective was to teach music. Body movements were thus used to represent musical rhythms that the students had just heard. Movements of the arms represented the timing of the music, and movements of the trunk and feet indicated note values. Dalcroze’s approach required concentration and rapid reactions. It contributed to the development of twentieth century dance, and has continuing echoes in the Orff Schulwerk system of musical education. Laban  Rudolf von Laban (1879–1958) (Fig. 25.5) was an aristocratic dance artist and theorist who was born in Bratislava. He is best known for the Laban system of movement analysis, a technique still used by some dance studios. Laban became director of dance festivals in Germany from 1934 to 1936, obediently removing “non-Aryan” pupils from his classes at the request of the Nazi administration, and writing subserviently: “We want to dedicate our means of expression and the articulation of our power to the service of the great tasks of our Volk. With unswerving clarity our Führer points the way.” Despite his clear allegiance to the Hitler regime, Laban was dismissed in 1938, apparently because one of his presentations still did not do enough to promote Nazi ideology. He then became a refugee in England, founding the Laban Guild for Movement and Dance. After World War II, he applied his ideas of movement ­analysis to industry, seeking to eliminate unnecessary “shadow movements” that he believed were wasting the energy of the worker. Alexander  Frederick Matthias Alexander (1869–1955) was the son of a Tasmanian blacksmith. As a young man, he moved to Melbourne, and began giving amateur Shakespearean recitals, but he was plagued by persistent hoarseness. Traditional voice trainers did not cure his problem, so Alexander began speaking in front of mirrors, attempting a conscious re-education of the muscles that regulated his voice. He concluded that this same technique might improve many aspects of a person’s health and well-being. Thus, he rented a premium office suite in downtown Melbourne, and began giving consultations to develop the voice, cure stuttering and address persistent muscular problems.

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Fig. 25.5  Rudolf Laban, teaching his system of movement notation and analysis (Source: http:// en.wikipedia.org/wiki/ Labanotation)

A lucky bet at the local race track provided him with passage-money to London. There, he established a West-End practice that became very popular among actors and the members of high society. Alexander soon became a wealthy man, but an initial good relationship with the medical fraternity soured when Dr. Spicer, a former supporter, claimed that the corrections of posture and respiration taught by Alexander were a medical prerogative, and not matters for “untrained amateurs and ignorant quacks.” Alexander responded with pamphlets accusing Spicer of plagiarism and distortion. In 1935, Irene Tasker carried the Alexander Technique to the Transvaal. The president of the Transvaal Teachers Association praised the technique, criticizing current patterns of physical education in the Transvaal. Dr. Ernst Jokl, then at the Witwatersrand University, saw this as a direct attack on the medical profession in general and himself in particular. Thus, he published a vigorous critique of the Alexander Technique in the Transvaal Educational News, and in 1944, he wrote an article for Volkskragte (Manpower), describing the Alexander Technique as ‘a dangerous and irresponsible form of quackery.’ Alexander sued Jokl for defamation, but anxiety about the trial precipitated a cerebral stroke, and he was unable to attend the hearings in person. The defense lawyer extracted from Alexander’s chief witness expression of the damaging view that “as a result of psycho-physical guidance under conscious control, resistance to infectious disease might be better.” Despite this evidence that Alexander practitioners were promulgating ill-proven ideas, the

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court awarded damages of £1000, and the judgment against Jokl was sustained in the Court of Appeal. However, a 2004 report concluded that the Alexander technique was “of unknown value or ineffective and so should not be considered” as an evidence-based treatment for lower back pain. Pilates  Joseph Hubertus Pilates (1883–1967) developed much of his system of physical education during the 1920s. His father was a prize-winning gymnast of Greek ancestry. Joseph moved to England in 1912, and he became a self-defense trainer for the London Metropolitan Police (Scotland Yard). Despite the fact that he was already working for a governmental security agency, Pilates was interned in Lancaster Castle as an “enemy alien” during World War I. He continued to teach wrestling and self-defense while he was imprisoned, boasting that the inmates of Lancaster Castle would emerge from captivity fitter than when they were first interned. Pilates believed that bad posture and inefficient breathing were responsible for much ill-health, and during his internment he devised a system of mat exercises that was intended to correct these problems. Participants applied the mind to controlling their muscles, focussing particularly on breathing and alignment of the spine. After World War I, Pilates returned to Germany, but coming under pressure to teach his system of exercises to the German Army, he opted to emigrate to the United States. There, his studios became popular with U.S. dancers and stage artists. Women’s League of Health and Beauty  During the Modern Era, many women continued to view physical activity simply as a means of enhancing their physical attractiveness. Programmes that combined exercise with acting skills fostered this belief. Thus, in 1930 Mollie Bagot Stack founded the Women’s League of Health and Beauty, promising outward beauty from inner vitality. By 1937, she boasted 166,000 members, and the movement had spread to Canada, Australia, Ireland and Hong Kong. Hitler was sufficiently impressed to establish a rather similar organization for women in Germany (the Belief and Beauty Society). Margaret Eaton School  The Margaret Eaton School of Literature and Expression at the University of Toronto provides an example of how these various ideas affected education for women during the Modern Era. The Margaret Eaton School opened in 1906, with strong support from the wife of the wealthy owner of Toronto’s largest Departmental Store. The School initially focused upon the teaching of drama, although physical education was seen as a necessary component to any study of literature, languages, and the dramatic arts. The School as such closed in 1926, and the main focus of the institution then shifted to the teaching of physical education to women who were planning to become school-teachers. In 1941, it formally merged with the University of Toronto, to become a distinctive female part of the University’s School of Physical and Health Education.

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Practical Implications for Current Policy Until very recently, women have been excluded from the medical profession, with a considerable loss to society of their insights into problems of health and fitness. In many countries, there still remain formidable barriers limiting the access of migrants of either sex to medical practice, and there is a need to weigh the merits of such safeguards to the quality of medical care against the potential for the infusion of valuable new ideas. Gender bias has been reflected in the research questions that have been asked, and the data analyses that have been performed. It is now difficult to find financial support for male-biased research in health and fitness. However, there remains a need to review much published data to examine how far conclusions have been flawed because of a lack of female subjects, and where necessary to repeat these studies. The nursing profession has until recently been the exclusive domain of female students, but its perspectives are finally being broadened as it has allowed interested males to undergo instruction for this profession. Birth control programmes are now widely available, but too many young women still find their futures marred by unwanted pregnancies and the consequences of abortions, pointing the need for more effective sex education in the schools and the home. It is now established that women can pursue the same range of sports and physical activities as men, in some instances outperforming them competitively. Nevertheless, there still remain some inequities to be addressed; for instance, university athletics programmes need to explore whether funds, coaching staff and exercise facilities are being shared appropriately between men and women’s teams. In reporting events, there also remains a temptation to report on the appearance and dress of female competitors, rather than to cover their successes on the sports field. It seems clear that currently many women still like different types of programmes to those offered for men. It remains debatable whether unisex programmes should be encouraged. Possibly, both sexes are using physical activity to enhance currently perceived sexual attributes- for the men, the goal is outstanding muscular development, as satisfied by weight machines, whereas the women look for graceful movement, offered by Pilates and similar programmes.

Questions for Discussion 1. Why do you think men were so resistant to the idea of women becoming medical practitioners.? 2. What knowledge has been lost by past failures to include women in research samples? How much of past research needs to be repeated, using representative population samples?

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3. Should the format of fitness and physical education programmes differ for women and men? 4. Is there any place today for programmes linking physical education with instruction in music and drama? Would these have particular appeal to women? 5. Do women (or men) still enter physical education programmes with a view to enhancing their sexual attractiveness? How does this influence programme design?

Conclusions Until very recently, rigid barriers limited the access of women to most medical schools, and a career in nursing was seen as the best option for females who sought a career in the health sciences. Universal suffrage, changes in dress codes, birth control and overall emancipation have now opened up possibilities for women to work in a wide range of health and fitness related professions and to participate in the same types of sport and physical activity as men, although some women still have a preference for programmes that link physical activity with music and drama.

Further Reading Andrist LC, Nicholas PK, Wolf K. A history of nursing ideas. Burlington MA, Jones & Bartlett Learning, 2006, 504 pp. Engelman PC. A history of the birth control movement in America. Sant Barbara, CA, ABC-Clio, 2011, 231 pp. Evans M. Movement training for the modern actor. Abingdon, OX, Routledge, 2009, 222 pp. Hall MA. The girl and the game: A history of women’s sport in Canada, 2nd ed. Toronto, ON, University of Toronto Press, 2016, 424 pp. Hallenbeck S. Claiming the bicycle: Women, rhetoric and technology in nineteenth century America. Carbondale, IL, Southern Illinois University, 2015, 240 pp. Hodgson J. Mastering movement: The life and work of Rudolf Laban. Abingdon, OX, Routledge, 2016, 352 pp. Liddington J. Rebel girls: How votes for women changed Edwardian lives. New York, NY, Little, Brown, 2015, 415 pp. McCrone K. Sport and the physical emancipation of English women, 1870–1914. Abingdon, OX, Routledge, 2014, 340 pp. McDonald L. Florence Nightingale: Extending Nursing. Collected works of Florence Nightingale, Vol. 13. Waterloo, ON, Wilfrid Laurier Press, 2009, 950 pp. Messing K. One-eyed science: Occupational health and women workers. Philadelphia, PA, Temple University Press, 1998, 244 pp. Murdoch L. Daily life of Victorian women. Santa Barbara, CA, ABC-Clio, 2013, 286 pp. Riska E. Medical careers and feminist agendas: American, Scandinavian and Russian women physicians. Picataway, NJ, Transaction Publishers, 2001, 171 pp. Stack P. Zest for life: Mary Bagot Stack and the League of Health and Beauty. London, UK, P. Owen, 1988, 182 pp.

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Stanton EC, Gordon AD. The selected papers of Elizabeth Cady Stanton and Susan Anthony. New Brunswick, NJ, Rutgers University Press, 2006, 587 pp. Todd J.  Physical culture and the body beautiful: Purposive exercise in the lives of American women, 1800–1870. Macon, GA, Mercer University Press, 1998, 369 pp. Toohey K. The Olympic Games: A social science perspective. Wallingford, OX, CABI, 2007, 368 pp. Vertinsky P, Hargreaves J. Physical culture, power and the body. Abingdon, OX, Routledge, 2006, 280 pp.

Chapter 26

The Emergence of Professional Associations and Journals in Health and Exercise Science

Learning Objectives 1. To trace the emergence of professional societies related to exercise science, health and fitness. 2. To recognize the development of peer-reviewed journals under the aegis of these societies. 3. To identify the appearance of landmark texts in exercise science, health and fitness. 4. To understand the importance of the accreditation of health and fitness workers by appropriate professional associations to the delivery of effective health and fitness programmes.

Introduction The past century has witnessed the emergence of a plethora of specialized professional societies devoted to the discussion of new ideas in exercise physiology, sports medicine, physical education, health and fitness. Almost all of these societies have developed their own peer-reviewed scientific journals. We will look at the more significant of these societies and their journals, commenting also on landmark textbooks and the key role of newly determined accreditation processes to the effective delivery of health and fitness programmes.

Professional Societies and Journals The survey of professional societies and their journals covers quite a broad spectrum of disciplines, including physiology, public health, physical education, sports medicine and applied physiology, sports science, and health and fitness. © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_26

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Physiology  The earliest professional groupings of interest considered themselves as physiologists, although the applied research conducted by some investigators would probably be thought out of place at a modern meeting of the Physiological Society. France  French investigators had a dominant influence upon the course of physiology during the first half of the nineteenth century. The Journal de Physiologie Expérimentale et de Pathologie began publication in 1821, and the Société de Biologie, founded in 1848, began publishing the Comptes rendus des séances de la Société de Biologie et de ses filiales in 1852. Germany  German universities also boasted many eminent physiologists throughout the Nineteenth Century. Pflügers Archiv für die gesamte Physiologie des Menschen und der Tiere (now known as the European Journal of Applied Physiology) dates from 1868, with Eduard Friedrich Wilhelm Pflüger (1829–1910) (Fig. 26.1) as its founding editor. Somewhat surprisingly, the German Physiological Society was not organized until much later (1921). Britain  While experimental physiology flourished in both France and Germany, it remained virtually non-existent in Victorian Britain. Indeed, when Ernest Starling was appointed as Demonstrator in Physiology at Guy’s Hospital in London (1887) he lamented: “The only physiological laboratory was a small empty room. When I applied for £200 to buy apparatus….I was informed that ‘a medical school is not a place to do research in’.” Fig. 26.1 Eduard Friedrich Wilhelm Pflüger (1829–1910 CE), Professor of Physiology at the University of Bonn, founded the first peer-­ reviewed journal in applied physiology (now known as the European Journal of Applied Physiology) (Source: http://en. wikipedia.org/wiki/ Eduard_Friedrich_ Wilhelm_Pfl%C3%BCger)

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The British Physiological Society began in 1876, with 19 male academics attending a meeting at the invitation of John Burdon-Sanderson (1828–1905) (Fig. 26.2). The main objective of the meeting was to formulate a cohesive response to the Royal Commission of Enquiry into Vivisection. Subsequent meetings focused more narrowly upon research. However, the initial format of sessions was that of a select dining club, with 22 members and 14 guests attending the first meeting at the Criterion Restaurant in Piccadilly Circus in May 1876,. The first issue of the Journal of Physiology appeared in 1878, and regular scientific meetings of the Society began in 1880. An initial membership ceiling of 40 was set. Election to the Society required the written support of six existing members, with no more than one “black-ball” among five voting members of the Society; this rule persisted into the 1950s, when I was first elected to the Society. Women were initially seen as preparers of meals for the summer river excursions of the Society, and females were not admitted as full members until 1915. They were subsequently required to identify themselves in the published proceedings of the Society by the use of their first names rather than by their initials (as was the custom for the male members). United States  The American Physiological Society held its first meeting in Washington, DC, in 1887, and the American Journal of Physiology began publication 10  years later. During World War II, many North American physiologists Fig. 26.2  While he was Professor of Physiology at University College, London, John Burdon-­ Sanderson (1828–1905) called a first meeting of British physiologists in 1876, to formulate a response to a Royal Commission into vivisection (Source: http:// en.wikipedia.org/wiki/ John_Burdon-Sanderson)

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became deeply involved in applied human research for the military, and in part for this reason, the American Journal of Physiology was supplemented by the Journal of Applied Physiology in 1948. Canada  For many years, Canadian physiologists were content to attend the scientific meetings of their American colleagues, and the Canadian Physiological Society did not become an independent entity until 1936. The Canadian Journal of Biochemistry and Physiology appeared from 1954 to 1963, followed in 1964 by the Canadian Journal of Physiology and Pharmacology. International Meetings  The International Union of Physiological Societies was formed in Montreal in 1953. Triennial meetings have subsequently taken place in various major cities around the world. Public Health  The organization of groups devoted to the discussion of public health, preventive medicine and health promotion lagged behind the formation of physiological societies. Britain  An Association of Metropolitan Medical Officers of Health was established in Britain in 1856, and in 1873 this became the Society of Medical Officers of Health. The Royal Society of Health (RSH) was formed in 1876, and in 1878 it began publication of the Journal of the Royal Society for the Promotion of Health. In 2008, the RSH merged with the Royal Institute of Public Health to form the Royal Society of Public Health, a body dedicated to the promotion of human health and well-being, and its house journal was renamed Perspectives in Public Health. The journal Public Health, initiated in 1888, also had close contacts with the RSH. United States  The American Public Health Association was founded in 1872, with the stated mission “to protect all Americans and their communities from preventable, serious health threats and strive to assure that community-based health promotion and disease prevention activities and preventative health services are universally accessible in the United States.” Its primary organ, the American Journal of Public Health, began publication in 1911. Canada  The Canadian Public Health Association was not founded until 1910; the Canadian Journal of Public Health began publication in the same year. The CPHA Health Digest was added in 1977.

Physical Education United States  The American Association for the Advancement of Physical Education was founded in 1885, setting as its primary objective the support of gymnastics education. It was renamed the American Physical Education Association in 1903, and subsequently blossomed as the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD).

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The American Academy of Physical Education (AAPE) was a more exclusive association of senior academics in physical education. It had its beginnings in 1904/05, with meetings organized by Luther Halsey Gulick (1865–1918), a physician who was superintendent of the Physical Education Department at Springfield College (Fig. 26.3). Formal meetings began in 1926, under the aegis of five distinguished physical educators, including R. Tait MacKenzie and Clark Hetherington, who was a champion of developmental play. Five additional names were added to the Academy’s roster each year, and when 30 names had been recruited a formal charter was established. Members of the Academy are today still identified simply by a serial number that identifies their date of recruitment. The original purpose of the Academy was “to advance knowledge in the field of physical education, to uplift its standards, and uphold its honor,” but this mandate was expanded in 1945, when the Academy was commissioned by the U.S. government to “play a part in helping to bring national policies and practices in line with the best thinking in the field of health and physical education.” The scope of the organization was further broadened in 1993 CE, as it became the American Academy of Kinesiology and Physical Education. Canada  A Canadian Physical Education Association was established in 1933, and the CAHPER Journal first appeared in1934. The on-line resource PHEnex was added in 2009. In 1963, the Canadian Association for Health, Physical Education, and Recreation (CAHPER) hosted its first fitness seminar in Saskatoon. Sports Medicine and Applied Physiology  Modern concepts of sports medicine date from 1928, when the Association Internationale Médico-Sportive (AIMS) was born, and an International Congress of Sports Medicine was held in conjunction with the Amsterdam Summer Olympic Games of 1928. The association underwent several changes of title to become the Fédération International de Médicine Sportive and since 1998 the Fédération Internationale de Médicine du Sport. By 1998, it claimed affiliate organizations in 83 countries. Its official journal, the Journal of Sports Medicine and Physical Fitness, began publication in 1961. Fig. 26.3  Dr. Luther Gulick, Superintendent of the Physical Education Department at Springfield College, Springfield, MA, provided the initial stimulus to foundation of the American Academy of Physical Education (Source: https://en. wikipedia.org/wiki/ Luther_ Gulick_(physician))

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Germany  The first national interest in sports medicine was seen in Germany. August Smith and Arthur Mallwitz organized an International Congress on Hygiene in Dresden in 1911, with the enthusiastic support of a local mouth-wash manufacturer. The congress, emphasizing the health benefits of sport participation, attracted five million visitors, both scientists and lay people. A second congress the following year discussed a very modern range of sports medical issues, including overtraining, the ECG of athletes, doping, sexuality and the participation of women in sport. The German Committee for the Scientific Investigation of Sports and Physical Exercise was founded in 1912, and the German Federation for the Promotion of Physical Exercise was established in 1924. The latter group immediately began publishing its own journal (Der Sportartz, the Sports Physician). By 1933, 3000 physicians were participating. Unfortunately, the Nazi regime took over and disbanded the Federation. Fritz Duras (1896–1965), Director of the Freiburg Sports Medicine Institute, had Jewish connections, and he was obliged to migrate to Australia, where he became one of the founding fathers of the Australian Sports Medicine Association. After World War II, German interest in sports medicine was revived by the efforts of Herbert Reindell (1908–1990) of Freiburg. The German Federation of Sports Medicine took shape in Hannover (1950), and the German Journal of Sports Medicine resumed monthly publication in 1951. Britain  The pioneer of clinical sports medicine in England was Sir Adolphe Abrahams (1883–1967), elder brother of the Olympic star Harold Abrahams (Fig. 26.4). Sir Adolphe served as medical officer to the British Olympic team from 1912 to 1948. The British Association of Sports and Medicine (BASM) had its beginnings in 1953, and in 1964 BASM began publishing the British Journal of Fig. 26.4  Sir Adolphe Abrahams, elder brother of the Olympic star Harold Abtahams, was the first president of the British Association of Sports and Medicine. The association holds an annual lecture in his honour each year (Source: https://en. wikipedia.org/wiki/ Adolphe_Abrahams)

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Sports Medicine. The group was subsequently renamed the British Association of Sport and Exercise Medicine, to reflect the growing importance of exercise to health promotion. United States  The American College of Sports Medicine (ACSM) had quite modest borigins, with the 11 “founding fathers” meeting at the American Association for Health, Physical Education, and Recreation convention in New York City in 1954. By June of 1955, a roster of 54 Charter Members had been recruited. The first issue of Medicine and Science in Sports appeared in 1969. The annual meeting of ACSM has subsequently grown to become one of the largest international gatherings in sports medicine, covering a broad range of topics in exercise, health, fitness and nutrition. The American Medical Association appointed an ad hoc committee on sports injuries in 1959, and this quickly became a Standing Committee on the Medical Aspects of Sports. The American Orthopedic Association also established a Committee on Sports Medicine in 1962, and in 1975 this became the American Orthopedic Society for Sports Medicine. Canada  Until the mid-1960s, Canadian sports physicians and scientists found intellectual stimulation through attendance at U.S. sports medicine meetings. The Canadian Association of Sports Sciences was founded in 1967, and the Canadian Academy of Sports Medicine (CASM) was inaugurated in 1969 (with its title ­subsequently becoming the Canadian Academy of Sport and Exercise Medicine (CASEM). In 1978, the support of Canadian athletic teams by CASEM, the Athletic Therapists Association and the sports physiotherapy section of the Canadian Physiotherapy Association became formally organized and coordinated through establishment of the Sports Medicine Council of Canada. Journals in Sports Medicine  In addition to Applied Physiology, Nutrition & Metabolism and Medicine & Science in Sports (above), relevant journals with high citation indices include (with respective dates of first publication) the British Journal of Sports Medicine (1964), the Journal of Athletic Training (1966), the American Journal of Sports Medicine (1972), Exercise and Sports Science Reviews (1973), the Year Book of Sports Medicine (1979–2013), the International Journal of Sports Medicine (1980), the review journal Sports Medicine (1984), the Journal of Sports Sciences (1983), the Clinical Journal of Sports Medicine and the Scandinavian Journal of Medicine & Science in Sports (both 1991).On-line initiatives include the International Journal of Behavioural Nutrition & Physical Activity (1994), the Australian-based Journal of Science & Medicine in Sport (1998) and Sports Medicine- Open (2015). Sports Science  Sports science groupings have in the main brought together investigators who were not physicians, and were interested in the science rather than the clinical manifestations of physical activity.

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Canada  An early Canadian initiative in the sports sciences was the foundation in 1899 of La Societé Canadienne pour l’avancement du Sport. Its objectives included the honouring of outstanding athletes, the establishment of archives and the ­introduction of a scientific approach to training and coaching. Unfortunately, it only survived for a year, due to a lack of operating funds. The Canadian Association of Sport Sciences (CASS) was inaugurated in 1967, at a scientific meeting held in conjunction with the Winnipeg Pan American Games. Organization followed long negotiations between the Canadian Medical Association and the Canadian Association for Health, Physical Education and Recreation, and it was initially hoped that CASS would provide a useful bridge between the two established bodies. Because of trans-continental travel costs, attendance at some early meetings of CASS was sparse, and the economics of annual conferences was further compromised by a decision to make a simultaneous translation of most sessions into French to accommodate a handful of francophone members. By 1969, Canadian physicians were already organizing an independent Canadian Academy of Sport Medicine, now the Canadian Academy of Sport and Exercise Medicine. This provided a more clinically-oriented forum, and allowed members to realize what for them had long been a major goal, the establishment of a specialty certification in sports medicine. Members of CASS with interests in biomechanics, sociology, psychology, and psychomotor learning also began to organize their own specialized annual conferences. The issue of “scientific separatism” was debated vigorously by the CASS membership, with some expressing the hope that CASS could function as an inter-­ disciplinary umbrella organization bringing together knowledge from the disparate factions. But reluctantly, it was eventually recognized that only the exercise physiologists were strongly committed to CASS and in 1993 CE the group was rebranded as the Canadian Society for Exercise Physiology. The new and more focussed format of meetings attracted a growing attendance, and the society’s journal, initially the Canadian Journal of Applied Sport Sciences (1976), was retitled Applied Physiology Nutrition and Metabolism. This is now a prominent journal in the fields of exercise science and sports nutrition. It has published some important Position Stands on key issues in sports science, and special supplements have summarized current evidence on such topics as the appropriate dosage and safety of therapeutic exercise for those who are healthy and for those with chronic medical conditions. Britain  In Britain, a growing tension between medically-qualified sports physicians and physiologically-oriented sports scientists led to formation of the British Association of Sports Sciences in 1983, with early publication of the Journal of Sport Sciences. Recognizing the growing scientific interest in exercise related to health rather than athletic competition, the name was changed to the British Association of Sport and Exercise Sciences in 1993. International Groupings  The International Council of Sport and Physical Education (ICSPE) was founded in Paris in 1958, under the auspices of UNESCO. Its

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stated goals were to address the widening gap between sport, sports science and physical education, and to reinforce links between professionals and governmental and non-governmental organizations. Specific objectives were to increase awareness of the human values inherent in sport and physical activity, to improve ­population health and physical well-being, and to develop physical activity, physical education and sport, bridging the gap between developed and developing nations. An International Committee for the Standardization of Physical Fitness Tests was founded in Tokyo, in 1964, under the leadership of Leonard Larson (1906– 2003). It published detailed recommendations for physical fitness and performance tests. Having achieved this goal, the group continued to meet periodically. It is now known as the International Council for Physical Activity and Fitness Research. Sub-specialties  The increasing specialization of sports sciences in recent years is high-lighted by the formation of groups focused on quite narrow issues, each with their own specialty journal. Interest in the athletic performance of children stimulated formation of the Pediatric Work Physiology Group. This group was the brain-child of Josef Rutenfranz (1929–1989). Its first meeting was held in Dortmund (1967). Attendance at small biennial gatherings was by invitation, and discussions focused on exercise in relation to the health and fitness of school-age children. Its house journal is Pediatric Exercise Science (founded 1989). Other specialist organizations have been devoted to issues of fitness and aging, covered by the Journal of Physical Activity & Aging (1991), adapted physical activity, with research published in the Adapted Physical Activity Quarterly (1984), and the International Society of Exercise and Immunology, which has held biennial international conferences since 1993, and publishes the Exercise Immunology Review (1995). Health and Fitness  During the early part of the Modern era, Germany was the dominant force in research on health and fitness, with a German Medical Association for the Promotion of Physical Activity being founded as early as 1924. In the United States, a growing array of associations devoted to health and fitness made their appearance in the Post-Modern Era, each with their house journals, Titles (with dates of first issue) include Preventive Medicine (1959), the American Journal of Preventive Medicine (1970), the American Journal of Health Promotion (1987), ACSM’s Health & Fitness Journal (1997) and the Journal of Physical Activity & Health (2004). The interest of the lay public has been such that in 1950 CE the Rodale Press also began publishing a magazine for the intelligent general reader (Prevention); this now boasts a world-wide circulation of 2.8 million. In 2008 CE, Canada saw publication of the first on-line issues of the Health & Fitness Journal of Canada.

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Landmark Textbooks A number of sports medicine texts appeared early in the early twentieth Century, although their focus was on athletic injuries rather than the role of physical activity in the prevention of disease. The English Encyclopedia of Sport and Games (1895) included a brief section on first aid planning for sports events, although Collier (the English “expert” on Athlete’s Heart around the beginning of the twentieth century) complained that the only two books available to him were translations of texts by Georg Kolb, physician to the Berlin rowing club (The physiology of sport, 1893) and The physiology of bodily exercise, by Fernand LaGrange (1890). Kolb (1893) reported dangerous rectal temperatures (104 °F), peak heart rates of 230 beats/min, and radial artery pressures of 185 mm Hg in the German oarsmen, with values decreasing progressively as the subjects became more trained. LaGrange also was concerned about possible excessive exercise, and quoted examples of animals that had continued running until they died. He warned:”excessive exercise induces wearing and degeneration of the muscle fibres … producing dilatation of the cavities of the heart … a thinning of the walls and diminished strength of their fibres.” Ferdinand Schmidt published a book entitled “Physical exercise according to the exercise value” (1893), indicating the types of exercise that he thought appropriate at various ages. Ferdinand Hueppe, first President of the German Soccer Association, also wrote “A textbook of hygiene” (1899) summarizing knowledge of exercise physiology to that date; he followed this a decade later with Hygiene of body exercises.” A comprehensive two-volume “Hygiene of Sport “was published by Siegfried Weissbein in 1910. Arthur Mallwitz presented a doctoral dissertation in sports medicine at Halle University in 1908, with the title”Maximum performances with special consideration of the sports done at the Olympic Games.” He focussed particularly upon the anthropometric characteristics of athletes. Herbert Herxheimer founded an out-patient sports medicine clinic at the Charité hospital in Berlin in 1926. He described the physical and psychological consequences of overtraining, including a decrease in maximal oxygen uptake, a reduced appetite, a tendency to sweat, shivering, jerky reflexes, and pronounced respiratory arrhythmia. He became a keen student of heart rate recovery curves, and produced the first systematic text in sports medicine (“Foundations of Sports Medicine for Physicians and Students) in 1932. Landmark publications in more recent years have included P-O Åstrand’s Textbook of Work Physiology, which has now passed through 4 editions, my own Endurance Fitness (1969) and the Physiology and Biochemistry of Exercise (1982), and 2 massive consensus volumes published by Human Kinetics (Exercise, Fitness and Health, 1990; Physical Activity, Fitness and Health, 1994).

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The Key Role of Professional Certification An important boost to the professional and effective management of health and fitness issues came with the certification of fitness professionals, beginning during the 1990s. Until this point, those operating fitness programmes had lacked the professional regulation long required in medicine, nursing and physiotherapy; this allowed ill-­ informed charlatans to offer what were sometimes inappropriate, dangerous or ­ineffective fitness programmes. Certification had twin objectives: the setting of appropriate minimum standards of education and experience for fitness professionals, and the provision of suitable recognition to those who had acquired appropriate advanced qualifications. United States  The ACSM Certification Programme began in 1975  CE.  It now includes three primary levels of certification [the Certified Personal Trainer®, the Certified Health Fitness SpecialistSM who provides programmes for both healthy individuals and those affected by various diseases, and the Certified Group Exercise InstructorSM (GEI)]. ACSM also offers two forms of clinical certification [the ACSM Certified Clinical Exercise SpecialistSM who works with clients having or at risk of developing, cardiovascular, pulmonary or metabolic disease, and the Registered Clinical Exercise Physiologist® (RCEP) who assists clients under treatment by a physician for cardiovascular, pulmonary, metabolic, orthopedic, neuromuscular or immunological disease. Finally, ACSM has introduced three specialty certifications: the ACSM/ACS Certified Cancer Exercise Trainer, the ACSM/NCPAD Certified Inclusive Fitness Trainer who leads individuals with physical, sensory or cognitive disabilities, and the ACSM/NSPAPPH Physical Activity in Public Health Specialist who promotes physical activity in public health agencies at the national, state or local level. Canada  The Canadian Society of Exercise Physiology initiated professional certification through its Health and Fitness Programme in 1981. It currently recognizes two levels of Certification: the CSEP Certified Exercise Physiologist® (CSEP-CEP) and the CSEP-Certified Personal Trainer, and it provides appropriate continuing education for its members through its Annual General Meeting. The person recognized as a CSEP-CEP possesses advanced formal academic preparation and practical experience in both health-related, and performance-related physical activity/ exercise science fitness applications for both non-clinical and clinical populations. Canada also saw establishment of the College of Kinesiologists of Ontario in 2007. The intent of the College was to regulate the profession of kinesiology in accordance with the Regulated Health Professions Act of 1991 and the Kinesiology Act, of 2007. The legislation covered such issues as minimum standards of education, use of title and designations, fees and billing, professional boundaries and collaboration, scope of practice and controlled acts, record keeping, mandatory reporting, and prevention of sexual abuse.

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Britain  The British Association of Sport and Exercise Science has now gained licensed body status with the British Science Council, so that accredited members can become Chartered Scientists. It, also, has introduced a form of accreditation, with 2 categories of qualification: BASES Certified Exercise Practitioner (renewable every 3 years) and BASES High Performance Accreditation. For the latter designation, the candidate must demonstrate knowledge of high performance physiology, biomechanics and skill acquisition and a personal commitment to high performance sport.

Practical Applications to Current Policy Early professional societies were small, with an elite membership determined by multiple peer recommendations based upon overall scientific recognition and the quality of papers presented at Society meetings. No fee was demanded for attendance at meetings, other than perhaps the cost of a dinner. However, many professional groups have now become large and unwieldy, with a substantial bureaucracy anxious to justify their salaries and committed to the profitability of the group. Both membership dues and congress registration fees have become large, and sometimes minimum qualifications for membership have diminished. There currently seems a need to review the membership criteria of professional societies, to re-instate the idea of merit based membership, to criticize the quality of publicly presented papers, and to reduce the fees for attendance at meetings so that young investigators can continue to attend and profit from academic debate. The number of professional journals has increased exponentially during the last 20 years, posing problems for librarians and investigators who wish to avail themselves of all recent information. The value of published articles is increasingly being evaluated by tools such as citation indices. There is a need to refine such tools, and also to increase the stringency of peer review in order to ensure that the top journals are only offering new and worth-while information to their readers. Given such measures, new journals of little merit may have a short life span, easing the current problem of university libraries. Physicians have had a code of ethical behaviour dating back to Hippocrates, but many of the issues that confront health and fitness professionals fall outside this code of conduct, and there is a need for the setting of norms and establishing rules of behaviour; procedures for the professional accreditation of health and fitness specialists are now beginning to meet this need, and their scope should be expanded.

Questions for Discussion 1. Early professional organizations in physiology and sports medicine were blatantly sexist. Has this problem now been eradicated from associations that are interested in health and fitness? Can you cite any recent issues of gender bias?

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2. Many professional associations and their associated journals have undergone repeated changes of name and objectives over the past century. Were such changes a wise decision? 3. In some countries, several professional associations seem to have pursued very similar objectives. Why do you think that they have developed as separate entities? 4. Is accreditation an important step for health and fitness professionals? Will it enhance their status relative to that of other health professionals?

Conclusions Beginning with physiologists, the development of various professional associations over the past century has allowed the vigorous debate of new ideas relating to health and fitness. Further, the emergence of peer-reviewed journals linked to the various professional groups has helped to bring these ideas before a world-wide audience. However, this process now seems threatened by an exponentially increasing plethora of new journals. Some outstanding textbooks in sports medicine, health and fitness have attained world-wide recognition, and they have served to consolidate new knowledge. The emergence of accreditation procedures now ensures that workers in the new disciplines delivering health and fitness programmes interact with the public in an effective and ethical manner.

Further Reading Bernstein NR. The first one hundred years; essays on the history of the American Public Health Association. Washington, DC, American Public Health Association, 1972, 97 pp. Berryman JW. Out of many, one. A history of the American College of Sports Medicine. Champaign, Il, Human Kinetics, 1995, 283 pp. Borms J.  Directory of Sport Science: A journey through time: The changing face of ICSSPE. Champaign, IL, Human Kinetics, 2008, 518 pp. Brobeck GR, Reynolds OE, Appel TA. History of the American Physiological Society. The first century, 1887-1987. Bethesda, MD, American Physiological Society, 1987, 583 pp. Bynum WF. A short history of the Physiological Society 1926-1976. J Physiol 1976; 363: 23–72. Day D, Carpenter T. A history of sports coaching in Britain: Overcoming amateurism. Abingdon, OX, Routledge, 2015, 215 pp. De Bellis N. Bibliometrics and citation analysis. Lanham, MD, Scarecrow Press, 2009, 450 pp. Edholm OG, Murrell KFH. The Ergonomics Research Society. A history 1949-1970. London, UK, Taylor & Francis, 1973, 39 pp. Heyward VH, Gibson A. Advanced fitness assessment and exercise prescription, 7th ed. Champaign, IL, Human Kinetics, 2014, 552 pp. Peavy RD. History of the American Academy of Physical Education, 1926–1950. College of Health, Physical Education and Recreation, University of Utah, 1973, 556 pp. Shephard RJ. The first fifty years. A personal perspective on the history of Canadian Exercise Physiology. Canadian Society for Exercise Physiology, 2015. http://www.csep.ca/view. asp?ccid=545. Van Oteghen SL, Swanson AM. AAHPERD leaders: first 100  years. Reston, VA, American Association for Physical Education, Recreation and Dance, 1994, 105 pp.

Chapter 27

The Growing Knowledge of Anatomy and Physiology Through to the Enlightenment

Learning Objectives 1. To appreciate the classical concepts of body function as enunciated by the ancient Greeks, and the fact that they remained unchallenged for many centuries. 2. To see the anatomical and physiological observations that led both Arabic scholars and Thomas Harvey to propose the radical new idea of a continuous circulation of the blood. 3. To grasp the key findings that led to a correct understanding of the process of respiratory gas exchange. 4. To follow early steps in understanding the mechanics of muscle contraction and the measurement of muscle force.

Introduction A full understanding of human anatomy and physiology is important to developing appropriate mechanisms to maintain health and fitness. There is now much information on how our appreciation of the workings of the human body has developed over the past 2 millennia. In this chapter, we will highlight a few of the bright ideas and false trails that have marked the progress of knowledge from early history and the Classical Era, through the new insights of mediaeval Arabic scientists, to the Renaissance and the Enlightenment, with a particular focus on biological mechanisms governing the cardiac, respiratory and neuromuscular systems.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_27

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Anatomy and Physiology in Early History Certain common threads run through early views of anatomy and physiology, as seen in Mesopotamia, Egypt, India and China, including an inter-connection of the various body organs, a flux of humours between these organs, and ill-health arising from a blockage of this flux and a resulting imbalance of the humours. Mesopotamia  The Mesopotamians saw the liver as the primary organ of the body. It was viewed as the centre for the production and distribution of blood, and it was also regarded as the site of the soul, the emotions and vitality of the mind. Disease was sometimes associated with a disturbance of the body humours, but it is less clear that the Mesopotamians sought to optimize health by attempting to rebalance their distribution. Egypt  The Egyptians considered the heart as the source of life material, able to “speak” to various parts of the body, and they believed that physicians could usefully study this “speech” by palpating the pulse. No clear distinction was drawn between blood vessels, tendons, and nerves; all served as channels for the passage of fluid, and illness was frequently attributed to a blockage of one of these channels, best corrected by a laxative. India  In India, the concept of three doṥas, corresponding to air, bile and phlegm, was formulated during the latter part of the Vedic period (1500–800 BCE). Prayers were addressed to two Vedic gods, the Aṥvins to preserve the balance of the three humours. Vata was responsible for movement, breathing, digestion, the movement of chyle and blood through the body, and maintenance of life. Pitta promoted digestion, metabolism and heat production, the movement of fluid to and from the heart and the production of colored pigments by the liver and spleen, while kapha provided mucus to the alimentary canal, promoted growth, bathed the sense organs with fluids, and promoted strength and endurance. Charaka (c. 300 BCE), one of the principal exponents of Ayurvedic medicine, believed that the heart had a single cavity, connected to the body through 13 main channels that carried nutrients to the tissues and removed waste products. Differences in the colour of arterial and venous blood were recognized in the Indian schema, but blood flow was seen as an up and down movement. The nerves were thought to carry the energy of prāṇa to the brain and other parts of the body. Around 600 BCE, the physician Suṥruta added a fourth element to the Indian schema (dhatus, blood, flesh and marrow); the other three doṥas were formed when the dhatus acted upon food. Inappropriate foods, poisons, fatigue and psychic disturbances could all upset the balance of the doṥas and a regimen that included dieting, exercise and herbal medications could be used to restore this balance. China  Chinese philosophers had long conceived the universe in terms of opposing forces, the yin and the yang, and a vital spirit, the qi. The yin was slow, soft, yielding, diffuse, cold, wet, and passive; and was associated with water, earth, the moon, femininity and nighttime, whereas the yang was fast, hard, solid, focussed, hot, dry,

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and aggressive, and was associated with fire, sky, the sun, masculinity and daytime. During the Zhou dynasty, this belief system was elaborated by incorporating the five basic elements of metal, wood, fire, air and earth. The union of these elements generated life and enhanced health, but their separation caused illness and potentially death. The body had five yang organs (the liver, heart, spleen, lungs and kidneys) and five corresponding yin organs (the gall bladder, small intestine, stomach, large intestine and urinary bladder). The ying qi was the nutritive substance formed from food; this circulated in the blood through a network of meridians, perhaps as many as 50 times per day. The fluid components of the blood went to yin areas, and the solid constituents to yang parts. However, the circulation of vapours was more important to life than the circulation of blood.

Anatomy and Physiology During the Classical Era Greek and Roman philosophers, physicians, and anatomists carried forward and developed many of the ideas of earlier societies, particularly the concepts of circulating humours, and an imbalance between these humours giving rise to illness. We will sketch briefly the flow of these ideas through Anaximander, Anaximenos, Empedocles, Alemacon, Hippocrates, Plato, Aristotle, Epicurus, Praxagoras, Erasistratus, Herophilus, and Galen. Anaximander and Anaximenes  The philosopher Anaximander of Miletus (c. 610–546 BCE) accepted earlier ideas that water was the source of creation, and that the universe was sustained by a geometric balance between earth, fire, air and water. His younger friend Anaximenes (585–528 BCE) also believed that there was an all-pervading principle in creation, although in his view the central essence was the pneuma, or air; this was responsible for life, and death occurred once the pneuma had left the body. Empedocles  The philosopher Empedocles (490–430  BCE) was a disciple of Pythagoras, and like his mentor, he attached great significance to the number four. He either originated or consolidated the notion that matter, including the human body, was composed of four basic elements: fire, earth, water and air. Each of these four elements could undergo transformation in the body, and appropriate combinations of the four elements formed the body humours of blood, phlegm, black bile and yellow bile. Equivalences were hot/dry = fire or yellow bile; hot/moist = air or blood; cold/dry = earth or black bile; cold/moist = water or phlegm. Different tissues contained differing proportions of the four elements. For example, Empedocles maintained that the nerves were 2 parts water, 1 part earth and one part fire, whereas the bones were four parts fire, two parts water, and one part each of earth and air. Parts of these concepts can be traced back to other countries in the ancient world, including India and China, and they became prominent concepts of Hippocratic medicine.

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Alemacon  The philosopher and medical theorist Alcmaeon of Croton, mid-fifth century, BCE, was an early advocate of anatomical dissection, and was the first person to distinguish between arteries and veins He saw the nerves as hollow conduits for transmission of the pneuma; the brain was the seat of the soul, and it was responsible for motion, sensation and thought. Hippocrates  Hippocrates (460–370  BCE) thought that living things were composed of only two elements, fire and water, but his son-in-law Polybus (c 400 BCE) followed the view of Empedocles and other ancient scholars in proposing that good health depended on a balance of four humours within the body (Fig. 3.14). Plato  (c. 427–347  BCE) Plato accepted Empedocles’ doctrine of the four basic constituents of matter. However, he distinguished three types of pneuma. Thge pneuma of the body was derived from the Gods, whose spirit was in the air. A second form of pneuma, or natural spirit, passed in a tidal motion between the veins and the alimentary canal. When the natural spirit entered the heart, it was transformed into vital spirit. This in turn passed to the base of the brain, where it was converted to animal spirit. Animal spirit was the essence of life, and it could pass along the nerves, activating the muscles. The blood was said to be red because of the fire produced in the heart, and the function of the lungs was to bring air and water to cool the heart. Aristotle  Aristotle (384–322  BCE) emphasized the essentially animal nature of humankind. He regarded the heart as a blood-producing organ, and he argued that its alternating contraction and expansion was the source of all movement. He attributed the underlying force to the heat produced by formation of blood within the heart, and he maintained that the main responsibility of the lungs was to cool the over-heated fluid emerging from the heart. In contrast, he regarded the brain as a cold organ, where ascending fluids were tempered to form the mucous secretions of the nose. Epicurus  The philosopher Epicurus (341–270 BCE) insisted that nothing should be believed unless it was tested by observation and logical deduction. He maintained that the body was full of atoms and pores, and that these atoms should be kept on the move in order to maintain health. His aims were to assure a happy and tranquil life, free of fear (ataraxia) and pain (aponia). Praxagoras  Praxagoras (350–300  BCE) made extensive post-mortem examination of animals, thus enabling him to improve on Aristotle’s concepts of anatomy. He concluded that the arteries were empty of blood, and thus served as conduits for the transport of air, or vital spirit. He differed from other Greek physicians in believing that respiration provided nourishment for the pneuma, rather than serving to cool the heart. He maintained that the arteries pulsated independently of the heart, and he argued it was most important to examine the pulse, since its characteristics provided a measure of the balance between 11 distinct body humours. Erasistratus  The Greek anatomist Erasistratus (304–250  BCE) worked in Alexandria. He described the valves of the heart, and he also distinguished between arteries and veins, recognizing that both were connected to the heart. He concluded

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that the heart functioned as a pump, distributing to the various body organs an animal spirit (pneuma) that had been drawn into the body by respiration. A person remained in good health as long as the blood was confined to the veins, and the arteries remained filled with air, but if blood entered the arteries, there was inflammation and fever. Erasistratus distinguished between sensory and motor nerves, proposing that the latter conducted a nervous spirit from the brain to the muscles. Herophilos  Herophilos (335–280 BCE) was an early anatomist who also worked at the University in Alexandria. Like Erasistratus, he distinguished between arteries and veins, and he noted that as the arteries carried blood, they pulsed. Like Praxagoras, he was interested in the characteristics of the pulse, and by exploiting the water clock, he was able to make accurate measurements of a patient’s pulse rate. He concluded that ill-health arose when an imbalance in one of the four body humours prevented the pneuma from reaching the brain.

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Galen  Galen (130–216 CE) gained a sound knowledge of anatomy by dissecting a hippopotamus, an elephant, a monkey, a pig and a man who had died by drowning. His views were held in great reverence for many centuries, and as late as 1559 CE, a Dr. John Geynes appeared before the British College of Physicians: “because he had been accustomed to declare in public that Galen had erred.. ...” Like others in classical Greece, Galen carried forward and elaborated many of the physiological concepts of his earlier Indian and Greek compatriots (Fig. 27.1). Food was conveyed by special ducts to the liver. Here, vital heat converted it into

W

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Fig. 27.1  The four basic humours of classical Greek medicine (yellow bile, black bile, blood and phlegm) were formed from the fundamental components of the universe, fire, earth, air and water

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blood (nutritive spirits). Excessive food was transferred to the gall bladder (where it formed yellow bile) and to the spleen (where it formed black bile). Some of the nutritive spirits were conveyed to the peripheral tissues by an ebb and flow motion in the veins, and some passed via the vena cava to the right ventricle. From there, it passed through microscopic pores in the inter-ventricular septum to reach the left side of the heart, where it was warmed by the innate heat of this organ. It then mixed with inhaled air (pneuma) in the lungs, forming vital spirits. Respiration was needed to cool the fire in the left ventricle. The vital spirits were conveyed to the brain via the cerebral arteries, and were transformed into animal spirits within the cerebral ventricles. The animal spirits in turn travelled though the nerves, inducing a swelling and thus a contraction of the skeletal muscles. The pumping action of the heart allowed excessive vapours and waste fumes to pass through the pulmonary veins and back to the lungs.

The Middle Ages During the middle ages, medical scholars in the Salerno region were largely content to elaborate the ideas of Hippocrates and Galen; it was the Muslim world that contributed most to science during the middle ages. After a brief look at medical views in mediaeval Italy and France, we will comment on the work of the Muslim scholars al-Razi, Ibn Nafis, Ibn Sina, and the Jewish expatiate Maimonides. Italy  The medical school in Salerno (Chap. 17) was perhaps the most advanced in mediaeval Europe. However, it was content to reiterate earlier wisdom, describing the typical characteristics of patients who they saw as lacking humoral balance. There was the sanguine fellow, surcharged with hot moist blood, inclined to obesity, and loving “mirth, musick, wine and women.” There was the phlegmatic person, whose spirits were dulled by an excess of cold phlegm; he was “squarish and given to rest and sloth.” Then there was the choleric patient, dominated by a plethora of hot and yellow bile; he was “all violent, fierce and full of fire.” Finally, there was the melancholy man, with a surplus of cold black bile and “a heavy looke, a spirit little daring.” France  Mediaeval physicians in France worked within the Greek framework of four body humours. Thus Gilles de Corbeil, twelfth century physician to Philip II sought evidence of an imbalance between the body humours in careful examination of the urine and the pulse. He described 18 gradations of urinary colour, together with characteristic odours and sediments. Likewise, in terms of the pulse he noted its resting speed (quick or slow), its pressure (hard or soft), the inter-pulse interval (rare or frequent), and any increase or decrease in the pulse rhythm.

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Muslim Scholars  The dominance of Muslim scholars during the middle ages reflects the major investments in hospitals and universities in the region around Babylon (Chap. 16). al-Razi  Abu Bakr Zakariya al-Razi (c. 854–925 CE) practiced medicine in Baghdad (Fig. 27.2). By careful clinical observation, he distinguished smallpox from measles. He also recognized fever as an important defensive reaction against infection, and he was the first person to describe allergic asthma and hay fever. He expressed doubts about the classical theory of four body humours, and although reluctant to criticize so respected a physician as Galen, he did argue against the practice of blood-letting in attempts to regulate the sanguine humour: “It grieves me to oppose and criticize the man Galen from whose sea of knowledge I have drawn much.” He described an early controlled study of heat stress; “A man travelling on a hot day fell into an acute fever; his face was red, his breath hot like fire, and his heart beat violently. I waited an hour or two expecting to see some flow of blood, but nothing happened; so I ordered his nose to be rubbed vigorously. Still there was no bleeding, and the fever and pain increased. Then I gave him ten pounds of cold water to drink, and this was soon followed by copious diuresis and decrease of the fever. But his servant, who got no water because all were busy with his master died before evening.” Al-Razi wrote a compendium of home remedies for instruction of the poor and those travelling out of town. Many of his remedies were based on the choice of a more appropriate diet. When herbal remedies were recommended, he checked their side effects by prior animal experimentation. Fig. 27.2 al-Razi (854–925 CE), one of the most innovative of the Arabic mediaeval physicians, cast doubt on the classical Greek theory of four bodily humours, and advised against blood letting to correct a supposed imbalance of these humours (Source: http://en. wikipedia.org/wiki/ Muhammad_ibn_Zakariya_ al-Razi)

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Ibn Sina  Ibn Sina (Avicenna, 980–1037 CE) was a Persian physician who wrote some 450 texts, including the Canon of Medicine (which became one of the leading medical texts during the middle-ages). He recommended quarantine for those with infectious diseases, and he recognized that tuberculosis was contagious. He advised a moderate amount of sleep as a means of balancing the four body humours, and placed a strong emphasis on the preservation of health through: “regulation of (1) exercise (2) food and (3) sleep.... Once we direct the attention towards regulating exercise.... there is no need for such medicines as are ordinarily required for remedying diseases.” Avicenna viewed exercise as having three components: massage, the exercise itself, and a final cold bath. The intensity of exercise was allowable: “as long as the skin goes on becoming florid.... After it ceases to do so, the exercise must be discontinued.” In agreement with earlier scholars, be believed that much could be learned from the characteristics of the pulse, particularly during exercise: “At the outset, as long as the exertion is moderate, the pulse is large and strong. This is because the innate heat increases.....as exertion continues, the pulse becomes weak...until it becomes formicant and very brisk” “If a person exercised to an extremely excessive extent, this would lead to a state akin to death, with the pulse vernicular, very brisk, slow weak and small.” Suitably adapted exercise should be continued into old age: “if, towards the end of life, the body is still equable, it will be right to allow tempered exercises. If one part of the body should not be in a first-rate condition, then that part should not be exercised until the others have been exercised...if the ailment were in the feet, then the exercise should employ the upper limbs: for instance, rowing, throwing weights, lifting weights.” Ibn al-Nafis  Ibn al-Nafis (1213–1288) practiced in Cairo and became the Sultan’s personal doctor. His most important contribution is found in his Commentary on Anatomy; this was written in 1242, but was discovered somewhat accidentally in 1924. It gives the first clear description of the circulation of blood from the right to the left ventricle through the lungs. People had previously accepted Galen’s doctrine that blood passed through invisible pores in the interventricular septum. However, after careful dissection, Ibn al-Nafis became convinced that this view was incorrect: “The thick septum of the heart is not perforated and does not have visible pores ... The blood from the right chamber must flow through the vena arteriosa (pulmonary artery) to the lungs, spread through its substances, be mingled there with air, pass through the arteria venosa (pulmonary vein) to reach the left chamber of the heart and there form the vital spirit.” Maimonides  Moses ben Maimon (Maimonides, 1135–1204 CE) was a Jewish physician who moved to Egypt, and became court physician to Saladin (1137–1193 CE). He recognized that Saladin’s lifestyle was far from ideal, and wrote a dietetic rule-­ book for him (the Regimen of Health). He advised:

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• “Care of self in the widest sense includes diet, physical exercise, training in the virtues and rational enlightenment • [Food ingestion should be limited] In the temperate season to an amount that does not distend the stomach...when the weather becomes warmer, one should reduce the amount of food • Exercise will expel most of the harm done by most of the bad regimens that most men follow...Not all motion is exercise...exercise is powerful or rapid motion or a combination of both...the respiration alters and one begins to heave sighs..”

The Renaissance In Europe, the new spirit of enquiry stimulated by the Renaissance saw a relaxation of restrictions upon anatomical dissection, and this in turn led to striking discoveries concerning the circulation of the blood, respiration and gas exchange, and the function of the muscles. Anatomical Dissection  The mediaeval church had rigidly opposed any dissection of the human body. Even animal dissection could lay a surgeon open to charges of sorcery and/or attempted divination.The lifting of these restrictions was a significant driving force behind medical advances during the Renaissance. Medical students in Salerno had begun studying the anatomy of the pig as early as the eleventh century, and a more general relaxation of the rules concerning human dissection began in the thirteenth century. Frederick II (1194–1250), the last Holy Roman Emperor, gave permission for one human body to be dissected every 5 years for educational purposes, and other post-mortems were allowed in efforts to discern the cause of the Bubonic plague. In England, the ban on human dissection continued until the sixteenth century, when King Henry VIII gave the Barber and Surgeons Company access to 4 bodies per year. Subsequent Royal edicts granted physicians and barber/surgeons a combined total of 10 cadavers per year. The Murder Act (1752) allowed the dissection of executed murderers, and in1832 the Pauper Act also allowed anatomists access to the cadavers of deceased paupers. Discovery of the Circulation of the Blood  At first, the main aim of Renaissance anatomists was to illustrate body parts that had already described by classical scholars, but as dissections continued, many errors were also brought to light. One of the most important new discoveries was the circulation of the blood. The first credit for this idea should go to Ibn Nafis (above). However, it is unclear how far his views had percolated to sixteenth century Europe. Others making specific contributions to our understanding of the circulation included Leonardo, Servetus, Vesalius, Columbo, Caesalpinus, Fabricius, Sanctorius, and Harvey (Fig. 27.3). de Luzzi  Mondino de Luzzi, Professor of Anatomy in Bologna, carried out his first public dissection in 1315. The standard teaching practice at that time was for the

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Fig. 27.3  The anatomist Mondino de Luzzi was probably the first teacher to personally dissect human cadavers as a part of his teaching programme. Earlier professors had sat in a raised chair, reading from a prepared (and often inaccurate) text, while an assistant carried out the actual dissection (Source: http://en.wikipedia.org/ wiki/Mondino_de_Liuzzi)

professor to read his prepared (and often inaccurate) class notes while sitting on an elevated chair, as a lowly demonstrator carried out the actual dissection. However, de Luzzi opted to carry out the dissections himself, and thus gained a much more accurate picture of body structures. A unique feature of his department, unprecedented in mediaeval times, was the employment of a female assistant. Leonardo  Leonardo da Vinci (1452–1519) was apprenticed to a Florentine painter at an early age. As a respected artist, he was granted permission to undertake a total of some 30 human dissections, allowing him to make 240 sketches of various body parts. He had planned to write a systematic anatomy text based upon this research, but because of difficulties in interpreting his mirror-image writing, the book was not published until 1796. Using fine grass seeds as markers, da Vinci noted similarities between the flow of water in rivers and the passage of blood through the aorta, and he suggested that the friction of blood against the rough inner lining of the ventricles generated the heat needed to convert the pneuma and the nutritive spirit into vital spirit within the cardiac chambers. Since the isolated lungs could be kept inflated by the insufflation of air, he also argued that there was no direct connection between the blood vessels and the bronchi.

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da Vinci deduced the action of the valves in the sinus of Valsalva, apparently by the use of plaster models, and he also provided an early description of atherosclerosis in an elderly man who claimed to be a hundred years old. He noted the striking contrast between the blood vessels of young children and those of the supposed centenarian: “as the vessels become old their branches lose their straightness and become so much the more bent and tortuous, and their coats thicker...” Servetus  In one of his theological tracts (Christianisimi Restitutio), the Spanish physician and theologian Michael Servetus (1511–1553) pointed out that the colour of the blood changed as it passed through the lungs: “The bright color is given to the sanguine spirit by the lungs, not by the heart...; the blood is conducted through the lungs where it is agitated .... and passes from arterial vein into the venous artery...then...it is mixed with inspired air and... cleansed of its sooty vapors. Thus finally the whole mixture is prepared for the production of the vital spirit. Unfortunately, the document in which this observation was published (Christianisimi Restitutio) contained a heavy dose of unpopular Anabaptist rhetoric. Thus, Servetus was first arrested by the Catholic authorities, and subsequently burnt at the stake by Genevan Calvinists, holding a copy of the controversial text in his hand. Calvin quickly ordered the destruction of all thousand printed copies of the book, but luckily three copies have survived to the present day. Vesalius  Andreas Vesalius (1514–1564) became Professor of Anatomy at Padua at the age of 23 years. He received both credit and opprobrium for pointing out limitations to the physiological inferences that Galen had drawn from animal dissections. He based his Seven books on the anatomy of the human body on a meticulous dissection of criminals. The text was beautifully illustrated, probably by a pupil of Titian. The first edition of his book accepted the Galenic tradition that blood: “soaks plentifully through the septum from the right ventricle into the left,” but in the second edition Vesalius commented: “I still do not see how even the smallest quantity of blood can be transfused through the substance of the septum from the right ventricle to the left ventricle.” Vesalius also described the mitral valves, and noted their contribution to the direction of blood flow. However, he had difficulty in believing that the heart was a muscle, because of the involuntary nature of its contractions. He was the first to describe mechanical ventilation of the lungs: “..life may in a manner of speaking be restored to an animal, an opening must be attempted in the trunk of the arteria aspera, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again..” Columbo  Realdo Columbo (1516–1559) became an assistant to Vesalius. He provided a good description of the mitral valves, and confirmed earlier observations that the arteries expanded during systole and shrank during diastole. Apparently independently of Servetus, he also described the aeration of the blood during its passage through the lungs, and he further underlined the absence of pores in the inter-ventricular septum.

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Fabricius  Hieronymus Fabricius Ab Acquapendente (1537–1619) was another Paduan anatomist. He revolutionized the teaching programme at his university by having a purpose-built theatre constructed for public dissections. One of his pupils was William Harvey, who is thought to have gained a premium view of the dissections by holding a candelabra over the operating table. Fabricius gave the first clear description of the semi-lunar structure of the venous valves, but he reached the mistaken conclusion that their primary purpose was to prevent a disastrous flooding of the extremities by a downward flow of blood. Caesalpino  A Pisan physician named Andreas Caesalpino (1519–1603) soon demonstrated the true function of the venous valves. He pointed out that swelling of a vein always took place below rather than above a ligature, an observation ­incompatible with the flood-gate hypothesis. He coined the formal term “circulation” to signify the passage of blood through the lungs to the left heart, rightly discerning that the vessel leaving the right ventricle had the properties of an artery, and that entering the left atrium had the properties of a vein. However, his concept of circulation involved a repeated evaporation and condensation of the blood rather than the physical circulation of the blood as proposed by Harvey a few years later. Sanctorius  Santorio Sanctorius (1561–1636) was Chair of Theoretical Medicine in Padua. He constructed a device to count pulse rates accurately. The observer shortened a pendulum thread progressively until it oscillated in time with the patient’s pulse beat. Sanctorius is best known for his eccentric and quantitative studies of human metabolism. He designed a special chair, and sat in it, weighing himself before and after eating, over a period of some 30 years (Fig. 27.4). He remained puzzled by a 5-pound discrepancy between the mass of food ingested and the increase in his body mass, after correcting for visible excretions; he attributed this difference to respiration that had occurred through the skin, an “invisible perspiration.” A final important contribution from Sanctorius was the design of a “thermoscope” or clinical thermometer. Harvey  William Harvey (1578–1657) was a pupil of Fabricius in Padua. On returning to England, he became royal physician, and hunting expeditions with Charles I provided him with many deer carcasses for dissection. In a short but celebrated treatise “An anatomical study of the motion of the heart and of the blood in animals (1628), Harvey outlined many of the anomalies in contemporary circulatory logic. If the two ventricles had differing functions, why did they have an almost identical anatomical structure and beat simultaneously? How could the pulmonary vein carry air in one direction and fuliginous vapours and blood in the opposite sense without causing an intolerable confusion? If the idea of a flux in both directions was correct, why was there never any sign of air or vapour within the veins? When he bled a sheep, the heart expelled the entire blood volume in a matter of minutes; surely, the liver could not manufacture 540 pounds of new blood per day! Rather, the existing blood must have recirculated. His final arguments showed a closely interwoven logic:

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Fig. 27.4  Sanctorius spent much of his time sitting in the suspended chair that he had designed to determine the difference in body mass associated with the eating of known amounts of food (Source: http://en. wikipedia.org/wiki/ Sanctorius)

• Contraction rather than dilatation of the heart coincides with the pulse, with the ventricles acting as muscular sacs that squeeze blood into the aorta and pulmonary artery. • The pulse is produced by filling of the arteries and thus their enlarging. • There are no pores in the inter-ventricular septum. • The same blood is found in the arteries and the veins. • The action of auricles, ventricles and valves is the same, receiving and propelling liquid and not for air, since the blood on the right side of the heart, thoroughly mixed with air, is still blood. • The blood sent to the tissues via the arteries to the tissues is not all used, but most of it returns through the veins. • There is no to and fro motion in the vein; the blood streams constantly from the distant parts towards the heart. The dynamic starting point for the blood is the heart rather than the liver. Renaissance Discoveries in Respiration and Gas Exchange  As a first steps in understanding respiration, Renaissance scientists sought to establish the nature of

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the gases that were exchanged, their physical properties, and their relationship to the body tissues. Important names in this context included Paracelsus, Van Helmont, Boyle, Hooke, Lower and Mayow. Paracelsus  Philippus von Hohenheim (1493–1541) gave himself the name of Paracelsus, implying that his erudition was better than that of earlier authorities such as Celsus (c. 25 BCE- 50 CE). Paracelsus attended medical schools in various European cities, and was not in the least impressed, wondering “how the high colleges managed to produce so many high asses.” He was himself appointed as an occasional Lecturer in Medicine at the University of Basel, but his appointment was terminated within a year because he had arrogantly chosen to burn some classical medical texts, and pour scorn on the ideas of most of his colleagues. Subsequently, Paracelsus spent many years as a mercenary barber/surgeon and itinerant miner, writing a book on what appears to have been silicosis. He was appointed as city physician and Professor of Medicine in Salzburg shortly before his death. Here, he proposed a new (but erroneous) concept of matter; to the Galenic four elements and Arabic concepts of mercury (volatility) and sulphur (combustibility), he added a residue of “salt.” In his view, mercury, sulphur and salt were the three primary constituents of the human body (the tria prima). Paracelsus did not see respiration as the ultimate source of life. He suggested that the body heat came from digestion, with the pulse and respiration serving to distribute this heat around the body. Further, as with his Greek predecessors, he suggested that appropriate chemical remedies could rebalance the tria prima. He was above all an alchemist, and he saw an essential harmony between the seven planets, and the seven metals (gold, silver, tin, copper, lead, iron and quicksilver). To ensure good health, the seven major organs (the heart, brain, liver, kidneys, spleen, gall bladder and lungs) needed to become a microcosm of this same harmony. Paracelsus devoted much time to distilling raw minerals into a mysterious and purportedly health-­ giving arcanum, a remedy that he carried in the knob of his sword. Specific medical contributions of Paracelsus included the introduction of opium as an analgesic, a clinical description of syphilis with a proposed mercury treatment, and an evaluation of the curative properties of mineral springs. Because he insisted that all vital phenomena had a chemical basis, some have argued that he should be considered as the founder of modern biochemistry. Van Helmont  The Flemish chemist Jan Baptist Van Helmont (1579–1644) introduced the word “gas” into our vocabulary. Like Paracelsus, he sought a strictly chemical explanation of health and disease, but he rejected the tria prima, since he knew substances that did not contain any of these three materials. In his view, the universe comprised two basic elements, “air” and “water.” Proof was seen in the growth of a tree. He planted one in 91 kg of soil. The mass of this soil changed little, but taking account of the leaves that were shed, the tree gained 169 pounds over 5 years, due to the incorporation of water into its wood, bark and roots. Perhaps the most important finding of Van Helmont was that the quality of “air” differed from time to time. “Gas” was not the same as steam. Likewise, the “air” produced by burning charcoal, adding acid to limestone or fermenting malt was a

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“gas sylvestre” that could extinguish a naked flame and make the air within a closed cave irrespirable. He detected this same gas in “air” originating from the stomach, and in emanations from a volcanic crater. He remarked on the contrast between gas sylvestre and the gas pingue that could support combustion. However, he had some difficulty in explaining how either of these gases could originate from water, as required by his ideas of matter. Van Helmont had some conception of the conservation of mass. Thus, if silica was converted into water glass, treated with acid and the precipitate was then burnt, the initial mass of silica was regained. However, he also had the leanings of an alchemist, retaining a strong faith in finding the “philosopher’s stone” that would turn dross into gold. Van Helmont concluded that digestion could not be attributed to body heat. If so, how could cold-blooded animals survive? Rather, the body must contain ferments that decomposed intestinal food, turning chyle into blood, and changing the colour of blood in the lungs. He believed that disease developed when alien forces took control of these ferments, releasing poisonous waste products into the body. He vigorously opposed the omni-prevalent practice of blood letting, and his primary prescription for health and longevity was moderation. Boyle and Hooke  Richard Boyle (1627–1691) was independently wealthy, but had some ambition to become a successful alchemist. Thus, in 1689 he was successful in obtaining repeal of a British law against alchemy. He made a “wish-list” of 24 discoveries he would like to achieve; these included a method of prolonging life, and: “potent druggs to alter or exalt imagination, waking, memory.” Robert Hooke (1635–1703) was fascinated by mechanics. As a youth, he took a clock to pieces, examined its mechanism, and built a wooden replica that “functioned well enough.” Boyle and Hooke are best known for their enunciation of the law of gaseous volumes They also undertook some early animal and human experimentation on respiration. They pumped the air out of a small decompression chamber, finding that in the process a flame placed within the vessel was extinguished, and the height of a mercury column declined. Larks, sparrows and mice all died as the air was extracted. Hooke himself next ventured inside a larger chamber. Fortunately, the pump that he used was not very efficient, and he emerged from the experiment merely complaining of an unpleasant pain in his ears. Hooke went on to demonstrate that the primary function of respiration was to supply the body with fresh air. A dog could survive if air was blown into its lungs and escaped through pin-holes made at the pleural surface. If movement of the aerating bellows was stopped, the animal survived for a brief period, but then went into convulsions and died. Boyle’s air pump was a popular display piece at the Royal Society, and demonstrations of decompression were given repeatedly to visiting dignitaries. Boyle drew a clear distinction between mixtures and compounds, and in a book entitled “The sceptical chemyst” he vigorously criticized those who followed Paracelsus in thinking that matter was composed simply of mercury, sulphur and salt.

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Lower  The English physician Richard Lower (1631–1691) extended the experiments of Hooke, showing that if dark blood was injected into the pulmonary artery of a dog, it emerged from the pulmonary vein a much brighter red, the change of colour being contingent upon continued ventilation of the lungs. He also demonstrated that there was something in normal blood that was essential to the pumping action of a dog’s heart; the cardiac contractions languished as an animal’s blood was progressively diluted by beer! He went on to study the effects of transfusion, believing that sick patients could be helped by an infusion of fresh blood. He tried this procedure in animals, and Jean-Baptiste Denys (1643–1704) carried out an animal to human transfusion in Paris shortly ahead of Lower. Lower introduced the concept of venous tone. He also undertook meticulous dissections of the heart, giving detailed descriptions of the ventricular muscle in various species. He noted inner and outer layers of oblique fibres, a whirl-like arrangement near the apex of the ventricles, and papillary muscles pulling upon the valvular leaflets. He commented: “the left ventricle, designed as it was for heavier work and greater effort than the right had necessarily to excel it far in the strength and thickness of the wall.” Some of his studies were based upon race horses. He noted: “The movement of the heart is accelerated in violent exercise as the blood is driven and poured into its ventricles in greater abundance as a result of the movement of the muscles...” However, his explanation of the health value of exercise remains somewhat suspect: “it is obvious how useful exercises... are as an aid to health, for the more often the blood is shaken up within the heart and thrown against the walls of the vessels, and is moved and activated in the body by contraction of the muscles, and finally driven through the pores of the body; the more must it be thinned and freed from those stagnations, to which the nutrient portion of the blood is otherwise over-subject.” Mayow  John Mayow (1641–1679) was an English chemist, physician and physiologist. He accepted Boyle’s contention that air was necessary for the survival of living organisms. He carried out further experiments on animals that were enclosed in glass vessels, observing that their survival time was halved if a lighted candle was introduced into the chamber along with the animal. He came close to the discovery of oxygen, speculating that the candle had burnt the “nitro-aereal particles” within the glass vessel, particles that could be derived from one of the acid components of nitre (potassium nitrate) that supported both life and fire. He estimated that the nitro-aereous particles accounted for about a fifth of the total air. He suggested that the lungs separated out this active constituent of air and transferred it into the blood. He further hypothesized that contraction of the heart or skeletal muscle reflected a combination of the nitro-aereous particles with salino-­ sulphureous particles in the tissues. The bell jar used for his animal experiments was inverted over a water seal. Thus, Mayow was able to document a decrease of gas volume within the vessel as the experiment proceeded. We now know that this reflected the animal’s respiratory gas exchange ratio and differences between the water solubility of oxygen and carbon dioxide.

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Muscle Function  For many centuries, health scientists had accepted the view that muscle contraction occurred as the muscles were filled with vital spirit, transmitted from the brain via the nerve fibres. Several Renaissance scientists shed a clearer light on the nature of muscle function, including Leonardo, Canape, Borelli and Glisson. Leonardo  Leonardo da Vinci (1452–1519 CE) commented that individual muscles and tendons became prominent during particular movements, and he went on to discuss the functions of the limbs and their possible range of movement in a way that presaged modern biomechanics. He constructed wire cages around the muscles to study the inter-play of muscular forces; in this way, he was able to differentiate the behaviour of muscles that acted across a single joint from those that acted over several joints. In order to make optimal use of human potential in his various inventions, he used a simple dynamometer to measure the force that could be developed by every limb and muscle at various joint angles. One application of these findings was the design of an armoured tank that could be propelled by eight burly soldiers. At first, he also thought that humans might be able to fly by flapping a pair of wings, but he soon realized that the arm muscles were not strong enough for this purpose, so he directed his attention to designing a hang-glider. Canapé  During the sixteenth century, Jean Canapé (royal physician to Francis 1 of France) published the text “The Movement of Muscles” in 1531. It was a careful translation of Galen’s original work, but it also recognized the contractile properties of muscle fibres, the functional significance of their architectural arrangement relative to the tendons, and the importance of muscle tone and antagonistic actions. However, Canapé erroneously concluded that muscle contraction arose from a rearrangement of existing structures, rather than a shortening of the active fibres. Borelli  Giovani Alfonso Borelli (1608–1679) was appointed Professor of Mathematics in Pisa. He argued that all of the puzzling phenomena of life and death would eventually be explained through the newly defined laws of physics. He pointed out that muscular forces could be dissipated either by unfavourable leverage, or by the resistance of air or water. He likened the action of the heart to that of a piston, suggesting that the elasticity of the arteries served to accommodate the blood expelled during ventricular contraction. He sketched (but probably never built) an early form of submarine, and he also proposed the development of a SCUBA apparatus for underwater exploration. His text “On the movement of animals” was published posthumously. It provided an extensive analysis of locomotion, underlining the concepts of muscle tone and contrasting strong active movements with the weaker antagonistic actions of certain muscles. Further, Borelli calculated the centre of gravity for the body, and recognized that this necessarily advanced during forward motion, requiring a swinging of the limbs in order to maintain balance.

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Borelli had the advantage of seeing the fine structure of muscle through a ­ icroscope, and he stated categorically that: “muscles do not exercise vital movem ment otherwise than by contracting.” Nevertheless, he supported the established wisdom that during contraction, a muscle increased in bulk, due to the infusion of some external substance. This could not be vital spirit, for when an actively contracting muscle was placed in water, there was no sign of any gaseous bubbles. Rather, the nerves must transmit some substance flowing from the brain that caused an explosive interaction or fermentation with fluid already within the muscle. Glisson  The English physician Francis Glisson (1597–1677) was a keen disciple of Harvey. He lived in central London during the Great Plague of 1665, and he claims to have escaped infection because he regularly inserted a vinegar-soaked sponge into each of his nostrils before visiting his patients. He is well-known for descriptions of rickets and scurvy, and his observations on the anatomy of the liver. In the context of muscular physiology, Glisson debunked Borelli’s notion of muscular turgescence. The Dutch anatomist Jan Swammerdam (1637–1680) had earlier found that if a frog muscle was enclosed in a small plethysmograph, the water level sank as the muscles contracted. Glisson showed that when a human arm contracted under water, again the water level did not rise. Thus, it could not be ballooning outwards due to fermentation, as postulated by Borelli. Glisson further suggested that all viable tissue was irritable, and could react to appropriate stimuli.

The Enlightenment A combination of the freedom of thought, a new understanding of physics and chemistry, instruction provided by medical schools, and technological advances such as the perfection of the microscope brought about a more accurate understanding of the processes of circulation, respiration and muscular contraction during the Enlightenment. Circulatory Discoveries  Investigators such as Malpighi, Swammerdam, van Leeuwenhoek, Steensen, Floyer, Hales, and Bernouilli all contributed to a growing understanding of the circulation of the blood. Malpighi  Dutch lens makers honed their skills during the 1590s, and Galileo exploited this expertise by making a device that could be used either as a telescope or as a microscope. Marcello Malpighi (1628–1694) was appointed to the Chair of Medicine in Bologna at the age of 28, but that same year he was enticed to an Academic appointment in Pisa. There, he began to exploit the potential of the microscope. Using his naked eye, Harvey had been unable to discern any arterio-venous connections, and he had thus assumed that blood reached the veins by oozing through the walls of the small arteries. However, microscopic examination of the

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frog lung convinced Malpighi that the pulmonary tissues were not solid, but rather were comprised of a network of air-filled vesicles, crossed by small and tortuous blood vessels. This anatomical structure explained how air could enter the blood stream. Malpighi further observed that the pulmonary capillaries were populated by “a host of red atoms.” Unfortunately, he mistook these red corpuscles for fat globules, but nevertheless he noted changes in their colour as they passed through the lungs. Swammerdam  The Dutch biologist and microscopist Jan Swammerdam (1637– 1680) devoted much of his time to the microscopic examination of insects, but he also gave the first description of red cells in the blood stream of a frog. Van Leeuenhoek  Antonie Van Leeuenhoek (1632–1723) was a citizen of Delft who succeeded in grinding lenses and building microscopes that could magnify objects 270-fold. This enabled him to extend the observations of Malpighi and Swammerdam. He gave more accurate descriptions not only of the capillaries and red cells within the lungs, but also of skeletal and cardiac muscle, and of single-celled organisms or “animalicules” found in water. He noted that the red cells were sometimes compressed into an oval shape as they flowed in single file through the capillaries of a tadpole tail. He further observed that as the arteries progressed towards the periphery of the body, they became progressively smaller in cross-section. Finally, he recognized clearly that: “arteries and the veins are one and the same continued blood vessels...” Using his powerful new microscope, he was able to contribute to public health by checking the local water supply for the presence of unwanted animalicules. He discovered that the animalicules died when vinegar was added to the water in which they were living, thus setting the stage for water purification. Steensen  The Danish anatomist Niels Steensen (1638–1686) developed a rigid geometric concept of muscular contraction, showing that although a muscle changed its shape as it contracted, its overall volume did not change. Perhaps his most important contribution was to recognize that the heart was not a source of heat or vital spirit; it was simply a muscle designed to propel the blood. Floyer  John Floyer (1649–1734) practiced as a physician in Lichfield, England. He is best known for making diagnoses based upon accurate measurements of pulse rate, using a watch with a second hand and a push-stop that he had developed for this purpose. Times measured with this device agreed with his minute-glass estimates to within 1 s. Floyer was a strong advocate of the health benefits of bathing in cold water, using his pulse watch to time immersions. In his view, if Noah’s flood had purified the earth, his patients could achieve a similar benefit from a prolonged cold bath. Floyer also provided an early description of asthma, noting the potential precipitation of attacks by exercise. Hales  The Reverend Stephen Hales (1677–1761) was the colourful curate of Teddington, to the west of London. He is best known for his studies of circulatory

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dynamics. He decided to determine the pressure developed by the heart, and introduced a long glass tube into the crural artery of a mare; the blood rose to a height of 8 feet 3 inches, the equivalent of a pressure of 185 mm Hg. In contrast, the blood in the animal’s jugular vein had a pressure of 22 mm Hg when the animal was quiet, increasing to 117 mm Hg when it became restive. He next dissected out the mare’s heart, estimating the volume of the cardiac chambers and thus cardiac output. He also gave a clear description of the actions of the mitral and aortic valves. He perfused the blood vessels of a dead dog with water, using the pressures that he had observed, and found a flow rate that far exceeded his estimates of cardiac output. He speculated that a part of the difference might arise because the blood vessels were relaxed in a dead animal, and part might reflect the fact that water had a much greater fluidity than blood. He noted that the “fatty globules” described by Malpighi and van Leeuwenhoek were only slightly smaller in diameter than a typical capillary; friction would thus slow the flow of blood as they were forced through the tissues. Hales had a keen interest in public health, pointing out differences of mortality based on the local environment. He contrasted the rural Parish of Farringdon (where 80% of newborn children survived to the age of 10  years), with central London (where there were almost twice as many people living in one household, only one child in three survived to the age of 2 years, and only one in seven was still alive at the age of 5 years). Hales believed that “gaol distemper” (probably typhus) was caused by contaminated air, and he designed a windmill and manually-operated ventilators to aerate the cells of Newgate prison, the holds of ships and mine shafts. The mortality in Newgate prison was supposedly reduced by 50% following the installation of his ventilator. He also commissioned construction of a clean water supply for his parishioners in Teddington. The water passed through a container and a pendulum, showing the total volume of water consumed by his parishioners was a substantial 30 tuns or 7200 gallons every 24 h. Bernoulli  Daniel Bernoulli (1700–1782) was a Swiss mathematician and physicist. He is particularly respected for his analysis of fluid dynamics. Multiplying the estimated resting stroke volume of the human heart (43 mL) by the corresponding heart rate, he obtained a realistic estimate of cardiac output. Bernoulli recognized that the heart acted like a piston, and by analogy with skeletal muscles, he estimated that the motive force of the heart was equivalent to supporting a weight >3000 pounds. Taking account also of the length of the resulting impulse, he was able to determine the cardiac work-rate. Bernoulli used newly discovered probability models to examine whether smallpox inoculation was advisable, and he demonstrated that on a population-wide basis, it was an appropriate public health policy.

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Understanding of  Respiration  Becher and Stahl complicated investigations of respiration during the Enlightenment by developing the erroneous phlogiston theory of gaseous composition, but new advances became possible as Priestley and Scheele each, apparently independently, described the true properties of oxygen. Black went on to define the nature of carbon dioxide, and Lavoisier advanced convincing evidence that the phlogiston theory was incorrect. Becher  The German physician and alchemist Johann Becher (1635–1682) is best known for developing the phlogiston theory. He suggested that phlogisticated matter contained a substance called phlogiston that was released during combustion. He argued that the four classical elements of fire, water, air and earth should be replacing by water, terra lapidea (vitreous earth), terra fluida (mercurial earth), and terra pinguis (fatty earth). In his view, the terra pingua had oily, sulphurous or combustible properties, turning into fire as it burned. The phlogiston theory was eventually disproven by quantitative chemists such as Robert Boyle and Antoine Lavoisier, who showed that materials such as magnesium gained rather than lost mass when they were burnt. Stahl  Another German physician and philosopher, Georg Stahl (1660–1734), generally followed the reasoning of Becher, although he renamed the terra pingua as phlogiston (from the Greek, “burning up”). He maintained that a naked flame was rapidly extinguished in a closed bell-jar because the air quickly became saturated with phlogiston emitted from the candle, and he argued that the air inside the vessel would no longer support life because phlogiston was already present at saturation level. The role of respiration was to remove phlogiston from the body, thus allowing internal combustion to continue. This loudly advocated theory continued to confuse even the two scientists who, independently, had discovered oxygen (Joseph Priestley and Carl Scheele), and somehow, they managed to constrain their findings within its bounds. Priestley  As librarian, tutor and travelling companion to the Earl of Shelburne, Joseph Priestley (1733–1804) had opportunity to indulge his interests in chemistry. He published a multi-volume tome describing Experiments and Observations on Different Kinds of Air (Priestley, 1774–1777). This text repudiated the classical four elements of matter, and described various gases, including “nitrous air” (nitric oxide); “vapor of spirit of salt” (anhydrous hydrochloric acid, HCl); “alkaline air” (ammonia); “dephlogisticated nitrous air” (nitrous oxide); and, most famously, “dephlogisticated air” (oxygen). Priestley observed the formation of oxygen when he used a magnifying glass to focus the sun’s rays upon a sample of mercuric oxide. This compound began to emit a gas that caused a candle to burn with increased intensity, and it allowed a mouse to live inside a closed vessel much longer than it would have done if it had been breathing normal air. Priestley noted that the gas was: “five or six times better than

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common air for the purpose of respiration, inflammation, and, I believe, every other use of common atmospherical air.” Priestley was the first to suggest a connection between blood and air, although he did so using the phlogiston theory, which he continued to defend against the careful quantitative reasoning of Lavoisier. Scheele  The Swedish chemist Carl Scheele (1742–1786) isolated oxygen slightly before Priestley, but he was robbed of credit for this discovery because his results were delayed in publication. Although most of his predecessors had considered air as a single entity, Scheele concluded that the atmosphere comprised a mixture of “fire air” (oxygen) and “foul air.” He burned various substances, including saltpetre (potassium nitrate), manganese dioxide, heavy metal nitrates, silver carbonate and mercuric oxide, and in each case “fire air” was released with heating. He observed that if bees were enclosed in a glass vessel, they gradually died, the speed of their death being proportional to the number of bees within the vessel. Normally, fire air comprised about a quarter of the atmosphere. However, within the closed vessel it was gradually replaced by “foul air;” this did not cause any immediate change of gas volume, but if a solution of lime-water was introduced there was a dramatic shrinkage, as the lime water absorbed the foul air. Black  The Scottish physician Joseph Black (1728–1799) repeated the earlier work of Van Helmont on “gas sylvestre,” and went on to describe “fixed air,” a substance produced by the burning of charcoal, the fermentation of beer, the treatment of limestone with acid, and the act of breathing. Black developed an accurate beam balance, and was able to show that the heating of magnesium carbonate led to a decrease in its mass, with the emission of “fixed air.” He noted that: the “fixed air” was denser than normal air, and it did not support life. Moreover, its presence could readily be detected, since it formed a white deposit when it was bubbled into lime water. He demonstrated that a large quantity of the white deposit was produced when a tray of lime water was placed in the roof ventilator of an over-crowded Presbyterian chapel. Lavoisier  It was left to the French nobleman and chemist Antoine Lavoisier (1743– 1804) finally to demolish the phlogiston theory. He did this by changing chemistry from a qualitative to a quantitative science. He noted that metals gained weight when they were burnt, as did phosphorus and sulphur. If phlogiston was indeed liberated during combustion, surely the weight should have been reduced rather than increased? The stalwart disciples of Stahl suggested that phlogiston was much lighter than air, and probably had a negative weight! However, Lavoisier pointed out that during combustion, there was also a release of “eminently respirable air.” He also repeated the observations of Black on fixed air, recognizing that an identical gas was formed when metal calxes were reduced by carbon, and in 1778 he adopted the term oxygène for his “eminently respirable air.” Lavoisier also demonstrated that water could be formed by burning a jet of hydrogen in a flask of oxygen, thus establishing that water was a compound formed from the union of hydrogen and oxygen rather than a single element.

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In terms of respiration, Lavoisier showed that when animals breathed in a closed vessel, there was a progressive depletion of “eminently respirable air.” Working with Pierre-Simon LaPlace (1749–1827), Lavoisier was able to collect 3 g of carbonic acid from the respiration of a single guinea pig over a 10-h experiment. By placing the animal in an ice calorimeter (Fig.  27.5), he demonstrated that over 24  hours, sufficient heat was generated to melt 370  g of ice, identical with the

Fig. 27.5  Lavoisier (1743–1804 CE) used an ice calorimeter to measure the quantity of heat produced by the metabolism of a guinea pig, and equated this with the production of an equivalent quantity of carbon dioxide produced by the burning of carbon (Source: http://en.wikipedia.org/ wiki/Calorimetry)

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amount of heat generated if an equivalent amount of carbon dioxide had been produced by the burning of carbon. Thus, he concluded that a slow combustion of carbon took place in the lungs, keeping the animal’s temperature above that of its surroundings. Breathing not only served to rid the body of “fixed air,but also eliminated the excess heat associated with combustion. In collaboration with Armand Seguin (1767–1835), Lavoisier further demonstrated the effects of muscular work upon metabolism. He persuaded a colleague to press a pedal repeatedly, thus lifting a mass of 7 kg a vertical distance of 200 m over a period of 15 minutes. This effort caused a two-fold increase in oxygen usage, with an associated increase of breathing and heart rate. Although the temperature of the blood “remained constant” during muscular work, the pulse rate and respiration “varied in a very remarkable manner.” Lavoisier noted also transpiration, the loss of water from both the lungs and the skin. Several scientific contemporaries of Lavoisier further refined the understanding of metabolism. Jean Hassenfratz (1755–1827) objected that since the lungs were no hotter than other parts of the body, combustion must occur throughout the organism. Lazarro Spallanzini (1729–1799) also noted that lowly animals without lungs could consume oxygen, as could excised skin and muscle. Thus the lungs could not be the unique site of metabolic combustion. Heinrich Magnus (1802–1870) provided final proof that metabolism occurred in the tissues, using an improved vacuum pump to show that arterial blood contained much more oxygen than venous samples.  asis of Muscle and Nerve Function  During the Enlightenment, Moore, La Hire, B Graham, Deaguilers and Régnier developed better techniques to measure muscle strength, while Von Haller, Galvani and Volta made important contributions to our understanding of the excitability of muscle tissue. Moore  The English surveyor and ordnance officer Sir Jonas Moore (1617–1679) used a capstan to compare the strength of workmen with that of horses. He concluded that five sturdy English labourers could develop the same force as a single horse. de la Hire  In France, the mathematician Philippe de La Hire (1640–1718) made absolute measurements of peak muscle force. Using a capstan, he estimated that the thigh muscles of a healthy man could lift about 68.5 kg. When walking with the trunk leaning forwards, a force of some 27 pounds could be exerted, but a much greater force was developed when walking backwards. In criticizing these observations, Aymar-Joseph Roquefeuil (1714–1783) noted that the force exerted depended on whether the cord was tied around a man’s waist or to his shoulders, and in calculating the overall effort, it was also necessary to take into account the energy expended in walking. Graham and Desaguliers  The English clockmaker George Graham (1675–1751) devised the first dynamometer, the precursor of an apparatus described by the French-born engineer and clergyman John Theophilus Desaguliers (1683–1744).

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The latter highlighted an important obstacle to regional comparisons of muscular strength- there was as yet no internationally agreed system of weights and measures. Desaguliers applied the principles of leverage to a functional analysis of the human limbs, and he found ergonomic applications for his careful observations of muscular strength in deciding upon the optimal loading of manual labourers. He also devised effective systems of ventilation for public buildings and sick rooms, including the British House of Commons. Régnier  The French pistol-maker Edmé Régnier (1751–1825) designed a handgrip dynamometer not unlike that used today. On gripping firmly with both hands, a force of some 50 kg could be exerted. He found that a man typically conserved this strength to about 50 years of age, but thereafter there was a progressive weakening of muscle force. Moreover, women exerted about two-thirds the force of a man. Von Haller  Prior observers had argued that although body systems were essentially mechanical, they required the influx of some vital principle to overcome their initial inertness. However, the Swiss anatomist and phsiologist Albrecht von Haller (1708– 1777) broke with this tradition, stressing that muscle could contract in response to a suitable stimulus, independently of the influx of any fluid arriving via a neural pathway. He further distinguished clearly between irritability (the propensity of muscles to contract when stimulated) and sensibility (the painful sensation induced by the stimulation of nerves). Galvani  The Italian physician and physicist Luigi Aloisio Galvani (1737–1798) became very interested in the topic of “medical electricity,” which had blossomed with the discoveries of Benjamin Franklin (1706–1790) and development of the electrostatic generator and the Leyden jar. Galvani made his early discoveries when skinning a frog. He had previously generated static electricity by rubbing its skin. He observed that if a metal scalpel blade touched either the gastrocnemius muscle or the sciatic nerve of the frog, there was an immediate spark, and the leg muscles contracted as though the frog was alive. Galvani concluded that muscular movement was induced by an inter-play between the external negative charge of the muscle and positive electricity passing down the motor nerve. He suggested that an electrical fluid was conveyed to the muscles through the core of the nerve, which was insulated by its outer oily sheath. Volta  Allesandro Volta (1745–1827) was Professor of Physics in Pavia, and a close colleague of Galvani. In partial opposition to Galvani, Volta maintained that animal electricity was simply a physical phenomenon, induced by the rubbing of frog skin. He argued that the frog’s leg was simply serving as a conductor of electricity, and that the electrical discharge could be conducted not only by a nerve, but also by brine-soaked paper. Disagreement with Galvani stimulated Volta to design the first electric battery as proof that electrical force was not peculiar to a living organism.

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Practical Implications for Current Policy The history of scientific discovery is marked by erroneous theories that held sway for centuries, and brilliant scholars who too often bent their observations to comply with established wisdom, rather than challenge error. Even today, it is sometimes hard to publish research that challenges the status quo, and it behooves investigators, reviewers and journal editors alike to be receptive to well-reasoned but surprising new findings. The idea of good health reflecting a balance between opposing body humours persisted for many centuries. Today, such an approach is discredited, with ill-health and disease attributed uniquely to bacteria, viruses, fungi and chemical agents. However, it remains worth considering whether the problems of some patients still reflect a lack of balance, whether between work and play, or physical and sedentary activity. Persistence of erroneous views in some instances reflected senior research workers leaving the bench work to menial investigators, and thus failing to make critical observations. This approach still remains a criticism of some laboratories, where studies are conducted largely by graduate students and technicians, with heads of departments simply signing their name to the published paper. Many of the leading figures in the early history of anatomy and physiology had a very wide range of interests; vocations included clergyman, pistol-maker and clockmaker among others. One may speculate that this breadth of vision and scholarship contributed to the striking advances in knowledge that some investigators were able to achieve. The broad background of some Renaissance and Enlightenment figures contrasts starkly with the narrow specialization of many scientists today, pointing to a continuing need for a wide understanding of science, if not in individual researchers, at least in the team conducting an investigation.

Questions for Discussion 1. Some of the erroneous ideas of Galen and his contemporaries held sway for1500 or more years. Why do you think they persisted for so long? 2. What were critical discoveries that radically changed biological understanding? Give some examples in the fields of cardiovascular and respiratory science. 3. What were the main pieces of evidence that established the circulation of the blood beyond question? 4. What was the phlogiston theory? How was it finally overturned?

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Conclusions From the dogmatic and often erroneous views of early history, knowledge of human anatomy and physiology progressed steadily as important new findings were made during the Renaissance and the Enlightenment. Landmark discoveries included the circulation of the blood, the nature of the respiratory gases, the sites of metabolism, and the basis of muscular contraction. Factors spurring these advances were a greater acceptance of human dissection, development of the microscope, animal experimentation, a change from qualitative to quantitative research, and the discovery of electricity. Although a firm groundwork to the understanding of human physiology was laid by the end of the Enlightenment, many details of body function remained to be clarified into the Victorian era and beyond.

Further Reading Almqvist E. History of industrial gases. New York, NY, Springer, 2012, 472 pp. Berryman JW. Exercise and the medical tradition from Hippocrates through Antebellum America: A review essay. In: Berryman JW, Parks RJ (eds). Sport and Exercise Sciences in the history of sports medicine. Urbana, IL, University of Illinois Press, 1992, pp. 1–57. Clark-Kennedy AE. Stephen Hales. Cambridge, UK, Cambridge University Press, 2015, 296 pp. Crone HD. Paracelsus: The man who defied medicine. His real contribution to medicine and science. Melbourne, Australia, Albarello Press, 2004, 202 pp. Crowther JG. Scientists of the industrial revolution: Joseph Black, James Watt, Joseph Priestley and Henry Cavendish. London, UK, Cresset Press, 1962, 365 pp. Debus AG. Chemistry and medical debate: Van Helmont to Boerhaave. Canton, OH, Science History, 2001, Donovan A. Antoine Lavoisier. Science, administration and revolution. Cambridge, UK, Cambridge University Press, 1996, 351 pp. Fancy N. Science and religion in Mamluk, Egypt: Ibn al Nafis, pulmonary transit and bodily resurrection. Abingdon, OX, Routledge, 2013, 200 pp. Gregory A. Harvey’s heart: The discovery of blood circulation. London, UK, Icon books, 2001 154 pp. Gregory JC. Combustion fromm Heraclitos to Lavoisier. London, UK, E. Arnold, 1934, 231 pp. Hunter M. Robert Boyle. Scrupulosity and science. Woodbridge, ON, Boydell & Brewer, 2000, 293 pp. Loewe M, Shaughnessy EL. The Cambridge history of ancient China. Cambridge, UK, Cambridge University Press, 1999, 1148 pp. McComas A. Galvani’s spark: The story of the nerve impulse. New York, NY, Oxford University Press, 2011, 391 pp. National Museum for the History of Science. Some Dutch contributions to the development of physiology. National Museum for the History of Science, Leiden, Netherlands, Museum Boerhaave, 1962, 60 pp. Ochs S. A history of nerve functions: From animal spirits to molecular mechanisms. Cambridge, UK, Cambridge University Press, 2004, 438 pp. O’Malley CD. Andreas Vesalius of Brussels, 1514–1564. Berkeley, CA, University of California Press, 1964, 480 pp. Pancaldi G. Volta: Science and culture in the age of the Enlightenment. Princeton, NJ, Princeton University Press, 2005, 381 pp.

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Selin H. Medicine across cultures: History of medicine in non-western cultures. New York, NY, Springer, 2006, 417 pp. Schofield RE. The enlightened Joseph Priestley: A study of his life and work from 1773 to 1804, University Park, PA, Penn State University Press, 2010, 461 pp. Tipton CM. History of exercise physiology, Champaign, IL, Human Kinetics, 2014, 608 pp. West JB. Essays on the history of respiratory physiology. New York, NY, Springer, 2015, 342 pp. Zysk KG. Asceticism and healingn in ancient India. Delhi, India, Motilal Banarsidass Publisher, 1998, 200 pp.

Chapter 28

Recent Gains in Knowledge of Anatomy and Physiology

Learning Objectives 1. To recognize the wide range of new technology that became available to physiologists over the past two centuries. 2. To understand how the application of this technology to determinations of individual “normality” has been limited by errors of measurement and uncertain upper limits of normal values. 3. To acknowledge developments in miniaturization of equipment that now allow accurate measurements of energy expenditure during athletic competition. 4. To observe modifications of physiological responses to exercise in challenging environments.

Introduction Technological developments during the nineteenth and twentieth centuries have offered a wide range of new instrumentation to those studying human responses to exercise. Continued enquiry has been stimulated by a desire to reduce physical fatigue in industry (Chap. 23), to enhance the health and fitness of the population, to quantitate the restrictions imposed upon physical performance by various chronic diseases, and to enhance human performance in challenging environments. Unfortunately, space limitations allow mention of only a few major developments in relation to our understanding of the circulation, respiration, muscular contraction, and body composition, with brief comments on the theory of evolution and the potential for exercise in extreme environments.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_28

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Knowledge of the Circulation The Victorian era provided cardiologists with blood pressure cuffs and stethoscopes, allowing them to explore the influence of exercise upon systemic blood pressures, and to interpret physical condition from the form of the pulse wave and the rate of recovery of heart rates following exercise. Subsequently, electrocardiographs became widely available, and echocardiography, angiography, magnetic resonance imaging, scintigraphy, and computed tomography offered multiple alternative options to examine the function of the heart in health and disease. We will look briefly at developments in our understanding of systemic blood pressure, pulse wave characteristics, the measurement of cardiac dimensions, cardiac mechanics and cardiac output, together with the introduction of the electrocardiogram, methods for the identification of myocardial injury and techniques of defibrillation before making a critical assessment of the impact of this new technology. Systemic Blood Pressures  During the Enlightenment, Stephen Hales had already made crude measurements of the resting arterial blood pressure by inserting a glass tube into the artery of a horse (Chap. 27). Names associated with further advances in the Victorian era include Poiseuille, von Vierordt, Laennec, Riva-Rocci and Korotkov. Poiseuille  The Parisian physicist and physiologist Jean Léonard Marie Poiseuille (1797–1869) was the first to use the mercury hydrometer for studies of mean arterial pressures in small experimental animals. von Vierordt  Karl von Vierordt (1818–1884) of the University of Tǖbingen pointed out that if a sufficient external pressure was applied to a human artery, the distal pulse could be temporarily obliterated, and based on this observation he developed a system of weights and levers that he termed a hemotachometer in order to measure blood pressures. Laennec  René Laennec was a physician at the Hổpital Necker, in Paris. He was primarily a respirologist, and in 1819, he devised the stethoscope (Fig. 28.1) as a means of auscultating the chest and heart sounds without placing his ear on the naked chests of female patients. Application of this device to the measurement of blood pressures was quickly appreciated. Riva-Rocci  The cuff sphygmomanometer was developed by Scipione Riva-Rocci (1863–1937), a pathologist and paediatrician at the University of Pavia. Many of his technical recommendations for the recording of blood pressure are still relevant today. Korotkov  Nikolai Korotkov (1874–1920) was a pioneer cardiovascular surgeon at the University of Moscow. He gave a careful description of the sounds heard during sphygmomanometry. The method of reporting diastolic pressures during cuff deflation (as a muffling of sounds, Phase IV, or a total disappearance of the sounds, Phase V) was debated for some time, but eventually was resolved in favour of Phase V

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Fig. 28.1  Sketches of the original stethoscope design, as published by Laennec in 1819 (Source: http://en.wikipedia.org/wiki/Ren%C3%A9_Laennec)

because of its greater reliability and a closer correlation with direct intra-arterial pressure measurements. During the early 1900s, major insurance companies began measuring blood pressures as a means of detecting hypertension prior to the sale of life insurance policies, and the recording of blood pressures became a staple item in a general clinical examination. Pulse Characteristics  Earlier generations had placed great reliance upon subjective observations on the characteristics of the pulse, as determined by palpation. However, objective data became possible during the twentieth century, with development of the wrist polygraph, Cureton’s heartometer, and the Polar pulse monitor.

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Wrist Polygraph  The Scottish cardiologist Sir James MacKenzie (1853–1925) developed a simple wrist polygraph to record the characteristics of the pulse., He distinguished 3 types of arrhythmia: the “youthful” pulse (now termed sinus arrhythmia), the “adult” type corresponding to ventricular extrasystoles, and the “dangerous” irregular rhythm, corresponding to atrial fibrillation. During World War I, MacKenzie became involved in the study of “Soldier’s Heart,” a condition with many of the symptoms of organic heart disease, but with no apparent physiological abnormalities. In contrast with many of his colleagues, he treated the affected patients by physical exercise rather than by rest and medication. Cureton’s Heartometer  Tom Cureton was for many years a physical educator at the University of Illinois (Urbana). Because he lacked a medical qualification, many laboratory tools such as the electrocardiogram were denied to him. He thus sought to counter this deficit by developing from the polygraph an instrument that he termed a heartometer. A light tambour and mechanical lever system positioned over the brachial artery gave a permanent record of systolic and diastolic pressures, pulse rate, and the force and character of the heart action. Unfortunately, the detailed interpretation of the heartometer data that he attempted was scientifically hazardous, since a large pulse wave could reflect either a fit subject with a large stroke volume or a person with rigid, atherosclerotic arteries. Further, the character of the record depended on skin texture, the thickness of subcutaneous fat, and muscle tension. Polar Pulse Rate Monitor  A pulse rate monitor based on the transmission of a chest-strap ECG signal to a wrist-watch recorder was developed for the Finnish ski team in 1977. This instrument was later marketed by the Polar Company in Kempele, Finland, and has proven invaluable in regulating the intensity of exercise training programmes. Cardiac Dimensions  Clinicians have long exploited the reflection of sound waves by the heart wall, using the rather imprecise technique of digital percussion as a means of approximating cardiac dimensions. The introduction of echocardiography provided objective data on the reflection of sound by the cardiac tissue. The first practical echocardiograph was developed by Edler and Hertz in 1953. They used their device to assess the increase in cardiac dimensions associated with mitral valve disease. The M-mode echocardiogram was popularized by Harvey Feigenbaum during the 1960s; he showed estimates of heart volume compared closely with those obtained by angiography. In 1974, Dekker introduced the refinement of a 3-dimensional echocardiogram. Sports physicians quickly used the echocardiograph to search for evidence of hypertrophic cardiomyopathy, which some authors had claimed was the commonest cause of sudden exercise-induced death in young athletes. However, the setting of upper limits to cardiac dimensions for endurance athletes remained a thorny problem, with norms undergoing frequent upward adjustment. A recent ultra-sound study of 114 Olympic athletes emphasized that despite large left ventricles, endur-

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ance competitors normally showed no cardiovascular symptoms, and little change of left ventricular morphology or function as their sport participation continued. Often, the only recourse in those suspected of having a pathological cardiac enlargement was the rather fallacious tactic of prohibiting exercise, and watching whether the size of the ventricles then decreased to “normal” levels. Cardiac Mechanics and Cardiac Output  The study of pressure-volume relationships within the heart has necessarily been based mainly upon observations in experimental animals. However, determinations of cardiac output in humans were made possible by the rebreathing of foreign gases and cardiac catheterization. Pressure-Volume Relationships  Otto Frank (1865–1944) was a physiologost who over his career worked at various laboratories in Germany. He applied the mathematical principles of length and force previously established in skeletal muscle to describe myocardial function, constructing pressure-volume curves for the perfused left ventricle of the frog heart. He noted: “The peaks of the isometric pressure curve rise with increasing initial tension....Beyond a certain level of filling the pressure peaks decline.” Building upon this research, Ernest Henry Starling (1866– 1927), promulgated the Frank-Starling pressure-volume relationship, showing that excessive diistension of the left ventricle actually reduced the cardiac stroke volume. Direct Measurements of Cardiac Output  In 1898, Zuntz and Hagerman sampled both arterial and venous blood, using the direct Fick method to measure the cardiac output of horses that were exercising on an over-sized treadmill. The development of cardiac catheterization has allowed similar measurements in humans, although generally the procedure has been considered too invasive to use unless information was needed for cardiac diagnosis or surgery. Nitrous Oxide Method  The German physiologist Adolph Fick (1829–1901) proposed a less invasive approach for humans, estimating cardiac output from the pulmonary uptake of N2O. In Copenhagen, Johannes Lindhard (1870–1947) exploited this approach to study cardiac responses at known intensities of cycle ergometer exercise. A cardiac output of 21.6 L/min and a cardiac stroke volume of 127 mL was estimated at a heart rate of 170 beats/min. Further, a course of physical training led to an increase of resting stroke volume, with a corresponding slowing of the resting heart rate. Acetylene Rebreathing  Acetylene was used by Grollman in his determinations of cardiac output, but unpleasantly high concentrations were needed to allow chemical analyses. More recently, the acetylene technique has gained favour, as sensitive infra-red gas detectors have allowed the breathing of safer and more pleasant concentrations of acetylene. The main problem with both nitrous oxide and acetylene is that the underlying principle is quickly compromised by a recirculation of blood to the lungs. Also, it is necessary to assume a steady state of gas exchange, and this condition is rarely met during vigorous exercise.

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Carbon Dioxide Rebreathing  János Plesch (1878–1957) was a Jewish-Hungarian physiologist who worked in Berlin until the Nazi persecution of Jews. He suggested another indirect method of determining cardiac output, estimating mixed venous carbon dioxide gas pressures by rebreathing into a small oxygen-filled bag. In more recent years, this approach has been used extensively by Norman Jones at McMaster University in Hamilton, ON. The Electrocardiogram  Marey recorded an electrocardiogram from an exposed frog heart in 1876, using a mercury capillary electrometer. Augustus Waller made the first skin surface ECG recordings on humans in 1887. Unfortunately, the inertia of the mercury column precluded accurate tracings. Beginning with Einthoven, improvements in technique have progressively allowed the accurate recording of ECGs during exercise, but debate continues on the usefulness of the ECG in identify pathological myocardial ischaemia and abnormalities of function in athletes. Einthoven  Willem Einthoven (1860–1927 CE) was a Dutch doctor and physiologist. In 1895, by using a string galvanometer, he obtained electrocardiograms of greatly improved quality. He was thus able to describe changes in electrical potential over the course of a cardiac cycle, setting observations in the theoretical framework of his “triangle” of limb leads. His original apparatus weighed 270  kg (Fig. 28.2). It was water cooled, and required 5 people to operate it, but once the clinical value of the electrocardiogram had been demonstrated, portable equipment was developed. By 1928, the weight of the clinical ECG had decreased to 23 kg. Technical Improvements  A combination of a “wandering baseline,” electrical signals from muscles underlying surface electrodes, and electrical “noise” from other

Fig. 28.2  The size of this early electrocardiograph stands in sharp contrast with modern portable instruments (Source: http://en.wikipedia.org/wiki/Willem_Einthoven)

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laboratory equipment such as treadmills made the interpretation of exercise ECG records very difficult through the early 1960s. However, better skin preparation, careful grounding of ancillary equipment, shielding of cables and the development of electronic averaging and filtering devices subsequently permitted quite precise measurements of the waveform and the extent of ST segmental depression during vigorous exercise. Pathological Myocardial Ischaemia  An ST segmental depression of more than 0.2 mV was thought to provide a useful warning of myocardial ischaemia, and was often proposed as an appropriate time to halt a progressive exercise test. It was initially hoped that the quantifying of exercise-induced ST depression might offer a simple tool to detect individuals at high risk of a heart attack. However, a clearer understanding of the theorem described many years ago by Thomas Bayes (1702–1761) showed that in a healthy population with a low prevalence of cardiac disease, the sensitivity and specificity of ECG stress tests was such that an unacceptable proportion of patients showed false positive responses, required further evaluation, and potentially developed cardiac neuroses. Cardiac Abnormalities in Athletes  Unfortunately, not everyone has yet recognized the difficulties of ECG screening implicit in Bayes theorem. Italian sports physicians in particular have argued strongly over the last 30 years that all athletes should receive an annual resting ECG, in the hope of detecting and avoiding sudden exercise-­related deaths. They have also claimed a small reduction in exercise-related deaths among their athletes following the introduction of mandatory ECG screening. However, critics have pointed out that the incidence of such episodes is still no lower in Italy than in North America (where ECG screening is not mandatory). Moreover, many of the Italian diagnoses of supposedly abnormal ECGs were based upon an increased voltage of the QRS complex (an almost inevitable consequence of the larger heart and thinner overlying layer of subcutaneous fat in athletes). ECG criteria of normality specific to athletes were not introduced until 2010. North American cardiologists still reject the idea of universal ECG screening of athletes, largely because it produces so many costly false positive test results. Identification of Myocardial Injury  Specialist techniques introduced during the Modern Era, including angiography, magnetic resonance imaging, scintigraphy, computed tomography, and determination of myocardial enzymes have all been used as methods of detecting myocardial injury. Angiography  Introduction of radio-contrast material into the coronary artery was facilitated by the development of cardiac catheterization. The first injection occurred accidentally in 1960, when the catheter of the American cardiologist Mason Sones slipped into one of his patient’s coronary vessels. The patient went into cardiac arrest, but this was quickly reversed, and the potential value of the intra-coronary imaging provided by dye injection was quickly recognized. Magnetic Resonance Imaging  Nuclear magnetic resonance imaging of the heart began around 1980. Cardiac and respiratory movements initially complicated the

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analysis of data, but this difficulty was largely solved by an ECG-based gating of the image. One can now visualize areas of heart muscle where the contrast material does not penetrate due to coronary narrowing or occlusion; the area of scarred and poorly vascularized muscle appears white, in contrast with dark, normally-perfused cardiac muscle. Cardiac Scintigraphy  An intravenous injection of radio-active material is distributed through the coronary vessels in proportion to the local rate of perfusion. Thallium-201 scintigraphy was first introduced as the marker in the late 1980s, but since the early 1990s many investigators have preferred to use technetium, because the images are of better quality and the marker has a shorter radioactive half-life. In 2003, Britain medical authorities recommended using scintigraphy as the “gate-­ keeper” evaluation for angioplasty candidates, although more recent guidelines have advocated a stratification of patients based on a scoring of coronary calcification. Computed Tomography  Computed tomography (CT) was invented by Godfrey Hounsfield and Allan Cormack in 1972. The patient receives an intravenous injection of iodine, and the heart is then viewed by a high-speed CT scanner. The test has a high negative predictive value (93%) but some 18% of false positive results. It is thus more useful in ruling out coronary disease than in diagnosing coronary obstruction. Myocardial Enzymes  Over the past decade, exercise biochemists have developed an ability to distinguish the myocardial protein (cardiac troponin) released by cardiac injury from similar proteins released by injury of skeletal muscle. However, controversy continues over the possible pathological significance of the small quantities of cardiac troponin that are sometimes detected in the blood of healthy individuals following ultra-marathon and triathlon contests. Some investigators argue that such minor leakage of myocardial protein is a normal component in the process of exercise-­induced cardiac hypertrophy. Techniques of Cardiac Defibrillation  In 1899, Prévost and Batelli demonstrated that whereas application of a small electrical shock to the dog heart would cause fibrillation, a larger shock restored a normal rhythm. Claude Beck first applied an a/c defibrillator to a human heart in 1947, and in the mid-1950s, Russian cardiologists began to experiment with applying larger alternating voltages to the exterior of the chest wall. In 1959, Bernard Lown proposed using a single 1000-volt dc shock, with an energy content of 100–200 Joules, discharged over 5  msec. The Lown design of defibrillator held sway until the late 1980s, when it was shown that a biphasic truncated electrical waveform was even more effective. Lower voltages were required for the biphasic device, reducing its weight, and allowing the development of portable equipment for use outside of hospitals. It is claimed that the mortality from acute coronary disease has been appreciably reduced in recent years through the widespread distribution of automated cardiac defibrillators in public areas. The latest equipment can be used by people with

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l­ imited training, since the apparatus itself is able to analyze the heart rhythm, determine chest impedance and apply a shock of appropriate magnitude. Impact of New Technology  Although the range of new cardiac technology looks impressive, diagnosis and prognosis have still shown only quite small improvements relative to simply taking a careful clinical history. Thus, in 1997 Ladenheim noted that in a sample of 1451 patients with a normal resting ECG, the clinical history accounted for 72% of information regarding the likelihood of a coronary attack within one year, and scintigraphy contributed only an additional 5%. In the remaining 208 patients, those with an abnormal resting ECG, the clinical history still contributed 58% of the prognostic information, although scintigraphy contributed a further 14%.

Respiration Respiratory concerns in recent history have included the measurement of static and dynamic lung volumes, the measurement of oxygen consumption in various field situations, and a determination of the characteristics of haemoglobin. The last few decades have seen replacement of traditional metabolic techniques such as the Douglas bag by the use of “metabolic carts” equipped with electronic flow meters and electronic gas analysers. Moreover, miniaturization has allowed use of this sophisticated apparatus on the athletic field. Respiratory physiologists have continued to explore factors limiting oxygen transport, but controversy has persisted over both the interpretation and the practical value of maximal oxygen intake measurements in studies of health, fitness and athletic ability. We conclude this section with some developments in our understanding of the pigment haemoglobin and the processes of tissue respiration. Static Lung Volumes  The measurement of static lung volumes began during the Renaissance and Enlightenment, with the work of Borelli, Hales and Davy, continuing with the studies of John Hutchinson at the beginning of the Victorian Era. During and following World War I, further attempts were made to classify recruits based on vital capacities and breath-holding ability. Borelli  The Renaissance physiologist Giovanni Borelli (160--1679 CE) had measured the inspiratory volume of the chest by having subjects inspire from a tube immersed in water, and noting the rise of water level within the tube. He had also appreciated that not all of the air was expelled from the lungs by a maximal expiration. Hales  Stephen Hales (Chap. 27) used a pneumatic trough to examine lung volumes. He estimated his own tidal volume as 620  mL and his inspired reserve as 2340 mL.

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Davy  Sir Humphrey Davy (1778–1829) used a counterbalanced water-sealed glass bell, estimating his vital capacity at 3.11 L. Using a hydrogen dilution method, he also reported a “residual volume” of 590–600 mL. Hutchinson  The British surgeon John Hutchinson (1811–1861  CE) undertook a large-scale survey of lung volumes in 1846, using a water-sealed spirometer. His sample of 4400 adults ranged from “paupers” to “gentlemen,” and included artisans, servicemen, pugilists and wrestlers. He noted a direct relationship of vital capacity to height and an inverse relationship to age. Given the prevalence of tuberculosis in Victorian London, he was able to show the substantial impact of this disease upon lung volumes, and offering his services to the Brittania Life Insurance office he used his data to make quite successful actuarial predictions of an individual’s likely longevity. Vital Capacity in World War I  During World War I, military recruiting offices made extensive measurements of vital capacity in efforts to grade the fitness of recruits. Georges Dreyer (1873–1934) recognized that for many, undernutrition was still a significant problem, and he drew up tables showing the expected relationship of vital capacity to height and body mass in healthy individuals. Dreyer argued that a clinically useful three-level grading of physical fitness could be obtained from vital capacity per unit of body mass, trunk height and chest circumference. He certainly demonstrated substantial differences of vital capacity between athletes and the general population, but this probably reflected chest muscle strength rather than cardio-­ respiratory fitness. Breath-Holding Tests  Breath-holding time was a substantial component of fitness assessment in the British Royal Air Force until 1939. However, it is now realized that breath-holding times reflect largely the motivation of the test subject. Times can be doubled if subjects are shown a clock where movement of the second hand has been deliberately retarded. Another popular test for Royal Air Force physicians was the ability to hold a column of mercury at a height of 40 mm for at least 45 seconds. As with simpler breathholding procedures, scores depended greatly on the subject’s motivation and his or her tolerance of the sensations associated with a high intra-thoracic pressure. Dynamic Lung Volumes  The main limitation of Victorian spirometers was the substantial inertia of both the spirometer bell and the water seal. This precluded the accurate recording of dynamic lung volumes. A further century elapsed before this problem was resolved by the introduction of Perspex bells and electronic flow meters. The idea of measuring the maximum respiratory minute volume over a 30 second period was introduced by Hermanssen in 1933. Dyspnoea develops if breathing exploits more than 50% of the maximal voluntary ventilation, and the MVV thus provides some estimate of cardio-respiratory fitness, although performance depends substantially upon motivation, The MVV test has now been eclipsed by determinations of the forced expiratory volume in one second (FEV1.0), the total volume expired over several seconds

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(FEV), and the ratio of these two measurements (FEV%). The FEV% finds application in the detection of bronchospasm, and a 10–15% deterioration in FEV1.0 or FEV% following exercise indicates the presence of exercise-induced bronchospasm. Oxygen Consumption  Edward Smith (1819–1874) was the first to examine exercise metabolism, looking at the nutrient needs of prison inmates who climbed for 2 hours daily on a punitive treadmill. He had subjects breathe out through a gas-­ meter, passing the expirate over a pumice stone soaked in concentrated sulphuric acid, and then into a canister of potassium hydroxide. The output of carbon dioxide, deduced from an increase in mass of the potassium hydroxide solution, was increased greatly by physical exertion. In terms of developments during the nineteenth and twentieth centuries, we will look at traditional approaches to the measurement of oxygen consumption, the changes introduced by electronic measurement of gas flow and gas composition, and the broadening of measurement horizons permitted by the miniaturization of equipment. Other items to consider include the plateauing of oxygen consumption data during vigorous exercise, the factors limiting maximal oxygen transport, and the practical interpretation of such maximal oxygen intake data. Traditional Approaches to Measurement of Oxygen Consumption  In the early cycle ergometer studies of the Danish investigator August Krogh (1874–1949), subjects were enclosed in a small chamber, allowing determination of changes in the oxygen and carbon dioxide content of a stream of air pumped through the chamber. At Harvard University, Francis Benedict (1870–1957) later exploited the spirometer to determine metabolic gas exchange; carbon dioxide output was indicated by a decrease in bell volume as gas was absorbed in soda lime. In Paris, Jules Tissot (1870–1950) collected expired gas in a large and carefully balanced water-filled spirometer, whereas in Germany other investigators such as Adolf Magnus-Levy (1865–1955) directed the expirate to a wet gas meter, with proportional sampling of the gas for later analysis. Also in Germany, the high altitude scientist Nathan Zuntz (1847–1920) developed a portable dry gas meter for use on an expedition to the Monte Rosa laboratory, and Ernst Simonson suggested directing small fractions of the expirate to a series of rubber sampling bladders. Refinement of this approach yielded the Kofranyi-Michaelis respirometer, manufactured by the Max Planck Institute and widely used in making measurements of oxygen consumption in industry and on field trips. But for many years, the most popular approach to the measurement of oxygen consumption was to collect the expired gas in a large rubberized canvas bag. William Prout first broached the idea in 1813, and the concept was popularized by C.G. Douglas in 1911. The main constraints faced by investigators were a limit to the number of bags available and the need for a tedious chemical analysis of the expirate, usually using the apparatus devised by John Scott Haldane (1860–1936). Electronic Gas Flow Analysis  The measurement of respiratory gas flow was greatly facilitated around 1950, when the Estonian physiologist Alfred Fleisch devised the

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pneumotachograph. Pressure differentials were measured across either a 35  mm pipe filled with small parallel tubes, or a thin metal gauze. The apparatus had two main problems- non-linear calibration curves because turbulence developed at high flow rates, and pressure differentials due to an accumulation of water droplets in the tubes or on the metal gauze. During the late 1950s, Basil Wright at the British Medical Research Council laboratories suggested the alternative of using a small turbine to measure respiratory air-flow. The turbine approach has been adopted in most metabolic carts, but data can be compromised because of inertia of the rotors at low flow rates and slippage of gas at high respiratory minute volumes. Electronic Gas Analysis  The electronic measurement of expired gases began soon after World War I, with introduction of the katharometer. This device exploited the fact that heat loss (and thus electrical resistance) in one arm of a Wheatstone bridge could be modulated by a change in the carbon dioxide concentration. Other early methods of electronic gas analysis included interferometry and mass spectrometry, but the non-dispersive infra-red analyzer developed by the German-American altitude physiologist Ulrich Luft (1910–1991) quickly became the method of choice for carbon dioxide determinations. The paramagnetic analyzer of the American chemist Linus Pauling (1901–1994) became the preferred method for oxygen analyses. Both of these devices had rather slow response times, and the infra-red CO2 monitor also required gas samples of at least 100 mL. Methodology changed when rapid response “metabolic carts” came onto the scene during the 1970s. Carbon dioxide was now determined using an electrode surrounded by a thin film of a bicarbonate solution; the CO2 modifyied the pH of the bicarbonate and thus the electrical output of electrode A polarographic electrode was adopted to determine oxygen concentrations; in this device, electron flow reduced oxygen to hydroxyl ions, creating an electrical output proportional to oxygen pressures. Other oxygen sensors that are now used occasionally include a high temperature Zirconia fuel cell and a mass spectrometer. Miniaturization  Miniaturization of components in oxygen consumption monitors now allows flow and gas composition sensors to be incorporated into the outflow tube of a standard face-mask, with data transmitted by radio-telemeter to a nearby recorder, or stored on a memory stick. Field measurements using this equipment have been particularly important for the sports scientist, since the maximal oxygen intake observed during a laboratory treadmill test does not reflect the full aerobic potential of a competitor such as a rower or a cross-country skier who uses both arm and leg muscles. Plateauing of Oxygen Consumption  Debate has continued over the proportion of individuals who can reach a plateau of oxygen consumption during a progressive exercise test. The International Biological Programme Working Party found that in healthy and well-motivated young adults, plateau values were obtained consistently during repeated testing of 24 young men, irrespective of whether a continuous (ramp) or discontinuous exercise protocol was used. Oxygen consumption plateaus

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have been seen less consistently in prepubescent children and in the elderly. However, in such samples, a failure to reach a plateau was associated with evidence of poor motivation such as a low peak heart rate, a low respiratory gas exchange ratio and low peak lactate readings. Capillary blood lactate levels have proven an important measure of the effort exerted during maximal testing, as well as a means of determining anaerobic threshold and the maximal lactate steady state. During the 1960s, lactate levels were usually determined by the Boehringer enzymatic method. Electronic analyzers based on the enzyme/electrode principle were developed during the 1980s, and these devices were in turn quickly supplanted by small portable lactate analyzers that could be used in the field. The latter employ an enzymatic electrode system, and their accuracy can be disturbed if they are used at cold temperatures. Factors Limiting Oxygen Transport  I pointed out in 1966 that oxygen transport is a closely linked chain reaction, involving maximal voluntary ventilation, the oxygen cost of breathing the maximal pulmonary diffusing capacity, and the maximal cardiac output. By looking at the distribution of gas pressure gradients, it appears that for oxygen the most important limiting factor in healthy individuals is the blood stream conductance (the product of peak muscle blood flow and the oxygen carrying capacity of unit volume of blood). However, other factors can limit maximal oxygen transport, both in athletes with a very large maximal oxygen intake, and in individuals with chronic disease. If the format of an exercise test does not involve most of the major muscles of the body, the local accumulation of lactate and a rise of blood pressure may limit muscular effort before the capacity of the central circulation has been fully taxed. Fatigue of the respiratory muscles is usually a minor factor, but in some people, maximal performance may be limited by dyspnoea. In athletes who develop very high respiratory flow rates, expiratory collapse of the airway can become a significant factor. Optimal circulatory transport of oxygen also depends on pulmonary venous blood becoming almost fully saturated with oxygen during its passage through the lungs; however, in some athletes, a poor matching of ventilation and perfusion allows a significant desaturation of pulmonary venous blood during maximal effort; this type of problem can also arise in chronic respiratory disease. In the central circulation, the maximization of stroke volume can be limited by poor venous tone and thus a limitation of venous return. Maximal circulatory transport also depends on the peak heart rate. The maximal heart rate decreases with age, and it may sometimes be limited by the therapeutic administration of beta-blocking drugs. Athletes may attempt to boost their haemoglobin concentration and thus oxygen carriage per unit volume of cardiac output by high altitude residence, autologous blood transfusion or the administration of erythropoietin to stimulate red cell formation. Conversely, anemia can compromise the volume of oxygen transported per unit of cardiac output. Finally, the ability to consume oxygen delivered to the muscles depends on local energy reserves, an adequate delivery of metabolic substrates and an adequate level of aerobic enzyme activity within the muscle mitochondria.

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One important factor influencing the transport of any gas is its effective solubility in blood. The effective solubility of carbon dioxide is only about a fifth of that for oxygen. In consequence, the conductances for carbon dioxide are more evenly distributed between the pulmonary and the circulatory systems. Interpretation of Metabolic Data  A concept foreshadowed by the findings of the IBP International Working Party on the standardization of maximal oxygen intake measurements (1966) was that peak oxygen intake would depend on the volume of muscle activated during an exercise test. In the IBP experiments, a treadmill test yielded a maximal oxygen transport 7% larger than that for cycle ergometry, and 4% larger than that for maximal stepping. Further studies by Henri Vanderwalle and associates showed that when exercising with either one or two legs, the arms or the forearms there was a gradation of peak oxygen intakes that correlated with anthropometric estimates of the muscle volume that had been activated, after taking account of the oxygen cost of maintaining body posture during the various forms of exercise. Sports scientists have demonstrated a more than two-fold difference of maximal aerobic power between endurance athletes such as cross-country skiers and ordinary adults. Nevertheless, the South African physiologist Tim Noakes has recently challenged the usefulness of measuring maximal oxygen intake in competitors, arguing that endurance performance is limited by an ill-defined “Central Governor” rather than by the oxygen-carrying capacity of the central circulation. Most exercise scientists would agree that athletes do limit their energy expenditure in prolonged endurance events, but they regard this as a pacing tactic learned in collaboration with their coaches rather than as evidence for the operation of a Central Governor. The objectives of the competitor are to avoid depleting glycogen reserves too early in an event, and to limit a punishing build-up of tissue lactate until the final sprint. Characteristics of Haemoglobin  The German chemist Julius von Meyer (1830– 1895) appreciated that oxygen was carried in the blood stream not only in physical solution, but also as a loose, unstable compound with a red pigment that had two distinct forms (scarlet and purple cruorine). When the atmospheric pressure was reduced, the amount of oxygen released from the blood was less than would have been predicted by application of Dalton’ Law of partial pressures. Karl Reichert crystalized haemoglobin in 1849, although he believed that he was looking at crystals of plasma protein that had been contaminated by the red pigment. In 1862, another German investigator (Ernst Felix Hoppe-Selyer, 1825– 1895 CE) showed that the haemoglobin molecule contained iron, that its biological function was to transport oxygen, and that the oxygen could be displaced by exposing the blood to carbon monoxide. Hoppe-Selyer also described the two characteristic spectral absorption bands, using them in a simple clinical method of determining haemoglobin concentrations. The English physiologist Sir Joseph Barcroft (1872–1947) underlined the importance of haemoglobin to human physical activity: “But for its [hemoglobin’s] existence, man might never have attained any activity which the lobster does not possess, or had he done so, it would have been with a body as minute as the fly’s.”

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Tissue Respiration  In studies of tissue respiration over the nineteenth and twentieth centuries, concepts of the conservation of energy and the conversion of the energy content of foodstuffs into external work were developed by German investigators such as von Regneault, Helmholtz, Voit, von Mayer, Rubner, and by Atwater and Benedict in North America. von Regnault. Henri von Regnault (1810–1878) perfected a closed-circuit metabolic apparatus for small mammals. He measured the oxygen consumed from the supply that was needed to maintain a constant partial pressure within the chamber and he determined the corresponding carbon dioxide production by absorption of the latter gas in alkali. His studies spawned the concept of the respiratory quotient. He compared the oxygen usage of animals from dogs to silkworms, noting that the smaller the organism, the greater the rate of oxygen consumption per unit of body mass. von Helmholtz. Hermann von Helmholtz (1821–1894) confirmed that no energy was lost during muscular movement, so that the intervention of a “vital force,” as postulated by earlier investigators, could finally be excluded. He developed very sensitive thermocouples, and established a close relationship between muscular heat production and the physical work that was performed. von Voit. Carl von Voit (1831- 1909) built a chamber large enough to accommodate a bed or a cycle ergometer, and estimated the metabolic rate of his human subjects by collecting expired carbon dioxide in an alkaline solution. He demonstrated that protein requirements were determined largely by a person’s body mass, rather than by the amount of work that he or she performed. Voit was able to measure the heat produced within his chamber, and by looking also at the other side of the equation (the energy content of the food that had been eaten and the energy remaining in the subject’s excreta), he gave a convincing demonstration that the principle of the conservation of energy applied to human metabolism; the same amount of energy was released from foodstuffs whether they were burnt in a laboratory calorimeter or consumed by body metabolism. von Mayer. Robert von Mayer (1814–1878) provided early estimates for the mechanical efficiency of exercise, showing that humans converted only about a fifth of their food energy into useful mechanical work, with the remainder of the energy appearing as heat. Rubner. Max Rubner (1854–1932) made detailed calorimetric estimates of the energy yielded by various foodstuffs. He also related resting metabolism to body dimensions, concluding that the daily heat production of animals ranging in size from dogs to mice approximated 4.16 MJ per m2 of their body surface area. In 1925, gave an early lecture on sports nutrition, emphasizing that intense activity was a pre-requisite for muscle gain. He recommended a daily diet for the athlete of 1.4 g of protein, 1.4 g of fat and 7.0 g of carbohydrate per kg of body mass. Atwater and Benedict. Wilbur Atwater (1844–1907) and Francis Benedict (1870–1957) built large metabolic chambers for exercise studies on human volunteers. Atwater showed clearly that humans did not differ materially from animals in following the law of the conservation of energy.

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Benedict is best known for establishing standards of metabolic rate in relation to age, sex, height and body mass, with nomograms facilitating clinical calculations of resting metabolism.

Muscle Physiology and Biochemistry During the nineteenth century, the English neurophysiologists Hughlings Jackson (1835–1911) and Sir Charles Sherrington (1857–1952) made major contributions to our understanding of the roles of the brain and spinal reflexes in muscular contraction. Angelo Mosso (1848–1910) invented a simple ergograph, allowing him to quantify the frequency of muscle contractions and the force generated by the fingers, and Hans Piper (1877–1915) and Edgar Douglas Adrian (1889–1977) adapted string galvanometer to make the first recordings of muscle action potentials. We will dwell here on more recent developments, including the development of isokinetic dynamometers, force plates, cycle ergometer tests, needle biopsy and non-­invasive assessments of muscle metabolism. Isokinetic Dynamometers  Some historians trace the origins of isokinetic equipment back to the exercise machines of Gustav Zander (Chap. 19). Early versions of these devices allowed only concentric contraction. However, in 1967, Perrin introduced the Cybex I isokinetic dynamometer, and this quickly became commercially available. A variety of servo-motors and microprocessors were added and several isokinetic dynamometers capable of assessing both concentric and eccentric effort were marketed during the 1980s. Subjects exercised at computer-controlled speeds throughout a pre-determined range of motion, usually at the knee and/or arm joints. One immediate objection is that the results obtained about these two joints may not be representative of muscle strength in other body regions. The nature of the movement also bears little relationship to that experienced in most forms of athletic endeavour. Force Platforms  The first force platform was used by the French physiologist Etienne Jules Marey (1830–1904 CE) at the end of the nineteenth century, but the modern form of this equipment only became available during the 1970s. It has greatly facilitated measurement of the explosive force developed by the legs, largely replacing the earlier jump tests of physical educators (Chap. 19). Cycle Ergometer Tests  The Wingate test and the calculation of force-velocity curves also examine muscle function. The Wingate test, developed by the Israeli physiologist Oded Bar-Or during the early 1970s, has provided a simple measure of the anaerobic power and capacity of the leg muscles. The force-velocity test, developed by Henri Vandewalle and Hugues Monod at the Hôpital Pitié Salpetrière in Paris during the 1980s, allows the extrapoelation of cycle ergometer data to both the peak power at zero velocity and the peak velocity at zero loading, when using either the legs or the arms to drive a cycle ergometer.

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Needle Biopsy and Muscle Fibre Characteristics  Needle biopsies of muscle have given new insights into muscle fibre types and metabolism. Throughout the 1950s, muscle fibres were classified simply as having either fast or slow twitch properties, based on estimations of myoglobin content. However, classification began to be based on enzyme profile during the 1960s, with fibres classed as slow or fast twitch based on their content of either myosin vs. actomyosin ATPase, or oxidative vs. glycolytic enzymes. A variety of fibre types are now defined very precisely in terms of their main protein constituents. Since the late 1960s, muscle biopsies have allowed determinations of muscle glycogen, with studies of how reserves are modified by diet and training. However, needle biopsy of the muscles was never very pleasant for the subjects involved. Non-invasive assessments of liver and muscle glycogen by nuclear magnetic resonance spectroscopy were first introduced in the late 1980s.

Body Composition The assessment of body composition (muscle, fat and bone) is now an important component of fitness assessment, with new methods of analysis allowing relatively precise assessments of these 3 important body constituents. Muscle Mass  During the last few decades, overall and localized muscle volumes have been determined by such techniques as creatinine excretion, isotopic creatine dilution, body potassium determinations, neutron activation of muscle nitrogen, dual energy x-ray absorptiometry, and nuclear magnetic resonance technology. Such measurements have been useful in the diagnosis of sarcopaenia. But for sports scientists without access to expensive equipment, muscle volumes have also been estimated with reasonable accuracy from measurements of limb circumferences, bone diameters and skinfold assessments of overlying fat, using prediction equations developed by Jones and by Shephard. Body Fat  The clinical importance of the regional distribution of body fat was first noticed by Jean Vague in 1947. During the 1980s, epidemiological research confirmed his hypothesis, showing that the waist to hip ratio was a better predictor of cardiovascular risk than the body mass index. New methods of estimating body fat introduced in recent decades have included ultra-sound, magnetic resonance imaging, computerized tomography and dual photon absorptiometry. In fitness laboratories, the bio-electrical impedance method has allowed safe, inexpensive and rapid estimates of body fat. The main limitation to this last approach arises from the effect of inter-individual differences in body shape on electrical conduction, as most commercially available devices simply adjust the wrist to ankle impedance for the square of the person’s height. Bone Health  Many options for the assessment of bone health have become available during the last fifty years, including single and dual photon absorptiometry,

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single and dual x-ray absorptiometry, neutron activation, computerized tomography and ultrasound. Dual energy x-ray absorptiometry, introduced by Jay Stein in 1987, is presently the most popular approach. The relative absorption of two x-ray beams of differing energy levels distinguishes soft tissue from bone. Radiation exposure is minimal, in contrast with dual photon absorptiometry, where there are problems with slowly decaying isotopes. Ultrasound has also been applied to determine bone loss, particularly in astronauts engaged in prolonged space missions.

Evolution The concept of an evolution of species, developed by Erasmus Darwin, Lamarck, Spencer, Charles Darwin and Mendel during the Victorian era, opened up a vigorous debate about the relative importance of inheritance versus environment and personal lifestyle as determinants of health and fitness. This question formed a key component of enquiries launched by Jo Weiner as part of the Human Adaptability Project of the International Biological Programme during the 1960s. Erasmus Darwin  Erasmus Darwin (1731–1802) stimulated evolutionary thinking in his book Zoonomia, where he wrote: “would it be too bold to imagine, that all warm-blooded animals have arisen from one living filament.... endued with animality........ the strongest and most active animal should propagate the species, which should thence become improved.” Lamarck  Jean-Baptiste Lamarck (1744–1829) worked at the Jardin des Plantes in Paris. He argued that one inherent force had driven organisms up a ladder of increasing complexity, while a second force had adapted creatures to their local environment through the use of specific characteristics. His “first law” of evolution offered support to those who recommended regular physical activity: “a more frequent and continuous use of any organ gradually strengthens, develops and enlarges that organ, and gives it a power proportional to the length of time it has been so used; while the permanent disuse of any organ imperceptibly weakens and deteriorates it, and progressively diminishes its functional capacity, until it finally disappears.” Although Lamarck’s theories were generally rejected towards the end of the Victorian Era, epigenetics now suggests that an individual’s inherited characteristics can indeed be modified by environmental factors that limit or enhance the phenotypic expression of certain genes. Spencer  The English philosopher and biologist Herbert Spencer (1820–1903) believed that evolution would eventually allow organisms to reach a plateau of perfect adaptation to their environment. He extended his ideas to social processes, arguing that humankind was also progressing towards an optimal form of social

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organization. This “Social Darwinism” led people to oppose efforts to enhance community health, in a belief that such policies would breed a nation of weaklings. Charles Darwin  Charles Darwin undertook an extensive study of the world’s fauna and flora during a five-year voyage on the H.M.S.  Beagle (1831–1836) (Fig. 28.3). Based upon careful observations made during this trip, he underlined the interaction between environment and fitness. He further proposed that all creatures had descended from a common ancestor through a process of natural selection, based on adaptation to the prevailing eco-system: “many more individuals of each species are born than can possibly survive.... any being, if it vary however slightly in any manner profitable to itself..... will have a better chance of surviving, and thus be naturally selected.” Darwin’s biological concepts were unfortunately high-jacked by people with anti-social ideas. His views provided justification for social Darwinism, racism, imperialism, eugenics and belief in a “master race.” Debate on the underlying scientific concepts continued well into the twentieth century, one notable landmark being the case of the State of Tennessee vs. John Thomas Scopes (1925), where a teacher was fined $100 for teaching evolution to his students. Creationism is still pushed by fundamentalist churches, particularly in the Southern U.S. States. Mendel  The Czech monk Gregor Mendel (1822–1884) provided an early backdrop to studies on the genetic transmission of fitness and training response. He focused on inheritance in differing pea strains; his data were tantalizingly close to

Fig. 28.3  Charles Darwin (1809–1882 CE) formulated many of his ideas on the evolution of species during a 5-year voyage study of the world’s fauna and flora aboard the H.M.S. “Beagle” (Source: http://en.wikipedia.org/wiki/HMS_Beagle)

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the expected 3:1 ratio for the inheritance of dominant characteristics, causing some to suggest he may have censored data that did not conform to his expectations. One end-result of Mendel’s discoveries is the potential for genetic manipulation. This holds promise for the treatment of inherited diseases, but also presents sports scientists with the disturbing prospect of “gene doping.” Weiner  Joseph Weiner (1915–1982), a Professor at the London School of Hygiene, organized the International Biological Programme in the 1960s. His major ­objective was to seek out and examine genetically isolated tribes that had survived for many centuries in difficult habitats, looking how far they had developed unusual adaptations to their particular environment. The biological characteristics of the isolated groups that were tested differed surprisingly little from population norms. Two possible explanations were suggested. Many tribes lived at the junction of two or more eco-systems, so that although an unusual characteristic might favour their survival in one eco-system, it could also prove disadvantageous on moving to the second habitat. Further, survival in a challenging environment depended as much on intelligence and the ability to transmit knowledge-to future generations as on the unusual physical and physiological characteristics of the individuals evaluated by the scientists involved in the IBP programme.

Exercise in Extreme Environments The demands for support of troops operating under challenging conditioins stimulated the development of large and well-equipped military environmental physiology laboratories in many countries. Research peaked in the period during and immediately following World War II.  These environmental facilities allowed an examination of human responses when exercising under extreme conditions, including simulated high altitudes, high ambient pressures, extremes of heat and cold, and high gravitational accelerations. In many cases protective equipment and/or medications were developed, with potential application not only in the armed services, but also in athletes and industrial workers. Interest also focused on the adverse effects of prolonged sleep deprivation and shifts of circadian rhythm. High Altitudes  Miners and mountain climbers had been the first to observe the effects of exercising at high altitudes, and the adverse effects of high altitude have interested athletes as much as aircraft pilots. Mountain sickness was described by the Jesuit missionary Antonio de Andrade (1580–1634), as he crossed the Himalayas into Tibet in 1624. During his South American expeditions, the English physiologist Sir Joseph Barcroft noted that mountain sickness affected people who were ­travelling by train across the Andes. Chronic forms of mountain sickness also seemed to be prevalent among high altitude Andean miners, although the illness was not always clearly distinguished from an industrial pneumoconiosis.

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Harold Raeburn made the first attempt to climb Mount Everest in 1921, and Edward Norton undertook two further expeditions in 1922 and 1924. Bottled oxygen was available, although the supply system did not prove very reliable, and there was some debate as to whether it was “sporting” for the climber to use such an artificial aid to physical performance. Because of the short gap between winter and the monsoon rains in Nepal, only 6–8 weeks was available for the training and acclimatization of climbers. Other issues were an inadequate supply of drinking water and clothing that provided insufficient insulation against the cold. Further unsuccessful attempts on Everest were made by Mallory and Bruce and by Norton and Somervell (with Norton nearing the peak at 8570 m). Sir Edmund Hillary and the Sherpa Tensing Norgay successfully reached the summit in 1953, while carrying 14 kg back-packs. Hillary was tall (1.95 m) and poorly coordinated, but superbly fit. Other members of this Everest expedition, such as Griffith Pugh initially had only an average maximal oxygen intake, but nevertheless they had spent much time in preliminary acclimatization and training in the Himalayan foothills. Pugh underlined the importance of oxygen tanks and adequate hydration to the success of their climb. Pugh subsequently became interested in the challenges that would face athletes when the Olympic Games were held in Mexico City in 1968. He predicted that despite acclimatization, the speed of long-distance athletes would be significantly slowed. On the other hand, the reduced air density would offer a small advantage to those participating in sprint, cycling and throwing events. His predictions proved correct. At least two weeks was required to maximize the adaptive increase in ­haemoglobin to the altitudes encountered in Mexico City, and even after their 29th day at altitude the speed of endurance runners was still reduced by 5.7%. Negative effects persisted not only from incomplete acclimation, but also from a disturbance of training routines, and some sports scientists argued that optimal performance would be achieved by arriving immediately before competition, and racing almost immediately, before their buffering capacity and blood volume were depleted by altitude exposure. The Mexico City Games brought into sharp focus the possibility of longer-term adaptations to altitude, as the Ethiopian and Kenyan teams shone in long distance events. Specific advantages of these competitors included not only a high haemoglobin concentration, but also a reduced sensitivity of the carotid chemoreceptors and an increased activity of aerobic enzymes in the skeletal muscles. When competitors returned to sea level, the increase of haemoglobin concentration induced by altitude persisted for several weeks. Since the 1970s, some athletes have thus decided to boost their haemoglobin “legally” by living and/or training at actual or simulated high altitudes prior to competition (Fig. 28.4). Although aircraft cabins were initially unpressurized, commercial aircraft now have a cabin altitude equivalent to 6000–8000 ft., an environment which has little impact on healthy individuals. For many military aircraft, the cabin altitude is still 25,000 ft., and much lower oxygen concentrations can develop rapidly if the cabin is damaged by enemy action. Environmental laboratories have thus developed not

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Fig. 28.4  Large low-pressure room constructed at an East German sports training facility to allow adaptation of athletes to low partial pressures of oxygen as a means of boosting their haemoglobin levels (Source: http://en.wikipedia.org/wiki/Altitude_training)

only personal oxygen systems, but also partial and full pressure suits to counter such an eventuality. Heat Stress  Heat stress has long been a concern among marathon runners and workers in deep mines, but is now becoming a more general health issue, given rising global temperatures and high participation rates in summer “fun runs.” High temperatures may also limit the physical performance of military units when they are operating in tropical environments. Several notable examples of heat collapse have occurred during endurance and ultra-endurance events over the past century, but the setting of standards for fluid replacement and the cancellation of distance running under unfavourable conditions have since reduced the number of incidents among track athletes. In contrast, heatrelated collapse and deaths among American footballers seem largely unchecked, in part because their heat loss is restricted by protective clothing. Modern landmarks in the understanding of heat stress include the concept of an upward shift in the set-point of body temperature during exercise, demonstration of the relationship between body temperature and sweat rate, appreciation of the need for fluid replacement, establishment of protocols for rapid heat acclimation, and recognition of the contribution of physical training to heat acclimatization. From St. John’s Newfoundland, Jan Snellen demonstrated that sweating was proportional to mean body temperature. With prolonged strenuous exercise, the body’s capacity for heat loss was exceeded, and core temperature rose. Above a critical level of 40 °C, the central motor centre was inhibited, giving a sensation of fatigue and limiting the danger from any further rise in body temperature.

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Optimal techniques of heat acclimation gained prominence during the 1960s, as troops and athletes travelled increasingly to hot environments, and South African companies wished to exploit ever deeper gold and diamond mines. The American runner and physiologist Sid Robinson had maintained that full heat acclimatization could be achieved by an appropriate regimen of endurance training, but Wyndham in the South African Chamber of Mines demonstrated categorically that maximum acclimation required a combination of physical activity and heat exposure. Moreover, complete adaptation to residence in a tropical environment could not be achieved simply by exercising in a hot chamber. The issue of the fluid needs of athletes has attracted considerable controversy over the last several decades. Ekblom suggested that even a 1% decrease of body mass increased the rise of rectal temperature when a person was exercising in the heat. However, much depends upon whether the exercise depletes muscle and liver reserves of glycogen, thus liberating associated water molecules. In such circumstances, performance is maintained until there has been at least a 2% decrease in body mass. In terms of maintaining hydration, water is often as effective as proprietary sports drinks, although Carl Gisolfi argued that endurance runners should drink a dilute glucose mixture (10% following a bout of vigorous exercise), and the likely physiopathology was shown to be the release of chemical mediators from airway mast cells as they were exposed to cold and dry air. Effects were reversed by drugs such as salbutamol and sodium cromoglycate, but debate has continued on how far such medications can be administered to athletes without boosting their performance. The issue of cold-induced angina gained prominence around 1970, as cardiac patients began to undertake physical activity in parks and streets. Possibly, a reflex spasm of the coronary vessels was initiated by the stimulation of tracheal receptors. Cold exposure also increased the work-load of the heart through vasoconstriction of the skin blood vessels, thus causing a rise in blood pressure. Disturbances of Circadian Rhythm  Disturbances of circadian rhythm have increased in recent years, with a growing need for shift-work to keep industrial plants operating 24 hours per day, and an ever-increasing number of people engaging in international air travel. Adverse health effects associated with shift work have included a reduction in the quality and quantity of sleep, fatigue and resulting injuries, anxiety, depression and neuroticism, an increased risk of cardiovascular disease, gastrointestinal disor-

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ders, disruption of the menstrual cycle and an increased risk of spontaneous abortion. The least harmful shift arrangement seems a rapid clockwise 8-hour rotation (morning, afternoon, night); particular attention must be paid to the recreational, dietary and transportation needs of those on the night shift. Attempts to speed the adaptation of circadian rhythms by exposure to bright lights began in the early 1990s. Benefit was optimized if exposure continued for 6–8 h per night for 4 days before the shift of rhythm, and dark glasses were worn during the daytime to minimize exposure to natural sunlight. Although the secretion of melatonin is involved in setting the circadian rhythm, attempts to speed adjustments by therapeutic use of melatonin have so far had only limited success.

Practical Implications for Current Policy The development of sophisticated test procedures has greatly increased options for both the assessment of current fitness and the diagnosis of disease. However, it is important that those using and interpreting such data appreciate the limitations imposed by uncertainties in norms, the error of individual measurements relative to the likely effects of poor physical condition or disease, and the risk of false positive findings implicit in Bayes theorem. Such factors have undermined the possibility of using the ECG to detect either cardiac abnormalities in athletes or atherosclerotic change predisposing to myocardial infarction in middle-aged adults. Likewise, although measurements of static lung volumes have been helpful in showing the extent of pulmonary damage from diseases such as tuberculosis, they have provided little useful data on the fitness of the average person or the performance capabilities of athletes. Early physical educators where denied the use of ECGs by clinicians, jealous to preserve their traditional “diagnostic territory,” and research was undoubtedly hampered by the substitution of less precise tools such as the “heartometer.” Although there is plainly still a need to protect the public from diagnosis and treatment by unqualified charlatans, it is to be hoped that in the future both research funding and research equipment will be freely available to the best qualified investigators, and medical practitioners should acknowledge that sometimes such individuals will be those who have specialized in fitness research rather than in medical topics. The caution expressed about violation of the Fick principle still limits the interpretation of much human data in exercise science; during a vigorous bout of exercise such as a progressive cycle ergometer test, it is most unlikely that a steady state will have been reached between gas exchange in the active muscles and that recorded by a metabolic cart. Despite the potential to defibrillate an increasing number of individuals who develop ventricular fibrillation, exercise scientists should strive as far as possible to avoid abnormalities of cardiac rhythm by a careful monitoring of the electrocardiogram. There remains a need for further evaluation of the proportion of resuscitations effected by rescuers with differing levels of training, and there is need to examine

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the long-term consequences of such resuscitation. In elderly individuals, resuscitation may be neither the optimal choice nor the outcome desired by a person with chronic health problems and a bleak future. The body has a substantial ability to acclimatize to high altitude and heat, and a lesser physiological adjustment to cold can be countered by provision of appropriate thermal insulation. Athletes who intend to compete in challenging environments are well advised to exploit such fully potential mechanisms of compensation.

Questions for Discussion 1. What approach would you recommend towards the pre-participation screening of athletes? Is mandatory ECG screening a helpful approach? 2. How far does the array of modern technology help in evaluating cardiac problems? What is the main limitation to the interpretation of data collected by modern equipment? 3. What factors limit the maximal transport of oxygen in the average person? What issues modify this limiting factor? 4. What useful information does the health professional gain from the measurement of maximal oxygen intake?

Conclusions The period from the Victorian to the Post-Modern era has been marked by the development of a broad array of novel and effective instrumentation. This has allowed investigators to study details in the performance of each of the body systems during vigorous exercise, in health and disease, and when faced by challenging environments. Comparisons of data within a given individual have contributed much new knowledge. However, findings of normality or of disease have sometimes been over-interpreted, without due regard for measurement errors and difficulties in defining norms of performance.

Further Reading Barcroft, Sir J.  The respiratory function of the blood. Cambridge, UK, Cambridge University Press, 1925, 215 pp. Benedict FG. Muscular work. Washington, DC, Carnegie Institute, 1913, 176 pp. Collins KJ, Weiner J.  Human adaptability: a history and compendium of research in the International Biological Programme. London, UK, Taylor & Francis, 1977, 358 pp. Dale H.  Henriksen JH. Ernest Henry Starling (1866–1927). Copenhagen, Denmark, Lægeforeningens Forlag, 2000, 140 pp.

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Desmond A, Moore J, Browne J. Charles Darwin. Oxford, UK, Oxford University Press, 2007, 160 pp. Edelson E. Gregor Mendel and the roots of genetics. New  York, NY, Oxford University Press, 2001, 112 pp. Fleming PR. A short history of cardiology. Amsterdam, Netherlands. Rodopi, 1997, 241 pp. Haldane JS. Respiration. Oxford, UK, Oxford University Press, 1935. Henriksen JH. Starling, his contemporaries and the Nobel Prize. Scand J Clin Lab Invest 2003; 63 (Suppl. 238): 1–64. Knight D. Humphrey Davy: Science and Power. Cambridge, UK, Cambridge University Press, 1998, 218 pp. Magner LN. A history of the life sciences, revised and expanded. Boca Raton FL, CRC Press, 2002, 520 pp. Naqvi NH, Blaufox MD. Blood pressure measurement: An illustrated history. New  York, NY, Taylor & Francis, 1998, 170 pp. Radomski M. DCIEM. The first fifty years, 1939–1989. Toronto, ON, Defence & Civil Institute of Environmental Medicime, 1989, 110 pp. Reiser SJ. Medicine and the reign of technology. Cambridge, UK, Cambridge University Press, 1981, 317 pp. Rubner M. The laws of energy consumption in nutrition. Amsterdam, Netherlands, Elsevier, 2012, 406 pp. Shephard RJ. Body composition in biological anthropology. Cambridge, UK, Cambridge University Press, 1991, 345 pp. Shephard RJ. Aerobic fitness and health. Champaign, IL, Human Kinetics, 1994, 357 pp. Shephard RJ, Aoyagi Y. Measurement of human energy expenditure, with particular reference to field studies: an historical perspective. Eur. J. Appl. Physiol. 2012; 112: 2785–2815. Snellen HA, Willem Einthoven (1860–1927), father of electrocardiography. New  York, NY, Springer, 2012, 140 pp. Swenson ER, Bärtsch PO. High altitude: Human adaptations to hypoxia. New York, NY, Springer, 2013, 496 pp. Tipton CM. Exercise physiology: People and ideas. Amsterdam, Netherlands, Elsevier, 2003, 510 pp. Tipton CM. History of exercise physiology. Champaign, IL, Human Kinetics, 2014, 596 pp.

Chapter 29

Exercise as Medicine in Antiquity and Today

Learning Objectives 1. To recognize that although there has been a growing emphasis upon the medical value of habitual physical activity in recent years, the virtues of engaging in moderate exercise as a means of maintaining good health was recognized by many in the ancient world. 2. To note that early scholars saw advantage in physical activity and exercise programmes that were divorced from athletic competition. 3. To observe that where formal exercise programmes in a gymnasium and elsewhere were not practicable, substantial health benefit was found in regular distance walking. 4. To see the current interest in this concept, as expressed in the Exercise is Medicine movement.

Introduction The idea of improving health and fitness by an increase of habitual physical activity is sometimes seen as an insight new to the twentieth and twenty-first centuries. Before considering the present day Exercise is Medicine movement, it is thus a useful corrective to note that regular physical activity was a strong recommendations of many physicians from ancient cultures, including India, China, and Greece.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_29

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India The ancient Indian physician Suśruta (c. 800 BCE) suggested that the body content of Kapha, or phlegm (Chap. 27), was increased by a sedentary lifestyle, sleeping in the day or eating an excess of food. To compensate for the seasonal excess of kapha, Suśruta recommended exercising in winter and spring at a half of an individual’s maximal capacity (to the point when sweating began), and he suggested “diseases fly from a person who is habituated to regular physical activity.” Charaka (c. 300 BCE), one of the early proponents of the Ayurveda system of lifestyle medicine (Chap. 27), also urged the benefits of running, swimming, jumping, tumbling and wrestling against opponents of superior strength. An appropriate dose of exercise was marked by: “perspiration, enhanced respiration, lightness of the body, inhibition of the heart,” and its benefits included: “lightness, ability to work, stability, resistance to discomfort and alleviation of impurities (doṥas).” A good physique was important to health: “Persons having proportionate musculature and compactness of the body... they are not overcome by the onslaught of diseases...” Moreover, “diseases of moderate nature.... can be cured by physical exercise and exposure to sun and wind.” Finally, Charaka underlined the role of a poor lifestyle in obesity: “Excessive corpulence (obesity) is caused by over intake, intake of heavy, sweet, cooling and unctuous food, want of physical exercise, day sleep, uninterrupted cheerfulness, lack of mental exercise.”

China China has had a long history of medical gymnastics. Typically, exercises were performed sitting or kneeling. Some poses mimicked animals, obviously a fore-runner of the “five animals” form of K’ung Fu. One manuscript suggested that the flow of qi (Chap. 27) was improved by flexibility exercises; even the use of a garden swing 1000 times per day would relieve difficulty in flexing the feet, knee pain and cold shins within 10 days. As early as 3500  BCE, the Emperor Yu-Kang Chi made his subjects exercise every day. Possibly, they practiced Kung Fu, which was reputedly a feature of the Xia dynasty. Confucius (551–479  BCE) recognized that physical inactivity was associated with organ malfunction and internal blockages, and he tried to perfect his personal exercise routine, probably using a form of kung fu. Gentle exercise was seen as contributing to longevity through the achievement of mental and physical harmony. The physician Hua Tuo (140–208  CE) was an enthusiastic proponent of light exercise as a means of health promotion. He recommended “frolics” patterned on the actions of wild life to strengthen the legs, enhance health and prevent aging., and he developed the “Exercises of the Five Animals” that mimicked the movements of deer, tigers, bears, monkeys and birds.

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In more recent Chinese history, Yen Shi-Chai (1635–1704 CE) argued that physical inactivity was ruinous to health, and that physical toil benefitted the muscles, bones, circulatory and respiratory systems. He and his disciples thus engaged in daily archery practice. However, much of Chinese society despised physical effort, and indeed the ultimate failure of the Sung and Ming dynasties has been attributed to the growing weakness of the population. The Jesuit missionary, Joseph-Marie Amiot (1718–1793  CE) gave a careful description of the breathing exercises practiced by the Buddhist monks (Fig. 29.1); his drawings of kung fu show seated monks performing stretching-type exercises.

Fig. 29.1  Père Joseph-Marie Amiot (1718–1793  CE) was a Jesuit missionary to China. In his book on the habits of the Chinese, he made specific comment on the breathing exercises practiced by the Buddhist monks, which he believed dated back to 2698 BCE (Source: http://en.wikipedia. org/wiki/Jean_Joseph_Marie_Amiot)

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Classical Greece Many physicians in classical Greece saw exercises such as running, wrestling and boxing as important components of medical therapy, designed to restore the balance of the body humours. Proponents of this belief include Herodicus, Plato, Hippocrates, Aristotle and Diocles. Herodicus  Herodicus is believed to have been one of the tutors of Hippocrates, and is sometimes considered as the father of sports medicine. Practicing as a physician in the fifth century BCE, he prescribed a brisk walk from Athens to Megara (a distance of some 42 km!) for many of his patients. This exercise was to be taken regularly, and at progressively increasing speeds, with an oil and herb massage to follow each session. Unlike some physicians, Herodicus followed his own advice; he: “used to train himself outside the city walls, starting from a certain distance, not very far away, but symmetrical. He was walking till the walls and then returning, and he did that many times.” Nevertheless, some critics, including Hippocrates and Plato, thought that Herodicus was obsessive in his demands for exercise, and that insistence on heavy exercise had sometimes caused the death of patients with fevers. Plato  Plato (c. 427–347 BCE)was originally known as Aristocles, but was given the nickname of Plato because of a physique marked by a broad and athletic chest. Despite his imposing physique, Plato poured scorn on professional athletes: “the habit of body such as they have is but a sleepy thing, and perilous to health.” For Plato, sport had value only when it was severed from the prospect of financial gain. He coined the word askēsis to denote a combination of diet and endurance training; this concept of asceticism developed further in the Middle Ages (Chap. 5). He sought to balance exercise for the body with development of the soul, and recommended gymnastics as the best form of physical activity. Hippocrates  Despite his criticism of the excessive zeal of Herodicus, Hippocrates (c. 360 BCE, Fig. 29.2) also saw the value of regular moderate exercise, particularly as a means of restoring a balance of the four body humours after an excessive intake of food. Although Hippocrates spoke of a moderate volume of physical activity, some of his prescriptions were indeed quite demanding. For instance, those with a diagnosis of consumption were required to walk 3.7 km on the first day, progressing to a daily distance of 18.5  km over the following 2  weeks, with a final target of 27.5 km/day. He recommended “sharp” runs to rid the body of excess moisture, and noted that running in a cloak would cause the body to heat faster, and thus accelerate that loss of flesh “which they wish to reduce.” Aristotle  Aristotle (384–322  BCE) was also a proponent of moderate exercise: “The best habit is one which comes midway between the athletic and the valetudinarian..... But the exertion must not be violent or specialized, as is the case with the athlete.”

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Fig. 29.2  Hippocrates of Kos (c. 460–370 BCE), as depicted by Paul Rubens in 1638 C,E. was an early advocate of moderate exercise for health (Source: http://en.w, ikipedia.org/ wiki/Hippocrates)

Diocles  The mathematician and geometer Diocles (240–180  BCE) was a strong advocate of exercise, and for those who did not have access to the gymnasion, he recommended walking tours: “The easiest way to depart for a walking tour is with the bowels emptied and proceeding not too energetically.... A staff is also useful...on downhill stretches... it supports the body...but when on uphill stretches one leans on it...”

Modern Exercise Is Medicine Movement From the Middle Ages until the mid 1950s, prolonged bed rest was one of the main recommendations of many physicians. However, interest in the therapeutic value of regular physical activity gained renewed world attention with the success of cardiac rehabiltation programmes, and subsequently with the hosting in Toronto of two International Consensus Symposia with the respective themes of “Exercise, Fitness and Health” (1988) and “Physical Activity, Fitness and Health” (1992). Exercise is Medicine is a global health initiative stemming from this new interest. It was launched in 2007 and is managed by the American College of Sports Medicine (Chap. 26). The main foci are on encouraging primary care physicians and other health care providers to include physical activity when designing treatment plans for patients and to ensure that patients are referred to appropriately credentialed exercise programmes and Exercise Professionals (Chap. 26).

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The Exercise as Medicine initiative encourages health care providers, regardless of their specialty, to t assess and record physical activity as a vital sign during patient visits, and to conclude each visit with an exercise “prescription” and/or referral to a certified health fitness professional or allied health professional for further counseling and support. The initiative also includes specific accreditation programmes that provide exercise professionals with the opportunity, the skills and the official credentials to work closely with physicians in delivering appropriate exercise programmes to individuals who are healthy, individuals with health-related conditions who have been cleared by their physicians for exercise, and patients who require on-going clinical support and monitoring. Finally, the initiative offers locations where community members can obtain structured physical activity, dietary and health discussions, and receive guidance on lifestyle behavioural change strategies. Branches of the Exercise is Medicine movement have now been established in various countries, including Canada (where its debut was in 2012).

Practical Implications for Current Policy Many classical scholars who believed in regular exercise thought that this was best practiced in the gymnasium. Nevertheless, they recognized that for economic and other reasons, the gymnasium was not open to all of society, and that health benefit could also be obtained from regular distance walking. Today, there are still individuals who cannot afford or do not wish to participate in group exercise classes, and regular distance walking can be suggested as an inexpensive but effective option for them, too. Possibly, such walking can take the form of active commuting to and from work, giving the individuals concerned the added benefit of a reduction in travel costs. The medical profession has not always been keen to accept the advice of health professionals on appropriate exercise prescriptions, nor has it always allowed them to supervise exercise programmes. However, the new accreditation procedures should alleviate such constraints, and give a new status to health professionals by clearly matching their competencies with levels of training and experience.

Questions for Discussion 1. Do you think the ancients were right to divorce regular physical activity from athletic competition? Does the prospect of athletic competition increase or decrease the likelihood that an individual will engage in an effective dose of exercise over their entire lifespan?

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2. The calls to engage in regular exercise seem to have been more frequent in the classical world than during the Middle Ages or the Renaissance. Why do you think this was the case? 3. Were the early exhortations to exercise addressed to the general population, or a small elite segment of the population? 4. How far do you think that the Exercise is Medicine initiative has been effective in boosting the physical activity of the general population?

Conclusions Some health scientists have regard the idea of physical activity as a form of therapy is a novel concept that emerged in the late 20th or early twenty-first century, focused around the Exercise is Medicine movement. However, historical records show that during antiquity many physicians in India, China and Greece were strong advocates of moderate exercise, seeing this as an appropriate method to restore the balance of the body humours and thus good health, whether the body’s balance had been disturbed by dietary excess, sedentary living or disease. The Exercise is Medicine movement nevertheless stimulates both physicians and kinesiologists to exploit increased physical activity as an important element in both health maintenance and rehabilitation.

Further Reading Bouchard C, Shephard RJ, Stephens T, Sutton J, McPherson B. Exercise, fitness and health. Champaign, IL, Human Kinetics, 1990, 720 pp. Bouchard C, Shephard RJ, Stephens T. Physical activity, fitness and health. Champaign, IL, Human Kinetics, 1994, 1055 pp. Gullotta TP, Bloom M. Encyclopaedia of primary prevention and health promotion. New York, NY, Springer, 2003, 1179 pp. Hardman AE, Stensel DJ. Physical activity and health: The evidence explained. London, UK, Taylor & Francis, 2009, 340 pp. Jonas S, Phillips E. ACSM’s Exercise is Medicine TM: A clinician’s guide to exercise prescription. Philadelphia, OA, Lippincott, Williams & Wilkins, 2012, 272 pp. Kokkinos P. Physical activity and cardiovascular disease prevention. Burlington, MA,Jones & Bartlett Learning, 2010, 416 pp. Kolecki JE. Physical activity and health. Burlington, MA, Jones & Bartlett Learning, 2016, 666 pp. Manley AF. Physical activity and health: A report of the Surgeon General. Collingdale, PA, DIANE Publishing, 1996, 278 pp. Meyer AL, Gullotta TP. Physical activity across the lifespan: Prevention and treatment for health and well-being. New York, NY, Springer, 2012, 276 pp. Moore G, Durstine L, Painter P. ACSM’s exercise management for persons with chronic diseases and disabilities, 4th ed. Champaign, IL, Human Kinetics, 2016, 416 pp. Shephard RJ. Ischaemic heart disease and exercise. London, UK, Croom Helm, 1981, 428 pp. Shephard RJ. Aerobic fitness and health. Champaign, IL, Human Kinetics, 1994, 357 pp.

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Shephard RJ. Aging, physical activity and health. Champaign, IL, Human Kinetics, 1997, 487 pp. Shephard RJ, Tudor-Locke C. The objective monitoring of physical activity: Contributions of accelerometry to epidemiology, exercise science and rehabilitation. Cham, Switzerland, Springer, 2016, 383 pp. Shephard RJ. Physical activity and the gastro-intestinal tract. Abingdon, OX, Routledge, 2017, 221 pp. Shephard RJ. Physical activity and the abdominal viscera. Abingdon, OX, Routledge, 2018, In press.

Chapter 30

The Post-modern Era and Beyond: Meeting Future Challenges to Health and Fitness

Learning Objectives 1. To be aware of limitations to current initiatives in terms of both pre-participation screening and the monitoring of trends in health and fitness through repeated population surveys. 2. To recognize the present trend for young adults to seek ever more dangerous forms of sport and recreation. 3. To understand the challenge inherent in designing conditioning programmes for a sedentary population with a substantial proportion of elderly individuals and a growing prevalence of chronic disease. 4. To explore the potential contributions of modern genetics to our understanding of health and fitness.

Introduction In this chapter, we conclude our brief historical survey of health and fitness by moving beyond the Post-modern era to speculate on future challenges. One issue will be the wise use of an ever growing array of tempting new technology. Vigilant quality control will be needed to ensure the validity of the information reported both by fitness laboratories and by those making mass surveys of population fitness and physical activity patterns. In terms of programme safety, further discussion will be required on an optimal screening protocol for those who are about to enter exercise programmes; is the complexity of the proposed test battery effective in cost-benefit terms? A growing number of nations are now engaged in regular monitoring of the health and fitness of their populations, and in terms of discerning secular trends, there will be a continuing debate over the need for a consistent screening protocol versus the temping potential of new objective monitoring devices. The safety of engaging in an active lifestyle will be increasingly challenged by the search of © Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5_30

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young adults for ever more dangerous forms of sport and recreation. New forms of aerobic and resistance training will require critical evaluation in terms of their effectiveness in conditioning both athletes and members of the general population. The prevalence of sedentary living, an aging population and an increased incidence of chronic disease will focus the interest of many health practitioners on the appropriate design of rehabilitation programmes. Finally, advances in genetics may allow both a greater understanding of health and fitness, and also an ability to modify unfavourable characteristics, but use of this new knowledge this will require an understanding not only of the human genome, but also a multitude of epigenetic responses.

Quality Control of Laboratory Data Even when using a mutually agreed protocol, there have too often been substantial inter-laboratory differences in the values reported when different investigators apply modern technology to the same individual. In Canada, this issue was highlighted by stark differences in the maximal oxygen intake reported for individual athletes when they were tested in different regions of the country. Problems were traced to systematic laboratory errors in determining both the concentrations of expired gas and the power output developed by the athlete on badly calibrated cycle ergometers. A Canadian Laboratory Accreditation project was thus organized by Norm Gledhill and Art Quinney during the 1980s. The accuracy of the data obtained on a panel of subjects by any given testing laboratory was carefully reviewed before that group of investigators was certified as an Accredited Fitness Appraisal Centre. Similar discrepancies almost certainly arise when using other areas of modern technology, and a similar rigid quality control of data needs to be developed and adopted before the reported data can be accepted with confidence.

Mass Screening Before engaging in any type of field testing of physical fitness, most investigators have argued the need for a simple mass screening tool to detect high-risk individuals who should exercise under immediate medical supervision. Similarly, screening protocols have been proposed for sedentary but otherwise healthy individuals who are proposing to begin a vigorous exercise programme. The U.S. approach to screening was foreshadowed in writing the 1975 edition of ACSM’s Guidelines for Exercise Testing and Prescription. Details of this protocol have subsequently been elaborated, but the general principles remain unchanged. The primary focus is upon the individual’s age and the presence of standard cardiac risk factors. These indicators are used to decide whether medical examination is required prior to joining an exercise programme, and whether physician-­supervision of exercise testing is necessary.

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A search for simple pre-test screening began slightly earlier in Canada. Potential procedures were evaluated on a large sample of the Saskatoon population during the summer of 1974, in preparation for a mass testing of aerobic fitness in that city. Participants responded to a short list of questions about their health prior to undergoing a standard double-step test. The clearance instrument, based on these questions, was further checked relative to physician-based screening on a large sample of people who were attending the Pacific National Exhibition, and the original Physical activity readiness questionnaire (PAR-Q) was born from this research (Fig. 30.1). Since no deaths and few adverse responses were seen during 4 decades of widespread use of this instrument, the PAR-Q was judged as a very safe and effective screening tool. The one practical drawback was that it referred a rather high proportion of potential exercisers to their physician for final clearance. Minor rewordings of the questionnaire failed to correct this problem, but over the last 5 years Darren Warburton and his colleagues have developed a new Physical Activity Readiness Questionnaire for Everyone (PAR-Q+). This now includes an appropriately-­branched electronic form of the questionnaire that introduces supplementary “probing” questions in specific situations where the safety of testing is still unclear. The format is being updated annually as necessary.

Mass Fitness Testing Until the mid 1960s, fitness surveys in the U.S. and Canada relied largely upon the scores attained in field performance tests. Some assessments, such as the Kraus-­ Weber Test (Chap. 19) and the Canada Fitness Awards were criterion based, and evaluations had a negative impact upon children who “failed” one or more items in the test battery. In response to this criticism, the Canadian Association for Physical Education and Recreation (CAHPER) moved to a fitness classification based on age and sex-specific percentiles, but during the late 1960s, it was demonstrated that the scores achieved on many of the field tests still depended more upon an individual’s body size than upon his or her physical fitness. In 1967, CAHPER conducted a nation-wide cluster survey of the fitness of Canadian children, taking cycle ergometers into selected schools. However, when a nation-wide survey of fitness in adults was planned, it did not seem feasible to carry cycle ergometers to thousands of homes scattered widely across the country. Thus, a simple step test was chosen as a field measure of the individual’s aerobic fitness (Fig. 30.2). In discussion with ParticipACTION and Fitness Canada, a Home Fitness Test Kit was built around an LP recording of music that set an appropriate age and sex-specific rhythm for performance of a double step test. Norman Gledhill and associates went on to develop a detailed manual for the field testing of aerobic fitness, muscular strength, flexibility and obesity built around this simple test, and it provides the basic protocol currently used in both field testing and the training of Canadian Certified Exercise Test Professionals (Chap. 26). However, there remains a need to establish the accuracy of these test procedures, and their sensitivity and specificity in the detection of abnormalities of health and fitness.

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Fig. 30.1  The 2002 modification of the PAR-Q questionnaire, developed for the preliminary screening of exercise test and programme participants aged 18–65 years

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Fig. 30.2  The Canadian Home Fitness Test, developed in 1973 around a step test with age and sex-specific pacing provided by music on an LP recording (or more recently on a tape or CD)

Critique of Population Surveys The United States, Canada, and a number of other developed nations are now engaged in the regular monitoring of fitness and habitual activity in representative samples of their populations, but as yet there are a number of shortcomings in the process and the interpretation of the findings. United States  Preparation for a series of National Health and Nutrition Examination Surveys (NHANES) began in the 1960s. The first survey, in 1971, ranged over many areas of health, including anthropometry, spirometry, resting electrocardiograms, chest radiographs, assessments of bone health and biochemical tests, but it included no measures of physical activity or fitness. NHANES II (1976–1980) and NHANES III (1988–1994) estimated food intake and obesity, but again there was no direct measure of fitness. Beginning in 1999, these surveys have been conducted on an annual basis. The Behavioral Risk Factor Surveillance System conducted telephone interviews with large samples of the U.S. population beginning in 1984. Annual surveys provided subjective reports on nutritional behaviour and physical activity patterns, but again no information on fitness levels was obtained. Such data have shown small improvements in the percentages of men and women claiming to meet the recommended minimum levels of weekly leisure activity (gains of 2.4% in men and 1.4% in women) between 1990 and 2000, but this promising trend is more than negated by adverse changes in other components of the total daily energy expenditure, particularly decreases in the energy expended at work. From 1950 to 2000, employment demanding a high level of physical activity decreased from 30% to 22.6% of the U.S. labour force, while low activity jobs grew from 23.3% to 41.0%. There was

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also an increase in the proportion of the population living in outlying suburbs, particularly between 1950 and 1980, leading to a 7.4% decrease in active commuting, and daily television viewing increased steadily by 36 minutes per decade between 1950 and 2000. The weakness in all of this data is that it was subjective. Self-reports of physical activity are notoriously unreliable, and many respondents undoubtedly exaggerated their habitual levels of physical activity. Irrespective of possible secular trends, most indicators currently point to a widespread prevalence of low levels of habitual physical activity in all age groups of the population. Because of changes in the physical structure of homes and the introduction of labour-saving devices, the daily duration of housework has greatly decreased for most women (although there has been a small increase in the time that men allocate to household tasks). The U.S. Bureau of Labor Statistics has also noted the decreasing physical demands of private industry (which accounts for about a half of the total labour force in the U.S.). In the early 1970s, a half of jobs required at least a moderate intensity of physical activity, but this is now true for less than 20% of private-sector workers; the average work energy expenditure has decreased by at least 400  kJ/day over the past 40  years, and this trend seems likely to continue. Agricultural employment (typically a high energy cost activity) accounted for 12.2% of the labour force in 1950, but less than 2% of workers in 2000. Canada  In 1966, I made measurements of maximal oxygen intake on the general Canadian population at such places as the Canadian National Exhibition, comparing data with published reports from other countries around the world. Values reported by the Åstrands for the residents of Stockholm far exceeded those for people from most other regions, including Canada, but the high Swedish figures were due at least in part to a selective sampling of the Stockholm population, underlining the need for future surveys to be based upon representative sampling of the target population. The Canadian Federal government created the Canadian Fitness and Lifestyle Research Institute (CFLRI) in 1980, and 2  years later they conducted the first National Fitness Survey. With the help of Statistics Canada, data were collected on a large and representative sample of Canadians aged 7 to 65 years. Despite the high costs of domiciliary testing, values for height, body mass, skin folds, grip strength, maximal oxygen intake as predicted by step testing, and back flexibility were obtained on a large population. Because of cost considerations, several subsequent surveys such as the 1988 Campbell Survey on Well-Being in Canada used physical activity questionnaires rather than direct physiological measurements. However, recognizing the systematic errors inherent in questionnaire estimates of physical activity, pedometer measurements of activity patterns were included in the 2007– 2009 Canadian Health Measures Survey. As in many other investigations, the pedometer data suggested that most people were taking substantially less physical activity than they had been reporting on traditional questionnaires. Estimates of physical activity patterns across Canada are at present discouraging. Over half of Canadian children and youth aged five to seventeen are not active enough to meet current recommendations for optimal growth and development, and

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most of those who were surveyed failed to accumulate a sufficient number of steps per day to meet the minimum criterion associated with maintenance of a healthy body mass index. After comparing six Canadian surveys from 1981 to 2000, ParticipACTION claimed to detect some increase of leisure activity over this period. They suggested that adults were 1.6 times as likely to undertake the recommended level of leisure activity in 1988 as in 1981, and 1.2 times as likely to be sufficiently active in 2000 as in 1995. However, these claims were based upon questionnaire responses, which are unreliable at the best of times, and are liable to distortion as social expectations change. Moreover, any interpretation of possible secular trends was largely invalidated by changes in methodology and questionnaire wording from one survey to another. Other Developed Nations  Population surveys in most other developed nations are also showing adverse physical activity and fitness trends. Thus, in Finland, there was some increase in the prevalence of people reporting a significant amount of leisure activity between 1972 and 2002 (from 66 to 77% in men, and from 49% to 78% in women), but this was offset by a decline in physically active employment from 60% to 38% in men and from 47% to 25% in women; moreover, reports of active commuting dropped from 30% in 10% in men, and from 34% to 22% in women. Likewise, a cross-sectional retrospective Swedish population survey suggested a decrease in the total physical activity of men in all age groups between 1970 and 2000, and the proportion of men in England and Wales who were active for at least 30 minutes per week declined from 1994 to 1998. In Catalonia (Southern Spain), residents showed decreases in both active employment and active commuting from 1992 to 2002, although they also reported a small increase in leisure activity. Even in China, the proportion of people with physically demanding jobs decreased from 64.6% in 1989 to 50.7% in the year 2000, and urbanization reduced the average total energy expenditure by 1.2–1.6 MJ/day. Future Needs  Future research will need to monitor these disturbing trends to a decrease in overall fitness and habitual physical activity, possibly using more sophisticated personal monitors, and it will also likely wish to examine how far additional information can be obtained from the recording of the proportion of the day that an individual spends sitting.

Secular Trends in Sport and Leisure Activities During recent years, the tendency among the younger segment of the population in many developed countries has been to engage in ever more dangerous extreme sports. High risk has apparently motivated participation, perhaps as a reaction against what seems an ever safer and more bland urban environment. Examples of dangerous leisure activities include mountain biking, Himalayan trekking,

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snow- and skate-boarding, surfing and wind-surfing, parachuting, hang-gliding, rock-climbing, and the use of mechanized off-road vehicles. Among the middle-aged, there has been a growing interest in mass participation events such as marathon and fun runs, mass cycle rides, and triathlon competitions. Trail walking and the Outward Bound organization have opened up other new possibilities for outdoor physical activity. On the other hand, some traditional sports facilities have seen fewer younger individuals patronizing their venues. This is particularly true of golf courses, where there has recently been a move to provide 8 or even 18 inch holes in an attempt to make the game less time consuming and thus appealing to busy younger patrons. Mountain Biking  By the late 1970s, companies were manufacturing mountain bicycles on a substantial scale, and many ski facilities permitted mountain bikers to take their bicycles up the mountain-side during the summer months. The cyclists then followed extremely rugged downhill trails at breath-taking speeds. Local physicians have recently evaluated injuries at the Whistler Mountain Bike Park in BC. Over a five-month season, 898 cyclists presented to the Whistler clinic, and other more serious injuries were transported to hospitals in Squamish and Vancouver. The toll seen at the Whistler clinic included 420 fractures and 101 cases of traumatic brain damage; however, the data did not allow any calculation of the proportion of cyclists who were injured. Currently, a general rule of thumb in Whistler is that one in 1000 skiers will be injured, compared with one in 100 snowboarders, and one in 10 downhill cyclists. Himalayan Trekking  Himalayan trekking was popularized by Arlene Blum and Hugh Swift, when they completed a 4500 km Himalayan traverse in 1982. As many as 100 million people per year, many of them in relatively poor physical condition, now explore the Himalayas. A recent estimate of risk for those climbing Nepalese peaks with a height > 8000 m put deaths at 544 per million days of climbing, compared with 1.1 death per million days of exposure during downhill skiing in the Alps. Snowboarding  In 1965, Sherman Poppen improvised a simple toy for his daughter, fastening two skis together and attaching a rope to one end to give her some control of the device as she stood on it and glided downhill. Over a million such “snurfers” were sold during the next decade, and snowboarding became an official Winter Olympic Sport in 1998 (Fig. 30.3). Ski resorts were slow to accept snowboarders, fearing that the boards that were used would wipe snow from their slopes. However, by 2004 CE the sport claimed over 6 million participants. The injury rate remains high, particularly for those who opt to perform acrobatic manouevres. The commonest site of injury is the wrist, with around 100,000 fractures per year. Head injuries are also 2–8 times more common in snowboarding than in downhill skiing. Skateboarding  Ocean surfers began skateboarding during the 1950s, finding it a useful alternative pursuit when sea conditions were unfavourable for surfing. Rapid expansion of the sport began when the steel wheels of the boards were replaced by

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Fig. 30.3  The future seems to hold promise of a search for ever more dangerous forms of sport and recreation. Here, Sebastien Toutant participates in the “big air” snowboard competition in Quebec City (Source: http://en.wikipedia.org/ wiki/Snowboarding)

polyurethane rollers. By 2002, there were reputedly 18.5 million skateboarders, 85% being under the age of 18 years. Many skateboarders are increasingly keen to perform acrobatic tricks, and this has exacerbated their risk of injury. Quite a number of teenagers now use skateboards as a form of active transportation. Irregularities in the road or sidewalk surface frequently lead to spills, although the injuries from such episodes are usually no more than minor scrapes, cuts, bruises and sprains. The main danger arises in hilly terrain, when a boarder may be tråvelling too fast to stop at a major intersection. Wind-Surfing and Kite-Surfing  Newman Darby began selling sailboards commercially in 1964. At first, it was not a very profitable venture, but in the 1970s, Hoyle Schweitzer mass-produced relatively low cost sailboards, and the sport became much more popular. In some European countries, one in 3 families now has a sailboard, and 20 million people engage in the sport world-wide. It has become progressively more dangerous with the introduction of extreme forms of wind-surfing. Kite-surfing was first introduced in 1996. Using the vertical lift from a kite, a surfer has the potential to make high jumps, even without exploiting large waves. Competitors now reach speeds of more than 55 knots, and sometimes cover total distances of over 2000  km. Racing-style kite-surfing was included as an official event in the Rio de Janeiro Olympics of 2016. Parachuting, Bungee-Jumping and BASE-Jumping  Parachute jumping became an important component of training for military pilots and airborne troops during the Modern Era, but it did not become an international sport until 1952. It is now performed recreationally, competitively and in displays. There is a significant mortality and morbidity associated with the sport, caused by parachute malfunction, mid-air collisions and landing problems. In 2009, there were about a half million jumps in the U.S., and 16 parachuting-related deaths. Modern bungee-jumping dates from 1979, when university students began jumping from the Clifton suspension bridge in Bristol, UK. Several million jumps have occurred over the past three decades, and despite industry-sponsored safety regulations there have been some fatalities.

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BASE jumping is made from a building, antenna, or bridge span. Because of the dangers of this sport, many public buildings such as the Eiffel Tower have banned BASE jumping. Figures from Norway suggest one death per 2317 jumps. Hang-Gliding and Para-Gliding  The modern form of hang-gliding began with the Americans Francis and Gertrude Rogollo. They developed a predecessor of the flexible wing hang-glider in 1948. The construction of hang-gliders was greatly facilitated by the introduction of the synthetic fabric Mylar, in 1952. Initially, the sport was regarded as quite dangerous, but with greater training, the fatality rate has fallen. In the U.S., there is currently about one death per 1000 participants per year, and in the U.K. there is currently one death per 116,000 flights. Paragliders are developed from parachutes, and are in essence foot-launched free-flying aircraft. One of the earliest designs was introduced by Domina Jalbert during the 1950s; it was patented in 1963. From around 1967, Australians began to use water-ski launching of hang-gliders, and this was soon followed by the foot-launching of paragliders. Those not content with the thrill of hang-gliding have now added acrobatic manoeuvres to their repertoire. Rock Climbing  During the twentieth century, rock climbing gradually evolved into a deliberate athletic activity, with extensive use of artificial hand- and foot-­ holds. This development allowed ascents that previously would have been considered impossible. Indoor climbing walls have now become a popular night-time and winter recreation, with risks somewhat lower than those for outdoor climbs. Great Britain listed 169 indoor climbing walls by 1996. Injuries due to falls are relatively uncommon among rock-climbers. The main clinical problem is an overuse injury affecting the fingers, the shoulders or the elbows. Mexchanized Off-Road Sports  The popularity of off-road motor cycling increased progressively as vehicle suspensions improved, and Japanese motor cycles became widely available; the racing of all-terrain vehicles also became common during the 1980s. The physical demands of controlling a recreational ATV are quite modest (an average oxygen consumption of 12  mL/[kg.min]), but energy expenditures are greater for off-road motor-cycling (21 mL/[kg.min]). Marathon Runs  The first Boston marathon run dates back to 1897. The Boston event grew steadily from an initial field of 15 entrants to 210 runners in 1955, and numbers then surged rapidly. By 1970, entrants were so numerous that competitors were required to certify that they had “trained sufficiently to finish the course in less than four hours” (Fig. 30.4). Women were allowed to participate beginning in the Boston runs beginning in 1972, and a wheelchair division was added in 1975. By the 100th anniversary, there were 36,748 entrants, and some 500,000 spectators. There have been at least two

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Fig. 30.4  Mass running events are attracting an ever-growing number of participants. Here, participants in the 2010 Boston Marathon run through Wellesley, having completed about a half of the 42 km course (Source: http://en.wikipedia.org/wiki/Boston_Marathon#2011_Boston_Marathon)

deaths in the Boston event; a 62-year-old Swede succumbed to a heart attack in 1996, and a 28-year-old woman died in 2002, apparently of hyponatraemia. Some runners, not content with a 42  km distance, have participated in ultra-­ marathon runs such as the 89  km Comrades marathon from Durban to Pietermaritzburg, RSA). Seven runners have died in attempting the longer race. Fun Runs  Large-scale and less competitive walks and fun runs have become increasingly popular over the last 30–40 years. In Canada, an early example was Hamilton’s Miles for Millions march, which began in 1967, with 17,000 entrants and 10,000 people completing the 56 km course. In many Canadian cities, the successor event has been the Terry Fox Run, named after Terry Fox, who attempted to run across Canada as a fund-raiser for cancer research in 1980, even though one of his legs had been amputated for an osteosarcoma three years previously. Fox was forced to abandon his effort half way across Canada, because of a recurrence of the tumour, likely precipitated by many weeks of very demanding physical activity and a resulting immuno-suppression. However, an annual 5–15  km Terry Fox Run is now held in many cities, and it has raised a cumulative total of over $600 M for cancer research. The popular trend seems to participation in somewhat shorter fun runs. In Vancouver, a 10  km circuit of Stanley Park began in 1985, and it now attracts 45,000–60,000 entrants. And in Sydney, the 14 km City-2-Surf fun run that began in 1971 now draws up to 80,000 participants.

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Mass Cycling Events  Mass cycling events have developed in North America in part as a means of pressuring municipalities into making better provision for cycling commuters. The 50 km Tour de l’Ile de Montréal was first held in 1985, and by 2011 it boasted over 17,000 participants. On the west coast of Canada, the Gran Fondo began in 2010, and now there are some 7000 cyclists who cover the hilly 122 km route between Vancouver and Whistler, BC. Triathlons  Triathlons vary in rigour from a 750 m swim, a 20 km cycle ride and a 5  km run to the very demanding Hawaiian Ironman, which comprises a 3.9  km swim, a 180 km cycle ride and a 42 km run. The initial North American triathlon took place in San Diego in 1974, and the first Hawaiian Ironman competition was held in 1978. Trail Walking  Long-distance wilderness trail walking saw its North American debut with construction of the 3515  km Appalachian Trail, officially opened in 1936 CE (Fig. 30.5). Two other major U.S. trails are the Continental Divide Trail (which will eventually run some 5000 km from Mexico to Canada, and is currently about 70% completed), and the Pacific Crest Trail (which runs 5000 km along the western coastal mountains from Mexico to Canada, and was officially completed in 1993). The Trans-Canada Trail is an even more ambitious project which will eventually stretch right across Canada, with parts of the journey made by canoe or kayak. In British Columbia, volunteers have recently constructed many popular shorter trails over Crown and private land for the pleasure of local hikers and mountain bikers. Outward Bound  Outward Bound is an international non-profit organization that aims to foster the personal growth and social skills of participants (typically teenag-

Fig. 30.5  There is a growing interest in the construction and use of lengthy walking trails. The picture shows a section of the Appalachian Trail (Franconia Ridge, NH) (Source: http://en.wikipedia.org/wiki/Appalachian_Trail)

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ers). The four pillars of the programme are physical fitness; a challenging expedition; a project that develops self-reliance; and the fostering of compassion through service (for example, in sea and mountain rescue). The Outward Bound organization now has 40 schools around the world, with some 200,000 participants each year. The first Outward Bound School opened on Wales in 1941, under the direction of Kurt Hahn, who had previously founded the very Spartan Gordonstoun School. The philosophy at Gordonstoun had included morning runs, cold showers, challenging outdoor activities and penalty drills based upon distance running for those who fell afoul of the programme director.

New Training Techniques Several new techniques of conditioning have become popular in recent years, including Fartlek, eccentric and plyometric training. Those concerned with either the development of athletic performance or population fitness will need to evaluate such approaches relative to traditional conditioning approaches, in terms of immediate gains in physical ability, client reactions and long-term impact upon health. More attention may also need paying to the frequency of over-training when using the various approaches. Fartlek Training  Fartlek conditioning comes from Sweden. It combines periods of continuous and interval training, for instance moderately paced running interspersed with 50–60 m sprints. It was introduced by the Swedish decathlete Gösta Holmér in 1937, and it was intended to develop both aerobic and anaerobic performance. It lacks the precision of continuous or interval training, but it is probably a good method both of improving general physical condition, and of maintaining the fitness of athletes between competitive seasons. Eccentric Training  Eccentric training implies contraction of the muscle as it is undergoing lengthening. It tends to produce muscle soreness, although progressive training with this form of exercise may reduce the severity of such symptoms during competition. The concept was first introduced by Erling Asmussen in 1953, and it is now used frequently not only as a means of muscle-bulking, but also in the treatment of chronic tendinitis. Plyometric Training  Plyometric training has become a preferred method of conditioning for the gymnast. Jumping exercises increase relaxation of the antagonist muscles, with an increase of coordination and leg strength, while possibly avoiding the muscle-bulking that gymnasts find disadvantageous. The introduction of plyometric training in the late 1960s is credited to a Russian track and field coach Yuri Verkhoshansky, and it was brought to the United States by the American athlete Fred Wilt during the early 1980s.

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Over-Training  Over-training has remained a clinical syndrome with no generally accepted single cause, and few reliable indicators other than a deterioration in the individual’s mood state. In the 1950s, international athletes such as Roger Bannister achieved world records with a surprisingly light training programme. However, the level of competition has increased steeply over the Post-Modern Era, and some athletes have now adopted the maxim that if a little training is good, more is undoubtedly better. Sometimes, performance has deteriorated rather than improved as weekly training schedules have increased, and there have been adverse clinical responses to an excessive volume of exercise such as an increased vulnerability to upper respiratory infections. The affected competitors are said to be over-reaching, or over-trained. Over-reaching is usually cured by a few weeks relaxation of training, but overtraining may impair an athlete’s performance for many months.

Fitness and Aging As the proportion of elderly people has increased in developed societies, there has been growing interest in developing programmes to enhance their quality of life and extend their period of independent living. If a conditioning programme can bring about a 20% increase in maximal oxygen intake or muscular strength, this effectively reduces this component of a person’s biological age by 10–20  years, with (other factors being equal) a corresponding delay in the age at which institutionalization is required. On the world stage, the International Coalition for Aging and Physical Activity is now promoting the enhanced delivery of services to older adults, and the collection, dissemination, and discussion of information on active aging. Congresses of this group take place approximately every 4  years, and the Journal of Physical Activity & Aging (founded in 1993) has become the official organ of this coalition. A major on-going concern is the progressive mental deterioration associated with aging. Evidence is accumulating that regular physical activity can slow the age-related loss of cognition. It remains to be clarified whether benefit arises simply from the greater range of social contacts and experiences enjoyed by an active older person, or whether physical activity has a more direct effect in stimulating the production of neurotrophins and/or reducing the formation of Alzheimer plaques in the brain.

Rehabilitation Programmes The novel view that progressive aerobic exercise would help a person who had sustained a myocardial infarction was advanced by Herman Hellerstein in Cleveland, and by Viktor Gottheiner in Israel, during the late 1950s, Initiatives designed for

Rehabilitation Programmes

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primary, secondary and tertiary rehabilitation in ischaemic heart disease have extended subsequently to programmes designed for patients with a variety of cardiac conditions and other chronic illnesses. Primary and Secondary Rehabilitation  Primary rehabilitation seeks to conserve good health in a sedentary but otherwise healthy individual. Secondary rehabilitation addresses such cardiac risk factors as obesity, a high blood pressure and a high serum cholesterol. Over the past two decades, Health Canada, the U.S.  Surgeon General, the American Heart Association, the American College of Sports Medicine, and the World Health Organisation have all developed recommendations on an appropriate minimum prescription for such rehabilitation. The general tenor of advice has been consistent, with adults expected to engage in at least 150 minutes of moderate aerobic activity per week. However, the details have inevitably differed between organizations, and these discrepancies have had the unfortunate effect of causing the general public to be sceptical about the advice that has been offered. Moreover, in most developed societies only a small proportion of the population has yet to meet any of the recent recommendations; the big issue is still to find an effective method of motivating those who remain sedentary. Tertiary Rehabilitation  Tertiary rehabilitation programmes addressing the needs of those who have developed symptomatic cardiac disease such as angina or myocardial infarction began to appear during the 1950s. A ground-breaking International Symposium on Physical Activity and Cardiovascular Disease was held in Toronto in 1966. One measure of the potential for successful rehabilitation was seen in 1973, when eight post-coronary patients trained by the Toronto Rehabilitation Centre elected to participate in the Boston Marathon under close medical supervision. The peak oxygen intake of the runners had increased greatly from their initial post-­ infarction values of 24–27 mL/[kg.min]; one of the eight had attained a value of 53 mL/[kg.min], and completed the Boston Marathon in a time of 3 h 17 min. The 1960s and 1970s saw many randomized controlled trials testing the efficacy of cardiac rehabilitation in terms of reductions in the recurrences of myocardial infarction and cardiac mortality. Meta-analyses across various trials suggested that mortality was reduced by around 20%, with benefit seen in terms of decreased all-­ cause and cardiac mortality, fewer incidents of non-fatal reinfarction and hospitalization, and favourable changes in modifiable cardiac risk factors. Rehabilitation in Other Chronic Conditions  The experience gained with cardiac patients was quickly transferred to the rehabilitation of patients with other medical conditions, beginning with chronic obstructive respiratory disease (COPD). Until the middle of the twentieth century, the advice for those with COPD had been to control dyspnoea by avoiding unnecessary exertion. An early pioneer of respiratory rehabilitation was Thomas Petty, in Colorado; he established an effective out-patient programme for COPD patients during the late 1960s. Nevertheless, motivation to exercise proved more difficult in chest patients than in those with cardiac disease, and the basis of any clinical improvement following

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rehabilitation remains controversial. Some at first attributed benefit simply to an increase of motivation, a desensitization to dyspnoea and an improved mechanical efficiency of walking. However, it was later appreciated that many investigators had been using programmes demanding too low an intensity of effort, and it was shown that with an adequate conditioning stimulus physiological adaptations could develop in those with COPD, including a lesser production of lactate in strengthened muscles and increased muscle enzyme activity. The international consensus conferences of 1988 and 1992 on physical activity, fitness and health (Chap. 29) identified many other diseases and conditions where regular exercise was beneficial in terms of both prevention and treatment.

Genetics of Health and Fitness There now seems some possibility that a study of genetic characteristics may help in identifying inherent talent for various types of athletic activity. In the planning of health and fitness interventions, it remains important to ascertain whether all individuals will react in a similar manner to a given programme. If responses such as an crease of maximal oxygen intake or a decrease ion body fat content show substantial genetically-related differences, this may help to explain why some clients fail to respond to treatment despite seemingly good programme compliance. The understanding of genetic issues has been advanced by twin and family studies, an analysis of inter-individual differences in training response, genome mapping, and a growing interest in epigenetic influences. Twin and Family Studies  Quantitative study of the genetics of fitness began in the early 1970s, with comparisons of maximal aerobic power between similar and dissimilar twins who had been exposed either to similar or to dissimilar environments during their years of growth. However, different investigators made strikingly dissimilar estimates of the heritability of aerobic fitness from such data. Beginning in the 1980s, the Quebec Family Study measured many fitness-related variables in entire extended families, with the intent of partitioning the variance in fitness and training responses between genetic and environmental influences. Unfortunately, once more the repetition of apparently very similar analyses yielded widely differing verdicts on the partition of this variance. Nevertheless, there now seems little doubt that some individuals are born with a higher maximal oxygen intake than others. A large study of firefighters found that 6 of 1900 young men with no history of specific physical training had a maximal oxygen intake that was some 50% greater than that of their peers, apparently in part because they were endowed with a large blood volume. Likewise, the maximal oxygen intake of 88 ml/[kg.min] reported for top cross-country skiers reflects as much a genetic advantage of body build (an ectomorphic frame, a low body fat content,

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and only moderate muscular development) as a response to years of rigorous endurance training. Inter-individual Differences in Training Response  In one study of apparently similar young men, an identical 20-week aerobic conditioning regimen caused an average gain in maximal oxygen intake of 400 ml/min, but the reported response of individual subjects ranged from 0 to 1 L/min. About a half of the apparent inter-­ individual discrepancy in gains of oxygen transport was traced to laboratory errors in the measurement of maximal oxygen intake, but there were still substantial genetically-based differences in individual response after correction for this issue. Genome Mapping  There has been considerable recent interest in mapping the human genome to seek specific gene configurations that modify the risks of cardiovascular and metabolic disease, and influence fitness attributes such as maximal oxygen intake, muscle strength and the response to various training programmes. Initial studies at the Mexico City Olympic Games of 1968 CE yielded negative findings; successful participants were not distinguished by such genetic markers as differences in red cell antigens or enzyme variants of red blood cells. The search has continued on a systematic basis, and a growing number of gene variants have now been linked to such factors as physical activity behaviour, cardio-­respiratory fitness and endurance performance, muscle strength and power, body mass and adiposity, and characteristics of glucose and lipid metabolism. One recent study found 21 single-nucleotide polymorphisms which together appeared to account for about 49% of inter-individual differences in the trainability of maximal oxygen intake. Nevertheless, in most cases, individual genes seem to account for only a very small fraction of the total variance in data relating to either initial health and fitness or to training responses, and the discovery of substantial useful information remains a tantalizing and distant dream. Further advances await a better understanding of interactions between individual genes, and clarification of epigenetic factors that can activate and deactivate particular segments of the human genome.

Practical Implications for Current and Future Policy Although much effort has been invested in developing simple yet effective screening tests for those planning to begin an exercise programme, there is as yet no objective evidence that such screening enhances client safety. Give the constraints imposed by Bayes theorem, it remains to be demonstrated that in a sedentary but otherwise healthy individual, any screening approach is more effective that insisting upon a gradual increase in an individual’s volume of training, keeping a careful watch for any adverse symptoms that may develop. Mass surveys of health and fitness have as yet had little success in demonstrating secular populations trends, in part because of changes in the test protocol from one survey to the next. Future investigations will need to weigh very carefully the lure

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of exciting new objective monitoring technology against the need for consistency in methods of data collection, albeit with methods that have significant limitations. Another current issue is the wisdom of adding estimates of sedentary time to such surveys. Is sedentary time merely providing a further method of identifying inactive individuals, or is there some specific harm to health associated with prolonged and uninterrupted periods of sitting? Where conclusions on secular trends are possible, it seems that the habitual activity of people in most countries continues to decrease. The health practitioner is thus challenged to determine why this is happening, and what new measures can be taken to reverse this trend. One outcome of many population surveys has been the formulation of statements on the minimum volume of physical activity needed to maintain good health. The evidence-base for such statements has typically been a questionnaire estimate of the weekly average level of physical activity, and often these estimates have been in error by a factor of 2–3. It will be interesting to see how far recommendations need to be modified as objective monitors provide more reliable data on minimal desirable levels of physical activity. If indeed large changes in recommendations are required, those concerned with health promotion may quickly face the problem of a loss of credibility among the general public. Given the dangers posed by many of the new forms of sport and recreation, there is a need to explore and understand the attraction that young adults are finding in such pursuits, and to see how far safer leisure pursuits can be made equally attractive. Until recently, it was thought that complete mapping of the human genome would greatly facilitate the training of athletes and the task of improving the p­ hysical condition of the average individual. However, the uncovering of epigenetic effects now faces exercise scientists with a challenging scenario, and it is likely to be many more years before it is clear how the genetic background of an individual influences reactions to either an individual bout of exercise or a given bout of training.

Questions for Discussion 1. What measures would you recommend in terms of medical clearance for a middle-­aged adult who wished to begin an exercise programme? 2. Are mass surveys contributing to our understanding of trends in population health and fitness, and if not, why not? 3. Why do you think some young adults are seeking out ever more dangerous forms of sport and recreation? 4. In what ways do you think advances in genetics will help future health and fitness practitioners?

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Conclusions Health practitioners continue to invest much time in devising progressively more sophisticated methods of clearance for those wishing to begin exercise programmes, although there is as yet no objective evidence that such efforts have enhanced programme safety. Many nations are now investing heavily in mass surveys of health and fitness. Changes in test protocol from one survey to another have made it difficult to discern secular trends, but in general it seems that despite governmental publicity, population activity is decreasing rather than increasing. On the other hand, sport and recreation are currently marked by the search of young adults for ever more dangerous and challenging forms of physical activity, with high risks of physical injury. Other current trends are a growing interest in mass-participation running and cycling events, and the development of ultra-long distance hiking trails. Many new forms of training are being introduced, and there is a need to evaluate which are the most effective in enhancing the physical condition of both the average individual and the member of an elite sports team. Sedentary living, an aging population, and an increased prevalence of many chronic conditions have already encouraged a growing interest in primary, secondary and tertiary rehabilitation; however, the challenge remains for exercise professionals to find effective methods of augmenting programme compliance. Genetic research is beginning to yield dividends in terms of demonstrating associations between specific gene combinations and fitness, but before such knowledge can be exploited in the selection of athletes and the design of personal treatment programmes, much remains to be learned about how such associations are modified by epigenetic influences.

Further Reading Bouchard C, Malina RM, Pérusse L. Genetics of physical performance. Champaign, IL, Human Kinetics, 1997, 400 pp. Canadian Fitness Professionals. Foundations of professional personal training, 2nd ed. Champaign, IL, Human Kinetics, 2016, 384 pp. Dempsey CH, Petty JD. Laboratory accreditation and data certification. Boca Raton, FL, CRC Press, 1991, 256 pp. Hoffman J.  Physiological aspects of sport training and performance. Champign, IL, Human Kinetics, 2002, 343 pp. Hopkins D, Putnam R. Personal development through adventure. Abingdon, OX, Routledge, 2013, 252 pp. Institute of Medicine. Children’s health, the nation’s wealth. Washington, DC, National Academies Press, 2004, 336 pp. Institute of Medicine, Food and Nutrition Board. Fitness measures and health outcomes in youth. Washington, DC, National Academies Press, 2012, 274 pp. Kerr JH. Motivation and emotion in sport. London, UK, Taylor and Francis, 2013, 238 pp. Kraus W, Keteyian S. Cardiac rehabilitation. New York, NY, Springer, 2007, 307 pp. Perk J, Mathes P, Gohlke H, Monpère C, McGee H, Sellier P, Saner H. Cardiovascular prevention and rehabilitation. New York, NY, Springer, 2007, 517 pp.

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Perry BL. Genetics, health and society. Bingley, UK, Emerald Publishing, 2015, 336 pp. Schneider AJ. Gene doping in sports: The science and ethics of genetically modified athletes. New York, NY, Academic Press, 2008, 128 pp. Schock H. Accreditation practices for inspections, tests and laboratories. West Consohocken, PA,ASTM International, 1988, 143 pp. Shephard RJ. Ischaemic heart disease and exercise. London, UK, Croom Helm, 1981, 428 pp. Shephard RJ. Fitness of a Nation; Lessons from the Canada Fitness Survey. Basel, Switzerland, S. Karger, 1986, 1896 pp. Shephard RJ, Rode A. The health consequences of “modernization.” Evidence from circumpolar populations. Cambridge, UK, Cambridge University Press, 1996, 306 pp. Shephard RJ. Aging, physical activity and health. Champaign, IL, Human Kinetics, 1997, 487 pp. Simon SE. Hyponatremia: Evaluation and treatment. New York, NY, Springer, 2014, 256 pp. Thompson PD. Exercise and sport cardiology. New York, NY, McGraw Hill, 2001, 504 pp. U.S. Department of Health & Human Services. Assessing physical fitness and physical activity in population -based surveys. Atlanta, GA, Centers for Disease Control, 1989, 657 pp.

Glossary

Aesculapium The aesculapium was a prestigious health centre in Pergamon. Ahura Mazda  Ahura Mazda was a Zoroastrian God who was reputed to have brought 10,000 healing plants to earth. Along with Ameretat, the god of longevity, he bestowed good health as a reward for obedience. Ahhiyawâ  Ahhiyawâ was the medical deity of the Minoans. Alaunus  Alaunus was the Celtic Sun-God, symbolizing fire, health and healing. Aleipte The Aleipte were massage therapists whose main task was to anoint the bodies of Athenian gymnasts with oil. Almshouses Almshouses were purpose-built small dwellings for the elderly in mediaeval England, usually clustered around the parish church. Angra Mainyu  Angra Mainyu was a Zoroastrian God who was reputed to have created 99,999 diseases. Animalicules Van Leeuenhoek gave the term animalicules to the single-celled organisms he observed on examining water through a powerful microscope. Animal spirit Animal spirit was the essence of life in Greek medical thought, formed in the brain from vital spirit and serving to activate the muscles. Askēsis Askēsis was a term coined by Plato to denote a combination of dieting and endurance training. In mediaeval England, it developed into the monastic idea of asceticism. Asclepion  The Asceleipon was a Greek centre of healing, particularly for those with pyschiatric ailments. Asclepius  Asclepius was the early Greek god of medicine, a son of Apollo, who had been taught the healing arts by a centaur named Chiron. Asthenia  In the eyes of John Brown, an Edinburgh physician, many illnesses were due to a lack of stimulation of the body (asthenia). Aṥvins The Aṥvins were 2 Vedic gods who helped to preserve the balance of the 3 body humours. Atharva-Veda  The Atharva-Veda is one of 4 sacred Hindu texts, and it contains of wealth of Indian views on medicine and health.

© Springer International Publishing AG 2018 R.J. Shephard, A History of Health & Fitness: Implications for Policy Today, DOI 10.1007/978-3-319-65097-5

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Atherosclerosis  Atherosclerosis is a hardening and narrowing of the arteries, associated with the build up of fatty plaques. It is often a manifestation of diabetes mellitus. Ayurvedic medicine Ayurvedic medicine is based on traditional Indian concepts, and persists today as a form of “alternative medicine.” Aztecs The Aztecs were a central American population group that dominated Mexico in the 14th, 15th and 16th centuries CE, before the Spanish conquest. Bai Da  Bai Da was a form of Chinese football where importance was attached to technique rather than the scoring of goals. BCE  BCE signifies “before the common era”- in the interests of religious pluralism, this term is now preferred to BC (before Christ). Beithe  Beithe was the first letter in the Ogham alphabet, signifying to mediaeval wizards the sacred properties of the beech tree. Beiwe  For the Sami, Beiwe was Goddess of the sun; she provided fertility and renewed sanity for those afflicted with seasonal depressive disorders. Body mass index (BMI)  The BMI (M/H2) is a simple surrogate measure of obesity, commonly used by epidemiologists. An index >25 kg/m2 reflects an excessive body mass, and values >30 kg/m2 are taken as evidence of obesity. Bubonic plague  The bubonic plague was an infection, transmitted by rat flea bites, and responsible for the Black Death. Byzantine Empire The Byzantine Empire represented the continuation of the Roman Empire in Eastern Europe, under the guidance of the Orthodox church. It fell to an Ottoman army in 1453 CE. Caliph  For the Muslims, a caliph was the steward of an area of territory, and considered as a successor to Mohammed. CE  CE signifies common era, and for reasons of religious pluralism it is now the preferred alternative to AD (Anno Domini). Charaka Samhita  The Charaka Samhita was an important early Indian medical text. Chukchi  The Chukchi are an indigenous people of Northern Russia, living on the Arctic Ocean. Until collectivization by Stalin in the 1920s, they hunted polar bears, marine mammals and reindeer. Chuíwán  Chuíwán is an antecedent of golf, popularized by the Chinese emperor Hui Zong. Coloni The coloni were lowly “tied” workers living on the large estates of the Roman aristocracy. Cruorine  Cruorine was the name given to red blood cell pigment by Stokes and von Meyer. Cùjū Cùjū was an early form of football played in ancient China, with a soft ball. Sometimes there was one goal at the centre of the field, and sometimes 6 crescent-shaped goals at either end of the field. DAF  The DAF was the substitute for a trade union movement introduced in Nazi Germany. Dao Yin  Dao Yin is a Taoist form of Yoga. A series of exercises performed mainly when sitting or lying seeks to restore the ch’i, the internal energy of the body.

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Denarius  The Denarius was the day’s wage for a Roman labourer. Dephlostigated air  Dephlostigated air was Priestley’s term for oxygen. Deuterated water  Deuterated water contains a high proportion of deuterium oxide (D2O) formed from a hydrogen isotope. It is distributed freely throughout the body, and from its dilution one can estimate body water content and thus body fat content. It is also used in estimating average energy expenditures over 2-week periods. Diabetes mellitus  Diabetes mellitus is a chronic medical condition where blood sugar remains high for long periods, leading to many clinical complications. One causal factor seems an inadequate volume of habitual physical activity. Dhanvantari  Dhanvantari was for Hindus the 17th incarnation of Vishnu, the physician of the Gods and the patron deity of medicine. Dhatus  The dhatus are the body tissues in the Ayurvedic approach to medicine; they are a fourth form of doṥa introduced into the system by the physician Suṥruta Doṥas  The 3 doṥas or doshos were body humours in the Vedic system of medicine. Ea  Ea was the Mesopotamian God of wisdom, water, healing and creation. Eeyeekalduk  was the Inuit God of medicine and good health. Elan vital The “elan vital” is the idea that the functioning of living organisms depends on a vital force, something quite distinct from normal chemical and biochemical reactions. Enkoimesis  Enkoimesis was an opiate-induced sleep or trance, used by the Greeks to make patients attending their psychiatric institutions more susceptible to treatment. Enlightenment The enlightenment was a period in European culture stretching from 1650 CE to the 18th century, when dramatic revolutions in science, philosophy, society and politics swept away many of the traditional views of the mediaeval world. Equites  The equites were highly paid cavalry officers in Roman society. Evenki  The Evenki were a traditional semi-nomadic population of northern Russia, with an economy based upon fishing, hunting, and the herding of small groups of reindeer and/or horses. Fartlek  Fartlek is a Swedish pattern of training that combines continuous and interval conditioning. Faunus  Faunus was the horned Roman God who brought fertility to fields and livestock. Fire air  Fire air was Scheele’s term for oxygen. Fixed air  Fixed air was Black’s term for carbon dioxide. Gas sylvestre  Gas sylvestre was Van Helmont’s term for carbon dioxide. Grammatistes The grammatistes taught academic material at the Athenian palaestrae. Gula  Gula was the dog-god of Mesopotamia, a herbalist and vegetation/fertility goddess. Gymansion  The gymnasion was the school from which Athenian children graduated at the age of 16 years.

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Gymnastes  The gymnastes were highly paid exercise specialists at both the palaestra and the gymnasia in Athens. Gynaikonitis The gynaikonitis was the section of a Greek house to which the women were confined. Han dynasty  Chinese civilization reached its zenith during the Han dynasty (206 BCE to 220 CE). Harrapa  The Harrapa were early agriculturalists in the Indus valley, about 2000 BCE. Hatha Yoga  Hatha Yoga includes the practice of postures (asanas) and specific breathing exercises (pranayamas). Helladic period  The Helladic period, from about 3200 BCE to around 1.050 BCE marks the bronze age culture of mainland Greece. Hetaerai  The Hetaerai were independently wealthy Greek women who entertained men as conversationalists and courtesans. Hisba  The Hisba, was the religious office regulating the practice of medicine in ancient Baghdad. HIV/AIDS  HIV signifies human immunodeficiency virus, AIDS signifies acquired immunodeficiency syndrome. Home erectus  Homo erectus is an extinct species characterized by an upright posture, probably originating in East Africa and living throughout most of the Pleistocene era. Homo habilis  Homo habilis is a human predecessor from the Pleistocene period, between 2.4 and 1.5 million years ago, and is thought to have been the first human ancestor to have mastered the art of making tools. Homo sapiens  Homo sapiens is the only surviving species of the genus Homo, with modern humans forming the sub-species homo sapiens sapiens. Hoplites  Hoplites were shield-carrying Spartan soldiers who passed a fitness test at age 18-20 years, and then served in the military or the military reserve until the age of 60 years. Hospitaller  The hospitaller was the administrator of mediaeval hospitals. Hudson House  Hudson House on Hudson Bay was the main Canadian trading post and distribution site for the Hudson’s Bay Company during the 18th Century. Humoral theory Hippocrates believed that the functioning of the human body could be explained in terms of the balance between humours formed from the 4 elements of matter, fire, earth, air and water. Idiotae In the mediaeval period, lay practitioners of medicine were sometimes described as idiotae. Igloolik  Igloolik is an Inuit community on the Foxe Basin, close to the Melville Peninsula. The local population were studied extensively as a part of the International Biological Programme Human Adaptability Project. Imhotep  Imhotep was a chancellor in ancient Egypt, and high priest of the sun god. He is reputed to have authored an early surgical treatise. Incas  The Inca kingdom embraced much of modern Peru, Bolivia, Ecuador and Colombia in the period immediately preceding the 17th century Spanish conquest of South America.

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International Biological Programme The International Biological Programme was launched in the 1960s; the objective of its Human Adaptability component was to study interactions between traditional indigenous peoples and their habitat before they became acculturated to a sedentary lifestyle. Ishtar  Ishtar was the Mesopotamian goddess of fertility, love and power, honoured by the Mesopotamian women in whirling dances. Janism  Janism is an ancient Indian religion that seeks a liberation of the soul. Kalahari  The Kalahari desert is a large and semi-arid region covering much of Botswana. The !Kung bush people are a small nomadic group living in this region. kapha  kapha was one of the 3 doṥas in the Vedic system of medicine. Katimavik  Katimavik is a programme of the Canadian government that recruits youth aged 17-21 years to spend 9 months working on volunteer projects in 3 varied communities. King’s evil  The King’s evil was a tuberculous infection of the neck glands. King’s touch The King’s touch was a royal “laying on of hands,” revived by Charles II, and purporting to cure the King’s evil and other chronic illnesses.. Kitharistes  The kitharistes taught singing and the lyre at Athenian palaestrae. Kofranyi-Michaelis respirometer  The Kofranyi-Michaelis respirometer is a light mechanical gas-meter that is carried on a subject’s back. It measures the volume of air breathed per minute, and also diverts small samples of the expired gas to balloons, allowing an estimation of oxygen consumption. Kumugwee  For the North-west Pacufuc Indians, Kumugwee was the god of the undersea world who had the power to heal the sick and the injured. !Kung bush people  The !Kung bush are a semi-nomadic group of hunter gatherers living in the Kalahari desert Kşhatriyas  The Kşhatriyas were the elite/military class in India. Lazaretto  A lazarretto was an isolation ward at a mediaeval monastery, reserved for those with contagious diseases such as leprosy. Leeches  Mediaeval physicians were often known as leeches because of their frequent use of blood-sucking leeches in the treatment of their patients. Leprosaria  A leprosarium was a mediaeval isolation facility built to accommodate patients afflicted with a skin condition that was thought to be leprosy. Macuilxochitl  The Aztec looked to the God Macuilxochitl for well-being, Malas  The malas were the waste products in the Ayurvedic medical philosophy. Maurya  The Maurya were a powerful iron-age dynasty that occupied the Ganges valley in the 4th and 3rd centuries BCE. Maximal oxygen intake  The maximal oxygen intake is a measure of an individual’s aerobic fitness. It is the maximal oxygen consumption reached when a subject engages in a treadmill or cycle ergometer test at progressively increasing loadings. Mediocres  Mediocres were low-level mediaeval craftsmen who did not belong to one of the formal trade guilds. Mesolithic Era  The mesolithic, or middle stone age, began around 10,000 BCE. It was marked by use of the adze, with construction of boats and fishing platforms,

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and more sophisticated hunting expeditions than those that were possible during the Paleolithic Era. Metabolic syndrome The metabolic syndrome is marked by the presence of at least 3 of 5 characteristics: abdominal obesity, an elevated blood pressure, an elevated fasting blood glucose, high serum triglycerides and a low concentration of HDL cholesterol. Miasma A miasma is an unpleasant and possibly toxic atmosphere, emanating from somewhere such as a marsh or a creek. Minerva  Minerva was the Etruscan goddess of health. Minoans  The Minoan civilization flourished inn Crete from around 2000 BCE to about 1400 BCE. MMR  MMR is the acronym for a vaccine effective against measles, mumps and rubella infections. Modern Era  The Modern Era extends from the end of World War I to the early 1960s. It was marked by a progressive erosion of traditional religious and social norms, mass production, mass communication and female emancipation. Muhtasib  The Muhtasib was the official who regulated medical practice in ancient Baghdad. Some of his functions were rather like those of a modern medical officer of health. Nacktcultur  Nacktcultur (naturism or nudism) was introduced in Vienna by Karl Wilhelm Diefenbach in the late 1890s. Namtar  Namtar was the Mesopotamian God of death. Nations During mediaeval times, foreign students at the University of Bologna grouped themselves into self-aid societies that they terms “nations.” NCR  NCR is the acronym for the National Cash Register Corporation. Ngetal  Ngetal was a letter from the Ogham alphabet, symbolizing the sacred properties of the reed. Neolithic era  The Neolithic Era, or new stone age, emerged in the fertile crescent of the middle east around 9500 BCE. Hunting and gathering were replaced by agriculture, and stone tools were supplemented by copper, bronze and iron implements. Ningishzida  Ningishzida was the Mesopotamian patron god of healers. Ninurta  Ninurta was a Mesopotamian solar god who had the power to release people from sickness and demons. Nirvāŋa Nirvāŋa is, for the Buddhist, the ultimate state of release from successive rebirths. Nutritive spirits  In Galen’s view, nutritive spirits were formed from food in the liver. When mixed with the pneuma in the heart, vital spirits were formed. OND  The OND was a Fascist recreational group for workers in Mussolini’s Italy. Ottoman Empire  The Ottoman Empire was founded in Anatolia by Oghuz Turks in 1299 CE, and over the next 2 centuries it gained increasing influence in Eastern Europe. Paean  Paean was the patron god of the seer-doctors in Minoa. Paidagogos The paidagogos were the slave/guardians of children attending the Athenian palaestrae.

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Paidotribes  The paidotribes were trainers at the Palaestrae. Palaestrae  The Palaestrae were Athenian schools for the teaching of physical and academic skills to children through to the age of 16 years. Paleolithic Era  The Paleolithic, or Old Stone Age, began around 200,000 years ago, and continued until the last age, about 11,000 BCE. Patecatl  The God Patecatl bought healing and fertility to the Aztecs. Perioikoi  Perioikoi were those Spartans who failed a fitness test at age 18-20 years, and in consequence lost all political rights. Phlogiston  The phlogiston theory was developed by Becher and Stahl. Phlogiston was supposedly released by combustion, and by saturating air in a closed vessel it extinguished a flame and made the air irrespirable. Pinga  Pinga was the Inuit Goddess of the hunt and fertility, Pitta  Pitta was one of the 3 doṥas in the Vedic system of medicine. Plebs  The plebs were lowly Roman workers with less than 400 denarii worth of possessions Pleistocene Epoch The Pleistocene Epoch began about 2,600,000 BCE, and spanned a period of repeated glaciation, with the last such episode concluding about 11,000 BCE. Pneuma  For the Greeks, the pneuma (also known as natural spirit) was a form of circulating air, necessary to function of the body organs. Pornai  The pornai were lower class Greek women who served as prostitutes. Post-modern Era  The Post-modern Era extends from the 1960s to the present day. Some post-modernists question how far scientific explanations of phenomena are valid for all cultures, societies and races. Qi  In traditional Chinese thought, the Qi is a form of material energy that circulates in the body, balancing the yin and the yang. Quarantino  In mediaeval Europe, a quarantino was a 40-day period of quarantine. Rigveda  The Rigveda is an ancient collectiion of Vedic Sanskrit hymns. Sami Lapps The Sami Lapps are a semi-nomadic people living in Northern Scandinavia; their traditional economy was based largely on reindeer herding. SARS  SARS is the acronym for severe acute respiratory syndrome. Senet  Senet was an Egyptian antecedent of the game of draughts. Shang dynasty The Shang dynasty controlled the Yangtse valley from 1700 to 1046 BCE). Ṥiva  The Hindu deity Ṥiva is sometimes expressed as the Cosmic Lord of the Dance. Sphaeristerium  The sphaeristerium was a large hall in prosperous Roman villas, set aside for the playing of ball games. Sthenia  In the view of the Edinburgh physician John Brown, sthenia reflected an excessive stimulation of the body. Śūdras The Śūdras were the lowest menial caste in Indian Hindu society. Sulis  Sulis was the Celtic deity who was reputed to have given healing powers to the waters at Bath, in Somerset. Suṥrutha Samhita  The Suṥrutha Samhita was an important early Indian medical text.

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Tarahumara Indians The Tarahumara Indians live in a mountainous region of Northern Mexico. They are famed for their ability to run ultra-long distances and to scale the mountain cliff-sides with surprising speed. Terra fluida Becher proposed that the 4 fundamental elements of matter were water, terra fluida (mercurial earth), terra lapidea (vitreous earth) and terra pinguis (fatty earth). Trentino  A trentino was a 30-day quarantine period in mediaeval Europe. Tria prima  For Paracelsus, the 3 primary constituents of the human body (tria prima) were mercury, sulphur and salt. Trireme  A trireme was a Greek ship with three banks of oars. Turners  The Turners were 19th century German gymnasts who followed the teachings of Friedrich Jahn; some were exiled to the U.S. and Canada, establishing gymnasia there. Ultramontanes The Ultramontanes were mediaeval Paduan university students drawn from countries to the north of the Alps. Universitas  The Universitas at the mediaeval University of Bologna were student collectives that bargained terms of employment and instruction with the local faculty. Vaiśyas  In early India, the Vaiśyas were a caste associated with agriculture and cattle rearing. Valetudinaria The valetudinaria were buildings attached to Roman fortresses, which are thought to have served as operating theatres and/or rehabilitation centres. Vata  Vata was one of the 3 doṥas in the Vedic system of medicine. Vedic civilization  The Vedic civilization blossomed in the Ganges delta from 1000 BCE to about 400 BCE. Vital spirit  In Greek medicine, vital spirit was formed from natural spirit in the heart, and was then transmitted to the brain, where it was transformed into animal spirit. Xia dynasty  The Xia dynasty held sway in the Yangtze valley of China from 2100 to 1600 BCE. Yin and yang  The yin and yang were opposing female and male forces, seen by the Chinese as governing the universe. Imbalance between these forces in the human body was thought to give rise to illness. Zhou dynasty  The Zhou dynasty controlled the Yangtze region from 1046 to 246 BCE. Zend-Avesta  The Zend-Avesta was the holy book of early Zoroastrians. It contained much medical information, including recommendations on health and hygiene.