The First Stage of the History of Orthopaedics in Norway : the Therapy of " Self-correction "

The First Stage of the History of Orthopaedics in Norway: The Therapy of JAN FROESTAD (*) SUMMARY 1.-Introduction. 2.-The orthopaedist Gunder Nielsen Kjolstad. 3.-The essential features of the therapy. 4.-The theoretical foundation of the therapy. 5.-The spread of the therapy. 6.-The valuation of the method of self-correction: from scepticism to approval. 6.1.-The evaluations of the medical profession. 6.2.-The assessments of the Norwegian government. 6.3.-The appreciations of the clients and the public. 7.-Prevailing ideological trends. 8.-A metaphysical theory in a metaphysical milieu. 9.-The new importance attached to physical education. 10.-The muscular theory. 11.-The renewed interest of the physicians in the orthopaedic field. 12.-The preventative qualities of the therapy. 13.-The efficacy of the therapy. 14.-The social composition of the clientele. 15.-The relation to the clients. 16.-Concluding remarks. RESUMEN En este artículo se investiga el primer estadio de la historia de la ortopedia en Noruega, que transcurre desde 1838 a 1880 y que se caracterizó por un peculiar método de reducción de las curvaturas de columna, la llamada terapia de «autocorrección». Se indagan, en particular, las posibles causas de la elevada estima que esta terapia ortopédica recibió en Noruega. Fecha de aceptación: 6 de mayo de 1992. (*) Department of Administration and Organization Theory. University of Bergen. Noruega. DYNAMIS Acta Hispanica ad Medicinae Scientiarumque Historiam Illustrandam. Vol. 13, 1993, pp. 73-1 15. ISSN: 0211-9536 74 JA.N FROESTAD 1. INTRODUCTION It seems reasonable to divide the Norwegian history of orthopaedics, before the second world war, into three time periods. The first runs from 1838 up to about 1880 and is characterized by a peculiar method for the straightening out of spine curvatures, the so-called therapy of «selLf~orrection». The next runs from 1880 to 1916 and is marked by the introduction in Norway of a new form of treatment, the Swedish physiotherapy. The last time period runs from the beginning of World War 1 to the beginning of World War 11. This phase is distinguished by the development of a much tighter link between orthopaedics and the organized care for cripples, which originated in 1892 as a philanthropic activity geared to the needs for craft training. In this contribution, however, 1 will limit myst:lf to account for the eairliest stage, and in particular indicate some possible causes of the high degree of recognition this orthopaedic therapy received in Norway. 2. THE ORTHOPAEDIST GUNDER NIELSEN KJgLSTAD The first medical orthopaedist in Norway, Gunder Nielseri Kjolstad, was born in 1794 in Modum, a municipality in the eastern part of Norway. His parents were fairly well off farmers with an educational leve1 some above average. By a small inheritance and the assistance of two parsons he managed in 1820 to pass the preliminary degree and set to study medicine. Seven years later he passed his medical degree. Aftenvards Kjolstad hold different offices as army surgeon until he in 1836 was appointed medical officer of health for the district of Gudbrandsdalen. Already during his period of study Gunder Kjalstad began to develop his peculiar orthopaedic therapy. Later in life he stated: e... as a medical student 1 got the idea that gyrnnastics had to be the proper remedy which really had the ability to straighten crooked peoples. It had only to be suited to the particular aim and developed as an exercise in self-correction ... )) (1). The starting incident was that a young girl, a close relation of Kjalstad (1) Forhandlinger ved De Skandinaviske Naturforskeres 7. Mete i Christiania 1856 (1857). Christiania, Carl C. Werner & Comp., p. 445; KER, F. C. (1887). Norges Lager i det Nittande Aarhundrede, Christiania, Alb. Carmermeyer, p. 609. The First Stage of the History of Orthopaedics in Norway 75 who his family had taken daily care of, developed a serious curvature of the spine. Kjalstad tried to teach the girl to correct the curvature herself, by physical exercises. According to his own statement she was completely cured. Having passed his medical degree Kjalstad only sporadic got the opportunity to develop further the new therapy. It took ten years before he chose to appear in public as orthopaedist. In 1838, however, he used the first months of the year to intensive self-tuition of available orthopaedic literature. The sixth of june he advertised for patients and opened, as the first ,physician in Nonvay, an orthopaedic institute located in the small town Lillehammer. The announcement caused quite a sensation and the responses were not altogether positive. Kjalstad was accused of immodesty, foolhardiness, charlatanism, etc. (2). 3. THE ESSENTIAL FEATURES OF THE THEñAPY On the Continent specialized orthopaedic institutes were established in the last decades of the eighteenth century. The institutes focused their attention on the different techniques for the straightening out of spine curvatures. The reason that this disease seemed primarily to strike women, especially teenage girls, was much discussed in orthopaedic and medical circles. The reports from the Nonvegian institutes confirm that they were no exception, they mainly received girls and women with spine-diseases, suffering for the most part from scoliosis. The patients distribution on age indicate a gradual shift towards an increasingly marked accumulation of teenagers (3). This may have been due to a common assumption at the time that among the patients suffering from scoliosis, the teenagers had the best prognosis. In contrast with most foreign institutes where mechanical pressureand tractiondevices were the most dominating elements in the therapy, Kjalstad developed a form of treatment where the patients by particular physical and muscular exercises should straighten out the crooked spine themselves. (2) KJaLSTAD, G. (1849). Orthopadiske ephemerider, n.* 1, Christiania, Carl C. Werner & Comp., p. 29. (3) Zbidem; TIDEMAND, A. (1876). Distriktslege Kjelstads Selvretningsorthopadi, Christiania Chr. Schibsted, p. 46; SALVESEN, J. M. (1855). Det orthopzdiske Institut i Bergen. Norsk Magazin for Lagevidenskapen, Forhandlingene, pp. 157-172, 301-318. 76 JAN FROESTAD A total cure consisted of six hours of daily exercise, three hours in the morning and three in the afternoon. The therapy started normally with ten minutes of standing mechanical traction in a device so construct:ed, according to Kjalstad, that the degree of extension depended on the platients ability to self-correction. Every day two such tractions in a standing; position was carried out. The essential element of the therapy, however, was the socalled «foot-walk-. It consisted of a very slow walk, where the weight of the body was gradually moved from one foot to the other, whilje at the same time the patient tried by image to keep the body in a so stretched out position as possible. After ten minutes of walk, the patients were allowed ten minutes of rest on a bed, lying on their back. In additian, during the three hours of exercise two short mechanical tractions in bed rest was undertaken. According to Kjalstad only to aid the method of self-correction. 4. THE THEORETICAL FOUAÍDATION OF THE THERAPY The orthopaedist Gunder Kjalstad regarded the spine (curvature as a bodily collapse caused by the weight of the upper part of the body on the spine. This weight had in his opinion won over the forces which normally kept the body stretched out. The task of the orthopaedist was thus to awake these dozing forces. The right method for this was the therapy of selfcorrection, also called the therapy of mental gymnastics. Usirig this method implied, according to Kjalstad, that «... the Mind and Matter flows together in the selfs Consciousness to One and Unity ...* (4). By thiis peculiar spiritual-physical method the forces which had the ability to straighten out the crooked spine should be activated. Tl~e orthopaedics of self-correction was a method where the physician urged the patient to straighten himself out as much as possible, and to keep himself in this extended position. Severa1 sources have stressed Kjalstad's own ability in this field, figuratively speaking he has been described as being able to «electrifyv his patients during the exercises (5). According to Kjalstad, however, the strength of will was not in itself sufficient to straighten out the patients. A suitable method was necessary, (4) KJDLSTAD (1849), op. cit. (n. 2), p. 6. (5) LUCHE, S. (191 1). Norsk Medicin i Hundrede Aar, Christiania, Steenske Bogtrykkeri, p. 133. The First Stage of the History of Orthopaedics in Norway 77 the so-called cpointuation)). This essential method consisted of imagining different points, especially the vertex-point, the heel-point and the toepoints. During the physical exercises the patient had to strive to assume a position where an imaginary vertical line drawn through the vertex-point and the navel touched the so-called bow-point between the heel-point and the toe-points. Gunder Kjalstad tried to make his theories and method more scientific with some peculiar mathematical and geometric arguments. For instance he insisted on the significance of the so-called sgeometric element» as a .sixth human sense, positioned in the navel, and the «ideal principie» comprehended as a line drawn from the zenith of heaven through the human axis to the centre of the earth, and the importance of the individual human being's specific weight in its relation to the centripetal force, as the qinstinct of self-preservationx (6). In this manner Kjolstad's own theoretical interpretation of his therapy indicate a clear bent towards nature-philosophical reflections. 5. THE SPREAD OF THE THERAPY Kjalstad's activity got offshoots in Christiania and Bergen. The following institutes, al1 practising Kj~lstad's method of seif-correction, were in operation in shorter or longer periods from 1838 towards the turn of the century (7). Period: Number of institutes: Directed by: 1838-1847 1 Dr. Kjolstad 1847-1 850 3 Dr. Kjolstad, Dr. Tidemand, Dr. Salvesen 1850-1 855 2 Dr. Kjolstad, Dr. Salvesen 1855-1 860 1 Dr. Kjolstad 1860-1862 1 Dr. Tidemand (Miss Dina Brown*) 1863-1865 O 1866-1 869 1 Dr. Tidemand 1869-1883 2 Dr. Tidemand, teacher Stokstad 1883-1 897 3 Teacher Stokstad, examinee Kjolstad, Miss Tidemand and Miss Gundersen (*) Miss Brown did not have her own institute. She was a former assistant of Salvesen who practised in Bergen in the 60s. (6) KJ0LSTAD (1849), op. cit. (n. 2), pp. 1-25. (7) Tidssknp for paktisk medzcin (1888), pp. 345-350. 78 JAN FROESTAD The oirthopaedics of self-correction had its flourishing period in the years between 1847 and 1850, with three institutes in operation, al1 directed by fully qualified physicians. Both Dr. Salvesen and Dr. Tidemand had learned the method as assistants of Kjolstad at his institute, Dr. Salvesen had also undergone a treatment for his crooked spine by him. Five years later only Kjolstad's institute was still in operation. After his death in 1860 the orthopaedic enterprise was tried continued by Dr. August Tidemand, until also this institute was closed in the fa11 of 1862. Three years later Tidemand resumed his orthopaedic work and was able to keep it up until his death in 1883, the first six years by means of public grants. In 1869 a new institute was established in Bergen, by the teacher Cristian Stockstad, an earlier patient of Kjolstad and assistant of Tidemand. Afteithe death of Tidemand the therapy of self-correction was maintained for some years, but now entirely by orthopaedics without formal medical education. Stockstad continued his enterprise in Bergen, assisted by some of the physicians in the town, Dr. Tidemands institute was maintained by his two assistants, one of them his daughter. At the same time the examinee Thorvald Kjolstad, the oldest son of the founder of the method, opened an orthopaedic institute iii the capital. During the 70s and especially after 1880, however, other forms of treatments, notably the various forms of physiotherapy, became the fashion (8). 6. THE VALUATION OF THE METHOD OF SELF-C0RREC:TION: FROM SCEP3rICISM TO APPROVAL The success of new medical therapies is usually contingenit on the social valuation of them. As the following account indicate the approval of the therapy of Kjolstad was in particular dependent on the assessments of the medical profession, the state and the public. 6.1. The evaluations of the medical profssion The first three years of his orthopaedics the attitudes towards Kjolstad's (8) Tidssknft for Den Norske Lcegeforening (1897), p. 41 and (1903), pp. 743-744; PIENE, R. D. (1979). Mellom beskjeftigelse og profesjon. Utvikling av sykegynznastyrket fram ti1 offentlig autorisasjon, Universitetet i Troms0, pp. 4447. The First Stage of the History of Orthopaedics in Norway 79 enterprise was negative, both with the public and with the medical profession. One reason for the professional scepticism might have been due to the method's distinctive new and original features. Severa1 conditions indicate, however, that this was not a very determining factor. The reason that Kjolstad in the beginning of his orqopaedic career was met with suspicion seems to be that he violated a standard for medical work which at that time was active in the medical profession, at least in the leading medical milieus. The fact is that JSjolstad instructed his patients not to express themselves about the cure and its effect, and kept secret his own experiences. This practice seems to have violated some ideals about frankness and the importante attached to a systematic valuation of the effects of new therapies. The activity of Kjolstad was discussed in the medical association in the capital in 1841 and more information about his method and its effects was expressed to be required. In july this year the editor of the Weekly reviezu of medicin and pharmacy called attention to Kjolstad's enterprise and characterized his practice as edecidedly unworthy. a medical practitioner. The editor indicated that the public medical authorities ought to take an initiative to get hold of the long wanted information (9). Kjolstad's own justification for his concealment was evasive and peculiar. Al1 the same he stated: C.. no deadly power will force me to speak where 1 can and ought to keep silent ... 9 (10). The reason for the whole episode seem to have been that Kjolstad was still uncertain as to the effects of the cure and wanted to keep the results secret until he with greater confidente could argue for its suitability. Gradually, however, Kjolstad must have felt the pressure put on him by his profession. A short time after the criticism of his practice by the editor he declared in a capital newspapers that he exempted his patients from their promise of secrecy. There are indications that the professional attitudes towards Kjolstad's therapy at that time was changing. One physician stated in the review, with regard to the cure: ethe effects seems, al1 considered, to be positive ... many patients shall have become considerably better and some even fully cured .. .» (1 1). Another physician accounted for ebrilliant effects» with regard to isolated cases (12). Having given up to keep secret his experiences, in the (9) Ugesknift jor Medicin og Pharmacie (1842), n."8, p. 256. (10) KJaLSTAD, C., quoted in: Ugeskn? jor Medicin og Pharmacie (1842), n." 28, p. 256. (11) Ugesknift jor Medicin og Pharmacie (1842), n."9, p. 380. (12) Ugesknift for Medicin og Pharmacie (1842), n." 50, p. 405. 80 JAN FROESTAD decade from 1842 Kjolstad took a lot of initiatives to get the therapy approved by the medical profession. In the fa11 of 1842 he got ~wo colleagues to evaluate the therapy. The physicians oversaw the cure for half a year, and stated subsequently in the newspapers that one third of 34 cases had been comlpletely straightened and that al1 the patients, with one possible exception, had improved their large and often very old curvatures (13). In 1844 Kjolstad held a lecture about his orthopaedic method at the ~Fifth meeting of the Scandinavian nature-scientistss. On this occasion, however, he did not succeed. The lecture was characterized as efirmbling with philosophiical and mathematical phrases .... (14). This experience seems only to have led Kjolstad to intensify his campaign for the therapy of self-correction. In the following years he at severa1 occasions tried to demonstrate to the medical association iin the capital, with the uise of plaster casts, the effects of his cure. He also got in touch with the medical association to have a committee of physicians appointed to evaluate the therapy. The deliberate intention was to attain a statement from the committee to be used at the sixth meeting of the scandinavian nature-scitzntists in 1847, where he once more tried to give an account of his therapy. On this meeting Kjolstad distributed the committee's statement, which was positive but not very concrete regarding the effects of the cure. Two of the physicians of the committee gave an additionial statement, declaring that they had witnessed the straightening out of severe cases of curvatures,. in a degree they had not thought was possible (15). It was probably more important, however, with regard to the recognition of Kjolstad, that it was some of the most distinguished physicians in Nonvay that made these statements. At the meeting Kjolstad also distributed declarations from the other medical orthopaedists in Nonvay, Dr. Tidennand and Dr. Salvesen, which stated that the therapy was superior to other orthopaedic techniques. In addition he demonstrated the effects of the cure with the help of plaster casts. According to Kjolstad's own statement his lecture and exhibitions at the meeting was highly accepted and he at last obtained the recognition he had long hoped for (16). In the next years Kjolstad was able to contribute to some more positive (13) KJ0LSTAD (1849), op. cit. (n. 2), p. 49. (14) LAACHE (1911), op. cit. (n. 5), p. 132. (15) KJ@L,STAD (1849), op. cit. (n. 2), p. 59. (16) Zbidem, p. 53. The First Stage of the ~istory of Orthopaedics in Norway 81 statements about his therapy and in 1849 he published a book about his orthopaedic method and theory, with al1 the advantageous statements from other physicians included. He also got in touch with the medical association in the capital to see that it continued its evaluation of the therapy. The committee's final statement was made in 1852. It declared that the patients had been extended about one inch lying down and a little more than one and a half inch in a standing position. Regarding the effect of the therapy on the patients general health the committee stated that it seerned to be very advantageous (1 7). When Gunder Kjolstad opened his orthopaedic institute in 1838 he was met in the surroundings by scepticism and suspicion. Gradually the attitudes changed and his method achieved considerable fame as a well suited therapy for the treatment of ~crookedn. Many of his colleagues and some of the most credited physicians in Nonvay also declared themselves in favour of the method. The professional attitudes towards Kjolstad's therapy seem to have altered chronological in the following manner: Period: Attitude: 1838-1842 Scepticism, rejection 1843-1 846 Some acceptance 1847-1 85 1 Approval 1852-1860 Regarded as a superior therapy After the death of Kjolstad in 1860 August Tidemand was regarded as the most competent orthopaedist in Norway. Otto Lund, the chairman of the medical association in the capital, spoke of Tidemand as e... the person that with us is the greatest authority in this matter ... » (18). The orthopaedic activity of Tidemand was discussed severa1 times at the meetings of the medical association during the 60s. It is evident from the reports that his orthopaedics was generally approved. On one occasion, however, the physician Joachim A. Voss drew attention to the fact that the acknowledged Danish orthopaedist A. G. Drachman had declared that the therapy of selfxorrection was a figment. Drachman had stated in a Danish medical journal: (17) Norsk Magazin for Legeuidenskapen, Forhandlingene (1852), p. 265. (18) LUND, O. quoted in: Norsk Magazin for Legevidenskapen, Forhandlingene (1867), p. 176. 88 JALN FROESTAD 1850-1857: The arrangement of ((confidential principal» was extended to an advisory committee with some room for independent initiatives - professor Conradi was appointed chairman of thie committee, appointed as additional members were Frans Christian Faye, professor of medicine and Henrich Steffens, chief physician. 1858-18'74: An office of deputy secretary with medical kniowledge was founded in the departrnent of interna1 affairs, as head of the health service - appointed was the physician Christian Kierulf, the former secretary of the advisory committee. In this context it is not the gradual strengthening of the medical professional element in the central state bureaucracy that is the most interesting feature, but the fact it is possible to relate al1 the physicians that was appointed to these offices to statements or initiatives in favour of Kjalstad or Tidemand. The professor Carl Wilhelm Boeck participated in the committee appointed by the medical association to evaluaite the therapy of Kjolstad, and with the physician Otto Lund he gave a very advantageous supplementary statement of its qualities at the meeting of the Scandinavian nature-scientists in 1847 (31). The chief physician Heinrich Steffens assisted Kj0lstad at the meeting so that he was able to show a big case of plaster casts to illustrate the effects of the cure (32). The professor Firans Christian Faye also involved himself in favour of Kj~lstad at this meeting. He personally requested the acknowledged Danish orthopaedisa Johann Christian A. Bock to carry out experiments to document the value of the therapy of Kj0lstad (33). Professor Conradi was among those physicians expressing themselves most in favour of the orthopaedics of Tidemand in the 60s. As mentioned it was Conradi who suggested to use the authority of the medical association to obtain public grants to the enterprise of Tidemand (34). The physician Christian Kierulf also involved himself in this initiative. Kierulf had himself a strong professional interest in orthopaedics. In 1852 he published a paper on the causes and treatment of the spine curvatures. As will be (31) KJ0LSTAD (1849), op. cit. (n. 2), p. 59. (32) Zbidem, pp. 52-53. . (33) FAYE, F. C. quoted in: Forhandlinger ved De Skandinaviske Naturforskiwes 5. M@te i 1847 (1849). Kabenhavn, Gyldendalske Boghandling, p. 917. (34) CONRADI, A. C. quoted in: Norsk Magazin for Lcegeuidenskapen, Forhandlingene. (1863), p. 101. The First Stage of the History of Orthopaedics in Norway 89 elaborated later he in this work pictured the orthopaedics of Kjolstad as a superior therapy (35). It follows that the state's financia1 support of the orthopaedics of selfcorrection both was related to the fact that this therapy obtained the approval of the central medical milieu in Norway and to the circumstance that leading members of this milieu, al1 positive in their attitude to the therapy, occupied the positions as medical experts of the central bureaucracy in this time period. It seems likely that the attitudes and involvements of these professionals with regard to the orthopaedic enterprises of Kjolstad and Tidemand in a large measure were conducive to the recommendation of the department to meet the requests for public grants. 6.3.' The appreciations of the clients and the public How did the clients view the therapy? Regrettable, there is less information left to throw light on this issue. It has been claimed, however, that the therapy of self-correction got a reputation among people as a suitable therapy for the treatment of ~crookedn (36). The approval of the cure must be assessed in relation to the variant therapies available to the patients at the time. It seems reasonable to assume that the protracted mechanical pressure and extension-therapy usually must have involved long and heavy sufferings. It was claimed that the cure in many instances was injurious to health. As distinct from this cure, the therapy of self-correction entailed that the patients were allowed to move about and they were instructed to do physical exercises that probably had a favourable effect on their general health. The orthopaedics of Kjolstad, however, was no bed of roses. The therapy required great patience and tenacity of the patients. Both Kjolstad and his colleagues complained as to how difficult it was to sway the patients to be sufficiently persistent during the therapy. Rumours spread on how tough the cure was and how strict the teacher could be. In 1856 Kjolstad found himself obliged to make a public pronouncement stating that he intended (35) KIERULF, C. T. (1853). En kritisk Fremstilling af de forskjellige Meninger om Rygradskrumningens Aarsager og Behandling. Norsk Magazin fw Lcegevidaskapen, Forhandlingene, p. 87. (36) Zllustreret Nyhedsblad (1857), n." 30, p. 152; (1860), n.", p. 30. 90 JA,N FROESTAD to found an association of elderly ladies to supervise the iinstitute. The statement was concluded by the names of 26 venerable ladies of the bourgeois, al1 engaged in social work (37). This may indicate that the method of self-correction never became as popular with the public as with the medical profession. The fatiguous and strenuous features of the therapy may have been a reason of the seemingly decreasing popularity of the cure in the 1870s, as other more pleasurable forms of physiotherapy came into fashion. The general impression is still that the therapy of self-correction during the two decades from about 1840 obtained a recognition in Norway as a well suited and even superior method for the curing of crooked spines. In what follows I will emphasize some circumstances which may have contributed to this approval. No attempt will be made to weigh the relative significance of the different conditions revealed, or to trace the relations between them. This would have required a more theoretical informed analysis, which is not the airn in this round. 7. PREVAILJNG IDEOLOGICAL TRENDS There is an enchanting affinity between the teaching and theory of Kjolstad and the prevailing ideological trends in Norway in the period from 1840 to 1870. In this time period pietism attained hegemony in i-eligious life and liberalism becarne the prevalent economic doctrine. Pietism emphasized the significance of asceticism as a way to purification and salvatia~n. Analogous, Kjolstad regarded comfort, indifference and frivolity to be vices of grave danger to his therapy. He stated: <<As in Divine, Religious and Moral life indifferentism is the most cunning and dangerous Enemy, as well as here in the orthopaediic life ... >> (38). The ideology of liberalism stressed the necessity to distinguish between the worthy and the unworthy in the society and t6 restrict the public commitment. Only the worthy ought to have certain rights of public support and the relief ought preferably to be given as a way to help pieople to help themselves. The theoretical basis of the method of self-correction highlighted (37) Byminner (1982), nr. 1, p. 6. (38) KJ0LSTAD (1849),. op. cit. (n. 2), p. 9. The First Stage of the History of Orthopaedics in Norway 9 1 the significance of the patients own effort and persistence and seems to have been well adjusted to the prevailing liberal ideas. Tidemand stated: ~Self-help is the claim of our time. In the same manner, however, as the lack of will to help oneself, if this is possible, make the person unworthy of the support of others, upright aspire to relieve one's own distress by work and diligence, constitute the essential conditions for progress in the relevant cause. To bring this principle to bear within a branch of the practica1 oriented medicine, this was the idea of our compairiot, the deceased medical officer of health, Gunder Kjolstad .... (39). It seems reasonable to assume that some of the theoretical reflections of Kjolstad and Tidemand, well adjusted to the prevailing ideological trends, must have had a legitimating effect with regard to their orthopaedic activity. It remains to be examined, however, if this accommodation is maintained as to the professional development in the same period. 8. A METAPHYSICAL THEORY IN A METAPHYSICAL MILIEU Gunder Kjolstad's philosophical and partly religious reflections was not accepted without restraint by the medical profession. His lecture at the meeting of nature-scientists in 1844 was not received with enthusiasm, as mentioned, because of his tendency to philosophical and mathematical expressions. The general impression is still that the nature-philosophical theories of Kjolstad to some extent was fully accepted by his colleagues, othenvise considered as a necessary element of his method. The chief physician Otto Lund, later chairman of the medical association in the capital, stated in 1842 that Kjolstad's therapy seemed to be «... based on a more accurate understanding about the principles for the treatment of spine curvatures ... D (40). The corps physician Thorvald Wetlesen stated at about the same time that the method c... seems to be based on a comprehension of the actual character of the crooked spine ...n (41). A medical prize paper on the different opinions of the causes and (39) TIDEMAND (1876), op. cit. (n. 3), p. 1. (40) LUND, O. quoted in: Ugeskrift for Medicin og Phamzacie (1842), n.90. (41) Wetlesen, T. quoted in: KJ0LSTAD (1849), op. cit. (n. 2), p. 49. 92 JAN FROESTAD treatment of the spine curvature was published in Norway ir1 1852 by the physician Christian Thorvald Kierulf. It is likely that the account was based to some extent on the experiences of Kierulf as army surgeon in the war between Denmark and Germany in 1848 and as surgeon at the'field hospital in Augustenborg during the armistice. In his description Kierulf represented the orthopaedic method of Kjolstad as a superior therapy. Regarding Kjdstad's philosophical and religious reflections IKierulf stated: «lt seems to me that a lot of this has to be a part of his method and not without harm can be separated from it ... al1 this mystical speech that he intensely impresses his pupils, make their whole spirit oriented on him and as a result they keep their minds on the teachings, remember the purpose and never forget the self-straightening ...a (42). Kierulf obviously did riot regard Kjdstad's reflections as entirely scientific valid, but considered them al1 the same as an essential therapeutic measure, and as a well suited method to evoke the spiritual force of the patient. The essential ideas of Kj~lstad, on which he based his orthopaedic method, the conception of an intimate link between the rmind and the body and the idea of the significance to activate the spiritual-physical force of the patient, seem for the most part to have been accepted by the medical profession in Norway, and by many acknowledged physicians considered as the one right principle for the cure of the spine curvature. This approval is easier to understand if it is realized that although medicine at the middle of the previous century had taken a step towards an empirical based science, many of the traditional met:aphysical and nature-philosophical reflections survived and continued to constitute the base of many therapies. The new scientific orientation did not give fast profits in the form of new and more efficient therapies. The modern, empirical based medicin was for a long time characterized by biological basic scientific research within the fields of anatomy, physiology and pathology, while most of the medical cure was still based on the classical, holistic teachings of the ~iddle Ages, regarding illness as a result of an intermption of the liquid balance of the human body. There are some enchaniting similarities between this teaching and Kjolstad's own reflections of the spine curvature, regarding it as a result of an uneven division of the bending and straightening (42) KIERULF (1853), op. cit. (n. 35), p. 91. The First Stage of the History of Orthopaedics in Norway 93 forces in the human body,' emphasizing the significance of the unity of mind and body in the therapy. One reason that his theory and method did not meet with more resistance may be related to the fact that it 'matched nicely to some fundamental, though maybe receding, perspectives on health, illness and treatment. In the Norwegian medical milieu many of the traditional conceptions was still viable, among them the common assumption of constitutio epidemica - the idea that unknown atmospheric forces had great influence on the spreading of epidemic diseases -, or the presumption that it was possible to transfer illness from human beings to animals, not to mention the faith of many recognized physicians in a lot of different healing remedies like rings and ointments against arthritis (43). This indicates that the distinction between formal medicin and the quackery was not very sharp in the middle of the nineteenth century. Against this background it is easier to comprehend why the theoretical reflections of Kjdstad did not give rise to eager objections. For a medical milieu that still had strong links to nature-philosophical conceptions it was not hard to accept a new therapy based on similar reflections. 9. THE NEW IAG'ORTANCIE ATTACHELI TO PHYSICAL EDUCATZON During the nineteenth century people's attitudes towards the body and the importance they attached to the health of the body experienced a marked change. As a result of the interaction of a number of social forces the society's prejudice viewing the body with a lot of contempt and suspicion, was shaken. The alteration of these attitudes has been seen in relation to such various circumstances as the new doctrine of man and nature propounded by Spencer and Darwin, the diffusion and popularization of the new insight into the medical fields of pathology and physiology, the new inquires into the living conditions and physical sufferings of the working classes and, in some countries, the particular interest of the state to have military recruits of strong physique (44). (43) GR@N, F. (1933). Det norske medin'nske selskap 1833-1933, Oslo, Steenske Bogtrykkeri Johannes Bjornstad A/S, pp. 60-92. (44) CRUNDEN, C. (1981). The concept of the body. Zn: MCNAIR, D.; PARRY, N. A., Readings in the Histo~y of Physical Education, Hamburg, Verlag Ingrid Czwalina. 94 JAN FROESTAD Simultaneously to these changes in the conceptions of health and body, a new attitude toward the importance of physical education developed. A clear indication of this alteration is the introduction of gymnastics in the schools. In Norway, during the entire century, the teachers of physical training was recruited almost exclusively from the non-commissioned officers of the military. As early as 1805 the corps of chasseurs sent an officer to the military institute of gyrnnastics in Copenhagen. Not until the 1850s, however, was physical training introduced at the primary schools in the towns, twenty to thirty years later at the schools in the country. At the colleges of education gymnastics were introduced during the 1860s. llere too, the teachers were officers of the military. In 1861 the «Central association for the spreading of physical exercises and the use of arms» was founded. This organization took a leading role in the promotion of physical education in Norway, both at schools and in other institutions. In 18'70 the «Central Public School of Gyrnnastics~ for the education of teachers of physical training was founded in the capital. Kjolstad introduced his variant of physiotherapy in a time period distinguished by a radical alteration of the popular attitudes towards the body and the health of the body. Throughout the century tlie importance of physical training and athletics for health reasons was payed attention to an increasing extent. It seems likely that this development offered favourable conditions for medical therapies emphasizing the significance of movements for the prevention and cure of diseases and deformities. In respect of women's participation in sport and phj~sicai training, objections was raised in Norway as in other countries that this would be injurious to health or that it was the antithesis of womanhood. The Nonvegian orthopaedists claimed, however, that the method of self-correction showed unique qualities even in this field. Dr. Salvesen, the former student and assistant of Kjolstad, stated: «The objection have been raised to gymnastics that it is improper for young girls, unwomanly and destructive to the female ideal in beauty. This objection, however, does not at al1 apply to the gymnastic method invented by Kjolstad. This method ought;in my opinion, 1:o be introduced in every school for girls ... (45). (45) SALVESEN (1855), op. cit. (n. 3), p. 317. The First Stage of the History of Orthopaedics in Norway 95 It seems likely that the new attention payed to physical education contributed to the approval obtained by Kjolstad. With regard to the military physical training, however, it is possible to establish a more specific relation to his therapy. In his period of study Gunder Kjalstad was appointed squadron surgeon at the corps in the district of Telemark. This office he hold for one and a half year posted in Kristiansand, participating also in the camp of Swedish and Norwegian troops in Skine in 1824. In 1828 he was appointed corps physician at the musketeer corps of the district of Hedemark, until he in 1836 was appointed medical officer of health for the southern district of Gudbrandsdalen. Kjolstad had, as many of his colleagues, a military career before he settled for a civilian office. It is most likely that he was influenced by the military physical education when he began to develop his orthopaedic method, in particular by the military keep-fit exercises. This gymnastics had a Iong tradition and, according to an instruction book from 1872 the intention was «... to develop and strengthen the Soldiers limbs and increase his control over them ...» (46). There are some alluring similarities between the therapy of self-correction and some of the reflections the military gyrnnastics was based on, as indicated by the following quotation from the instruction book: «... by the contraction of it the muscle is exerted, and by repetition of . - this exercise experience is gained, the muscle is strengthened and it is brought under the control of will ... (47). Within the method of Kjalstad it was the foot-walk, the most essential part of the therapy, that most clearly indicated the connection to the physical dril1 of the military. The foot-walk was arranged as an organized form of exercise where the patients were divided into two rows and moved themselves under the orders of the therapist. As the orthopaedist sounded the number «one» both rows of patients raised their heels as high as possible and stood tiptoe until the number «two» was sounded. Now the patients moved their right foot forward and down at heel. As the number Nonen once more was sounded the patients again had to raise their heels (46) Instruktion i Gymnastik og Bajonetfegtning for Infanteriet (1872), Christiania, p. 1. (47) Ibidem, p. 5. 96 JAN FROESTAD and stand tiptoe until they now moved their left foot fonvard and down at heel as the number ~two. was sounded, and so on (48). Military background was not, however, something that distinguished the career of Kjolstad. In the first half of the nineteenth ceiltury most of the medical practitioners in Nonvay were employed by the military for a shorter or longer part of their professional career. In the 1830s about one third of the physicians had military appointments (49). There is reason to believe that this common experience with the military physical education constituted an additional factor contributing to the approval of Kj~lstad. 10. THE MUSCULAR THEORY In the last decades of the eighteenth century specializeti orthopaedic institutes were established in severa1 of the continental cities. In the first phase of this development of orthopaedics as a distinct therapeutic field, the assumption was that accidents like falls and blows or, more common, poor deportment when walking or sitting, were the principal causes of the spine curvatures. Postura1 faults, one assumed, could entail that some groups of muscles contracted, with a wryness of the spine as the inevitable result. Stretch-bandages, pressure-corsets, lifeand breast-belts were correspondingly considered to be suitable correcting remedies. A reaetion to this assumption developed within the next decade. In some ortbopaedic milieus the presumption gained confidente that it was diseases in the bones and the softness of the bones that caused the crooked spines. According to this theory the use of stretch-bandages and life belts could affect the bone structure and give rise to wryness. As a result the therapy increasingly took the form of ueatment by long laslting horizontal bed rest, usually combined with pressure and extension of the body. Gradually this became the dominant cure at most orthopaedic institiltes, a therapy often utilized for severa1 years and as the only remedy to straighten out the spine. The constant use of the bed rest, however, had a very bad influence on the patients general health. The orthopaedists tried tol remedy these defects by different therapeutical adaptations like the supine position on (48) Forhandlinger ved De Skandinaviske Natufoorskeres 7. M0te i Christiania i 1856 (1857). Christiania, Carl C. Werner & Comp., p. 466. (49) LARSEN; BERG; HODNE (1986), op. cit. (n. 29), p. 350. The First Stage of the Histoof Orthopaedics in Norway 97 an inclined plane or on a plane that could be switched between a horizontal and a more vertical position. The orthopaedic field in the eighteenth and nineteenth century was characterized by many different theories and schools of thought and by an often bitter and lasting conflict between the different milieus. The various therapies seem, however, to have been guided by one of two basic considerations. The bed rest, combined with pressure and extensiondevices, was particularly utilized by those who sought the causes of the spine curvature in the bones and vertebras of the body. Rival milieus took to a greater extent the muscular system of the body as their basis. It had been noticed that most of the crooked spines was bent fonvard to the right. This observation led to the development of a theory that the spine was easily affected if an uneven muscular force acted on it. It was known that the muscles on the right side of the body usually are suonger and more advanced. It was thus supposed that the muscles on the concave side of the curvature had defeated its left adversaries and contracted. The muscles on the convex side of the curvature had been extended correspondingly and had lost much of their force. This theory legitimized the development of therapies that emphasized the significance of restoring the muscular balance of the body. l In 1828 the acknowledged French orthopaedist Jaques Mathieu Delpech published a work where he rejected the long and continuous bed rest and introduced gymnastics and bath as means to strengthen the weakened muscles of the patients. In short time physical exercises were introduced as a preventative remedy at most orthopaedic institutes. Gradually this led to the development of more specialized orthopaedic gyrnnastics, of which the physiotherapy of Pher Henrik Ling in Sweden became the most famous. The intension of this therapy was, by the execution of accurate physical exercises, to strengthen specific groups of muscles in such a way that they could counteract the force of the opposite muscles and draw the spine into a natural position. When the physicians in Nonvay during the second or third decade of the nineteenth century began to take an interest in the orthopaedics, it was the muscular theory that had caught the wind. Gymnastics had already been introduced as a therapeutic or preventive remedy at most orthopaedic institutes. One of the first medical practitioners in Nonvay that took an interest in the spine curvature and its treatment was Christen Heiberg. Heiberg 104 JAN FROESTAD died hard, but had gradcially to give way to another perspective which in its different variants emphasized the congenital weakliness of girls and their unfavourable upbringing. Kjolstad himself seldom expressed his opinion regarding the specific causes of the crooked spine. A statement he made in 1856, however, indicate that he went far towards accepting the theory o€ the female weakliness. With regard to the weakening of the spine he stated that it often seemed to be the effect of eyoung girls long and unscrupulous sitting at school, imposed both there and at home with too much intellectual work and needlework in proportion to their age and sex ...* (64). Kjolstad's assistant, Dr. Salvesen, expressed himself in a similar manner: .. . how easy the one-sided strive for the tender girls intellectual education is done at the expense of her physical health and due to this break down her figure ... » (65). The theory of the female weakliness combined with to much sedentary work as a main cause of the crooked spine seems gradiially to have been accepted by most orthopaedic and medical milieus. Regarding the most prevalent curvatures of the spine Christian Kierulf stated i,n 1852, with reference to the experiences at the orthopaedic institute at Tuborg in Denmark: N,.. normally, in fact almost without exception, it has a deeper cause and that is weakliness ... » (66). Regarding the evolution of scoliosis in these tender girls he claimed that it most often could be observed that «the curvature evolves at the time when their schooling is most exhausting ... >> (67). A decade later the acknowledged Danish medical orthopaedist A. Drachmamn expressed a similar opinion as he stated with regaird to scoliosis: «... it injures almost exclusively slight, pale, lean and weak girls and most often during the phase of fast physical growth ...» (68). In respect of the social distribution of scoliosis the orthopaedist claimed: (64) KJQLSTAD, G. (1857). En nzermere Forklaring .over Selvretningsmethoden, end hidtil er givet gjennem det skriftlige og trykte Ord. In: Forhandlinger ved De Skandinaviske Naturforskeres 7. M0te i Christiania 1856, Christiania, Carl C. Werner ,Se Comp., p. 450. (65) SALVESEN (1855), op. cit. (n. 3), p. 317. (66) KIERULF (1853), op. cit. (n. 35), p. 781. (67) Ibidem, p. 11. (68) DRACHMANN, A. quoted in: Bibliothek for Lczger (1861), p. ,95. The First Stage of the History of Orthopaedics in Norway 1 O5 «It exists principally as a cultural disease in larger places and among the well-to-do classes that educate their children in a soft manner and keep them to teaching and long sedentary work at an early age .... (69). This review indicates a favourable relation between the theory of the female weakliness, the therapy of self-correction and the growing ambitions of the medical profession at the middle of the nineteenth century. The orthopaedics of Gunder Kjolstad became attractive not only because of its suitability to prevalent ideological and theoretical trends but as well owing to the fact that the method, in a period where the medical profession had the ambition to assert itself in new fields, could be used as a prophylactic, as contrast with the mechanical therapy. Kjolstad had the vision that the therapy of self-correction ought be made general, it ought in his opinion to become an essential part of education, both in the family and at school. In that case Kjolstad had the conviction that .al1 curvatures like al1 powerlessness, weakliness, sickliness and a lot of specific diseases will vanish from earth ...w (70). Within the medical association questions relating to school hygiene were subjects of discussion, particularly in the 1830s and 1860s. In 1835 the Norwegian professor Frederik Holst claimed that the schools for girls had an injuring effect on the pupils health and put forward as evidence the fact that the pupils were less of growth than girls that did not attend school. He argued that the physicians ought to involve themselves in this matter (71). The therapy of selfcorrection did not only have a potential as a prophylactic, the Norwegian orthopaedists took concrete initiatives in that direction. In 1849 the former assistant of Kjolstad, Dr. Salvesen, introduced a preventative physiotherapy for young girls at his institute in Bergen. Most of the girls, but not al1 of them, suffered from small curvatures. In cooperation with the theologian Dahl he also succeeded to bring in physical exercises of selfcorrection at the largest school for girls in the town (72). Kjolstad, on his side, gave orthopaedic cure by the hour, chiefly with a preventative adaptation, designed for patient with small or incipient curvatures (73). (69) Zbidem. (70) KJ0LSTAD (1849), op. cit. (n. 2), p. 9. (71) GR0N (1933), op. cit. (n. 43), p. 54. (72) SALVESEN (1855), op. cit. (n. 3), pp. 316-318. (73) KJDLSTAD (1849), op. cit. (n. 2), p. 11. 106 JAN FROESTAD The growing interest of the physicians in Nonvay in school hygiene, the focus of the theory of female weakliness on the unfavourable effects of protracted school attendance and the apparent preventative qualities of the method of self-correction, it seems likely that the combination of these circumstances contributed to the acknowledgement that Gunder Kjolstad obtained. It follows that the attraction of his orthopaedics maly be related both to the wish of the physicians to reinforce their control of this therapeutic field and to the growing ambitions of the medical profession to expand the field of activity and societal influence of the occupation. 13. THE EFFICACY OF THE THEWY In 1897 the acknowledged German orthopaedic surgeon Albert Hoffa stated: «In my opinion, the problem of the treatment of scoliosis is the main problem of the orthopaedics of the future ... » (74). He seems to have been right. More than fifty years later the English orthopaedist OsmundClark stated: ~Scoliosis is remarkable for the stubbornness with which throughout the ages this deformity has defied explanation ... D (75). In 1981 the three recognised Arnerican orthopaedists T. Taylor, P. Gosh and G. Bushell, declared: «It is regrettable that the last two decades have not seen a single major advance in the treatment of scoliosis based on a scientific understanding of the aetiology and mechanisms of curve progression ... (76). The treatment of scoliosis seem for the bulk of the twentieth century to have been charactenzed by a shortage of scientific knowledge and a non-availability of a fairly reliable therapy. There is no reason to believe that this situation was any more advantageous in the middle of the previous century. At the middle of the nineteenth century, however, formal medicine was on the defensive not only with regard to the treatment of scoliosis. It has been claimed that the confidence in the physicians in Norway, during the first half of the previous century was impaired' and that large parts of the (74) LE VAY, D. (1990). The History of Orthopaedics, London, The Parthenon Publishing Group Ltd., p. 529. (75) Zbidem. (76) ' Zbidem. The First Stage of the History of Orthopaedics in Norway 107 population rather consulted the quacks. At the middle of the century the medical profession seems to have had zi lower status than ever before (77). . . It may be assumed that the recognition that Kjolstad and his orthopaedic colleagues obtained to some extent was tied up with the effects of their therapy. The evaluation of Kjolstad's activity by other physicians gave, as mentioned, a favourable result. Both his two colleagues that valued the method in 1842 and the committee appointed by the medical association in the capital, which made its final statement ten years later, spoke in favour of the therapy. According to the estimations of Tidemand, about 20% of the approximate 200 patients suffering from spine-curvatures he treated in the period from 1866 to 1874 were cured or nearly cured, another 60% were improved, while 5% did not benefit from the therapy. With respect to the remaining 15% the results were uncertain or the patients were not measured (78). This assessment correspond in the main to the evaluations of the practices of Kjolstad and Salvesen. It is not easy today to reckon the validity of these nineteenth century evaluations. It seems, however, that the physicians often payed serious attention as to the proper way to accomplish exact measures. The committee of the medical association stated: <<We soon realised how very difficult it is to obtain a fixed and accurate conception of, and to control the alterations, that the spine undergoes by orthopaedic treatment. Severa1 methods were tried ... We came to the conclusion to use plaster casts of the spine, and it was decided to take a cast of each patient at the intake and discharge ...), (79). Employing this method the committee concluded, as mentioned, that the patients had been extended an inch to an inch and a half on the average, dependent on wether the measures were done while the patients were standing or lying down. If these measures and evaluations are credited it is indicated that the effect of the treatment was favourable. Of no doubt, however, the medical milieu in Nonvay did credit these valuations and gradually came to consider the therapy to be both efficient and superior. (77) REICHBORN-KJENNERUD, 1.; GRaN, F.; KOBRO, R. (1936). Medicinens histmie i Norge, Oslo, Grondahl & S~ns Forlag, p. 125. (78) TIDEMAND (1876), op. cit. (n. 3), Beretning om anstaltens virksomhet fra 1-11-1866 ti1 31-12-1874, pp. 16-20. (79) Norsk Magazin for Lagevidenskapen, Forhandlingene (1852), p. 263. 108 JAN FROESTAD The approval of the method of self-correction, however, must be seen in relation to the other available therapies at the time. It is indicated that the physicians experienced that they had few remedies to suggest when faced with patients suffering from spine curvatures. The physician Wilhelm Boeck stated in october 1862: N... we are in our practice badly off with regard to the treatment of spine curvatures, and not many have the opportunity to send their children to the expensive institutes abroad ... (80). Moreover, the confidence in these institutes had been impaired due to the unfavourable effects of the protracted, bed-ridden mechanical extension therapy. As mentioned, Christian Kierulf claimed in 1852 tl-iat the young girls often returned frorri these institutes with a broken health. At least until the second half of the 1870s the medical profession, or at any rate the university teachers and the physicians in the capital, regarded the orthopaedics of Kjolstad as superior not only in comparison with the mechanical cure, but also as compared with other treatments like the Swedish physiotherapy. The physician Joachim A. Voss expressed at one of the meeting of the medical association in 1862 that he thought it unfortunate that Tidemand had been compelled to close his institute, andl stated: N... as a temporary expedient wle now have to refer the patients to ~physiotherapy or to the treatment by ellectrification at the hospital ...,, (81:). An institute for physiotherapy was opened in the capital in 1867 by the physician Tycho D. Lange. The discussions at the meetings of the medical association indicate, however, that the method of self-straightening had a higher status at least until the second half of the 1870s. Lange repeatedly complained that his colleagues did not show an interest in his work and did not refer patients to him that would benefit from physiotherapy. Without doubt, the therapy of self-correction was by far the most credited orthopaedic therapy irn Nonvay in this time period. The approval of the therapy must also be assessed in relation to the general curative ability of formal medicine in the previous ceritury. It ought (80) BOECK, W. quoted in: Norsk Magarinfor Lregeuidenskapen, Forhandlingene (1863), p. . 100. (81) Zbidem. The First Stage of the History of Orthopaedics in Norway 109 to be remembered, in this connection, that until the last decades of the century the physicians had no or very dubious remedies to suggest against the most common sufferings dominating every medical practice, the infectious diseases (82). Many of the therapies prescribed by the physicians were still to an essential degree based on the classic, holistic teachings of the Middle Ages, and the effects of their treatment were usually slight. The peasants did not normally seek their services. Formal medicine was no temptation owing to its efficacy and it frightened most people due to the cultural differences between the physicians and the public. Instead, they consulted the local quacks, whom they trusted. It has been claimed that the physicians had to be pushed the people by public offices and laws against quackery (83). The peasants fought this policy and succeeded in 1871 to liberalize the qiiack-law. Against this background it is easier to comprehend that the physicians, especially the university teachers and the physicians practising in the capital who were least reasonable towards the quacks, came to approve the orthopaedics of Kj0lstad. In the first place, it is no wonder that the physicians appreciated an attempt to introduce a new medical activity, previously dominated by layrnen. In addition, it is not unlikely that he therapy of Kj0lstad was a hit, compared to most of the medical work in the previous century. It is quite plausible that the method of selfcorrection, after some preliminary problems, came to be considered by the medical profession as a great success, as one of few opportunities to improve the status of the occupation. 14. THE SOCIAL COMPOSITION OF THE CLIENTELE In the period from 1847 to 1850 three orthopaedic institutes were in operation in Norway, al1 practising the method of Kjolstad. Thirty to forty patients were treated at the same time. The marlet for orthopaedic institutional treatment was, however, very restricted at least until the 1870s. This made it difficult to maintain the institutes. Dr. Salvesen, the former assistant of Kjolstad, stated that the treatment was often broken of too early, partly because of the impatience of the patients, but as often due to the limited (82) EVANG, K. (1955). Helsestellets utvikling i Norge i 75 ir, i. Tidssknj for da norske l~gejiiening p. 53. (83) BERG (1973), op. cit. (n. 62), p. 39. 110 JAN FROESTAD will or ability of the relatives to pay the expenses (84). To cushion these circumstances both Salvesen and Kjolstad were in many instances forced to reduce the regulated fee. Kjolstad stated: ((Economic conditions and other circumstances has made it impossible for many to make use of the ordinary cure ... in Norway the money have a too restraining effect on the orthopaedics ... far more would have been straightened it not the lack of money had prevented a longer cure ... >) (85). In spite of some pilblic grant the maintenance of the orthopaedic institutes in Nonvay was chiefly based on the fees from the loatients. Only a few places at the institiutes were reserved for patients of limited means. In the 60s, at Tidemand's institute the payment for the boardi was 48 N kr., a month, the washing of clothes not included. The cost of the treatment was 32 N kr. a month. It decreased to some extent, however, if the cure lasted more than half a year (86). It is highly probable that thie therapy was considerably cheaper than the earlier practice to send thie patients to recognised institutes abroad. Nevertheless, a cure at the instiitute was both long lasting and expensive. At that time the salary of teachers at the board schools in Bergen was about 1 .O00 N kr. annually, a male telegraph operator had an initial annual salary of 1.000 to 1.200 N kr., unskilled workers most certainly were payed far less (87). It may be assumed, without much doubt, that the cure at the orthopaedic institutes must have been far too expensive for most people. It is likely that the client basis was mainly constituted by patients from well-to-do families. This restricted the market for orthopaedic practice. Xt is plausible, however, that this influx of a high status clientele accounts for some of the acknowledgement that the orthopaedic institutes obtained. The professional approval of the therapy of self-correction has now been assessed both with regard to its apparent therapeutic qualities and the social composition of the clientele. It still remains, however, to consider how the recognition was tied to the shaping of the relatiori between the (84) SALVESEN (1855), op. cit. (n. 3), p. 159. (85) KJOLSTAD (1849), 'op. cit. (n. 2), pp. 11, 49-50. (86) Byminner (1982), n.* 1, p. 10. (87) HAGEMANN, G. (1992). Skolefolk. Lmernes historie i Norge, Oslo, Ad IlJotam Gyldendal a.s., p. 50. The First Stage of the History of Orthopaedics in Norway 11 1 therapist and the patient, as a consequence of some remarkable features of the method. 15. THE RELATION TO THE CLIENTS The physicians had, as mentioned, undoubtedly an ambition to bring the orthopaedic field back under the control of formal medicine. They had voiced severe criticism against the orthopaedic institutes, led by laymen. It may be assumed, however, that if the physicians had engaged themselves in this field without being able to show good results, the status of the occupation could easily have been further reduced. Fortunately, in this respect, the method of self-correction exhibited another sympathetic feature. It altered the relation between the patient and the therapist in a favourable direction. It is very much to the point that Kplstad translated the word ~orthopaedics~ as ~right educatiom (88). With regard to t.he therapy he stated: «... it's whole curative ability and its healing of mind and body is based exclusively on instruction, teaching, conviction and improvement, both morally and intellectually ... » (89). Thus Kj~lstad declared: M... the exercise of my orthopaedics is tied to teaching in an inseparable manner ... » (90). He defined his medical work in a pedagogical, to some extent also in a theological, direction. The patient was assigned an active role in the therapy. The cure was described as a method to teach the patient to heal himself. The role of the therapist was depicted as to teach the patient the quality of the curvature and how it was sustained, and what the patient could do to counteract it. The effects of the cure, however, Kj~lstad regarded as directly conditioned by the persistence, patience and strength of will of the patient. In case of the passive treatment with mechanical pressure and extension devices the patient could hardly be blamed if the results of a long lasting and expensive cure fe11 short of the expectations. The criticism was in that event levelled at the therapist or the owner of the orthopaedic institute. The method of self-correction altered this circumstance in a significant (88) KJ0LSTAD (1849), o@. cit. (n. 2), p. 10. (89) Ibidem. (90) Ibidem, p. 13. 112 JAN FROESTAD manner. The method implicated that the patient to a large exitent could be hold responsible for the results of the cure. If the effects of the treatment did not meet the expectations of it, this could be explained as the result of a weakness of the patients persistence, effort or moral. Tidemand stated: ~The effects of the cure are essentially dependent on the efforts of the patient, to the extent that the faithful and hard-working may attain greater progress in a certain period of time, than the lazy and careless may never gain ... (91). , In this manner the rnethod of self-correction took the sting out of criticism. Xn a way the therapy was ximmunizedn. Al1 favourable effects could be attributed the qualities of the therapy, al1 unfavourable results ascribed to the patient. Regarding the need of the medical profession to improve its status, this must have been a sympathetic feature. My interest in this story was aroused by the observation that the orthopaedics of self-correction obtained a high degree of approval in Norway in the time period from 1840 until the second half of the 1870s, in particular by the medical profession. This acknowledgement seemed in the first round astonishing, both in respect of the peculiar, almost «impenetrablle» theoretical basis of the cure and with regard to the practica1 accomplishment of the therapy, tlhe slow, curious «footwalk» and the method of <cpointuation» being the essential elements. My intention has been moderate, simply to specify some possible connections between the approval of the orthopaedics of self-correction and other cultural elements of the Nonvegian society in the previous century. On one hand, an affinity between the therapy and some contemporary ideological trends and values has been indicated. The orthopaedics of selfcorrection seem to some extent to have been legitimated by a theoretical accommodation both to the ideology of pietism in religious life and to the predominant liberal doctrine of economics. In addition, the therapy derived (91) TIDEMAND, A. quoted in: Norsk Magazinfor Lagevidenskapen, Forhandlingene (1869), p. 98. The First Stage of the History of Orthopaedics in Norway 113 advantage from a new comprehension and valuation of physical education as a prerequisite of good health. Within a more limited context some specific relations between the orthopaedics of Kjolstad and the scientific community of medicine has been assessed. It was emphasized that formal medicine in this period still maintained many of its traditionai links to metaphysicai and nature-philosophical conceptions, and that the absence of more eager resistance toward the theory of self-correction must be viewed in this light. Further, it was argued that the gradual acceptance of the idea that physical exercises could prevent and cure diseases and deformities, the development of the muscular theory, and, in addition, the common experiences of many physicians in Norway with military gyrnnastics, offered favourable conditions for the new orthopaedic enterprise. The approval of the orthopaedics of self-correction has thus been assessed by referring to its accommodation to prevailing ideological trends and main professional currents of the previous century. The attraction of the therapy, however, has also been assessed in relation to social interests, particularly with regard to the demands of the medical profession in the previous century. Obvious, the development of orthopaedics was in this time period a peripheral movement within medicine. It has still been indicated that the recognition of the Norwegian orthopaedists was to some extent tied to the growing ambition of the rnedical profession to improve its status and societal influence. The approval of the therapy of self-correction seems in the first place to have been related to the wish of the medicai profession to bring orthopaedics back within the subject of medicine, and to the fact that Kjalstad repeatedly demonstrated that he accepted the assessment of his colleagues as the decisive criteria to value the suitability of the therapy. The orthopaedics of Kjolstad, however, also exhibited several other sympathetic features. To some extent the attraction of the therapy seems to have been related to its preventative qualities. The medical profession had a growing ambition to assert itself in new fields, paying increasing attention to questions related to school hygiene and problems in connection with protracted school attendance. In contrast with the mechanical therapy, the method of selfcorrection could be used as a prophylactic and the Norwegian orthopaedists took concrete initiatives to make such use of it, notably it was introduced at primary school. Further, the approval of the therapy seems to have been