Copyright 1989 by John D. Perry
by John D. Perry, Ph.D. & Leslie B. Talcott, M.S., RN.
Behavioral Medicine Institute - Philadelphia
As we celebrate the 20th Anniversary of this revolutionary society, we dare to propose a disquieting fact: The field and practice of biofeedback began not 20 but 40 years ago. Biofeedback began, not in an austere Psychology Lab on the East Coast, but in a posh gynecology office in suburban Los Angeles. The first biofeedback subjects were not Norwegian white rats, but California suburban housewives. The first standard sensor placement was not on the top of the head or the ear of a cat, but at precisely the opposite end of the torso, in the most private of places. Far from being experimentally unreplicable, the world's first biofeedback therapy has been repeated thousands of times, and always with the same excellent results. It is tempting to imagine that biofeedback was first widely used to enhance human creativity and perhaps even to achieve 20th Century Nirvana, but in reality the first therapy was for a far more pedestrian purpose: the control of urinary leakage.
[The Kegel Perlneometer showing
resistive chamber in position, connected to a manometer for visual guidance in muscle
education. (Journal of the American Medical Association, July 7, 1951, p. 916)]
Based on the principle that those who fail to understand history are condemned to re-live it, we propose today to examine the rise and demise of the world's first biofeedback instrument, the Perineometer, and the man who invented it, California gynecologist Dr. Arnold Kegel. That this inspired inventor and pioneering, physician has not been called "The Father of Biofeedback" is a great tragedy, and one which we ought to investigate and understand. While we were busy conducting analyses of variance and arguing over theoretical models of animal learning to explain our statistically significant results, Kegel was quietly curing incontinence in California.
Most authorities erroneously date the beginnings of formal biofeedback toward the end of the 1960s, but the actual inception was in the same creative aftermath of World War II that brought us the Baby Boom and Sigmund Freud. Arnold Kegel and his colleagues actually experimented in 1947 with the new war-surplus amplifiers and electromyography, but in the end practical considerations prevailed and a simple air-pressure balloon and automobile tire gauge became the very first biofeedback device in widespread clinical use. Except for its pre-electric simplicity, Kegel's Perineometer meets all the criteria currently proposed as standard for our field. Consider, for example, the most recent formulation by Dr. Mark Schwartz and his associates in their "Biofeedback: A Practitioner's Guide " (1987).
(l) "...a group of therapeutic procedures..." - Kegel developed not only the diagnostic and therapeutic instrument itself, but an entire behavioral discipline consisting of detailed medical examinations, patient education materials, take-home exercises and a patient record-keeping system.
(2) "...utilizes electronic or electromechanical instruments..." - Here Kegel was simply .ahead of his time, for voltage-controlled oscillators had not been invented in 1948. Now, of course, his manometric system has been superseded by a more accurate electronic EMG Perineometer and vivid, elaborate computerized biofeedback displays.
(3) "...to accurately measure, process, and feed back to persons..." - This drawing and its caption, published in the CIBA Symposium in February, 1952, illustrates how clearly Kegel understood the role of feedback, fully a quarter-century before the rest of us.
"Figure 19 - The
Perineometer gives the patient visual evidence that she is cntracting her muscles
correctly. She is also able to keep a record of progress made."
(4) "...information with reinforcing properties..." - Kegel wrote that "A woman who is able to observe the slow but steady day-to-day progress on the manometer will be encouraged to keep up the good work."(1956, p. 547).
(5) " about their neuromuscular and autonomic activity..." - Although he wrote mostly about the former, he also discussed the later, especially in regard to sexual functions of the muscle. His patients were carefully educated about their anatomy and the role of this muscle exercise in restoring urinary control.
(6) "...in the form of analog...feedback signals..." - Kegel's simple device was calibrated in "millimeters of mercury" and provided numerical data which patients were required to enter into a practice log that cleverly and conveniently served as a line-graph of progress over time_years before computerized plotting was possible.
(7) "...Best achieved with competent biofeedback professional..." - Kegel wrote several journal articles, and even produced a documentary motion picture, which provided comprehensive directions for his fellow physicians to follow. Unfortunately, they were more interested in surgery, and left the patient education to their technicians (nurses), who, even more unfortunately, were not provided with the biofeedback instrument itself. Thus began out of necessity the myth of the "simple" Kegel exercises without biofeedback.
(8) "...the objectives are...greater awareness and voluntary control..." - Without delving into the reasons (which were pretty obvious in the 1940s), Kegel concluded that between one third and one half of women were out of touch with their pelvic muscles. Through what we now call "biofeedback", they learned how to make voluntary contractions. He also understood the self reinforcing properties of beneficial habits when he wrote: "Few (relapses) were seen, because a good functional pattern bring comfort to the patient and once established, tends to become habitual ( 1959, p. 189).
(9) "...by first controlling the external signal..." - Since most people are unable to see their own pelvic muscles move, reliance on the external meter was an obvious answer -- and a brilliant innovation by Dr. Kegel. We can only wonder how, never having attended a BSA meeting, he came to this incredible insight. He prescribed three twenty-minute home practice sessions every day using the manometer for visual feedback.
(10) "...and then by the use of internal psychophysiological cues." - Kegel understood the principles of generation before they were even articulated, and he recommended that the contractions also be practiced several times throughout the day, without the biofeedback device. And although most people associate the interruption of the urinary stream with his name, he himself attributed the idea to a colleague, Joshua W. Davies, who first described the action in 1938. But it was Kegel who made the idea famous.
Thus the Kegel Perineometer fulfills all of the criterion laid down by the most respected of contemporary authorities, and we are forced to the uneasy conclusion that Biofeedback, by any other name, first began in the late 1940s, and not some twenty years later. Based on our historical analysis, it is clear that Arnold Kegel and his Perineometer deserve far greater recognition than this society has hitherto accorded them.
Kegel's contribution also fulfills broader criteria not mentioned by Schwartz but implicit in his analysis. At least three additional elements must be present before a process can become a reality and a concept creates a career.
First, it must be supported by a body of professional publications. Unfortunately there has never been a single published volume exclusively on Kegel's theories and work In his own efforts be respectable, he contributed chapters to a couple of good gynecology text books, but his timeless chapters became lost when the texts themselves became outdated.
Second, it must be culturally relevant. Kegel's attempts to eliminate unnecessary (and unsuccessful) surgery surely ran counter to the medical trends of the 40s and 5Os. Biofeedback would not become established in what we can now call its second incarnation were it not for the happy coincidence of (1) cost containment concerns and (2) the proliferation of self-help programs.
Third, it must be commercially viable and available. Arnold Kegel made a tragic mistaken in not entrusting his invention to the mainstream medical distribution system; it gradually became harder and harder to acquire the Perineometer, as hospital purchasing became more centralized, and the myth was soon born that one could do Kegel's exercises without his device (which one couldn't locate anyway).
Finally, Kegel even anticipated the Ghost-in-the-Box controversy. As early as 1951 he offered this theoretical explanation: "The procedure may be compared with the effort...to teach wiggling of the ears with the aid of a mirror." We'd have saved a lot of time if we'd listened to him then. In summary, we have not recognized the pioneering work of the world's first biofeedback clinician; let us remedy the oversight and correct the injustice, and then move forward into the forty-first year of biofeedback.
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