Backache is pain of spinal origin, plus its radiations. Low backache has been unduly emphasized. It is only one-sixth of the problem, because similar pains, with analagous radiations, occur in every part of the spine.
The four following quotations, extracted from a great deal in the same vein in medical literature, are worthy of thoughtful consideration. They illuminate the position of the doctor and the patient in the ailment most frequently seen-even if rarely recognized-by doctors.
An editorial in The Practitioner (1957) stated:
Backache is the bane of the general practitioner's life. The unfortunate victim cannot understand why the doctor can do nothing to put it right, whereas every hoarding and most popular journals contain myriad remedies guaranteed to produce that result so devoutly desired by the patient. 1
D.G. Wilson in The Lancet (1962) wrote:
It is clear that very many patients still have recourse to irregular practitioners (of manipulation) and this is a constant reflection upon the skill and competence of the profession, on the general practitioner in particular. 2
J.R. Armstrong in Lumbar Disc Lesions (1958) stated:
There is not even a street in this country, (England, which has many small streets) in which there are not one or two individuals who have been martyrs to lumbago or sciatica for the major part of their lifetime. They have run the whole gamut of treatment and have come to accept their affliction and do not trouble to seek further medical advice 3.
In a sentence that is particularly appropriate to this situation Hippocrates said:
It is disgraceful in every art, and more especially in medicine after much trouble, much display, and much talk, to do no good at all. 4
In spite of all this, the profession has been dimly aware of the approach for twenty-five hundred years. In ancient Greece Hippocrates (Fig.1) practiced manipulation of the spine, as did Cato the Wise (Fig.2) in Rome and Galen [of Pergamum] (Fig.3) in various places in Asia Minor and in Rome.
We know that for centuries bone-setters practiced their hereditary craft in Britain. It is probable that they learned the art from the Romans. They set fractures, reduced dislocations, manipulated spines, and were skilful in the treatment of stiffened joints which until recent times were common afflictions. For hundreds of years they were the orthopaedic surgeons of Britain, and even today they have not been displaced. Bone-setters were (and are) crude but effective and they have remained a thorn in the flesh of the profession. They were, however, unable to recognize tuberculous joints and it is said that the few disasters the bone-setters suffered came from wrenching these joints.
Long ago, monasteries supplied the only hospital beds and a monastic bone-setter was in attendance. About 1590 an Augustinian monk, Friar Moulton, wrote The Compleat Bonesetter, and a revised edition, now owned by the Royal College of Surgeons of England, was published by Robert Turner in 1605.
In 1860 Hugh Owen Thomas, "the father of Orthopaedic Surgery," submitted, grudgingly you may be sure, to manipulation by one Hutton, a bone-setter. He described the experience:
I was instantly relieved of the pain I had suffered for six years . . . I had been lame and in pain, and could now walk, and was at ease. 5
He did not further describe his ailment nor the treatment, but we can deduce both, later on.
In 1867 in an article in The British Medical Journal - The Cases The Bone-setters Cure - Sir James Paget advised,
Learn to imitate what is good and avoid what is bad in the practice of bone-setters.
Sir James also advised that we should "still further observe the rule, Fas est ab hoste doceri* in which no calling is wiser than ours"6.
*It is right to be taught by the enemy.
Seventy years later Timbrell Fisher wrote:
At the present day, we find that in spite of the efforts of Sir James Paget, Wharton Hood, Lucas Champonniere, Sir William Bennett, Sir Robert Jones and others, manipulation does not receive the attention it merits. Although in other realms of medicine great strides have been made, manipulative treatment still lags behind ... There is inadequate research into the fundamental underlying principles. Even if it could be proved that disaster and disappointment frequently follow manipulation, and there is no evidence that this is the case, cures are still so many, and so well authenticated, that the subject demands the fullest investigation.7
In the United States in 1874 Andrew Still introduced osteopathy, and though he claimed divine inspiration, it is likely that he had at least heard of bone-setting. He taught that subluxation of joints, particularly the ribs, hips, shoulders and spine, obstructed blood and nerve supply and so caused disease. "It was put in my hand by the God of Nature," said Still.
Andrew Still and his disciples awarded each other doctors' degrees and secured legal licenses to practice medicine throughout the United States. Their influence was less in Canada, but osteopathy has enjoyed.a vogue here for ninety years.
In Britain osteopathy bad a more difficult time. In 1936 the British Medical Association published a report - Proceedings before a Select Committee of the House of Lords on the Registration and Regulation of Osteopaths Bill. The Select Committee found that osteopathy as a method of healing suitable for the treatment of all diseases had not been established, and that it would not be safe or proper for Parliament to recognize osteopathic practitioners as qualified. They also decided that the only existing establishment in England for the education and examination of osteopaths had been exposed as being of negligible importance, inefficient for its purpose, and above all, in thoroughly dishonest hands.10 After the hearing had continued for ten days, the weight of evidence was so much against them that the osteopaths asked and were granted, leave to withdraw their petition for recognition.
At about the same time as the British osteopathic fiasco, a Canadian Commission was investigating osteopathy. Dean Etherington of Queen's University presented the findings of the Canadian Commission before the Annual Congress on Medical Education, Licensure, and Hospitals in Chicago in February, 1935.
The Dean regretfully said that it might be thought a presumptuous procedure for him to come from Canada to present a paper on the subject of Osteopathy and Licensure.
Osteopathy, he observed, Is the ill-formed child of lowly parentage, your child, not ours, which first saw the light of day sixty years since at Kirksville in the State of Missouri. With the passage of the intervening years, its unwished progeny have drifted across the international border to harass and annoy those of us concerned with medical registration.
Dean Etherington described the Department of Anatomy at one of the osteopathic colleges:
On a table was the body of a coloured man, which appeared to have undergone partial decomposition. Altogether the place might aptly be described as a chamber of horrors. It seemed to brand not only the department of anatomy, if such a term could be employed, but the whole institution with an indelible mark of inefficiency and dirt. Des Moines is a clean looking city. It must be that the municipal health officials are unaware of this nuisance.
Eventually even the osteopaths began to realize that there was a great deal wrong with their ideas. Some schools have been trying to raise their standards, and if they succeed they will eventually go the way of the homeopaths and be absorbed into medicine. The rest have been or are being eliminated by the competition of the chiropractors.
In 1895 D.D.Palmer became divinely inspired. He simplified Still's ideas, and founded chiropractic. He taught that subluxations in the spine compressed the nerves and obstructed the flow of "vital nerve force." If the lung nerve were compressed the flow of vital nerve force was reduced and lung disease resulted; if the liver nerve were affected, liver disease occurred and so on. He labelled the spinous processes somewhat as follows: The upper cervical spinous processes were manipulated for diseases of the head, the lower ones for diseases of the throat and arms. The upper dorsal processes controlled diseases of the heart and lungs; the lower ones, abdominal ailments. The lumbar processes were concerned with diseases of the urogenital system and the legs.
Treatment was limited to the application of vigorous shoves and twists to the appropriate region of the spine. There is no doubt that with experience chiropractors acquire some skill in the art of manipulation; but it is the patients who have become selective. In general, if they have spinal pains they go to a chiropractor, for everything else they consult their own doctor.
With richly undeserved good luck, Palmer came fairly close to actual fact. The subluxation, or the "little bone out of place which presses on a nerve" is satisfactory to both chiropractor and patient. The patient felt his back "go out of place." He felt the reduction by manipulation and the ensuing relief of pain. The fact that medical men were unable to demonstrate these subluxations was of little concern to either of them; and chiropractors have become the most successful of all irregular practitioners.
Palmer and his disciples followed the lead of the osteopaths and awarded each other doctors' degrees. They secured licenses which gave gave them great latitude in the practice of medicine in the United States. The licenses in Canada were intended to be limited to manipulative treatment. In Britain chiropractors were not granted licenses.
The often good, and sometimes spectacular, results of their manipulations reinforced their faith in themselves, and increased public approval of their methods. The wisdom of the people, not the wisdom of our profession, has separated the good from the bad. The people have become so convinced that manipulation is the treatment of choice in backache that there are now sixty-five thousand irregular practitioners of manipulation in the United States, for example, compared to ninety thousand physicians in general practice.
Canada has been afflicted to a lesser degree, but today there are seventy-five irregular practitioners, licensed by the government, in Vancouver. Most of them have been here for many years and some of them are second, and even third-generation manipulators.
The chiropractors and the general public have also connected the various radiating pains in the limbs and elsewhere with backache in any part of the spine to such an extent that chiropractors today are quite well established in the public mind as spinal and nerve specialists, and these are titles which are openly claimed in their advertising.
Since the whole theory and practice of chiropractic could be taught to a ten-year-old boy in a few hours, chiropractors have had difficulties in establishing their version of a four-year course. I have in my possession a good body of evidence that they do not take the "prerequisite" high school graduation or the "four-year course" too seriously. Typical is the correspondence of one potential chiropractor who claimed a grade three education, though on reading his letters, one might be pardoned for having the gravest doubts that he had gone even that far. He explained that it was not convenient for him to take their four-year course, and he succeeded after some haggling, in obtaining an offer of a Doctor's degree in Chiropractic from "Midwestern University", also a diploma and textbook, all for five hundred dollars. It seemed probable that if he were to see the "President of the University" personally, a smaller sum would be accepted. He was urged to accept the offer and then to proceed to post-graduate studies in a variety of subjects including internal medicine, surgery, obstetrics and gynaecology.
Let us concede that many chiropractors, in spite of the crudity of their empirical methods and their total lack of anything even remotely resembling a professional education, frequently and possibly routinely, obtain good results in the treatment of backache. Can we account for the cure of conditions diagnosed by doctors such as migraine, neuritis, neuralgia, pleurisy, pleurodynia, angina, fibrositis, myofascitis, cholecystitis, chronic appendicitis, and a host of others? We can and we will.
It must have been cases like these that Timbrell Fisher had in mind when he wrote that
Hutton's descendants are still effecting cures in cases which have baffled some of the most eminent members of our profession. 7
I have gone into some detail to contrast the almost total lack of formal education and scientific training with what should be to us the appallingly significant success of lay manipulators. They are taught, or through experience they acquire some sort of skill in manipulation of the spine. They are unable to select their cases but their patients make their own diagnoses. If a patient has pain in any part of the spine, or pain elsewhere that seems to be related to the spinal pain, he is likely to repair to the chiropractor. The patient's own doctor often tells him with commendable honesty that he knows nothing about backs. It is a regrettable fact that many doctors, disenchanted by the efforts of orthopaedic surgeons in back cases, refer patients to chiropractors.
In 1957 W.B.Parsons wrote about traction and manipulation in the treatment of low back pain. He observed that:
In today's medical schools the student learns much about gastrectomy for ulcer but nothing about these simple methods of bringing relief from infinitely commoner conditions. When will orthodox medicine meet this challenge? 8
Let us be comforted by the thought that the irregular practitioners have only partly adopted an ancient medical art that has survived through the ages. They have to some extent focused our unwilling attention on this art. We might be consoled by the fact too, that many contributions to medicine have come from unexpected sources. For example, an English sea captain, when he gave his sailors lime juice, was the first to use Vitamin C in the treatment of scurvy, and it was a French washer-woman who first demonstrated the mite that causes scabies.
The position of the doctor when faced with spinal pain and particularly its radiations, is a wretched one. He has been taught to consider several hundred possible diagnoses. He is unable to, recognize most of the radiations. If he is unusually conscientious he proceeds doggedly through interminable and pointless examinations which provide no conclusion. Too often his treatment is limited to bed rest, the application of heat, the administration of pain and sleeping pills, muscle relaxants and tranquilizers, and the injections of local anaesthetic solutions or cortisone.
Sir Robert Jones said:
We should mend our ways rather than abuse the unqualified. Dramatic success at their hands should cause us to inquire as to their reasons; it is not wise or dignified to waste time denouncing their mistakes, for we cannot hide the fact that their successes are our failures.
We should be aware of the f act that Hippocrates described the use of traction and manipulation in the treatment of spinal pain. He wrote that it was an ancient method of treatment and he suggested to his students that they should not think that just because it was old that it was not good. Traction and manipulation have survived not merely the test of time but the test of ages.
Let us heed the advice of Sir James Paget therefore, and proceed to separate what is good from what is bad in the practice of bonesetters, even though we may be somewhat discouraged by Darwin's remark:
Nearly all men past a moderate age, either in actual years or in mind, are, I am fully convinced, incapable of looking at facts under a new point of view.9