THE MEDICAL PROFESSION

Subluxation

“Some dislocations are complete and perfect, as when the bone wholly falls out of its cavity: othersome are unperfect, as when it is only lightly moved, and not wholly fallen out; wherfore we only call them subluxations or strains.” (Johnson, 1649, p. 380)

There is evidence to show that from the sixteenth century the Latin word ‘luxation’ was used in written English to describe complete dislocations of joints and that from the seventeenth century the word ‘subluxation’ was used to described incomplete dislocations (Oxford English Dictionary, 2022).

In the 1820s the concept of the subluxation and its implications received focused attention in the writings of a British physician named Edward Harrison. He proposed a link between the subluxation of spinal joints and organic disease, suggesting that diseases of organs might result from spinal deformity through interference to vascular and nervous communications. On the subject of neurological compromise caused by spinal subluxation he wrote (Harrison, 1820, p. 369):

“A small irregularity in the height and disposition of some particular vertebrae is perceptible, on examination, in most delicate females. This disorderly arrangement and disposition of the component parts of the spinal column, though hitherto overlooked and wholly neglected, are, I am persuaded, of great consequence to future health. The effects of this subluxation, not being distinguishable by the symptoms, have never been traced to their origin in the spine. A very slight and partial compression of the cord, or some of its nerves, will disturb the organs to which they run. If we admit the operation of this cause upon all the vertebrae of the neck, back, and loins, in different persons, we shall be at no loss to account for the almost infinite variety and endless complication of nervous symptoms which harass many individuals through life, and baffle the most eminent of the faculty. When we take into account the number, the size, and the distribution of the spinal nerves among the viscera and muscles, we are led to conclude that scarcely a complaint can arise in which they do not participate.”

In writing these words Harrison paved the way for the thinking of others who later wrote about the ‘irritation’ of spinal nerves, including Thomas Brown and John Evans Riadore (Brown, 1828; Riadore, 1842). Perhaps more importantly, in making a link between spinal subluxations and diseased organs, Harrison preceded the thinking of Andrew Still (the founder of osteopathy) and Daniel Palmer (the founder of chiropractic) and he did so by more than fifty years. Harrison employed manipulative techniques along the lines of those used by the ancient Greeks (Harrison, 1824, p. 354). It was his view that (Harrison, 1821, p. 113):

“the obvious indication for the care of spinal affections consists of restoring the displaced bones to their natural situations, that the spinal cord and its nerves, relieved from injurious pressure and disturbance may be re-instated in their former abilities.”

Statutory regulation

Although Harrison was a formally educated physician, it would be wrong to assume that his ideas were well received by all within the medical community. As a matter of fact his book Pathological and Practical Observations on Spinal Diseases (1827) was subject to serious criticism in the Medico-Chirurgical Review (1828). Its appraiser went as far as to claim to be ashamed to record its existence. Not only were Harrison’s views on spinal disorders unpalatable to some, so also were his opinions on medical reform. In 1806 he had reported findings from a survey of medical practice in Lincolnshire, which drew attention to the high proportion of ‘irregular’ medical practitioners working in the county. With respect to the district of Horncastle, the following was recorded (Harrison, 1806, p. 38):

“5 Physicians, all graduates of Scotland, reside in this division.
11 Surgeon-apothecaries exercise medicine in this division.
25 Druggists. Probably one served an apprenticeship.
40 Irregulars, of both sexes, over and above the druggists.
63 Midwives. Not one has received any instruction.”

Harrison called for change, for a suitable course of preparatory study as a precondition for the practice of medicine and for standards to be made consistent not only in every part of the United Kingdom, but also, in so far as possible, across the British Empire. As part of his vision he recommended widening the recognition of medical schools. This brought him into conflict with elites within the Royal College of Physicians of London, who required members to be graduates of either Oxford or Cambridge (Weiner and Silver, 2008). Harrison’s medical doctorate was from Edinburgh.

Ironically Harrison’s efforts to afford social closure, to exclude those he considered to be irregulars from the practice of medicine, met with opposition from London physicians who did not consider him appropriately qualified to be a part of their group. Even so, perhaps inevitably, calls for change did in time lead to increased integration and regulation of medicine at national level. The statutory regulation of medical practice progressed from the Apothecaries Act of 1815 (UK Parliament, 1815), and political agitation led to the Medical Act of 1858 (UK Parliament, 1858) through which a distinction was drawn between legally qualified medical practitioners and others. A single register of medical practitioners, which included physicians, surgeons and apothecaries, was established under the authority of what would become the General Medical Council. The Act helped to protect the public from quacks and charlatans. It enabled those in need of medical attention to identify qualified practitioners. At the same time, it is fitting to recognize, it came to protect the interests of the registered at the expense of the unregistered.

Medical science

In attempting to distinguish truth from falsehood, evidence adds strength to a position. Observations on personal clinical experiences, such as those described by Harrison in his assessment of spinal disorders, are of value, but conclusions drawn from reflections on personal experiences are open to criticism where more rigorous and systematic examination of a situation is possible. In circumstances such as these scientific study provides a level of justification for claims to knowledge that is not achievable through other means.

During the nineteenth century the value of scientific evidence was recognized and applied to medicine in a way not seen before. Its application affected the training of medical practitioners and the practice of medicine. In Britain, prior to the nineteenth century, the social status of a medical practitioner was determined, to a greater or lesser extent, by family background, lifestyle and the status of one’s patients, the elites of medicine archetypally fashioning themselves as ‘gentlemen’. Notwithstanding the teaching of medicine at Cambridge, Oxford, and at other universities, medical education was of inconsistent quality. In many ways, medicine was more art than science. During the nineteenth century however, an increasing scientific underpinning of medical claims to knowledge occurred. As science came to be more valued within society, and as scientific medicine achieved diagnostic and therapeutic results, so this foundation helped to transform medicine in Britain and in other countries into a practice that was in itself more prestigious (Bynum, 1994; Shorter, 1993; Starr, 1982).

References

Brown T. (1828). On irritation of the spinal nerves. Glasgow Medical Journal 1 (2), 131-160.

Bynum W.F. (1994). Science and the Practice of Medicine in the Nineteenth Century. Cambridge University Press, Cambridge.

Harrison E. (1806). Remarks on the Ineffective State of the Practice of Physic in Great Britain; with Proposals for its Future Regulation and Improvement, and the Resolutions of the Members of the Benevolent Medical Society of Lincolnshire. W. Stratford for R. Bickerstaff, London.

Harrison E. (1820). Remarks upon the different appearances of the back, breast, and ribs, in persons affected by spinal diseases: and on the effects of spinal distortion on the sanguineous circulation. London Medical and Physical Journal XLIV (5), 365-378.

Harrison E. (1821). Observations respecting the nature and origin of the common species of disorder of the spine: with critical remarks on the opinions of former writers on this disease. London Medical and Physical Journal XLV (2), 103-122.

Harrison E. (1824). Observations on the pathology and treatment of spinal diseases. London Medical and Physical Journal LI (5), 351-364.

Harrison E. (1827). Pathological and Practical Observations of Spinal Diseases: Illustrated with Cases and Engravings. Also an Inquiry into the Origin and Cure of Distorted Limbs. Thomas and George Underwood, London.

Johnson T. [translator] (1649). The Workes of that Famous Chirurgion Ambrose Parey. R. Cotes and W. Du-gard, London.

Medico-Chirurgical Review (1828). Article IX. Spinal pathology. Medico-Chirurgical Review 9 (17), 87-90.

Oxford English Dictionary (2022). Luxation and subluxation. Oxford English Dictionary (Third edition). Modified online version. March 2022. Oxford University Press, Oxford.

Riadore J.E. (1842). A Treatise on Irritation of the Spinal Nerves as the Source of Nervousness, Indigestion, Functional and Organical Derangements of the Principal Organs of the Body, and on the Modifying Influence of Temperament and Habits of Man over Diseases, and their Importance as Regards Conducting Successfully the Treatment of the Latter; and on the Therapeutic Use of Water. John Churchill, London.

Shorter E. (1993). The history of the doctor-patient relationship. In: Companion Encyclopedia of the History of Medicine (Edited by W.F. Bynum & R. Porter), pp. 783-800. Routledge, London.

Starr P. (1982). The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. Basic Books, New York.

UK Parliament (1815). Apothecaries Act. An Act for Better Regulating the Practice of Apothecaries Throughout England and Wales. 1815, Chapter 194, George III.

UK Parliament (1858). Medical Act. An Act to Regulate the Qualifications of Practitioners in Medicine and Surgery. 1858, Chapter 90, Victoria.

Weiner M-F. and Silver J.R. (2008). Edward Harrison and the treatment of spinal deformities in the nineteenth century. Journal of the Royal College of Physicians of Edinburgh 38 (3), 265-271.

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