THE CRIPPLED CHILD

 

I

 

THE historical background of deformity is dark with the shadow of annihilation, persecution, ridicule, and neglect. 

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In the dawn of time, nothing can be more certain than that there was a quick way with the crippled. Under a primitive and nomadic tribal system there cannot be provision for the halt or maimed, and though the teaching of Hippocrates may fairly claim to lie at the very foundations of modern orthopaedics, the light vanished between ancient and modern times.

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During the Dark and Middle Ages the spiritual blight of theocracy and the influence of Arabian medicine overshadowed surgery and degraded the cripple for more than a thousand years. To be crooked in body meant to be crooked in mind. Alternate fear and ridicule represented the medieval attitude. On the one hand, Luther advised the killing of deformed infants, and on the other it became the custom to employ dwarfs and hunchbacks as ‘ jesters ’ in kings’ courts and barons’ castles.

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The psychological effect of ridicule, oppression, or contempt maturing over two thousand years needs no further elaboration. Right up to the nineteenth century to be crippled meant isolation and malignity. Of this dark background literature has left us a remarkable store of evidence. The centuries which separated Richard III from the Hunchback of Notre Dame or Scott’s Black Dwarf from Dickens’ Quilp show little evidence of a change in popular opinion. Even in modern fiction to be crippled is still a convenient simile for crime.

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The real revolt from the superstitious in life, literature and medicine came with the eighteenth century. The intellectual preceded the industrial revolution. The “ age of sensibility,” as it was labelled, produced loud and persistent reverberations.

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Humanitarianism was heard in the voices of Voltaire, Rousseau, Paine, Locke, and Goldsmith. Unfortunately, with an awakening of public sentiment the lot of the deformed became not better but infinitely worse. The industrialism of the nineteenth century, firmly planted in factory and mine, commenced to produce cripples in such numbers that instead of being incongruous they were in certain districts almost universal. 

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Those were the days, less than a century ago, when tiny children worked fifteen hours a day before returning to hovels where nothing penetrated except gin and squalor. The mothers of these hapless little ones hauled trucks in the mines at a time when the problem of negro slavery caused every

householder to glow with British rectitude. Industrialism became the most prominent contributor to the production of cripples. It was the greatest advertisement of the artificial causes of deformity until the Great War—to be thrust upon public attention. As Macaulay remarked, “ It is not the evils which are new, but the recognition of them.”

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There was every reason to recognise them. Cripples, instead of being so rare as to cause boisterous laughter, were, from the beginning of the nineteenth century onwards, being faster and

faster manufactured by industrial conditions, slums, direct infection, and accidents.

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What was the attitude of medicine towards this alarming, but obscure problem ?

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II

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When a very titled lady once confided to Robert Jones that had she not received so much relief from her own chiropodist she would have patronised Nelson Street, she expressed the universal perplexity regarding the word ‘ orthopaedics ’ before the War. And even after the Armistice a worthy and extremely well informed person, upon being asked to contribute to an orthopaedic centre, withdrew into himself and said “ I have no doubt whatever it is a worthy object, but I prefer

to help British hospitals,”

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It is essential if the work of Robert Jones is to be understood not merely by some, but by all the readers of this record that a paragraph be devoted to the word “ orthopaedics.’’ It was coined by Nicholas Andre, Professor of Medicine in the Royal College and Senior Dean of the Faculty of Physick at Paris. In 1741, he wrote a book called “ Orthopaedia, or the art of Correcting and Preventing Deformities in Children ”  the root principle, being “ straight,” and  “ a child ”—not the Latin pes “ a foot.” Andre with the sterling pedantry of the academic mind had invented a term which

has remained a conundrum and an obstacle for nearly a hundred years.

 

This “ art of correcting and preventing deformities in children” introduced a very extensive field of surgery and preventive medicine. Unfortunately the treatment of injuries was not sufficiently advanced in the days before antiseptics and anaesthetics, to be of much avail. The position, as a consequence, was extremely interesting at the period when Hugh Owen Thomas commenced practice. A certain amount of surgical progress had been made in Great Britain and abroad.

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In this country Hunter laid the foundation for bone and joint surgery, and in 1780 Venel established the first orthopaedic institute at Orbe in Switzerland. They were succeeded by Duchenne (1806-75), Stromeyer (1804-76) and John Little (1810-94), There followed after this brief period of research

an eclipse with the discoveries of modern surgery. To the progressive surgeon in the heyday of Thomas the field of orthopaedics made no appeal. Thus was the destiny of the crippled child practically concerned with 11, Nelson Street.

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But it would be incorrect to regard Thomas as a man chiefly moved by a humanitarian impulse. The day was not due for that. “ Thomas,” remarks his friend Ridlon “ did not know the meaning of ‘ social service,’ but he gave a greater skill to the crippled poor than anyone else could give. He did not

realise he was ‘ interested ’ in orthopaedics. Nor was he more interested in children than in older people,” 

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It is all the more important, therefore, to attempt to check any evidence of the social as apart from the professional impulse in Robert Jones. At what stage in his career did he realise that the conventions of his age would and must be challenged, and with them the historical apathy towards crippled children ?

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Or to put it another way, at what time in his life did he grasp that, even amongst well-to-do people, Victorian habits of conduct actually produced cripples in the leisured classes just as surely, though less terribly, than in the mines ?

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There is no doubt that, in the late ’eighties, Robert Jones was about thirty years in advance of his time. This is evident by an original and prophetic paper written so long ago as in 1888 and called “ Hygiene of School Children ” a subject upon which his successors to-day establish reputations

as extremely far-seeing persons. But what people thought of it all, forty years ago, is another matter. As a commentary upon modern physical culture compared with compulsory deformity it is arresting. “ I am afraid,” says this young surgeon of thirty, “ I shall not be able to dwell at any length upon a subject in which I am very much interested, namely, the hygienic supervision of children in schools. There is one phase, however, which demands our close attention, and that is their physical training. How many of us, having sent daughters or sisters to schools spirited and healthy, have lived to see them return round-shouldered, deformed, martyrs to headaches, pains in the limbs, or one of the many conditions which threaten to destroy their whole future happiness. This more particularly appertains to the girl than to the boy, and when we study the facts, it is not at all to be wondered at.

Some years ago, a girl’s life was one to be profoundly commiserated with ; even yet, it is not always to be envied. From the very earliest age, their instincts were checked, and artificial deportment insisted upon, as a homage to the so-called proprieties. Their natural movements were made ignorantly subservient to what was facetiously termed ladylike ; but very little opportunity was given to them, and, even yet, there is far too little in the way of free and easy, natural, and mirthful frolic, without which every muscle in their body deteriorates.”

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After explaining the necessity for developing the human body, he adds a paragraph—“ I have said but very little with regard to the gymnasium, but where exercise cannot be carried out in fresh air, it is a great boon for our school children to obtain that necessary stimulus which systematic muscular

movements alone can produce. So that the recreative element may come in, all exercises should be to the accompaniment of music, for nothing is more dreary than the old fashioned drill-sergeant’s method, which had not in it one element of harmony or poetry of movement.”

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The conclusion is prophetic. “ I will here end my prolix and diffuse meanderings, but while I do so, I would express a hope that many of us may live to see this Society reaping a rich and abundant harvest in helping to lengthen the days and lighten the burdens of the poor ; we should be an immense power for good in the world. We ought soon to eradicate rickets and with it, at one stroke, the pitiful deformities which follow in its path. Infantile diarrhoea is due to fermentive changes. Now, so terrible a scourge should be as rare as it is common. By a healthy school supervision postural deformities should but rarely be seen, and by allowing our girls that freedom which our boys take as a right, they should in time not merely compete in the intellectual arena, but enter into

a healthy competition in games of physical powers. All this cannot be now far off, and when it comes, we poor physicians and surgeons, many of us at least, may be relegated into the

ranks of the unemployed. Meanwhile let the State and municipality help to eradicate some sources of disease ; a few more playgrounds for the poor ; more breathing spaces for our densely populated towns ; let them exercise a stricter supervision upon insanitary property, prosecute a few rascally

plumbers, and our descendants will soon have cause to bless the zeal and enterprise of their ancestors.”

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Here was the practical vision which actually challenged the problem of the crippled child in 1898, and from that date onwards declared war against the causes of disease. But as he knew hygiene in schools would take years of propaganda, Jones commenced within the field of surgery and set out to help the crippled child. The prevention of deformity had in fact not occurred to anybody as even a practical possibility.

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But in his Sunday clinics, when Thomas gave free advice and treatment to two hundred poor people, there was the first step towards the whole vast structure which his successor Robert Jones carried to so fine a place in national life. When Thomas died in 1891, the prospects of treatment and recovery for crippled children were negligible. In the United States through the enterprise of men like Sayre, Bradford, Ridlon, and Lovett, orthopaedics as a special branch of surgery was being advanced. But the problem as a curable and preventable one was not suspected. It was not in America or upon the Continent, but in Liverpool that the first great step was taken upon which the whole structure was consolidated in surgery and medicine.

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It seems like a paradox, but the greatest obstacles which obstinately confronted Robert Jones in his early struggles with deformity were not indifference or hostility, but sentimentality and incredulity. The crippled child was regarded as a hopeless case with a right to indolence and ignorance. To

be a cripple meant in town house and country cottage generation after generation of weaklings growing up with no use either of brains or limbs.

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Parents preferring to believe in the hopelessness of treatment were not discouraged by the medical services and general practitioners of the ’nineties. Treatment of crippled children was carried out in the general wards of town hospitals and infirmaries, but it strengthened rather than weakened public

apathy. Dr. Charles Macalister has written of the methods used :

 

“ Who among the older members of the profession can forget the almost heart-breaking operations on children which we witnessed as house surgeons ? Excisions of hip and knee joints, for instance, which were frequently undertaken in the early stages of disease, in order to avoid the risk of subsequent suppuration and destruction. On examining the removed joint and observing the limited amount of trouble, and then contemplating the beauty of the child thus mutilated, one wondered and wondered. A very obvious deformity resulting from such operations was so common at the period at which I write, that it was observable almost any day as we went about the town : i.e.y lame people, with a shortened limb compensated by a hideous high soled boot/’

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Robert Jones realised that there was little hope without consecutive treatment in some special institution. Too frequently patients were patched up and sent home. These drifted almost inevitably into chronic deformity. Secondly, large numbers of children suffering from chronic diseases were

treated ineffectively in their own homes. By him as by no one else forty years ago it was clearly seen that the future of the crippled child was both surgical and social, a state not only of limbs, but of mind, and ultimately not satisfied with the promise of recovery he laid eager hands upon the means by which so much suffering could be prevented.

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On June 24th, 1898 a preliminary step was taken, when the following points were agreed between Robert Jones and Charles Macalister, Miss Ellen Sedgwick of the Liverpool Home for Incurables, and Miss Gaskell. They are a revelation of prophetic clarity :

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(1) —There are few children so incurable that they cannot become well if placed in proper circumstances for treatment.

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(2) —A hospital for such children, suffering from chronic diseases, should be recognised as being a place to which they may be sent, in order to have the best chance of recovery.

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(3) —Such an institution should be conducted on the lines of a hospital. It should be situated in the country, and placed under scientific and sanitary auspices. A resident doctor, or a local one acting on the spot, should be appointed to look after the cases, but the main responsibility should rest with a physician and surgeon visiting, say, once a week.

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(4) —Such a hospital should have an operating theatre, so that the children might at once get the benefit of the fresh air, after being operated upon—if such a course became necessary.

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(5) —Experience has proved that if operations are performed or medical treatment adopted for such cases in the country, the chances of recovery are greatly enhanced.

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(6) —Such a hospital should not be regarded as a convalescent institution or confused with such an institution.

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The question of the preliminary selection of crippled children presented very little difficulty. There were as a start the free Sunday morning clinics at Nelson Street, where nearly 7,000 poor cases were seen by Robert Jones annually.

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“ I worked for many years in my younger days amongst the children of the poor,” he remarked to Welsh students in 1928, “ and I received nothing but gratitude for any help I gave to parents in the rearing of their children. In spite of great hardships they sacrificed much to help them, an example

which might well be followed by many of their more fortunate sisters. In those days we had no Child Welfare Societies nor Country Hospitals, and the children could be found dotted about Liverpool in courts and alleys lying outside their houses on improvised couches made of soap boxes.” This was, in fact, the first chapter in the open-air cure and the soap boxes were the contribution of Thomas and Jones.

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It is difficult to-day to understand that it was almost eccentric in the ’nineties to regard deformity without aversion or dismay. And yet in the professional experience of Robert Jones, the cripple was not merely triumphant over his own disability, but actually brought a new meaning in life to his

environment. “ One day,” Agnes Hunt has recalled, “ I was having lunch with him in his studio in Nelson Street when a tall young man with a slight limp was ushered in. He spoke with a strong American accent, and asked Dr. Jones if he remembered a little lad from Manchester with a very

bad hip disease—and, added ‘ you were only a youngster yourself in those days. You came twice a week to see me and you induced a lady to give me a violin and teach me how to play it, and now I am managing director of a violin and instrument factory in the United States, and I humbly ask

you to accept this small donation for any cripple institution in which you may be interested/ (The donation was a five hundred dollar bill.)

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“ As the door closed I turned to Robert Jones and asked for his story. ‘ Yes/ he said, ‘ I will tell you the story, because it shows what an exceeding influence for good a cripple child can exercise. He lived in a wretched slum in Manchester, such a home which only drink-producing poverty can achieve. The mother, an apparently hopeless slattern, the father learning good money and spending it all on drink ; they had but one redeeming feature, a great love for the cripple boy.

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The gradual restoration of that home was what will interest you. I got a friend to teach the child the violin, and going there one Sunday evening heard a violin accompanied by many childish voices singing ‘ Abide with me.’ Apparently the whole street used to gather there on Sunday evenings to sing hymns with that cripple boy. Finally, he asked me to have a cup of tea with him ; the tea was perfectly served and the house spotlessly clean. With tears in her eyes the mother said that the father brought home every penny of his wages.’

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“ The story is very typical of Robert Jones ; he told it to me because it showed what exceeding influence for good a cripple child can exercise ; not a word of the quiet talks he had with the drinking father, not a word of his gentle advice to and his influence over the mother. Credit, if credit there

was, all given to the cripple child—such was Robert Jones. 

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Always helping and never claiming any reward, never seeking the limelight, caring very little for the approbation of the world, asking only that he might be allowed to help, always looking for the best in people and striving with all his might for peace and love.”

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The idea of treating chronic cases of crippled children in any special institution aroused instant opposition. The project was regarded as impracticable and likely to injure existent institutions even including “ The Home for Incurables.” But the necessity of prolonged treatment had been clearly indicated by the recovery of children in that very Hospital !

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On November 15th, 1898, a meeting was held and a provisional committee appointed to promote the foundation of a hospital for children suffering from chronic diseases. As a result of the proceedings published in the Liverpool Daily Post the Committee of the West Kirby Convalescent Home for Children offered to provide a ward for the treatment of such cases.

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The first experimental step had been taken. It had become possible for the first time for the crippled child to be given a real chance of recovery. The remarks of Sir Edward Russell (later Lord Russell of Liverpool) who opened the hospital ward on November 4th, 1899, are worth recording because they

show that the advance was taken with a sense of its critical and historical importance :

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“ In that hospital they had three elements without the combination of which the aims of the institution could not be successfully achieved. They were, first, splendid medical and surgical skill ; secondly, surroundings and air of that pure and healthy kind which were good for all, but especially good for the young ; thirdly, the vital principle of not with drawing children from the treatment so long as they were not perfectly cured. It was that principle which struck so many of those present at the meeting in Liverpool. The hospital, he believed, would be looked upon as a great experiment to be followed in other parts of the country, and he was convinced that if they kept their principles in view, the hospital might be the beginning of a national undertaking, and that the country at large would realise the importance of so treating the rising race that nothing of which science could make a

certainty should be left to chance. If, besides tolerating the temptations, corruptions, and surroundings which debased and weakened the human frame, the community allowed children to grow up physically unfit to face the exigencies of life, it incurred risks which no community ought to incur.

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While public opinion was alive, and the means of remedy could be found, they would send children from that hospital capable of attaining proper manhood and womanhood. The wards of the institution were a saddening and gladdening sight gladdening because of its beneficence and its surroundings, saddening because he did not doubt that many of the cases, if enquired into, would be found related to circumstances in the condition of the community which they would be glad to

change. There the children had good air, beautiful hygienic conditions, and the most affectionate as well as the most scientific treatment.”

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That meeting must be recognised as a landmark, because it focused public interest upon the  doctrines of H. O. Thomas and Robert Jones—the trinity of rest, surgical treatment, and fresh air, which had at last taken hold in the city of their long medical service. The remainder is a matter of social history. Principally by the personal energy and generosity of Holbrook Gaskell, and Andrew Gibson, both well-known Liverpool philanthropists, and many other generous benefactors, the efforts of Robert Jones and Charles Macalister were rewarded, and the foundation stone of “ The Royal County Hospital for Children, Heswall,” was laid on April 21st, 1900.

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The walls of sentimentality, prejudice, and apathy were cracking. The torch of knowledge was being carried into the dark places of despair and ignorance. Henceforth crippled children would pass beyond the town for treatment. The greatest forward step since AEsculapius had been taken in the

treatment of the physically defective. And the children seemed to know it. “I shall never forget,” said Lord Derby at a public banquet to Robert Jones in 1921, “ the shout of delight of those children when he came into the ward.” That was all part of the new spirit of Nelson Street, and although the small patients did not realise it as they went into the operating theatre they, too, were pioneers, after whom countless other children would be healed.

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All they knew, with the swift infallible comprehension of children, was that in Robert Jones they had a friend. This gift for winning the love of little children was a very beautiful thing. But it is also a part of modern orthopaedics. “ Most people,” wrote Francis Thompson, “ must forget what they were like when they were children, otherwise they would know that the griefs of their childhood had as passionate abandonment as the griefs of their maturity. Children’s griefs are little, certainly ; but so is the child, so is his endurance, so is his field of vision, while his nervous impressionability is keener than ours.”

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The above Chapter was taken from: -

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THE LIFE OF SIR ROBERT JONES
BY
FREDERICK WATSON

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