Monday, October 24, 2011

Vincent Nesfield, Dr Rees and the history of the treatment

The originator of what I have named Nesfield’s Treatment was a brilliant English surgeon, Mr Vincent Nesfield. Among many achievements in his life, he invented chlorinated water. I have, therefore, taken the liberty of calling the procedure Nesfield’s Treatment in this book because I believe it accords Mr Nesfield the recognition he merits. People can also easily remember a non-medical name instead of the various tongue-twisting medical names it is known by; e.g. percutaneous neurotomy, percutaneous rhizotomy, rhizolysis and others. I would like to think that other medical practitioners will begin calling it Nesfield’s Treatment as well.
Vincent Nesfield was a Harley Street specialist. He worked in a broad range of medical fields; from cancer, ophthalmology, deafness, blood pressure, bubonic plague, tuberculosis, rheumatism and eczema, to diets for infants. Although he was a qualified surgeon at the tender age of 21, he had to wait until he was 25 before the Royal College of Surgeons would accept him as a fellow – he was too young.
Those who knew him described him as a deeply spiritual man and a dreamer, a man who lived ‘out there’ in a figurative sense. By all accounts he was not a personally ambitious man. He died in 1972 at the age of 92. At the time he was working on a serum for cancer.

Nesfield, incidentally, did not believe there was such a thing as a slipped disc (although I disagree with him). He wrote ‘The agonising pain in the back which may continue for months and is usually diagnosed as a slipped intervertebral disc, has never in my experience of very many cases over 30 years, been due to a slipped disc; but has been due to a sensory nerve caught up in a muscle or tendon fibres. This not only gives pain in the back, but referred pain in the hip, thigh and the leg, and indeed in the sciatic nerve itself’.
Nesfield developed his procedure in 1918. He used it on soldiers returned from the First World War for what he described as ‘trench back’. He performed it on an average of six patients a week during his working career.

In December 1959, a prominent London journalist, Horace Hughes, who had suffered debilitating back pain since 1945 and whose career was threatened by his affliction, because none of the many treatments he undertook had worked, noticed an article in the now defunct Daily Sketch.

Ever had backache? Suffered agony when you moved, stood, sat or lay down?
And then said to yourself: “I’ve got a slipped disc”
Well, you’ve had your worry for nothing. For in a new pamphlet to-day called ‘Backache and Slipped Disc’ a Harley Street specialist says THERE’S NO SUCH THING AS A SLIPPED DISC.
‘The slipped disc theory has been evolved during the last few years,’ he says ‘due perhaps to post-mortem findings after a crush from buildings falling on people during the bombing’.
He points out that in the vertebrae the intervertebral discs are extremely firmly attached.
‘In fact’ he says ‘it is impossible to move a disc without cutting the ligaments and using a chisel’.
So how could it slip?

The cause of that excruciating pain, says the specialist, is damage to a muscle fibre, muscle sheath or ligament.
It could be in the thigh, the muscles between the shoulder blades, the shoulder and the neck, or the muscles of the chest.
The cure? So simple and uncomplicated it’s almost ridiculous in comparison to the long drawn out business of plaster casts and painful operations. Just a tiny incision one-eighth of an inch wide and about half an inch deep. The relief is immediate, the cure complete.

It’s so quick that when the specialist treated a daughter while her mother momentarily left the room, the mother returned to find that her daughter could stoop, sit, lie down without pain, things the girl hadn’t been able to do as nine months before she’d got a ‘slipped disc’ when she’d fallen from a horse.
The specialist sums up:

‘The agonising pain in the back which may continue for months or years, usually diagnosed as a slipped intervertebral disc, has never in my experience over a period of 30 years been due to a slipped disc.’
‘It has been due to a muscle or fibre caught up with a sensory nerve’
‘The recognition of the simple fact that a so-called slipped disc is NOT A REALITY would release many thousands of people from plaster jackets and relieve a very great deal of pain and suffering’.

Hughes wasted little time in following up on the article but perhaps it is better that he recount the story in his own words, in a letter he kindly wrote to me on 23 March 1993.

                                                                                                  Horace Hughes
                                                                                                  9 Trewithan Parc
                                                                                                  Cornwall PL22 OBD
                                                                                                  United Kingdom
I had had fourteen years of unmitigated pain and disability and things were indeed desperate as there was a real possibility of having to give up work, leaving my wife to become the breadwinner. My right leg had lost all feeling; the foot had turned in and dragged. Then, miraculously, appeared the article in the Daily Sketch. I was able to obtain the name of the doctor, Mr Vincent Nesfield. (Mr Hughes then obtained a referral from his doctor and made an appointment with Mr Nesfield).
I crawled into his consulting room. He performed a simple but brilliant operation under local anaesthetic which took ten minutes. The feeling returned to the leg, the foot turned back to its normal position and the (sensation of) blood could be felt rushing down the leg. A period of six further visits, one a month, dealt with residual (pain) spots ending on the right hip. To this day, 36 years on, there has never been a day’s pain or disability of any kind. At 80 year of age I can walk miles and garden for hours.  He had no back pain up until his death in his late eighties.

A short time after Horace Hughes’ treatment, a woman friend of his told a Welsh renal surgeon, Mr W. Skyrme Rees, about Hughes’ miraculous recovery at the hands of Nesfield. Rees was highly sceptical and doubted it was true. At the insistence of the woman, Mr Rees eventually made an appointment to meet Nesfield and watch for himself the procedure being performed. To his astonishment, he witnessed a male patient enter the surgery suffering acute back pain and walk out afterwards, apparently fully cured. Nesfield seemed to place no great importance upon the value of his innovation. In fact he did not even have a name for the procedure; it was merely something he did to alleviate back pain.
The effect upon Rees, however, was profound; it caught his imagination. It was to change his life.
As a renal specialist, bad backs were not something he usually encountered in the course of his work. Nonetheless he set about conducting his own research, including considerable anatomical research on monkeys and various birds. Rees, like Nesfield, concluded that the majority of back pain was not caused by what are called ‘slipped discs’ at the front of the spine but by derangement of the zygapophyseal*  joints at the back of the vertebra. Rees believe that by cutting the nerve supply to these joints he had discovered a way of safely switching off back pain.
Rees performed this operation for the first time on a Mrs Sally Jones-Davis, aged 59, at Llandudno General Hospital, North Wales after the house physician sent him a request for consultation.

Apophysis is a protuberance (process) coming out of a vertebra. Zygapophyses are processes on the side of each vertebra that move in co-ordination (articulate) with the corresponding process on the next vertebra. The zygapophyseal joints are the small joints at the back of the vertebral body and spinal cord.

Mrs Jones-Davis was described as having right-side severe sciatic pain. By then she had been bedridden in agony for four weeks.

Dr Rees describes what followed:
 On arriving at the hospital on 16 June 1960, I found a frail lady lying in a high bed in the general ward. The ward sister explained that Mrs Jones-Davis had been placed in this high bed because there were problems of nursing.
The patient’s sciatic pain was triggered off by the slightest movement and the high bed minimised her discomfort. Her history was of very severe right side sciatica of sudden onset four weeks previously. She told a long history of minor pain in the back, not amounting to disability, before the present attack struck her suddenly, making all movement impossible. She had been in bed at home for one month.
I performed the described operation at the level of the 4th lumbar vertebra, using a von Graefe cataract knife.
At the completion of the operation Mrs Jones-Davis climbed out of her high bed at my behest and took tea with us and her fellow patients, free from all pain.  She walked out of hospital the next day. This freedom from pain remained for 15 years until her death in 1975 from heart failure.

Later, in 1960 as consultant surgeon to the hospitals of Caernarvonshire and Anglesey, which were going through a period of great difficulty from hospital cross-infection, Rees was given a grant by the Welsh Hospital Board to travel to the United States to report on methods used there to control the problem.
He decided to combine this visit with his own investigation into the treatment of back pain as practised in America. In the course of his visit, he met with a Dr Hackett in New York and found that he had been treating lumbago and sciatica by injecting a sclerosing (hardening) solution into the ligaments of the zygapophyseal joints. Dr Hackett called his treatment Pro-Lan therapy. Rees concluded that Pro-Lan therapy was, in some ways, similar to his own work.
Dr Hackett thought that by placing the sclerosing fluid around the weakened ligaments in the spine, a stronger ligament was produced by scarring and that after three weeks, when the ligament was firm again, the pain would be relieved permanently. Dr Hackett did not demonstrate this treatment to Rees but gave him the address of a Dr Peterson in Boston, whom Dr Hacket had trained and who was performing Pro-Lan therapy successfully. Rees met Dr Peterson and watched the procedure being performed. Although he was impressed at first by the theory of it and its apparent success rate, he was concerned about the amount of pain it caused patients, so much in some cases that even morphine failed to alleviate it. Later, before leaving America, Rees was disturbed to discover that at least two patients who underwent Pro-Lan therapy had become paraplegics. He immediately excluded it as a treatment.
Upon his return to Britain, Rees decided to continue his research into treatment of back pain and to modify the treatment he had learned from Nesfield. In the next five years, Rees says he performed the operation successfully on 88 patients disabled by lumbago and sciatica.
However, in 1965 Rees attracted national attention for his views about the hygiene standards of British hospitals. As experts in cross-infection, he and five other doctors accused British hospitals of being ‘The dirtiest hospitals in the world’. In the ensuing uproar the five others backed down and withdrew their accusations. Rees refused and was suspended from duty. As a direct result of that, Rees resigned, sold up his possessions, took a refresher course in general medicine in order to become a general practitioner again, and vanished.
He re-appeared a few months later on the other side of the world in Tocumwal, New South Wales, a small town in the Australian bush. There, as plain Dr W Rees, GP at the age of 53, he introduced his startling surgical innovation (which he called rhizolysis), to the back pain sufferers of the bush. Rees chose to become a general practitioner in Tocumwal with great deliberateness, because it was a place of sheep shearers and fencers, a great number of whom suffered bad backs.
Now, as a general practitioner, he was able to gain direct access to large numbers of them. It was an amazing transition for a consultant surgeon and highly successful one; he began curing bad backs by the hundred. As news spread of his extraordinary success, people began flocking to see him from all over Australia.
Along with a rapidly burgeoning patient base, Dr Rees attracted national attention from both the media and a somewhat sceptical medical fraternity. In 1972, Rees was the subject of a (then) Australian Broadcasting Commission documentary “Four Corners”. The report included interviews with a number of orthopaedic surgeons who voiced their reservations about his work after watching the procedure being performed.
Nonetheless Dr Rees’ medical career flourished and he was soon invited to the United States and other countries to give lecturers about rhizolysis. At home, he was so much in demand that he opened clinics in Shepparton, Melbourne, Sydney and Wellington, New Zealand.
For reasons that will become clear, interest in rhizolysis began to dwindle by the mid-1980’s. By then an old man, Dr Rees closed the last of his consultancies, in Macquarie Street, Sydney and went into semi-retirement at his home in Woollahra to look after his ailing wife, Marjorie. Privately, he was embittered that his remarkable surgical innovation had not gained the world-wide acceptance from orthodox medicine he had hoped for it. Nor had he been recognised for his work in this field. Indeed, while he had been handsomely financially rewarded, he concluded there had been a ‘conspiracy of silence’  - a backlash – against it.
Dr Rees was only partially right. There was a backlash, and a powerful one, against rhizolysis but there was one of equal intensity against Dr Rees himself. I know of cases where orthopaedic surgeons refused to treat patients any further if they dared to go and see Dr Rees.
Dr Rees was a colourful man with total confidence in himself and his innovation; an articulate, superior, flamboyant Welsh gent, who is elegantly disdainful of his Australian medical peers and highly zealous in promoting the virtues of rhizolysis. He admits to ‘cocking a snook’ at them and flaunting his financial successes, ‘laughing all the way to the bank’ as he would put it. His personality, his extroverted ways – a chauffeur-driven white Rolls Royce with red leather seats, presidential suites at hotels, silver-knobbed walking canes – went down badly with the conservative medical mainstream.
They turned their backs on him and successfully vilified a man of impeccable medical credentials, accomplishments and great personal charm.
Personally, I consider Dr Rees a gifted physician and a valued personal friend. I will always be grateful to him for what he has taught me, just as I will always recognise the great work he carried on from Vincent Nesfield in the treatment of back pain. Until his retirement in March 1993, he enhanced the lives of many thousands of suffering people, and he has enhanced my own. I believe he has been unfairly denied the recognition he surely deserves for his work in this field. He has been badly wronged, although he is outwardly philosophical about it. ‘It is better to be wronged than to do wrong’ he says quoting Socrates.
On balance, though, I also believe that Dr Rees ‘sold’ the treatment badly. In my opinion, the explanation as to the mechanism of pain relief was incorrect and his selection criteria for who he treated was in-precise; he used it as a cure-all. Thus, he stepped away from mainstream medicine and was perceived badly by conservative practitioners. He compounded his problems by being seen to have become wealthy as a result of it – and then flaunting it.
In many ways the backlash against him was fairly understandable. But the tragedy, so far as back pain sufferers were concerned, was that mainstream medicine tried to bury the procedure with Rees. To me it seems they – the specialists – were shooting the messenger because they did not like him. Nor, of course, did they like his message; it could be performed by general practitioners in their own surgeries.
By 1988 the demise of this demonstrably viable option for pain sufferers was virtually a fait accompli. There was every reason to believe that it might eventually die with Dr Rees.
There was a small of doctors quietly, and persistently practising the procedure in Australia. But, by and large, no-one in mainstream medicine spoke of it, and it certainly was not included int eh curricula of any medical schools in Australia. Opponents had adopted a policy of silence, like a family refusing to speak of a black sheep or ignoring something in the hope that it will go away. It was highly effective; officially, Nesfield’s Treatment had ceased to exist.
In that year, of course, my patient Ken and his miraculous cure led me to meet Dr Rees and learn the procedure. It has taken me on a fascinating, privileged medical journey, or quest, and has caught me up in the lives of hundreds of back pain sufferers. It has taken me so far to two continents to express my views on, and my knowledge of, the subject of my international peers. It has been an enlightening experience.
More importantly, Nesfield’s Treatment is alive and well again. I have been asked whether I have taken up the banner once held by Dr Rees? My answer is a qualified yes. While I have taken up the banner I have also changed it because I do not accept the reasons Dr Rees gave for the treatment’s success. I acknowledge his enormous contribution in enhancing the lives of many of the 16,000 patients he treated in the course of his extraordinary career. I applaud his work, and Nesfield’s, in shifting the emphasis away from the slipped disc theory as the major cause of back pain. Dr Rees, however, like many practitioners, did not place any great emphasis on follow-up research after patients left his surgery. This gave his critics further ammunition, which they used to try to shoot him down, especially his claim that he cured 99.8 per cent of his patients.
I decided at the outset of my work to carry out appropriate follow-up with all of my patients and to monitor the long-term effects of the treatment with a view to determining a statistically reliable success rate. If Dr Rees had made mistakes, I was going to try to avoid them where possible.
There is little doubt that, despite my caution, I will stir up a hornets’ nest among my medical peers as a result of writing a book like this. Many of the older specialists still remember Dr Rees and it is likely they will lump me in with him in their opinion of me and the procedure.
In the pecking order of the medical world, it should be borne in mind that I am a general practitioner, not a specialist who has passed a multitude of examinations to achieve a higher medical status. Some specialists look down on general practitioners like myself, especially when we enter their specialised areas e.g. treatment of back pain.
The specialists are correct in part, but it seems to make little difference to their former patients who come to me and experience a great reduction in their back pain.
As you will read in a later chapter, I have tried to publicise Nesfield’s Treatment or percutaneous neurotomy as it is called medically, through official channels – medical journals – here in Australia but have met with stern and, in more than one case, vehement resistance.
By writing a book like this aimed primarily at a non-medical audience, and hopefully for as many back pain sufferers as possible, I acknowledge that I run a great risk of backlash from my colleagues. Although I doubt whether I would make much of a martyr, I sincerely believe the greater good lies in the opportunity for back pain sufferers to benefit from this treatment.
I often look back on that moment when Ken hobbled into my surgery, and wonder what would have happened if he had not returned to me with his revelation, or how I would have felt if my first patient failed to improve after the treatment? Quite likely, I would have dismissed the technique out of hand and carried on with my practice exactly as before. Little doubt, I too would have been sceptic.
In taking up the banner of Nesfield’s Treatment and changing it, and acknowledging that I run some of the risks of Dr Rees, I also decided I would try to minimise these wherever possible. I promised myself that I would do whatever was required to place the procedure on a better, more credible medical footing with a view to it gaining greater acceptance among doctors everywhere – and their patients.
In keeping accurate follow-up records, I believe I have made some progress in this. If this book provides further assistance in my quest, then my role as a medical practitioner will offer more relief for back pain sufferers.

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