No Bone-setter can find fault with Sir James Paget’s lecture beyond his vulgarising, if I may so term it, his opening illustration. Such an instance might occur, for there are “Bone-setters and Bone-setters.” The term is doubtless assumed by many whose practice brings disgrace upon those who pursue an honorable calling, even if they do not belong to a chartered society, or are recognised by Act of Parliament and therefore not “legally qualified practitioners,” it is true that they are qualified by long experience, by early training, and the skill gained by the constant practice of many years, but the law does not recognise them.

Sir James Paget appears to imagine that all the formula of a Bone-setter is to say that “a bone is out,” and to use a wrench to put it in again, which wrench he admits does good in some cases. He admits “of course they have a certain number of real fractures and dislocations which they reduce, and of old ankylosis which they loosen.” “Of these,” he adds, “I need say nothing; for I believe there is nothing in their practice in these cases which is not as well or better done by regular surgical men.”

He instances what he calls the “rare accident” of the slipping of a tendon which a wrench may cure, and he is polite enough to say “I can hardly doubt that a Bone-setter has occasionally done unwittingly, a lucky trick, when, with wrenchings and twistings of a joint, he has made some dislodged tendon slip back into its place.” Sir James further enumerates a series of cases of injuries to joints, which may, and indeed are, daily cured by Bone-setters, and he shows how sometimes patients themselves may unlock a stiff knee whether caused by loose cartilages, a stiffness of the muscles, or from other causes. “It may be admitted generally,” he tells his audience, “that from paying particular attention to this class of cases, which are constantly occuring, that the Bone-setters have achieved their great reputation where eminent surgeons have failed.” Sir James too dwells on suppositious cases, which if treated by the Bone-setter’s wrench would certainly end in mischief, and alludes to bad boys who simulate stiff joints who often “escape disgrace by lying and letting the Bone-setter be believed when he professes that he has ‘put in’ their dislocations.” “Amongst all these cases of muscular difficulty,” Sir James says, “there is a good harvest for Bone-setters and without doubt their remedy is rough as it is real.” “But,” he continues, “there is yet a larger class of cases which Bone-setters sometimes succeed in curing very quickly, namely, ordinary sprains.” “I cannot doubt,” he says, “that some recently sprained joints may be quickly cured, freed from pain, and restored to useful power, by gradually increased violence of rubbing and moving.” He admits that this has sometimes been introduced into regular surgery, but, he goes on to state, that it is in cases where old sprains have remained long uncured that Bone-setters, and especially those who combine rubbing and shampooing with their setting, gain their chief repute. He, therefore, cautions the surgeons against giving too much rest, to avoid cold joints, excessive exercise, and try more gentle methods than are popularly attributed to the Bone-setter, as if the latter gloated over causing pain, which is not the case, though he often thinks that one sharp pang is better than days of agony, and, when over, his patient always coincides with him. The great Master-Surgeon also points out that what are called “hysterical joints” afford a rare opportunity for a victory for a Bone-setter, which may be cured by sheer audacity of being pulled about.

“From this you may see,” says Sir James, “that the cases that the Bone-setters may cure are not a few, but,” he continues, “the lessons which you may learn from their practice are plain and useful. Many more cases of injured joints than one commonly supposed to be thus curable may be successfully treated with rough movements.”

“Learn, then, to imitate what is good, and avoid what is bad in the practice of Bone-setters; and if you would still further observe the rule, Fas est ab hoste doceri, which in no calling is wiser than in ours, learn next what you can from the practice of rubbers and plasterers; for these know many clever tricks; and if they had but educated brains to guide their strong and pliant hands, they might be most skilful curers of bad joints, and of many other hindrances of locomotion.”

Such is in brief the testimony of the great Master-Surgeon of the age to the methods of practice adopted by the Bone-setters, who have practised their art as their fathers and grandfathers have done before them. His testimony at least shows that the Bone-setter works on truly scientific grounds, and that he is not a mere “lucky trickster,” a charlatan who works on the credulity of the public for the sake of gain, pretending to cure others by his own conceit. As I have before pointed out, Sir James Paget himself had occasion to modify his originally expressed opinion when the process and mode of cure practised by the late Mr. Richard Hutton was explained by Dr. Wharton Hood.

To this gentleman the profession and the public were indebted for the first published authoritative account of the Bone-setter’s art. There are but few Bone-setters who will say that Dr. Hood has exhausted the subject, for he has not; he has only indicated a few salient points, in which the practice of Mr. Hutton varied materially from that taught in surgical schools. He showed that more might be done in the surgical world by the leverage of the limbs, than by the employment of complicated and expensive apparatus. He bemoaned the “cost and loss” which the practitioners of surgery have sustained by the resort of patients, affected by impaired mobility or usefulness of limbs, after disease or injury to the Bone-setters, who so frequently give relief and speedily cure a patient by their manipulations and treatment. It is but just to Dr. Hood to say that he has given a number of cases illustrative of his statements, which the faculty have “condescended” to notice, and some of which, in my desire to give the widest illustrations of the usefulness of the Bone-setter’s art, I have embodied in this treatise. He dwells somewhat on the supposition that all Bone-setters declare that “a bone is out” in every case of thickened or stiff joint that is brought to them, but he seems to forget that these are only a fraction of the “cases which Bone-setters cure,” and on which our reputation so securely rests. The quarry men of North Wales, as detailed in the British Medical Journal, in 1875, preferred Mr. Thomas Evans, of Pen-y-groes, to their old regular medical practitioner in cases of external injury to body or limb, and though the profession were indignant at any medical men, being associated with a mere Bone-setter in the rules of Friendly Society or Sick Club, the connection is not unfrequent. The faculty have evidently much to learn ere they can successfully compete with Bone-setters in the special cases to which they devote their time, abilities and attention. The patients are the best judges of results, and by results the surgeon must be judged. Their case is not helped by detailing how a Chinese farrier killed a girl the Emperor desired to marry, by forcibly straightening her hump-back, as recorded in page 900 of the Lancet for 1872. It is far better for them to admit as Dr. G. Reed admitted in the same journal that he “had his eye wiped” by a Bone-setter, at Liverpool, who cured a sailor whom he failed to relieve.

Throughout the medical publications from 1871 to 1880, there are frequent allusions to the bone-setter and several admissions by surgical practitioners,5 that they have followed the method of the bone-setter with success, and discarded therefore the teaching of the schools; for though the Lancet itself welcomed Dr. Wharton Hood’s exposition of the art of the Bone-setter, as tending “to afford the means for the suppression of a widely prevalent and very mischievous form of quackery which has been based, as every success of the kind must be upon some neglected or forgotten truth. The late Mr. Hutton, on whose practise, Dr. Wharton Hood’s papers are founded, was for many years a sort of bugbear to not a few of the most distinguished surgeons of London, and every few months some fresh case was heard of in which he had given immediate relief and speedy cure to a patient who seemed vainly to have exhausted the legitimate skill of the metropolis.” This is an admission somewhat at variance with its previous utterances, and not as frank as the organ of a boasted liberal profession should be, and is far from generous, for its tone is embittered.

It however goes on to say, that “in some country places and especially in mining districts, in which large labouring populations are much exposed to chances of injury, bone-setters become formidable opponents to regular practitioners, and, like their London representative, have their surprising cures to boast. It is true that they often inflict injury; but this is not the aspect of the case to which our attention should be first directed. They are not valued because they do harm, but because they do a certain amount of good; and the way in which this good is brought about is the matter of chief interest to the profession.” The Lancet goes on to say “that quackery is only an expression of the extent to which legitimate practitioners fail to meet the desires of the sick,” and then somewhat unfairly and unjustly introduces the quack who pretends to cure phthisis or other mortal illness, as if Bone-setters professed impossibilities. After this inconsistent divergence it points out “that in the particular in question (the art of the Bone-setter) it is incontestible that a large number of irritable and useless joints have been restored to a natural condition by Bone-setters after a long period of unavailing surgical treatment, and that the profession has not known how this desirable result has been produced, or what has been the true nature of the lesion treated. The quack always said that a bone was “out” and that he had replaced it, and the doctor knew quite well that these statements were not correct. The doctor would not meet the quack; and the quack kept his methods secret, and would not show them to the doctor. The quack obtained more credit for a cure after the doctor had failed, than the doctor for a hundred cures in an ordinary course; and the Bone-setter, of all quacks was the one who did most to injure the reputation of the profession.

We once heard a military man of considerable distinction describe how his son was instantly cured of a sprained knee by Hutton, after a distinguished hospital surgeon had treated him to no purpose; and the speaker wound up with the remark ‘you doctors are all duffers.’

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“At all events, for good or evil, the treatment pursued by Bone-setters will now be fairly before the profession and scientifically educated surgeons will soon be in a position to define accurately its merits, its dangers, and the limitations of its usefulness. Its application by ignorant men to unsuitable cases has often been followed by injurious consequences; but no such consequences ought to occur in the hands of the profession. We have little doubt that Dr. Wharton Hood has really called attention to a neglected corner of the domain of surgery, to morbid conditions that have been only very faintly described in books, and scarcely at all recognised in practice, to precautions that have been either unfounded or exaggerated, and to a method of cure at once simple and intelligible. We hope to see as the result of his labour, that the art of the Bone-setters will become extinct, after having been for a time exercised only upon those cases for which treatment by movement would be really unsuitable, and, as a necessary consequence, hurtful instead of curative.

“There may be other forms of quackery also under which some valuable knowledge may lie concealed; and no better service can be rendered to the profession or the public than to bring quack knowledge to the light of day, and to make it available for the general good.”

The publication of Dr. Wharton Hood’s book had however a different effect on the public mind than what was intended. There was previously a sort of general belief that the doctors might be right in dubbing Bone-setters “quacks” without much discrimination as to who the bone-setter was. Some of the complaints which appeared in the Lancet prior to this, were like the petulant utterances of a child deprived of its plaything, rather than the opinions of a scientific inquirer, for it must have struck the thinking part of the faculty, as it subsequently did Sir James Paget, and gleamed on the writer in the Lancet, that the fame of the many cures could not have been the effect of chance, or the “luck” of ignorant charlatans. Mr. Archibald Maclaren, who noticed Dr. Hood’s book in Nature, seems to have been aware of this. He pertinently says with reference to his work On Bone-setting, “It will be asked, What is Bone-setting, who are the Bone-setters, and who are their patients? And it will be readily answered Why, of course, Bone-setting is the art of setting bones that have been broken, or joints that have been dislocated, and this is done doubtless by surgeons; and equally doubtless, and of course their patients are persons whose bones are fractured, or whose joints are dislocated—

Perhaps not, but the answer is quite wrong for all that; quite the reverse, indeed, of what is actually the case, for Bone-setting is NOT the art of re-setting broken bones or dislocated joints; Bone-setters are NOT surgeons, or regular practitioners in any sense of the title; and then patients, even when they have suffered injury to joint or bone, have been pronounced by the regular practitioner cured before seeking the help of the Bone-setter.”

The writer very properly calls this “a triple paradox,” and quotes what Dr. Hood has to say in explanation:—

“A healthy man sustains a fracture of one or both bones of the forearm, and applies at a hospital, where splints are adapted in the usual way. He is made an out-patient, and the splints are occasionally taken off and replaced.

“After the lapse of a certain number of weeks the fracture becomes firmly united, the splints are laid aside, and the man is discharged cured. He is still unable to use either his hand or his forearm, but is assured that his difficulty arises only from the stiffness incidental to long rest of them, and that it will soon disappear. Instead of disappearing, it rather increases, and in due time he seeks the aid of the Bone-setter. The arm and forearm are then bent nearly at a right angle to each other; the forearm is intermediate between pronation and supenation; the hand in a line with it; and the fingers straight and rigid, the patient being unable to move them, and also unable to move either the wrist or elbow. Passive motion can be accomplished within narrow limits, thus produces sharp pain, distinctly localised in some single spot about each joint, in which spot there will be also tenderness in pressure.

“The Bone-setter will tell the man that his wrist and his elbow are “out.” The man may object that the injury has been in the middle of the forearm, perhaps from a blow or other direct violence. The reply be then; perhaps the arm had indeed been broken as alleged, but that the wrist and the elbow had been put out at the same time, and that these injuries had been overlooked by the doctors. The Bone-setters would then, by a rapid manipulation hereafter to be described, at once overcome the stiffness of the fingers, and enabled the patient to move them to and fro. The instant benefit received would dispel all scruples about submitting the wrist and elbow to manipulation, and these also would be set free in their turn. The man would go away easily flexing and extending his lately rigid joints, and fully convinced that he had sustained grievous harm at the hands of his legitimate doctors.”

“The art of Bone-setting, then, is the art of overcoming these impediments in joints, these conditions or impaired freedom which not unfrequently supervene on the curative processes of treatment in use by surgeons in case of fracture or dislocation, or which may arise from and be observed only after the subsidence of active rheumatism, gout, gangrene swellings, or other local affections; and this brings us to the question—How is it done? how are these stiffened joints set free? how are these impediments to healthy action overcome? The answer of the regular practitioner is that which has been already quoted, namely—‘to rest it’—advice which usually entails a distressing failure; the answer of the irregular practitioner, i.e., the Bone-setter, is precisely the opposite, namely—that freedom can only be restored to the stiffened joint by movement, by manipulation, and manipulation, too, of the most formidable kind, nothing less than suddenly and forcibly rupturing, tearing asunder the adhesions formed between the articulating surfaces of the affected joint, an operation which is so frequently successful that it forms the very basis of the Bone-setter’s craft.”

This is very forcibly and clearly expressed, but its verbiage tends somewhat to place the Bone-setter in a formidable and forbidding light, as opposed to the regular practitioner, but as a matter of every-day experience such is not the case. It is true, that the injury of years cannot be removed in a twinkle of an eye, without the patient suffering any pain or inconvenience. No bone-setter pretends to do that, but his mode of procedure is not of that violent and repellant character which Mr. Maclaren’s words would seem to imply:—

“It is here,” continues Mr. Maclaren, “that the Bone-setter steps in front of the scientific surgeon, and we must confess to a feeling of disappointment that their relative positions are not reversed, that the surgeon is not called in to rectify the malpractices of the quack, instead of the latter being sought out to complete the shortcomings of the former.” These are not our words, but the words of an independent reviewer in a scientific periodical. He tells his readers that the Bone-setter is not a man with only one remedy and one resource, but that “he has a clearly defined system of treatment for each separate joint, if not for each specific affection to which each joint is subject.” What qualified surgeon, what regular practitioner has more than that? He follows the dogma and doctrine of the schools. The Bone-setter that of experience, practice and the traditions of generations of practitioners. The one is recognised by law, and the other is not.

Mr. Maclaren seems to have seen that there was something which required explanation in all this. With the facts in Dr. Hood’s book before him, he says “Bone-setters, we are told, are for the most part uneducated men, wholely ignorant of anatomy and pathology.” In the anecdotes of Mr. Hutton, this is always accentuated in the professional accounts of his proceedings, for he made a little boast of his ignorance, but the writer continues, “we are not told what we greatly wish to know, and that is, the manner and method in which the secrets, the mysteries, and the other traditions of the craft, are communicated to each other.6 No doubt there exists a freemasonry in the craft, so that when individual members meet, revelations are made and notes compared, but we are not informed of any regular or organised system of instruction, either for the maintenance and extension of the craft, as a craft, or for the enlightenment of the separate and detached members of the fraternity. The most celebrated, we may even say distinguished,7 Bone-setter of our day, was the late Mr. Hutton, whose successful treatment of cases which had baffled the skill of the foremost surgeons now living, as related in detail by Dr. Hood, and about the accuracy of which there can be no question or doubt, is little short of marvellous; and the question is ever recurrent, while we read ‘How and where was this skill acquired?’ for a Bone-setter of Mr. Hutton’s calibre could put his finger on the spot, where lurked the seat of an affection that had crippled a patient for half a dozen years, and had defied the scientific treatment of the ablest surgeons of our time; nay, he could point to this spot without ever seeing the limb affected, guided merely by observing the attitude, gait, or action of the patient. Now whence comes this skill of these illiterate men? It appears to have been gained solely by observation of symptoms and results of treatment, the accumulated knowledge of from day-to-day experience; and, as we often see that one sense is quickened and functional power increased by the loss or impairment of some other sense; so, perhaps, the narrowing of the field of instruction and counting of the sources of information, may have intensified the powers of observation of the Bone-setters, allowing in a measure for the absence of the revelations of science.”

Is not this equally applicable to the oculist, the aurist, the dentist, and to the “specialist” of every description. The Bone-setter keeps within his special knowledge, and though he may be called “a quack,” he can point to the results of his skill and experience, and ask if these are quackery? The patients, whose sufferings have been alleviated, must answer, “If this is quackery, we wish there was more of it in the world.”

CHAPTER V.

THE FACULTY IN DOUBT.

“Why, what have you observed, sir, seems so impossible.”—Ben Jonson.

Like the Royal Society, when Charles II. asked that learned body the answer to certain propositions, the medical profession continued for years to “hum and haw” over the self-evident fact that Bone-setting was not only an institution, but a successful profession. I have taken somewhat at random from my voluminous collection of notes on the subject, a few of the printed opinions of those “who were convinced against their will,” but could not “be of the same opinion still,” but wished to modify the self-evident facts or gloss them over to harmonise with previously expressed declarations.

In 1880, the Clinical Society, at their meeting, held on April 9, had the subject of “Bone-setting” under discussion. Mr. Howard Marsh, whose experience is elsewhere given (page 95) gave instances of a number of cases he had treated after the Bone-setter’s manner, and which had been quite successful. He gave his testimony to the great service Sir James Paget had rendered to the profession by drawing attention to the subject in his clinical lectures which had since been republished with others (see pp. 69-74). He further said that displacements of cartilages, and slipped tendons might be, and doubtless sometimes were, put right by Bone-setters; but he believed the cases of adhesions—especially such as occurred after an injury outside a joint, which itself was healthy, afforded by far the most numerous instances of improvement after forcible movement, and he expressed his conviction that they were much more frequent in practice than was generally supposed. He gave other several instances where he had followed the Bone-setter’s treatment as given by Dr. Wharton Hood. He, of course, was silent as to the practice of the Bone-setters in reducing fractures, and their treatment of cases which never came under the care of the faculty at all, and which were satisfactory to the patients.

Mr. Hulke thought it was an approbrium to surgery that so many persons sought advice from Bone-setters, and he mentioned that “even intelligent people are blinded by these men!” Many alleged instances of injury following the treatment of the Bone-setter, but there was a little contemptuous tone with respect to country surgeons, which ere long evoked a reply.

In the next number of the Lancet, there appeared a letter from Dr. D. H. Monckton, of Rugeley, pointing out that it would seem “that the chief object sought in the debate was to prove to country surgeons that their metropolitan brethren understand, and can cure such conditions of the joints if only they are sent up to them.” In other words, they want to occupy the place and receive the fees of the ousted Bone-setters, whose secrets they had appropriated, after covering them with approbrium as quacks and empirics.

At another meeting of the profession there was the same pro and con argumentation. The obvious “willingness to wound,” but yet “afraid to strike” in the face of the overwhelming testimony in favour of the bete noir of the profession:—the healer outside the fold “who in the wilderness doth stray.” At this meeting Dr. Bruce Clarke read a paper on the practice of the Bone-setter, in which after briefly alluding to the variety of cases that found their way to the Bone-setter, and derived benefits from his treatment, he adverted to the pathology of stiff joints, and showed from observations of several cases which he had been able to examine after removal of the limb, that adhesions were usually found outside joints and tendon sheaths, and were due to contractions of the connective tissue of the limb. Adhesions were rarely formed inside the tendon sheaths or joints, and when they were, the disease was far more serious and rarely yielded to treatment. In cases of old stiff joints, the skin, and probably the subcutaneous tissues, became weakened and atrophied by disease, and were so rendered more liable to injury—in proof of which he cited several examples of tearing and lacerating the skin without the employment of due violence. The usual history, he tells us, of the class of cases that came under the hands of the Bone-setter was this:—

The patient met with an injury resulting in a dislocation, or fracture, or perhaps, only a severe bruise, or a sprain. He readily recovered up to a certain point; but when all inflammation had subsided, there remained a stiffness accompanied by pain on movement. In other cases there were periodical attacks of synotictus. The treatment in all such cases was active movement, with or without chloroform, which was usually accompanied by a click or crack, ascribed by the Bone-setter to the replacement of a bone, but which was due to the freeing of the connective tissue bands. In slight cases, one violent flexion might cure the trouble of months: in severe cases, the treatment might be measured by months rather than minutes. The pathology of such cases was as well marked as that of iritis, where there was the advantage of seeing the adhesions not only form but rupture and disappear. He expressed his obligation to Mr. Wharton Hood’s lecture which had induced him to study the subject. The difficulty of these cases was the selection of time for rupture, and for rest. Signs of inflammation were their guides in that matter. Rest should be regulated to its proper position in surgery, and should not be kept up when it increased instead of abating the patients’ troubles.

Dr. Keetley thought Dr. Clarke could hardly have chosen a more interesting subject, undoubtedly, the Bone-setter frequently earned great credit by the manipulations which broke down adhesions outside a joint, and at the same time, removed the cause of inflammation, for in these cases there was no contraction of membrane. When there was an osseous fibrous hand the case was of a strumous origin, it was due to the presence of organisms. In such cases the joints became altered, and there was great danger from the rough usage of the Bone-setter. In the treatment of such joints he had put on ice for several days with great advantage, and had repeatedly put them straight. When once convalescent, a joint very rarely became strumous. There was much bewilderment with regard to the value of rest, which was only a negative factor. It was the natural tendency of a column of germs to die as the joint became healthy.

Dr. Alderson related the case of a knee which became enlarged fourteen days after confinement, but without pain. He called in Dr. Hewitt who ordered rest, and the knee to be rubbed with salad oil. He also used Scott’s dressing. Subsequently, at Brighton, a sea-weed poultice was used. The treatment was successful.

Dr. Alden Owles had seen several cases confirmatory of the opinions advanced in the paper. Once was a shoulder, the manipulation of which caused agony to the patient, but in which motion was regained. Another regarded at first as a strumous joint was eventually cured by somewhat violent manipulation.

Dr. Vinen referred to the case of an officer of the 60th Regiment, who sustained a compound fracture below the knee whilst playing at football in India. The bones were set by some naval surgeons who were watching the game; but in consequence of the leg being deformed, the adhesions were broken and the limb reset. The ankle then remained fixed, and the patient’s health suffered. However, Mr. Erichsen was called in, broke the adhesion, and the patient recovered so thoroughly, that he was enabled to rejoin his battalion in the Transvaal. Dr. Bruce Clarke in reply, pointed out the necessity of distinguishing chronic cases, as such were usually made worse by movement.

In the course of this discussion only one point of the Bone-setter’s practice was alluded to—that of rigid or strumous joints, as if the renown of the Bone-setters art rested on these alone. “There are none so blind as those who will not see.”

CHAPTER VI.

DISPARAGEMENT AND VINDICATION.

“Who shall decide when doctors disagree?”

Dr. Howard Marsh, the learned Editor of Sir James Paget’s Lectures, who had previously been subjected to the criticism of country practitioners for his somewhat supercilious allusion to their failure to adopt the processes of the Bone-setter, thought it becoming at the jubilee meeting of the British Medical Association at Worcester in 1882, to resume the worn-out sneer at the Bone-setter’s ignorance and superstition. He seems, indeed, to have drawn on his imagination for his facts, or to have resuscitated the history of his own profession for that of the modern Bone-setter. From his high and mighty stand-point he told the assembled medical practitioners in the “faithful city” this faithless story:—

“Bone-setters are a very miscellaneous group, who resemble each other mainly in the negative point, that they have never studied either anatomy, pathology, or surgery. Some are blacksmiths on the Cumberland hills, or shepherds in the sequestered valleys of Wales. Practitioners of this kind, standing in the same relation to surgery that herbalists bear to medicine, have existed in these remote districts from immemorial times. They belong to the same order which in bye-gone times included fortune-tellers, ring-charmers, and the workers of all kind of village miracles. At the other end of the scale are practitioners of a less unsophisticated stamp. Residing in large towns they equip themselves with the names of the principal bones and muscles, and with a few stock medical phrases they procure a skeleton on which they undertake to show patients the precise nature of their complaints; they employ anæsthetics freely, and make full use of daily passive movements, rubbing and shampooing; while in spinal cases they often put on Sayre’s plaster jacket. These individuals however, are in the same position as the most homely of their order in this important particular—that diagnosis, properly so called, forms no part of their system. Indeed, diagnosis and their method are two things incompatible. At present, the Bone-setter’s programme is both concise and logical. In every case alike he asserts that “a bone is out,” and that he can put it in. Now, the second clause of this formula postulates the first. But let him once enter upon diagnosis—let him once find, not that a bone is out, but that the case is one of tumour, or paralysis, and he has cut the ground from under his own feet. No. Beyond the assertion that “a bone is out” or similar phrase, he never goes. If pressed for particulars, he cuts the knot by saying, “I can cure you—what more do you want?” Old Mr. Hutton, of Watford, used to say, “Don’t bother me with anatomy—I know nothing about it.” A patient, therefore, who consults a Bone-setter, is simply playing a game of hazard. His fate depends on what is the matter with him. If he has a stiff ankle after a sprain he will very likely be cured. If he has a strumous joint he will be more or less injured, while if he has a bunion, or a node on his tibia, he will find himself neither better nor worse for his venture.”

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I have quoted Mr. Howard Marsh thus far without comment in order to show that he is something like the Old Bailey advocate, who thinks to serve his clients best by abusing the attorney on the opposite side. He seems neither to have learned Sir James Paget’s admissions, or was anxious to pose as a dogmatic teacher at the expense alike of truth and experience. His whole knowledge and deductions are made from the two or three cases related by Dr. Wharton Hood, for so learned a doctor was not likely to look for facts in the domain of general literature outside the schools. He then proceeded to say—“But how is it that Bone-setters sometimes succeed where surgeons have failed? My answer is the following:—There are a considerable number of minor ailments of and around the joints that interfere with free movement, or produce pain, such as adhesions, slipped tendons, hysterical affections, rigidity of the muscles, &c. These conditions, though they differ widely from each other, and are met with under a great variety of circumstances, have yet this one point in common, that they may be cured by free movement.

“Now, how have Bone-setting and surgery respectively dealt with these cases? What is Bone-setting? Bone-setting is a system embodied in a single clause. Ignoring alike anatomy, pathology, and diagnosis, it begins and ends in a summary act of treatment. It consists in the process of carrying the affected joint through its full natural range of movement in all directions, especially in the direction in which there is the greatest resistance. Thus, a Bone-setter, who says, in every case alike that a bone is out, and that he can put it in, is like a practitioner who should tell all his patients alike that their complaint was constipation, and should promise to cure them all with sulphate of magnesia. Now, although sulphate of magnesia given for strangulated hernia or typhoid, or Bone-setting employed for sarcoma or a scrofulous joint, can do nothing but harm, there are many cases in which both these agents do real good; and these genuine successes, like the fragment of truth that lies at the bottom of every method which shows any sustained vitality, are enough, when they are seen through the glamour that surrounds this system to outweigh in the eyes of the public the failures that stand on the other side of the account. How has it been with surgery? Surgery is no stranger to the use of manipulation. The method has frequently been employed, and is fully discussed in the writings of many surgical authorities; but it has always been unpopular; and for this reason.

It has been used mainly in cases in which limbs have been left stiff or distorted after the subsidence of serious disease of the joints themselves, and the result has been disappointing. The joint though yielding freely under manipulation, has usually grown stiff again; and not rarely there has been a fresh outbreak of the original disease. These, however, are not the cases which are suitable for this method. If the secreting structure of the synovial membrane has once been destroyed, or if the cartilage has been removed and replaced by adhesions, the joint is practically converted into a cicatrix, and although that cicatrix may be completely torn across the functions of the articulations cannot be restored. The effect of these cases has been that, finding they have done no good, and sometimes even harm, surgeons have too much discarded manipulative treatment, and have too exclusively adopted the motto non vi arte. Thus it has happened that Bone-setters, helped by their ignorance, have stumbled on success, while surgeons, deterred by the unsatisfactory results, met with in a particular group of cases, have refrained from manipulation in instances in which it is the only treatment that is likely to be efficient.

I have said that a Bone-setter’s formula is, that a bone is out, and that he can put it in. To do this he carries the limb through all its natural range of movement, and he stops only when all resistance has been overcome. Thus, if a knee is flexed, it has to go straight just as a horse that jibs at a fence—if he happen to have a rough rider on his back—has to go over it. In the majority of cases, however, the force that is used in a majority of cases is absolutely slight; for, in the first place, an anæsthetic is often given, so that the muscles being relaxed, the effort used takes effect directly on the source of abnormal resistance, whatever that may be. Secondly, Bone-setters acquire by practice much facility in handling and moving the various joints; they know how to seize the limb at a advantage, not only with the force, but with the skill of a wrestler; and thirdly, in cases in which an anæsthetic is not given, they take care to divert their patients’ attention so that the muscles are off their guard.

In the common run of cases in which Bone-setters succeed, very moderate force is sufficient to break down all resistance that is encountered. This latter is a very important point. The main objection entertained by surgeons to manipulation is that it is a resort to violence; it is vi non arte. This view, however, if founded mainly on the experience of cases in which fibrous ankylosis of the larger joints has been broken down. But these, I venture to repeat, are not the cases by which to judge this method. I can recall but few cases in which free motion has been restored to a joint that could be moved only by the use of considerable force. The most striking successes are obtained in instances in which some slight impediment to motion is easily overcome. Indeed, it may be taken as an axiom—almost, perhaps, self evident, that the less the force which is required to remove the impediment, the more successful will be the result. Thus so far from the opinion being a correct one, that manipulation is necessarily a resort to violence; the truth is, that in appropriate cases, force which could inflict injury on the natural structures is very seldom required. I think when this fact is more clearly recognised, much of the distrust now entertained respecting manipulative treatment will have been removed.”

Thus Dr. Howard Marsh argues admittedly on the slightest and most imperfect knowledge of the Bone-setter’s art and their method of procedure. He is kind enough to admit that they sometimes reduce recent dislocations, disperse a bursa, and succeed in nervous so-called hysterical joints and spines. (See George Moore’s case, 29-32 ante.) They sometimes, he admits, “replace a slipped tendon,” and operate successfully in cases of internal derangement of the knee joint, and in relieving joints which, though healthy, are stiffened and painful from surrounding adhesions. He approves to some extent of manipulations, and his whole paper is one of disparagement, or “damning with faint praise.”

CHAPTER VII.

VINDICATION.

“Is this then your wonder?
Nay, then, you shall understand more of my skill.”—Ben Jonson.

Lest it should be thought that I have only my own authority for calling in question Dr. Howard Marsh’s dogmatic assertions with respect to the method of practice by modern Bone-setters I find at the same medical jubilee, Mr. R. Dacre Fox, Fellow of the Royal College of Surgeons, of Edinburgh, the surgeon to the Southern Hospital, Manchester; surgeon to the Manchester police force, and whose other practice and official appointments entitle his opinion to some weight, gave his practical experience of the Bone-setter’s art, so entirely different and so much nearer the truth, that I shall content myself with merely quoting, whilst thanking him, for his remarks which appeared in the Lancet, for 1882 (vol. ii. pp. 844.) Speaking from three years’ experience with the late Mr. Taylor, a celebrated bone-setter at Whitworth, Lancashire, whose family have been bone-setters for more than two hundred years, he told the medical men in plain terms that, “Much misconception exists as to the practice of Bone-setters; many of the methods of treatment popularly attributed to them have no other existence than in the imagination of ignorant patients, whose stories we, as a profession, are perhaps rather too ready to believe. It is certain that some families—notably the Taylors, Huttons, and Masons—have by their manipulative and mechanical skill justly acquired a great reputation. In what has their practice consisted? First, in the treatment of fractures and correction of deformities. The general impression in the profession appears to be that the Bone-setter’s art consists of nothing more or less than the forcible “breaking up” of stiff joints, so as to make the same man walk as if by a miracle. The practice at Whitworth was a large one, furnishing constant employment for at least two active men, and consisting chiefly of the cases I have mentioned. Speaking from memory, I do not believe that fifty joints of all sorts were “cracked up” during the time I was there; but it was not an uncommon event to have to put up half a dozen fresh fractures and twice as many recent sprains in a single morning. In the North of England, the origin of nearly all the men who are fairly good at Bone-setting can be traced to the Whitworth surgery, and while, so far as I know, the Taylors, in their various settlements at Whitworth, Todmorden, Stock-wood, and Oldfield-lane, were the only qualified surgeons who practised Bone-setting; amongst the hills and dales of Lancashire, Yorkshire, and the Lake district, there were many who did so without being qualified, some of whom, I must in fairness say, put up fractures uncommonly well. But apart from the legitimate credit they have won by the skill displayed in their handicraft, they owe some of their success to the carelessness or indifference of the general body of practitioners, who are apt to overlook little injuries which often become very painful and troublesome. It sometimes seems to me that it is beneath the dignity of the ordinary practitioner to employ any active treatment whatever for a sprain. It is hardly fair then to guage the work of Bone-setters solely by their method of treating diseased joints (probably the most unsatisfactory class of cases in the whole realm of surgery), but we ought also to take into account the patience and skill they display in the treatment of injuries for which they are not unfrequently consulted by the patients of qualified practitioners. I have no desire to hold a brief for every idle fellow who calls himself a Bone-setter, but I am anxious to give credit where credit is due, and to explain that the art of Bone-setting is not what it is often thought to be a mere mixture of charlantanism and good luck.

******

From my own experience, I should classify weak joints as follows:—

1.—Those that have become stiff from enforced rest.

2.—Those that have become stiff by chronic disease.

3.—Joints stiff from injury to the bones entering into their formation.

4.—Joints stiff and weak from sprains, including displacement of tendons and partial luxation.

Apart from the previous history of the case, and the evident existence of constitutional disease, there are some external appearances which help to distinguish cases and to afford indications of treatment, and of these the Bone-setters have learned by experience to avail themselves.

1.—In the first-class I have mentioned the stiffness of the structures about the joint impeding its movement is the result of purely mechanical causes, is in fact simply due to prolonged disuse. No cause for functional activity exists, and consequently the elasticity, the flexibility and power of adaptation to movement in the parts about the joints not being required they become stiff and rigid. No degenerative changes however taking place, and they are capable of being recalled into activity unimpaired. In such a joint, the bony points, and the outlines of the tendons and ligaments about it, seem unnaturally prominent, probably from absorption of the adipose and connective tissue; the rigid ligaments impart a sense of hardness, and if the limb be flexed to its utmost, it shows considerable resilliency, such joints may, I believe, be “cracked up” without fear of consequences, and this constitutes one of the successful operations of Bone-setters. My own recollection carries me back to some apparently almost miraculous results. I am convinced suddenness ought to be insisted on in doing this; the advantage derived from it being, I believe, mainly due to the fact, that it is less likely to set up any irritation in the joint than the “dragging” of gradual extension.

2.—In the next class of cases, in which stiffness is due to degenerative changes, the external appearances are exactly reversed, the outlines of the joint are more or less gone. In these cases, no matter the character of the disease, manipulative interference is positively vicious; and while it is in them that ignorant Bone-setters do so much mischief, the better informed, by the use of splints and well applied pressure, are highly successful in their treatment. I am sorry to say many cases of this kind come to Bone-setters which have not been properly treated before, owing to their not having been recognised, especially hip-joint disease.

3.—On the third-class of cases, in which a fracture has taken place into the joint, causing stiffness, the condition is due to disturbed relationship of the bones from faulty setting, and is recognised by comparison with the bony landmarks of the sound limb. In these cases forcible treatment does good; though, of course, the result is in proportion to the amount of bone-displacement, but it should be supplemented by passive movements for some time. In joints stiff after diagonal fracture through the condyles of the humerus so common in children, I have seen many most gratifying results; one in a boy about twelve years old, whose elbow had been stiff three years is especially impressed on my mind.

4.—In the fourth-class of cases, and those to which I would draw particular attention, I include lameness, and weakness, the result of the various forms of injury, which we group together under the general term a “sprain.” I affirm most unhesitatingly, from an experience of some hundreds of cases, that nothing has done more to lower the prestige of regular practitioners, and to play into the hands of unqualified Bone-setters, than the way in which so many practitioners tamper with a sprained joint. Sprains, of course, vary greatly in severity; they may be broadly divided into two kinds, of which one consists merely of a temporary over distention of the parts round a joint which rest, and anodyne applications soon cure, while the other involves pathological results a much more serious nature. A severe sprain is the sum of the injuries that the parts in and about a joint sustain, when, by their passive efforts, they exercise their maximum power of restraint to prevent luxation. Under such conditions I conceive the following changes to take place in the integrity of a joint. In the case of the synovial membrane, temporary hyperæmia accompanied by pain, and some slight effusion into the cavity of the joint.

In the case of the tendons, over-stretching and loosening of the lining membrane of their sheaths, more or less disturbance to the adjacent cellular tissue forming the bed of the tendon groove, and hyperæmia with exudation of plastic fluid, subsequently forming adventitious products. In the case of the non-elastic fibrous ligaments—firmly attached at either end to the adjacent periosteum—over-stretching, mostly involving partial rupture, with swelling, softening, and disintegration of their structure. It is beyond the purpose of this communication to draw attention to the plan of treatment adopted by Bone-setters under these circumstances; it is, however, described in a paper of mine, of which an abstract is given in the British Medical Journal, of September 25th, 1880. The stiffness of a sprained joint is partial. The surface is generally cold, or more or less œmatous, and each joint has one particular spot in which pressure causes acute pain; the Bone-setters have learned by experience the situation of these spots, and this fact has done more than anything to strengthen the popular faith in their intuitive skill; they certainly form an important guide to treatment since they indicate the seat of greatest injury to the ligaments, and point out where their power of passive resistance has been most severely tested, and where adhesions are most likely to have formed, Dr. Hood, in his record of Mr. Hutton’s practice, has enumerated some of these painful spots, the chief of them are as follows:—

1.—Over the head of the femur in the centre of the groin, corresponding to the ilio-femoral band of the capsular ligament (which is most severely stretched when the thigh is over extended, as when the trunk is flung violently backwards the commonest cause of a sprained hip).

2.—For the knee joint, at the back of the lower edge of the internal condyle, in other words, at the posterior border of the internal lateral ligament where it blends with Winslow’s ligament, and where the senior membranosus tendon is in intimate relation with it. These parts suffer most because as Mr. Morris says: ‘During extension they resist rotation outwards of the tibia upon a vertical axis’ and a sprained knee is almost always caused by a twist outwards of the foot.

3.—For the shoulder at the point corresponding to the bicipital groove, because in nine cases out of ten a man sprains his shoulder to prevent himself from falling, his hand grasps the nearest support, the body is violently abducted from the arm, the long head of the biceps is called upon to exert its utmost restraining power, the bicipital fascia is overstretched, and the tendon very often displaced.

Again for the elbow the painful place is at the front of the tip of the internal condyle; the fan-shaped internal lateral ligament has its apex at that point, and it is most stretched in over-supination, with extreme extension of the forearm. On the front of the external malleolus, at the apex of the plantar arch, the tip of the fifth metatarsal bone, the styloid process of the ulna, the inside of the thumb, and the annular ligament in the front of the wrist, are respectively the most painful spots when those joints are severally sprained.

The manipulative part of the treatment of joints stiff from being sprained may be briefly said to consist in pressure over the part most injured, and momentary extension of the limb, followed by sudden forcible flexion. The method varies with each joint, and I can with confidence refer you to Dr. Wharton Hood as being faithful word-pictures, supplemented, too, by very accurate drawings.

The following are some of the lesser injuries, the non-recognition of which has frequently come under my notice at Whitworth. In the upper limb: fracture of the tip of the acromion; practical luxation of the acromio-clavicular and sterno-clavicular joints (often happening to men who carry weights on their shoulders); partial dislocation of the long head of the biceps, with over extension of the bicipital fascia (common in men who throw weights or use a shovel as malsters or navvies). Dislocation of the head of the radius forward on the condyle, which is very common in children, and has a marked tendency to cause stiff elbows; fracture of the tip of the internal condyle; overlooked Colles’ fracture; partial luxation of the head of the ulna (impeding supination of the hand, and having a tendency to gradually grow worse); severe sprain at the carpo-metacarpal joint of the thumb (very common in stone masons and caused by the ‘jar’ of heavy chisels).

In the lower limb: Fracture of the fibula, just above the malleolus and at its tip (these are fruitful sources of lameness, often overlooked, and, if of old standing, very troublesome to treat); partial rupture of the ligamentum patellæ at its insertion into the tubercle of the tibia, which is much more common than is ordinarily supposed; neglected over-stretching of the ligament of the plantar arch, and tearing of the plantar ligament at its insertion into the os-calcis; rupture of the penniform muscular attachments of the tendo Achillis and muscular hernia in the calf.

I trust I shall be forgiven if I have dwelt too much on the étourderie of some of us, but I am sure so-called trifling injuries deserve more attention at our hands, since living at the high pressure men do now-a-days, with every part of their bodies tested to its utmost capacity, the slightest impairment of the mechanism of a limb must be an incalculable source of personal annoyance, discomfort, or disability.

“When doctors disagree who shall decide?” The readers of this little manual will probably say as they read Mr. Dacre Fox’s paper, that it is alike a testimony and a vindication of the “Art of the Bone-setter.”

CHAPTER VIII.

WHAT BONE-SETTERS CURE.

“Man’s life, Sir, being so short, and then the way that leads unto the knowledge of ourselves, so long and tedious; each minute should be precious.”—Beaumont and Fletcher.

Throughout the many references to the Bone-setter and his art, which I have quoted in the foregoing pages, the Bone-setter is constantly misrepresented. He is described as a man of one idea, one formula, and one mode of operation. His ruling idea is said to be that a “bone is out” in all cases submitted to him. His formula to wrench the joint so as to break adhesions, and to replace the bones in their normal conditions. His mode of operation is said to be brute-force suddenly applied. Nothing can be further from the truth. It is an offhand generalization from a few cases out of thousands, and therefore misleading. If these statements were true there would be but few who would trust themselves and their painful limbs to the Bone-setter’s care lest his force should be applied in the wrong direction. A brother Bone-setter (Mr. J. M. Jackson, of Boston), has pointed out how irrational and absurd Mr. Hood’s statements on the one hand and admissions on the other necessarily are. Bonesetters, as a rule, are as regular and legitimate in their practice as any medical man can be, though they are not recognised by law. As Mr. Jackson truly says: “All kinds of fractures and dislocations, and other injuries are constantly being placed under their care and treatment, with the utmost confidence on the part of the patients and their friends; a confidence inspired by indisputable success on the part of a practitioner in a given locality and district, for a series of years—it may be for a lifetime.” Mr. Jackson, in his timely little pamphlet, very truly points out that “living reasons” for this confidence can be found in town and country where the practice has been carried on, or who have experienced the greatest benefits under the skilful treatment of the Bone-setter, even after the wisdom of the faculty had declared there was nothing wrong. That such men are ignorant of anatomy, and but seldom have dislocations under their care, and, that when they have, and succeed in replacing the joint, that it is done unconsciously, and what they do is the result of blind chance and ‘sudden movement’ without any knowledge of how, or why such results are brought about; the idea is ridiculous in the extreme; upon this hypothesis the practitioner would nearly approach the “supernatural!” I am glad to record this opinion, because it not only reflects the opinion of the public, but shows that the faculty have tried to prove too much. The position of the Bone-setter may be clearly defined, thus:—“We lay no claim to skill beyond what is the result of sound original teaching, thoughtful consideration, and common sense,” and we possess well-earned reputations won in proof that we have succeeded in our special practice.