“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.”

******

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.”