“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.

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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 oematous, 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.”