_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.”