on bone-setting by wharton p. hood

5/22/2018 On Bone-Setting By Wharton P. Hood

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ON BONE-SETTING.


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ON BONE-SETTINGCALLED],

AND

ITS RELATION TO THE TREATMENT OF JOINTSCRIPPLED BY INJURY, RHEUMATISM,INFLAMMATION, &c. &c.

BY WHARTON P. HOOD, M.D., M.R.CS.

31

antl JdefoMACMILLAN AND CO.1871.

[The Right of Translation and Reproduction is resen>ed.]


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LONDON :R. CLAY, SONS, AND TAYLOR, PRINTERS,BREAD STREET HILL.


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PREFACE.THE substance of the following pages appearedin the columns of the Lancet during March andApril of the present year. My own impression ofthe practical importance of the subject, strength-ened by the numerous letters I have since receivedfrom many members of the profession, has inducedme to re-publish the papers in a separate form,with such additional matter as I could command.The following is the history of their production :About six years ago my father, Dr. Peter Hood,

in conjunction with Dr. lies of Watford, attendedthe late Mr. Hutton, the famous bone-setter,through a long and severe illness. On his recoverymy father refused to take any fees from Mr.Hutton, out of consideration for the benefit whichhe had rendered to many poor people. Mr.Hutton expressed himself as being thereby placed


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PREFACE.under great obligation, and as being very desirousto do something to show his gratitude. Heoffered, as an acknowledgment of the kindness hehad received, to explain and show all the detailsof his practice as a bone-setter. Pressure of workprevented my father from availing himself of thisoffer, and Mr. Hutton then extended it to me.After some consideration, I determined to acceptit ; and accordingly I went, when I could sparethe time, to Mr. Hutton's London house, on thedays of his attendance there. My decision wasprompted not only by the curiosity I felt to seehow he treated the cases that came under his care,but also by the desire to make known to theprofession, at some future time, any insight thatI could gain into the apparent mystery of hisfrequent success. I did not feel justified, however,in publishing anything during Mr. Hutton'slifetime, because, although he exacted from meno conditions, he was freely imparting what hethought, and was fairly entitled to think, animportant and valuable secret. I have nothesitated, however, to discuss his methods with


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PREFACE. vii

private friends ; and Mr. Mutton's recent deathhas released me from any scruples about thepropriety of making these methods more widelyknown.

During a second illness from which Mr. Huttonsuffered, I took absolute charge of the poorer classof patients whom he was accustomed to attendgratuitously, and found that I could easily accom-plish all that I had seen him do. I declined, how-ever, to undertake the remunerative portion of hispractice, and from this and other reasons my inter-course with him had wholly ceased for about twoyears prior to his death. I found, however, that ithad lasted long enough to give me knowledge ofa kind that is not conveyed in ordinary surgicalteaching, and that, when guided by anatomy, isof the highest practical value, as well in preventive *as in curative treatment.

In the present work, therefore, I purpose givinga brief account of the salient features of a bone-setter's method of procedure in the treatment ofdamaged joints, of the results of that treatment, andof the class of cases in which it was successful. And


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viii PREFACE.

here, in the first place, I must bear tribute to Mr.Hutton's perfect good faith and honesty. He hadreceived but a plain education, was entirely desti-tute of anatomical knowledge, and firmly believedthe truth of his ordinary statement that the jointwas out. To him there was no other possibleexplanation of a constantly recurring sequence ofevents. A joint previously stiff, painful, and help-less, was almost instantly restored to freedom ofaction by his handling, and the change was oftenattended by an audible sound, which he regardedas an evidence of the return of a bone to its place.When this, to him, pleasant noise was heard, hewould look in his patient's face and say, in hisbroad dialect, Did ye hear that ? The replywould be Yes ; and his rejoinder, Now ye're allright use your limb. To the patient, probablyas ignorant of anatomy as Mr. Hutton himself,who had hobbled to him on crutches, often afterprolonged surgical treatment, and who went awaywalking and leaping, it can be no matter forsurprise that the explanation was also fullysufficient.


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PREFACE. ixWhen I first knew Mr. Hutton, I often tried to

argue the point with him, and to explain what itreally was that he had done. I soon found, how-ever, that, if I wished to learn from him, I mustsimply content myself with listening and observ-ing. He had grown old in a faith which it wasimpossible to overturn.

I think, however, that the time is come whenthe profession should no longer be prevented, bythe customary mis-statement that a bone isout, from making themselves acquainted withthe means by which the conditions thus falselydescribed may be cured ; and at which they mayalso reconsider with advantage some of thosetraditions about rest and counter-irritation whichhave been handed down to them through suc-cessive generations of surgeons.

UPPER BERKELEY ST., PORTMAN SQ.July 1871.


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CONTENTS.CHAPTER I.

INTRODUCTORY

CHAPTER II.PATHOLOGY 24

CHAPTER III.MANIPULATIONS 59

CHAPTER IV.MANIPULATIONS (continued) 73

CHAPTER V.AFFECTIONS OF THE SPINE 138


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LIST OF ILLUSTRATIONS.FIG. PAGE1. MANIPULATION OF WRIST 77

2. ,, ELBOW 8l

3- ,, SHOULDER 85

4- ANKLE 89

5- , KNEE 93

6. ,, HIP . . .' 97

7- SPINE 147


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A TREATISEON

BONE-SETTING, ETCCHAPTER I.

INTRODUCTORY.IT is known to most practitioners of surgery,and has become known to many to their greatcost and loss, that a large proportion of cases ofimpaired mobility or usefulness of limbs, afterdisease or injury, fall into the hands of a class ofmen called bone-setters. In all these cases it isthe custom of such men to say that the affectedbone or joint is out, although there maybe anentire absence of the anatomical signs of displace-ment ; and then to proceed in due course to theperformance of manipulations by which, in manyinstances, the patient is speedily cured. Teachers

B


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ON BONE-SETTING.of surgery, when they condescend to speak at allof bone-setters and their works, are more proneto dilate upon the injury sometimes occasionedby assumed rough handling, than upon theimprovement which it oftentimes effects. It isdoubtless necessary to caution students againsttwisting or pulling an inflamed or ulcerated joint ;but it would surely also be well to inquire care-fully what is the nature of the cases in which bone-setters do good, and what is the change -whichtheir manipulations bring about. Mr. Paget, ina clinical lecture delivered at St. Bartholomew's,and published in the British Medical Journal threeyears ago, stands probably alone in having madethis laudable attempt ; but he laboured under thedisadvantage of being guided only by conjecture,or by the imperfect descriptions of patients, in hisideas of the nature of the bone-setter's treatment.It necessarily followed that his conjectures werein some respects erroneous ; but his authority maynone the less show the great practical importanceof the questions at issue. He says to his students : Few of you are likely to practise without having


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INTRODUCTORY.a bone-setter for your enemy ; and if he can curea case which you have failed to cure, his fortunemay be made and yours marred. It would at firstsight seem likely that the conditions thus statedby Mr. Paget could only be realized in the practiceof surgeons of slender skill, and among the poorerand more ignorant classes of the community. Thissurmise, however, would be very wide of the truth ;for I shall have to refer to instances in which thefailures Have been those of men not less emi-nent than Mr. Paget himself, and in which thepatients have occupied positions of prominence ordistinction. Such cases may not only seriouslyinjure the individual practitioner, but they serveto lower the whole art of surgery in the estimationof the public. They render it obligatory, I think,upon any one who may possess the power, to placebefore the profession a clear account of the so-called bone-setting of its methods, its failures,and its successes. To this task, so far as mypowers extend, I purpose to address myself inthe following pages.What has been called bone-setting may be con-

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ON BONE-SETTING.cisely defined as the art of overcoming, by suddenflexion or extension, any impediments to the freemotion of joints that may be left behind after thesubsidence of the early symptoms of disease orinjury; perhaps, indeed, more frequently of thelatter than of the former.

I could, perhaps, describe no more typical case,and none of more frequent occurrence, than thefollowing :A healthy man sustains a fracture of one or

both bones of the forearm, and applies at a hos-pital, where splints are adapted in the usual way.He is made an out-patient, and the splints areoccasionally taken off and replaced. After thelapse of a certain number of weeks the fracturebecomes firmly united, the splints are laid aside,and the man is discharged cured. He is stillunable to use either his hand or his forearm, butis assured that his difficulty arises only from thestiffness incidental to long rest of them, and thatit will soon disappear. Instead of disappearing, itrather increases, and in due time he seeks the aidof a bone-setter. The arm and forearm are then


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INTRODUCTORY.bent nearly at a right angle to each other; theforearm is intermediate between pronation andsupination ; the hand in a line with it ; and thefingers are straight and rigid, the patient beingunable to move them, and also unable to moveeither the wrist or elbow. Passive motion can beaccomplished within narrow limits, but producessharp pain, distinctly localized in some single spotabout each joint, in which spot there will also betenderness on pressure. The bone-setter will tellthe man that his wrist and his elbow are out.The man may object that the injury had been inthe middle of the forearm perhaps from a blowor other direct violence. The reply would be thatperhaps the arm had indeed been broken as alleged,but that the wrist and the elbow had been put outat the same time, and that these injuries had beenoverlooked by the doctors. The bone-setter wouldthen, by a rapid manipulation hereafter to bedescribed, at once overcome the stiffness of thefingers, and enable the patient to move them toand fro. The instant benefit received would dispelall scruples about submitting the wrist and the


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ON BONE-SETTING.elbow to manipulation ; and these also would beset free in their turn. The man would go awayeasily flexing and extending his lately rigid joints,and fully convinced that he had sustained grievousharm at the hands of his legitimate doctors.

This, however, like all types, is to some extentan ideal case ; and it may be worth while toappend to it a series of actual narratives. In oneinstance, where I have obtained permission to doso, I have given the name of the patient, not onlyas a guarantee of authenticity, but also as anadditional evidence that the art of the bone-setterhas been successfully called into requisition bypersons who were able to command, and whoactually did obtain, the aid of London surgeonsof the highest professional position. The fact thatthese gentlemen failed to cure the patients, andthat a quack immediately succeeded in doing so,is the ground of my belief that the practice of thebone-setter has not only lain in what the Lancetcalls a neglected corner of the domain of surgery,but also that it has been based upon sound tra-ditions handed down from some earlier day. I


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INTRODUCTORY.can believe it possible that the first bone-setterwas the servant or the unqualified assistant of asurgeon who had known exactly what could bedone by sudden movements, and how those move-ments should be executed.Such knowledge might easily perish as a pro-

fessional possession (for, even in our own day ofbooks and pamphlets and journals, what a vastamount of the experience of every man dies withhim ), and might as easily be handed down as thesecret of a quackery by those who had good reasonto appreciate its value.From the inquiries I have been able to make,

I gather that the practice of all bone-setters ismuch alike as far as manipulation is concerned,and that they differ in the results they bring aboutpartly because some of them possess more naturalmechanical tact than others, but in a far higherdegree because some possess sufficient acutenessof observation to note and to remember the mani-fest symptoms in cases that turn out unfavourably,and to avoid others like them in the time to come.Mr. Hutton probably owed his reputation and sue-


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ON BONE-SETTING.cess to a combination of both these qualities. Itwould be impossible for any man who was ignorantof anatomy and pathology to enter upon the careerof a bone-setter without doing much mischief andencountering many disastrous results ; but it wouldbe quite possible for him, if sufficiently intelligent,to learn to shun pitfalls by the light of experience.He would come in time to know the aspect ofjoints that it was prudent to leave alone, as wellas of those that might be moved with safety andadvantage. Experience, however, would in no wayenlighten him with regard to the nature of thedifference, or with regard to the character of thelesions that he relieved. The tradition of thecraft is that a bone is out, arid to this statementits members steadily adhere, less perhaps fromduplicity than from pure ignorance.A sufferer comes with a joint that is stiff, pain-ful, and helpless ; and such a joint is restored tofreedom and activity by movements that producean audible sound, easily to be regarded as beingcaused by the return of a bone to its place. Tothe patient, as well as the bone-setter (both being


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INTRODUCTORY.

equally ignorant of anatomy and the meaning andsigns of dislocation), the explanation appears tobe amply sufficient ; and a surgical denial thatany such injury had existed would carry butlittle weight with a sufferer whom the surgeonhad failed to cure, or with the non-professionalwitnesses of the case.The effect produced upon such persons may be

illustrated by the following letter, which appearedin the Echo newspaper in March 1870 :

SIR, A short time ago, a painter, working for me, fellfrom one floor to another, was much hurt, and sent to Bar-tholomew's Hospital. After remaining there about threeweeks he was sent out as cured, although he could not walkwithout crutches. After about a fortnight, seeing that hegot no better, I sent him to Mr. Hutton, of WyndhamPlace, Crawford Street, W., who found that his left hip andknee were both dislocated, which since then he has putinto their right places, and the man now comes to his workas he used to do before the accident. I have several other cases showing the incapacity of the

surgical profession. They, the students, are taught to knowhow to amputate legs and arms and make cripples, butnot one of them knows how to deal with dislocations,and thus save the necessity of amputation. I have myselfbeen the cause of saving, through Mr. Hutton, two legsfrom being cut off. Of this I am ready to give positive


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io ON BONE-SETTING.proof. This question is worth attention, with the view toestablish a hospital for dislocations. I am quite ready toassist and be a considerable subscriber, in case the projectcan be realized.

Yours respectfully,THOMAS LAWES.65, CITY ROAD.

I think there can be little doubt that the neglectof the profession to inquire into the truths lurkingunder bone-setting has been mainly due to twocauses. First, to the serious and often fatal re-sults that have occurred in the practice of all bone-setters, and that have probably occurred very oftenin the hands of the less skilful and less discreetmembers of the fraternity. Secondly, to thepractical effect of the statement that a bone wasout, and that it had been replaced. Surgeonswho knew this statement to be entirely withoutfoundation have perhaps been too ready to at-tribute it to intentional fraud, and a desire todeceive ; and have not been sufficiently readyto make allowances for the ignorance of thosewith whom it originated. Hence they have beenannoyed and disgusted both by its falsity and by


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INTRODUCTORY. uthe imputation which it would cast upon them-selves, and have attributed the cure to the opera-tion of mental influences, or to the mere lapseof time, or to the effect of previous treatment,and have refrained from inquiring what colourableground there might be upon which the idea ofdislocation could rest, or what change the mani-pulations of the bone-setter had really broughtabout.With these preliminary observations I proceed

with the account of the cases to which I havereferred :A gentleman whom I will call Mr. A ,when sitting on a stool in his office, hastily de-scended to welcome a friend. As soon as hisfeet reached the ground he turned his bodywithout moving them, and in doing so he twistedor wrenched his left knee. He immediately feltconsiderable pain in the joint, which lasted for anhour or two, but decreased as the day wore on ;and he continued to move about as occasion re-quired. In the night he was aroused by increasedpain, and found the joint much swollen. Mr.


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12 ON BONE-SETTING.A was the brother of the professor of mid-wifery at one of the principal medical schools inLondon, and he had the best surgical advice thatLondon could afford. He was ordered to restthe limb, and to apply heat and moisture. Inthis way he obtained some diminution of the pain,but the swelling continued. He at last sent forMr. Hutton, who at once declared that the kneewas out, and proposed to replace it. An ap-pointment for this purpose was made, but in themeantime the patient had again seen eminentsurgeons, and he wrote to prevent Mr. Huttonfrom coming. Two years of uninterrupted surgicaltreatment passed without improvement, and thenMr. A sent for Mr. Hutton again. On this,the second visit, I accompanied him, and what Iwitnessed made a great impression on my mind.We found the knee-joint enveloped in strapping ;and when this was removed, the joint was seento be much swollen, and the skin shining anddiscoloured. The joint was immoveable, and verypainful on the inner side. Mr. Hutton at onceplaced his thumb on a point over the lower edge


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INTRODUCTORY. 13of the inner condyle of the femur, and the patientshrank from the pressure and complained of greatpain. He (Mr. Hutton) made no further exami-nation of the limb, but said, What did I tellyou two years ago ? Mr. A replied, Yousaid my knee was out. And I tell you so now,was the rejoinder. Can you put it in ? said Mr.A . I can/' Then be good enough to doso, said Mr. A , holding out his limb. Mr.Hutton, however, declined to operate for a week ;ordered the joint to be enveloped in linseedpoultices and rubbed with neat's-foot oil, madean appointment, and took his leave. During thedialogue I had carefully examined the limb, hadsatisfied myself that there was no dislocation, andhad arrived at the conclusion that rest, and notmovement, was the treatment required. At the ex-piration of the week I went again to the house, andMr. Ilutton arrived shortly afterwards. How'sthe knee? was his inquiry. It feels easier.Been able to move it? No. Give it to me.

The leg was stretched out, and Mr. Hutton stood infront of the patient, who hesitated, and lowered his


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14 ON BONE-SETTING.limb. You are quite sure it is out, and you canput it right ? There was a pause, and then, Giveme your leg, I say. The patient obeyed reluctantly,and slowly raised it to within Mr. Hutton's reach.He grasped it with both hands, round the calf,with the extended thumb of the left hand pressingon the painful spot on the inner side of the knee,and held the foot firmly by grasping the heelbetween his own knees. The patient was told tosit steadily in his chair, and at that moment Ithink he would have given a good deal to haveregained control over his limb. Mr. Huttoninclined his knees towards his right, thus aidingin the movement of rotation which he impressedupon the leg with his hands. He maintained firmpressure with his thumb on the painful spot, andsuddenly flexed the knee. The patient cried outwith pain. Mr/ Hutton lowered the limb, andtold him to stand up. He did so, and at oncedeclared he could move the leg better, and thatthe previously painful spot was free from pain.He was ordered to take gentle daily exercise,and his recovery was rapid and complete. In a


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INTRODUCTORY. 15few days he returned to business, and from thattime until his death, which occurred three yearsafterwards, his knee remained perfectly well.A case hardly less remarkable was that of theHon. Spencer Ponsonby, which attracted consider-able attention at the time. As Mr. Ponsonby haskindly written out for me the history of his case,and as his description is very graphic, I cannotdo better than give it in his own words. I needonly add to it that the initials A , B ,C , &c., represent the names of men of con-siderable standing in the profession.

On Nov. 26th, 1 864, in running across thegarden at Croxteth, near Liverpool, I felt andheard something crack in the calf of my left leg.It was so painful that I rolled over like a shotrabbit, and could scarcely reach the house, a fewyards off. I at once put my leg up to the kneein a pail of hot water, and boiled it for an hour.Next day, being no better, I sent for a medicalman in the neighbourhood, who told me I hadsnapped a muscle, and must keep quiet for afew days. He rubbed in a strong liniment, there


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16 ON PONE-SETTING.being no sign of inflammation ; and put on astrong leather plaster. In a couple of days Iwas able to hobble ; but being telegraphed toLondon, and going into an empty house, Iknocked my toe against a tack in the floor, andhurt myself worse than ever.From this time (Dec. 2nd) to the beginning

of May I was attended by Mr. A and Mr.B in consultation, who agreed in saying thatthe * stocking of the calf was split ' (gastrocnemius,I think they called it), and treated me accordingly.Occasionally my leg got better ; but the slightestexertion produced pain and weakness.

On the 2nd of May, Mr. C undertook me.He agreed as to the injury, but thought that,constitutionally, I was out of order, and gave mesome iron, &c., without effect. My leg was alsofixed in an iron machine to relieve the musclesof the calf from the weight of the leg. Anothereminent surgeon came in consultation on June26th. He agreed in Mr. C 's treatment, and inthe cause of the lameness, as did Dr. D ,who was consulted as to my going to Wildbad.


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INTRODUCTORY, 17Aug. I4///5. As I did not improve, Mr. C

put my leg into a gum-plaster for a month. Ithen went yachting, so as to obtain perfect re-pose for that time. My health, which had beengetting bad, was improved by the sea-air, butmy leg was no better. The surgeon on boardthe yacht, Dr. E , also examined me, andagreed as to the cause of the lameness, but said,' An old woman may cure you, but no doctor will.'

On Sept. /th the gum-plaster was removed,and galvanism was then tried for about threeweeks. At the end of this time I went on ayacht voyage for four months, and, during thewhole of this period, had sea-water douches. Allthis time I had been either on crutches or twosticks. My health was much improved by thesea-voyage, but my leg was the same as before,and had shrunk to about half its proper size.

April $th. Mr. F - began his system tocure my leg. His idea was, that the muscleswere separated, but that if brought together con-tinuously, they would rejoin. I wore a high-heeled boot during the day, and during the night

C


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1.8 ON BONE-SETTING.my heel was fixed so that it was kept in the sameposition. No good arose from this treatment,and consequently, after a month's trial, I wentto Mr. Hutton, who,, on seeing my high heel,said, ' What do you wear that machine for ? Doyou want to lame yourself?' I was proceedingto tell him the opinion of the various surgeonson my case, when he said, ' Don't bother me aboutanatomy ; I know nothing about it : but I tellyou your ankle is out, and that I can put it inagain.'

After a few weeks, during which he had beento the North, and could not therefore undertakemy case, I returned to him on June 2/th, tellinghim that I had in the meantime consulted sur-geons who had assured me that, whatever elsemight ail me, my ankle was most assuredly ' allright/ but that I would notwithstanding submitto his treatment. He again examined me mostcarefully, beginning at the ankle round bone, andhe then put his thumb on to a place which hurtme a good deal, and produced a sensation of asharp prick of a pin. He proceeded to operate


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INTRODUCTORY. 19upon me, and, after a time, there was a distinctreport, and from that moment the pain was gone.Mr. Hutton desired me to walk moderately, butto take no violent exercise for a long time, andto use a good deal of cold water. From thatmoment my leg gradually got better. I was ableto walk out shooting quietly in September, andon the 14th October, having missed a train,walked home fifteen miles along the high road.In the following year I resumed cricket, tennis,and other strong exercise, and have continuedthem ever since.I omitted to mention that on July 5th, 1866,

about a week after my first operation, I hurt myleg again by over-exertion, and was as lame asever. But Mr. Hutton repeated his treatment,and I have never had another relapse. His state-ment to me was, that the ankle-joint being mis-placed, the muscles were also misplaced, andwould not heal.The history of the following case has been

kindly communicated to me, partly by the patienthimself, and partly by my friend Mr. Keyser, of

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20 ON BONE-SETTING.Norfolk Crescent, who took charge of it at a lateperiod. The patient, Mr. G , was a memberof the House of Commons, and had been in goodhealth until October 1866.One morning, in the beginning of that month,

while staying in the country, he awoke sufferingfrom severe pains in almost every joint of hisbody. He remained in bed until his servantswere stirring ; and when assistance came, he triedto rise. He found himself almost unable to doso, but by dint of great effort he succeeded, onlyto return to bed again after a short interval.The pain, which was decided by his medicaladvisers to be rheumatic in character, increasedas the day wore on, and ultimately centred inthe left knee and left wrist, where it was ac-companied by considerable swelling and heat ofthe joints.The patient was treated for this condition in

the usual manner; and, after the lapse of sometime, his pain was relieved. He then came totown, and was under the care of Mr. Keyser andtwo hospital surgeons. Notwithstanding all treat-


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INTRODUCTORY. . 21ment, however, his knee and wrist were leftimmovable. Active mischief having at lengthceased, gentle passive motion of the joints wastried ; but was discontinued on account of theextreme pain produced when an attempt wasmade to flex either limb beyond a certain angle.A starch bandage was then applied to the knee,but proved unbearable, and was removed at theend of two days. Various local remedies werenext employed, and by the aid of crutches Mr.G was rendered able to hobble about.

Six months after the commencement of hismalady, no marked change having taken place,he determined to try what a bone-setter coulddo for him. He sent for Mr. Hutton, who placedhis thumb upon a spot on the inner side of theknee, and produced great pain by pressure there.Mr. Keyser, who was present, placed his thumbalso on the same spot, and assured himself of itstenderness. The delay of a week for poulticingand oiling was recommended ; and at the end ofthat time the joints were manipulated in thecustomary manner ; and the painful spot when


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22 ON BONE-SETTING.sought for by Mr. Keyser was no longer to befound. Comparative freedom of motion followedthe treatment. The patient was at once able tocross the affected knee over the other, a positionnever attained since the beginning of the illness,and the usual motions of the joint were notonly nearly perfect, but were unattended by pain.In Mr. G 's own words, he felt, after the ope-ration, that the leg had once more got into a linewith the thigh. He then made rapid progress torecovery, and soon regained the almost completepower over his knee which he still possesses.The important point in his case was the fact that

he had remained for many weeks stationary, withtenderness on the inner side of his knee, and thatthe immediate effect of the manipulation to whichhe was subjected was the loss of this tenderness,and the commencement of a speedy recovery ofnormal function.The next case has been kindly communicated

by Dr. Douglas Reid, of Pembroke. Lady ,having sustained an accidental injury to one ofher thumbs, was taken by her father to a very


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INTRODUCTORY. 23distinguished hospital surgeon, under whose advicea splint was applied, and iodine used externally.At the end of some weeks the joint was still

stiff, useless, and tender ; and the patient heartilytired both of its condition and the treatment.She determined to apply to a bone-setter, whogave the usual verdict upon her case, and with asingle sharp flexion and extension restored her tocomfort, and the injured thumb to usefulness.

Such, together with others to which I shallcome in the sequel, are the kind of cases in whichsome of the best skill of surgeons has been atfault, and in which speedy relief has been givenby the proceedings of a quack. It will be theobject of the following pages to show to whatprinciples these proceedings were indebted fortheir curative power ; and in what way the appli-cation of these principles may be undertaken,safely and scientifically, by the legitimate mem-bers of the profession.


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CHAPTER II.PATHOLOGY.

PREMISING that the treatment employed by bone-setters consists in the sudden and forcible over-coming of resistance to motion, it is necessaryto inquire what is the nature of the cases in whichthis treatment may be beneficially employed, andwhat are the impediments that can be thus over-come. The actual practice of bone-setters is ren-dered more perplexing than it need be by theirerrors that is, by their liability to overlook con-ditions which should prohibit interference ; but, ifabstraction be made of this source of difficulty, itwill be found that the cases they treat successfullyhave certain common characters on which a classi-

ffication may be based.They originate, in most instances, In disease or

injury either of the affected joint itself or of some


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PATHOLOGY. 25part contiguous to it, and the immediate effects ofthe disease or injury must have already in greatpart passed away. If the joint itself has beenoriginally implicated, it will usually be more orless tumid and tender, with perhaps a slightelevation of temperature ; but if not originallyimplicated, these conditions will not exist. Inany case it will be stiff, and will be described bythe patient as weak ; and an attempt to moveit beyond a certain range will be productive ofpain. On careful examination some spot will befound, often very limited in extent, at which painis produced by pressure, and it will be from thisspot that the pain of movement radiates. Inmost instances the original mischief will havebeen treated by rigidly enforced rest, and thepatient will often present himself wearing somesplint, bandage, machine, or other appliance inrestraint of movement. It is quite necessary,however, that some possibility of passive move-ment should remain, and bone-setters are power-less against true osseous anchylosis, in which jointsare absolutely fixed and painless. They avoid


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26 ON BONE-SETTING.cases in which there is much heat, or swelling, orredness, or acute general pain ; and also cases inwhich there is any discharge of dead bone, or evenof pus ; except possibly in a few examples of whata surgeon would describe as sinuses in the neigh-bourhood of a joint, but not actually implicating it.The various positive and negative conditions thusdescribed may of course be variously broughtabout, and the morbid states that are actuallysuccessfully treated I should classify in the follow-ing manner :

1. Stiffness and pain of joints following fractureof one of the bones forming them. These casesare of two classes : (a) simply stiff joints, renderedso by want of movement, and by having beenincluded in the splints applied to the fracture ;and (b) stiff and swollen joints, which had beenmore or less implicated in the original injury.

2. Sprains, whether of recent date or of oldstanding, but which have been treated by rigidlyenforced rest.

3. Joints that have been kept at rest voluntarilyfor the avoidance of pain, either after some injury


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PATHOLOGY. 27to themselves, or to the soft parts around them,or after some painful disease affecting eithere.g. a stiff shoulder-joint following inflammationand suppuration of the bursa beneath the deltoidmuscle ; or a stiff hip-joint after inflammation ofthe bursa over the great trochanter.

4. Rheumatic and gouty joints.5. Displaced cartilages.6. Ganglionic swellings about the carpus.7. Subluxation of bones of the carpus and tarsus.8. Displaced tendons.9. Hysterical joints.The manipulation of cases of nearly all these

kinds has fully convinced me that when a jointis kept at rest, it is apt to undergo changes inrestraint of movement affecting either its ownstructures or those immediately surrounding it.It is probable that some constitutional statesinvolve a special proclivity to such changes, andthat they occur earlier in some persons than inothers. It would be difficult to speak with cer-tainty about their seat or nature without anato-mical examination ; but they resist passive motion


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28 ON BONE-SETTING.with a sort of elastic resistance, as if the jointswere restrained by ligamentous or strong fibroustissue. Possibly, in some cases, the proper liga-ments may become contracted or rigid, or adherentto neighbouring parts ; in others, external or in-ternal adventitious fibrous bands may be formed ;in others, muscles may have undergone shortening.Again, effusion may have become solidified, andthus movement be impaired, as if by a state ofthings analogous to a rusty hinge. It is evenprobable that one effect of rest may be to dimi-nish secretion (the natural stimulus afforded bymovement being withdrawn) both in the articu-lations themselves and in the sheaths of tendons ;and so to produce a kind of unnatural dryness,analogous to that which we may suppose to existin the case of a horse that is stiff at starting.In all, however, the impediment to motion be-comes a source of pain when motion is attempted ;and this pain is often erroneously looked upon asan indication for continued rest. A patient willunintentionally deceive his surgeon by saying thatthe affected joint feels weak, an expression


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PATHOLOGY. 29that seems naturally to suggest the use of someform of mechanical support. While this is wornit gives a slight increase of power, but its removalleaves the former condition essentially unchanged.The meaning of weakness in such cases is thatthe joint cannot be moved without pain, andpeople only use the word for want of knowinghow to describe accurately the existing condition.Any one who has ever suffered from lumbago willunderstand this. A person so suffering feels weakness in the sense that the power to risefrom the recumbent posture is apparently gone.It is not really gone, but there is an instinctivedread of calling the affected muscles into action ;and this dread conveys to the mind an impressionof inability to move, which can only be overcomeby a most determined effort of the will.Now, the cases in which bone-setters attain their

successes are those in which some restraint ofmovement, due either to an injury or to the restconsequent upon it, or to both together, and whichpainfully checks the motions of the joint, admitsof being at once overcome by manipulation. In


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30 ON BONE-SETTING.the case of Mr. A , already described in thepreceding chapter, no doubt some adventitiousband was restraining movement, and that one ofits attachments was to the lower margin of theinternal condyle of the femur. Pain at this spotwas experienced, and further movement waschecked, as soon as the band was rendered tense.Its frequent traction upon its insertion causedthat part to be constantly tender under pressure ;and its generally disturbing influence excited andmaintained an irritated and swollen condition ofthe joint. Mr. Hutton ruptured the band whenhe twisted and sharply flexed the limb ; and allthe troubles consequent upon its presence eitherimmediately or gradually subsided. I frequentlysaw him handling joints which at the time seemedto me not likely to be improved by such treat-ment ; and yet, when the operation was finishedand much pain had been produced, the patientsjoyfully expressed their sense of increased powerand freedom of movement.

It has often been pointed out by distinguishedwriters on medicine, and by none more forcibly


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PATHOLOGY. 31than by Sir Thomas Watson, that the varietyof structures contained within the eye renders itliable to many of the diseases that affect otherparts of the body, while its transparency allowsthem to be studied with a precision that is unat-tainable elsewhere ; and that it is hence wellcalculated to afford a key to many obscure ques-tions in pathology. I venture to think that wemay obtain an illustration from it in the presentinstance.

It is well known that, in moderately contractedstates of the pupil, the posterior surface of theiris rests in absolute contact with the anteriorsurface of the crystalline lens ; but that, whenthe pupil is fully dilated, the two structures areseparated by a layer of aqueous humour.When the iris is inflamed, if it continue in

absolute contact with the lens, we see adhesionstake place speedily ; whereas, if the pupil bewell dilated, and its margin no longer touchesthe lens, the lymph that would have formed anadhesion remains as an harmless nodule, orbecomes diffused through the aqueous humour.


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32 ON BONE-SETTING.We therefore see that, in a shut cavity containingfluid, the effect of inflammation is to producespeedy agglutination between surfaces in contact.The adhesions produced by iritis may, at an

early stage of their formation, be stretched bymovement. The application of atropine willdilate the pupil ; and if made in time will trans-form the adhesion into a band, or will even detachor rupture it If the application be too longdelayed, the adhesion will resist its influence, andthe lymph will undergo a subsequent process ofcontraction.When the subsidence of an attack of iritis

leaves behind it an adhesion that has neither beendetached nor thoroughly stretched, this in mostcases becomes a source of future trouble. Itabruptly checks the natural changes of the pupilat some given point. When this happens, thepatient is often conscious of a feeling of tension, theeye is generally more or less irritable, and anotherattack of iritis will sooner or later be the resultThe original iritis may not only be excited

by direct injury, or arise from syphilis, rheuma-


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PATHOLOGY. 33tism, exposure to cold, or other general cause,but it may be, and often is, produced by theextension of inflammation from parts externalto the ocular cavity, as from the conjunctiva inpurulent ophthalmia.Now, reasoning from the analogies thus pre-sented to us, I am disposed to infer that intra-articular inflammation, however arising, may easilyproduce adhesions between surfaces resting in ap-position ; that such adhesions, if so placed as torestrain movement, will cause pain and irritationwhenever they are rendered tense ; and that in-flammation sufficient to produce them may beinsidiously set up in a joint by extension fromneighbouring structures.

In support of this view, Sir B. Brodie, in hiswork on Diseases of the Joints, says : I haveseen several cases where, from the appearance ofthe joint and other circumstances, there was everyreason to believe that the inflammation had pro-duced adhesions, more or less extensive, of thereflected folds of the membrane (synovial) to eachother; and I have observed occasionally in dis-

D


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34 ON BONE-SETTING.section such partial adhesions as might reasonablybe supposed to have arisen from inflammation atsome former period.

Apart from these considerations, there can beno question about the amount of mechanicalimpediment to movement that may be producedby extra-articular inflammation. If we considerthe amount and character of the effusion thattakes place after some sprains and injuries, insome gouty and rheumatic affections, and in somecases of suppuration occurring in bursa or beneathdeep fascia, we cannot doubt that such effusionmay easily assume forms in which it will tiedown muscles, tendons, or even articular extre-mities themselves.

If we return to the consideration of the pheno-mena of iritis, we shall find that the adhesions ofthe pupillary margin may sometimes be broken,or so stretched as to become innocuous, by thepersistent use of atropine ; but that when theyresist this treatment, modern surgeons break themmechanically, by introducing a hook or forceps intothe eye and employing the necessary traction. I


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PATHOLOGY. 35think that the use of gentle or gradually increasingpassive movements of partially fixed joints is fairlycomparable to the use of atropine ; and that thesudden rupture of articular adhesions is fairlycomparable to the operation of corelysis.

In my own early endeavours to overcomeimpediments to articular motion, 1 fell, notunnaturally, into the error of not using sufficientforce to overcome the resistance. I was too tenderin my handling, because possessed by a perfectlygroundless fear of exciting inflammatory action.Mr. Hutton has often told me that he had neverseen inflammation follow his manipulations ; andalthough it is very possible that some persons inwhom it did follow may have kept away from him,I have no hesitation in saying that it is not tobe feared as a result of forcibly overcoming thekind of restraints to motion that I have been con-sidering. Such restraints would be present ingreater or lesser degree in the first four of theclasses of cases that I have set down ; althoughin the fourth class, the gouty and rheumatic joints,there would often be such other changes as to

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36 ON BONE-SETTING.render the treatment by movement of only limitedutility. Cases of displaced cartilage, too, wouldoften be attended by voluntary restraint of move-ment for fear of pain, and hence by the formationof some kind of adhesion ; and then manipulationmight effect the double purpose of breaking theadhesion and of rectifying the displacement.

Ganglionic swellings about the carpus are com-monly attended with pain and weakness of thejoint. Their occasional stony hardness inducesbone-setters to look upon them as displacedbones ; even if told better, they are unable to en-tertain the idea that a bag of fluid can give sucha sensation to the touch ; and when ganglia dis-appear from under the thumb, from the pressureand flexion employed, it is easily believed thata bone has slipped into its place.

Subluxations of carpal and tarsal bones mustoccur, I think, in a considerable number of in-stances. I mean by subluxation some disturbanceof the proper relations of a bone, without absolutedisplacement ; and I believe that such disturbancemay be produced either by the traction of a band


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PATHOLOGY. 37of adhesion about the joints, or by a twist or otherdirect violence. I see no other explanation, forexample, of Mr. Ponsonby's account of the accidentthat happened to him after the first manipulation.It seems clear that in the first instance the artificialposition so long maintained had given rise tosome kind of adhesion about the tarsus, the exactspot where pain was so acute being over the upperportion of the calcaneo-cuboid articulation, andthat this adhesion was broken through and thefoot restored to freedom. But the lameness thatwas soon after produced by over-exertion, andthat was immediately removed by manipulation,must surely have been due to some change in therelations or apposition of the articular surfaces.

Displacement of a tendon is certainly of morefrequent occurrence than is usually supposed ;and, excluding several cases where the symptomswere unmistakable, I have seen numerous othersoperated upon in which the alteration in theappearance of the joint immediately afterwardscould only be accounted for by this explanationof the injury. Mr. Paget refers to this accident


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38 ON BONE-SETTING.in his lecture already quoted ; and Mr. Curlinghas published the following interesting case :A young gentleman, about twenty- one yearsof age, in May last met with an accident in jump-ing, by his left foot slipping on a stone andturning outwards. He felt considerable pain inthe ankle, became lame, and sensible of some-thing being wrong. On taking off his boot, hefound a projecting cord at the outer and frontpart of the ankle ; this he easily pressed back,with instantaneous relief. In the course of thefollowing week, the displacement recurred twice ;and the patient sent for Mr. Bailey, a surgeon atWansford, who at once ascertained the case tobe a dislocation of the tendon of the peroneuslongus muscle. He applied an angular piece ofcork to the margin of the fibula, so as to preventthe tendon from slipping over it; and confinedthis with a bandage. A few days afterwards, thepatient called on me, when I found the tendonin its usual site, rather more prominent thanusual. The cork pad was re-applied, and kept inplace with strapping and a bandage ; and walking


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PATHOLOGY. 39exercise forbidden. After a few weeks, I had alaced-up ankle-support, with a pad to fit behindthe fibula, made; and he was then allowed tomove about, and he shortly returned into thecountry. He paid me a visit in December, sevenmonths after the accident. He stated that thetendon had kept in place ; but he occasionallyfelt a weakness in the part, and a sensation asif the sinew was not secure, especially in walkingon rough ground. He was about to emigrate toAustralia. I recommended his continuing to wearthe laced-up sock and pad for some years.

Dislocation of the peroneus longus tendon isso rare an accident, that the particulars of a caseare worthy of record. Two or three of my pro-fessional friends state that they have met with it,but I have no recollection of having read anyaccount of it in books. The nature of the casecan readily be recognized, and the tendon can beeasily replaced behind the fibula. The greatdifficulty is to keep it there after rupture of thesheath, as the tendon so readily slips forward inthe movements of the foot, which at once gives


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40 ON BONE-SETTING.rise to lameness. This has caused so much an-noyance, that it has been proposed to divide thetendon subcutaneously. In the above case, thetendon had been retained in place many monthsby great care on the part of the patient, whofully appreciated the difficulty of the treatment,and never moved about without the support ofthe bandage.

In the instances that I have myself seen, thetendency to recurrence of the displacement hasnot been present in anything like the degree thatis here described ; but the difference might dependpartly upon the extent to which the sheath hadbeen torn ; and partly upon the character of thereparative process.The cases of hysterical joints that comebefore bone-setters are probably numerous, andfor the most part are likely to have been longunder medical treatment. In some of them theremay be conscious imposture which the patient isweary of, and wishful of an excuse to lay aside ;in others the nature of the treatment and theattendant circumstances may effect a cure by their


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PATHOLOGY. 41operation upon the mind ; in others again, I think,the originally hysterical affection has broughtafter it an actual malady. Mr. Skey describesa hysterical joint in the following words :You will find, on the occasion of your first

visit, the patient walking lame. This lamenesshas existed for several days, probably weeks,before attention has been attracted to it, and hascome on very gradually. The joint is stiff notthat it will not bend, but the movement is painful.There may be increased heat in the joint whencompared with that of the opposite limb, but notmuch in degree. The knee is slightly swollen.If you see the case after treatment has com-menced i. e. after the repeated application ofleeches, blisters, and tincture of iodine (the almostuniversal agent in difficulty) the swelling will bepalpable, and the outline of the joint has under-gone a change.The same author also says : In the course of last year I was consulted by

the family of a young lady, eighteen years of age,living at a distance from London, relative to an


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42 ON BONE-SETTING.affection of the knee, from which she had beensuffering for a period of ten months. The jointwas stiff and painful ; she moved about oncrutches ; there was no considerable amount ofheat, and what alteration existed in the form andoutline of the knee was due to the activity of thepast treatment ; the tissues had lost their naturalsoftness and flexibility ; the joint had been re-peatedly leeched and blistered, and subjected tothe application of liniments in variety of colourand composition ; an issue had been made on theinner side of the patella, which, judging from thecicatrix it left behind, had not been a small one,and the curative influence of which had not beendiscoverable

during four months, at the expirationof which nature was allowed to heal it.If we carefully consider this description, and

admit, as I fear we must, that it has been verifiedin innumerable instances, I think we shall alsobe driven to the conclusion that adhesive inflam-mation in or around a joint may very well havebeen excited by the combined effects of rest andof counter-irritation, and that the art of the bone-


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PATHOLOGY. 43setter may have been the precise thing that wasrequired to remedy, not the original nervousmalady, but the prejudicial effects of treatment.We have abundant evidence that even an ordinaryblister will at times excite inflammation in a sub-jacent serous cavity; such as the pleura or thepericardium ; and I see no reason to doubt thatit will do the same in the cavity of a joint ;causing adhesions which may sometimes yield tothe gradual traction produced by efforts to resumeordinary movement, but which may sometimesrequire to be torn through by sudden flexion.

In my original papers on this subject in theLancet, I said that acute articular disease must beexcluded from the class of cases in which themovements practised by bone-setters could beuseful. There is, however, a period at which thisstatement ceases to hold good ; and in whichtimely movement may prevent the occurrence ofpermanent adhesion. I have met with a narrativeof two cases, published by Mr. Carter in the thirdvolume of the London Hospital Reports, by whichthis is particularly well illustrated ; so much so,


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44 ON BONE-SETTING.indeed, that I have thought it worth while totranscribe them. They are entitledTwo cases of Acute Suppuration in Knee-joint, in

which recovery with free motion ensued. H. C , a coal miner, in the prime of life,

and remarkable among his fellow-workmen for hisgreat strength and endurance, received a blowupon his left knee, by the falling of some massesof stone from the roof of the stall in which heworked. Notwithstanding severe pain, he con-tinued to labour until his usual hour ; and thenwalked a mile and a half to his home. On arrivingthere, he went to bed, and enveloped the injuredjoint in mustard poultices. The next day I wasasked to see him.

It is not remarkable that a joint thus injured,and thus ingeniously maltreated after the injury,became the seat of inflammation ; nor that, whenthe inflammation had somewhat subsided, thearticular cavity was left much distended by fluid.

In due time, an exploratory puncture showedthe contained fluid to be pus ; and it was evacuated


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PATHOLOGY. 45by a free incision into the joint, in the directionof the axis of the limb, and just external to theouter border of the patella. The pressure of thedistended joint upon the veins had produced con-siderable oedema of the leg ; and, on this account,it seemed desirable to obtain firm and accuratemechanical support for the leg, as well as im-mobility of the articulation. For these purposesthe following contrivance was employed :

A splint, as light and thin as was consistentwith the necessary strength, was cut from a flatpiece of deal. This splint was long enough toreach from the tuber ischii to the os calcis. Atthe upper end it was about three inches in width,and it gradually tapered to an inch and a halfat the lower end ; so that, when in position, itwas everywhere overlapped by the limb. It waspadded by two or three strips of blanketing, andby a little cushion to fill the ham ; and it wassecured upon the centre-piece of a many-tailedbandage. This centre-piece was somewhat longerthan the splint, so as to turn round the heel, andreach along the sole of the foot to the root of


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46 ON BONE-SETTING.the toes. The tails were rolled up and tackedto two pieces of tape, and the whole apparatusso fastened together that it could be put intoits place by once elevating the limb. The heeland malleoli were then protected by strips of softleather, spread with lead plaster ; the splint wasplaced in position, and the leg gently lowereddown to rest upon it. The pad under the hamwas accurately adjusted, a little cotton-woolplaced to fill up any hollows, and then the tailsof the bandage were laid down firmly and closelyfrom the toes upwards, and thoroughly securedby starch. Opposite the knee-joint two tails oneach side were left unstarched ; but the starchwas again applied above. The unstarched tailswere pinned, so that they could be opened torenew some charpie, placed over the wound toabsorb the discharge. As soon as the starchhad hardened, the limb was slung by tapes froma common cradle, so as to move freely from theacetabulum, and to allow the patient to lie inalmost any position.

After a few days the subsidence of oedema


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PATHOLOGY. 47loosened the bandage. It was then carefully cutthrough on both sides of the limb, and the wholedressing removed and re-applied with the smallestpossible movement or disturbance.

The discharge from the joint, at first purulentand profuse, gradually became serous and scanty.After a time it formed a scab, by which thewound was completely sealed. I expected nobetter result than anchylosis, and when the scabfell and disclosed a firm cicatrix I removed thesplint and bandage, and left the patient in bed.On visiting him the next day he was up anddressed, sitting in a chair with both knees bentin the ordinary manner. He said that a stiff legwould cripple him as a miner, that he determinedto try and bend his knee, and that the attemptsucceeded. No bad symptoms followed, and hesoon returned to his work. He remained undermy observation for more than two years ; andthe joint that suppurated was in every respectas strong, as flexible, and as useful as the other.With the preceding case fresh in my recol-

lection, I was asked by the late Mr. Fox of


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48 ON BONE-SETTING.Nottingham to visit for him a pauper patientwho lived near my own house. I found a youngwoman, the daughter of parents in easy circum-stances, but who had been seduced, and had lefther home in consequence. She had earned ascanty subsistence by needle-work ; and, when Isaw her, she had been three weeks delivered ofa puny infant, that died shortly afterwards.A few days after her confinement, her rightknee-joint became inflamed. I found her withthe joint much distended and pointing, in ahigh degree of irritative fever, half-starved, andthoroughly miserable. Mr. Fox was kind enoughto surrender her entirely to my care, and tofurnish me with orders to the relieving officer foreverything that her case required.A free incision into the joint gave exit to alarge quantity of pus, and to masses of pus clot,some of which were so large that they requiredto be eased through the wound. After theincision, the splint and bandage already describedwere carefully applied.

On account of the unfavourable condition of


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PATHOLOGY. 49the patient, it was manifest that a good resultcould only be obtained by extreme care ; and,living near, I availed myself of the proximity tosuperintend the nursing. For many weeks I tookcharge of the affected limb during every changeof bedding, clothing, or position. The case wasmuch more protracted than the former one ; butits course was in all essentials the same. Thepurulent discharge became serous, and. die woundwas sealed, after a time, by a scab, under whichit united firmly. When this scab. fell,, gentlepassi/e motion was carefully employed. It wasfollowed by increased heat of the joint ; and thisheat was subdued by irrigation with cold water.By slow degrees, free movement was obtained ;but, for many months, increased heat was pro-duced by any undue exertion, and sometimes byatmospheric change. Cold water was alwayseffectual as a remedy, strength was graduallygained ; and, after the lapse of a year, the patientwas able to say that nothing remained, save thecicatrix of the incision, by which she could dis-tinguish the joint that had been inflamed from its

E


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50 ON BONE-SETTING.fellow. I saw her at intervals for nearly threeyears, and her condition underwent no change.

Regarding these cases by the light of my ownexperience, I cannot avoid the conclusion thatin the former of them, if the patient had lain stillwith a straight limb, permanent and probablyirremediable anchylosis would have been producedby the firm adhesion of the opposed articularsurfaces. By rising, and bending the knee com-pletely and with decision, the patient rupturedevery impediment to motion, and was at oncecured. In the second case, if Mr. Carter hadproceeded in a similar manner, he would probablyhave brought about a similar result. Instead ofthis, he proceeded, as he thought, more cautiously.Instead of at once rupturing the adhesions, hestretched them a little while they were still yield-ing, and produced pain and heat by the tractionupon their attachments. When the pain and heathad subsided, the same process was repeated withthe same consequence ; and, as it fortunately be-fell, the adhesions were thus in time either broken


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PATHOLOGY. 51through, or so stretched that they were no longerimpediments to motion. Every one of the gentleattempts at passive movement was probably quiteas dangerous as, while it was far less efficaciousthan, the single complete flexion that would haveovercome the difficulty in a moment. Allowingthis, the successful issue even of the second case isof great interest, and may well make us inquirehow many of the limbs that have been left toundergo anchylosis might have been saved fromthat condition by timely movement.Upon the whole, then, I think it is tolerably

clear that the success of the bone-setter rests, inpoint of fact, upon the frequent occurrence of whatmay be called a minor degree of false anchylosis,variously produced, and perhaps located in dif-ferent natural or adventitious structures.While pronounced degrees of false anchylosis

have long been recognized, and have lately, inan increasing number of cases, been successfullybroken through, the minor degrees seem to havealmost entirely escaped observation ; and it isworthy of remark, that their partial character has

E 2


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52 ON BONE-SETTING.probably served to disguise their nature, and tocause them to be mistaken for more active formsof articular disease. A complete false anchylosisalmost entirely prevents movement ; while an ad-hesion that only checks movement will be a con-stant source of injurious strain upon the structuresof the joint, and will be liable again and again toset up acute irritation. It seems, therefore, in thehighest degree important that these single orpartial adhesions should be fully recognized bythe profession ; and that it should no longer beleft to unauthorized practitioners to treat themsuccessfully after surgeons have failed to do so.For their ready recognition I think two chief in-dications are fully sufficient, when once attentionhas been drawn to their occurrence. A slightdegree of mobility, checked by pain, and accom-panied by a spot tender on pressure, is sufficient,in the absence of any evidence of acute disease,to justify manipulation having for its object thebreaking down of adhesions. The chief lesson,however, which these cases should teach is thedesirableness of so treating the original malady


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PATHOLOGY. 53as to prevent adhesions from being formed. Tothis part of the subject I shall return in a futurechapter.Not less important than the pathology of the

conditions in which motion will be successful, isthat of the conditions in which it would certainlyor probably be injurious ; and any surgeon whoattempts to deal with instances of partial adhesionin the manner I am about to describe, can hardlyexercise too much caution in the selection of hiscases, and in the exclusion of those in which anymischief would be likely to ensue.

It is well known that bone-setters often inflictserious injury upon their patients ; but I believethis can only happen when they overlook thepresence of conditions which a surgeon ought atonce to recognize.

Mr. Paget, in his lecture already quoted, relatesan instance in which a recent fracture of the fore-arm was moved about by a bone-setter ; and Mr.Prall, of West Mailing, has communicated to theLancet two cases, one of which is described ashaving been inflammation at the ankle-joint, the


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54 ON BONE-SETTING.other as hip-joint disease ; in both of which, move-ments effected by a bone-setter were followed bysuppuration and death. Mr. Frail's communi-cation would have been more valuable, if he haddescribed the original maladies of these patientswith greater precision, and especially if he hadtold us whether the symptoms in either case weresuch as to render the diagnosis at all doubtful.For although, in the hands of a quack, it isinevitable that errors must be committed in theapplication of any treatment, and that these errorsmust be followed by a certain proportion of disas-trous results ; yet it is surely unnecessary to warnprofessional readers against disturbing a case ofmanifest acute intra-capsular disease. The onlywarning required by them would be against errorsof diagnosis in doubtful cases ; and even theseneed scarcely ever be committed. In cases thatcan be cured by movement, the application of thetreatment can never be very urgent in point oftime ; and may always therefore be delayed fortime to clear up any point that appears to beobscure. The mischief now done by bone-setters,


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PATHOLOGY. 55or rather by the attitude of some members of theprofession towards their methods, is, that patientsare cured by them whom legitimate surgeons havefailed to cure or have pronounced incurable, andhence the confidence of the public in surgery isrudely and unnecessarily shaken. If surgeonswould only give proof of their knowledge of thegood that bone-setters accomplish, the publicwould then be ready to listen to any reasonablewarnings about the harm, and would be equallyready to submit to any precautions by which thisharm might be reduced to the smallest possiblequantity. A practitioner who said, This jointmight probably be cured at once by a sharp move-ment, but before moving it I should like to waituntil assured of being able to do so with perfectsafety, would generally retain both the confidenceof the patient and the care of the limb. He would,at all events, not lose his reputation, even if abone-setter should intervene successfully ; and atthe worst could only be accused of having exer-cised over-caution. But the cures effected by bone-setters have been far too real and too striking to


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56 ON BONE-SETTING.be ignored ; and hence a practitioner who shutshis eyes to them, or who imagines that they canbe rendered non-existent by a sort of set-off ofmistakes, will find to his cost that he will everynow and then lose, not only an important patientwhose cure will be effected in direct contraventionof all the surgical treatment to which he had pre-viously been subjected, but that he will also, andin a very serious manner, lose credit generally inhis locality, or among the class to which his patientbelongs. Such a case as that of Mr. Ponsonbywould not only foster the practice of bone-settingall over the kingdom, but it would also promotethe success of every kind of quackery in the circlesin which he moves. Errors of opinion and oftreatment that the event renders only 'too mani-fest, and that are committed by qualified surgeonsof high reputation, can hardly fail to lead thosewho are not very profound thinkers to the beliefthat equally grave errors are as likely to becommitted in other departments of practice.

It would be wholly foreign to the scope of thistreatise to enter at any length into the diagnostic


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PATHOLOGY. 57signs of those diseases of joints for which move-ments are either directly contra-indicated or wouldbe especially hazardous. The symptoms whichdenote acute synovitis or ulceration of cartilagewill generally be as unmistakeable as those offracture ; and, as already suggested, must in anycase be cleared up by time.The necessity for the exercise of great caution

will be most conspicuous when there is any evi-dence of either local or constitutional struma ;and although, as Mr. Harwell has shown, the factthat the disease is strumous does not afford anyreason why the adhesions left by it should noteventually be broken, yet it does afford a reasonfor treating the patient with extreme caution,and for obtaining certainty that we do not stirsmouldering embers into flame.The most noted successes of bone-setters have

been obtained on patients past the age at whichstruma shows itself actively ; and it is probablethat their most disastrous results have been in theyoung. A marked elevation of the temperature ofa joint, and the existence of pain when its articular


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58 ON BONE-SETTING.surfaces are gently pressed together, without anyother disturbance of their relations, would both besigns before which the careful surgeon would holdhis hand ; and beyond this it is difficult to saymore than that every case must be carefully studiedwith due regard to its history, its symptoms, andthe constitutional conditions with which it is asso-ciated. The presence of the specific deposits ofgout, for example, would make the adhesions leftbehind by inflammation less tractable, and theinflammation more liable to be re-excited, than ifit had been the result of rheumatism, of injury,or of non-specific irritation ; and in these jointcases, as in all others, he will be the most suc-cessful who most carefully weighs all the elementsof the problem with which he is called upon todeal. It is only in this way, indeed, that therandom successes of the bone-setter can be re-placed by the proper and legitimate results of thescientific surgeon.


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CHAPTER III.MANIPULATIONS.

THE methods of handling employed by bone-setters, and the way in which they proceed tobring about their cures, have hitherto beenmatters only of speculation for surgeons, andhave been surrounded with very unnecessarymystery by the imaginative narratives of patients.Mr. Paget says, for example, Bone-setters vio-lently move the joints, against the resistance ofmuscles, until the latter are wearied and beaten ; and the late Mr. Charles Waterton, the eminentnaturalist, has written an account of his owntreatment which I may be pardoned for believingto be exaggerated, and which is certainly wellcalculated to impress the mind of the unprofes-sional reader.

This description I proceed to quote ; and I am


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60 ON BONE-SETTING.sure that what I have afterwards to say, in theway of an unvarnished version of what is re-quired to be done, cannot seem otherwise thanflat by comparison. Mr. Waterton says :

Before I close these memoranda, I have todescribe another mishap of a very dark com-plexion. Let me crave the reader's leave to pendown a few remarks on bone-setting, practisedby men called bone-setters, who, on account ofthe extraordinary advance in the art of surgery,are not now, I fear, held in sufficient estimationamongst the higher orders of society. Everycountry in Europe, so far as I know to the con-trary, has its bone-setter, independent of thesurgeon. In Johnsons Dictionary, under thearticle 'Bone-setting,' we read that a Sir JohnDenham exclaimed, * Give me a good bone-setter 'In Spain the bone-setter goes under the significantdenomination of Algebrista. Here in England,however, the vast increase of practitioners in theart of surgery appears to have placed the oldoriginal bone-setter in the shade ; and I myself,in many instances, have heard this most useful


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MANIPULATIONS. 61member of society designated as a mere quack ;but most unjustly so, because a quack is generallyconsidered as one devoid of professional education,and he is too apt to 'deal in spurious medicines.But not so the bone-setter, whose extensive andalmost incessant practice makes ample amendsfor the loss of anything that he might haveacquired, by attending a regular course of lectures,or by culling the essence of abstruse and scientificpublications. With him theory seems to be amere trifle. Practice daily and assiduous practice

is what renders him so successful in the mostcomplicated cases. By the way in which you putyour foot to the ground, by the manner in whichyou handle an object, the bone-setter, throughthe mere faculty of his sight, oftentimes withouteven touching the injured part, will tell you wherethe ailment lies. Those only who have personallyexperienced the skill of the bone-setter can forma true estimation of his merit in managing fracturesand reducing dislocations. Further than this, hisservices in the healing and restorative art wouldnever be looked for. This last is entirely the


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62 ON BONE-SETTING.province of Galen and his numerous family ofpractitioners. Wherefore, at the time that I un-equivocally avow to have the uttermost respectfor the noble art of surgery in all its ramifications,I venture to reserve to myself the following (with-out any disparagement to the learned body ofgentlemen who profess it) sincere esteem for theold practitioners who do so much for the publicgood amongst the lower orders, under the de-nomination of British bone-setters. Many peoplehave complained to me of the rude treatmentthey have experienced at the hands of the bone-setter ; but let these complainants bear in mindthat, what has been undone by force, must abso-lutely be replaced by force ; and that gentle andemollient applications, although essentially neces-sary in the commencement, and also in the con-tinuation of the treatment, would ultimately beof no avail, without the final application of actualforce to the injured parts. Hence the intolerableand excruciating pain on these occasions. Theactual state of the accident is to blame not theoperator.


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MANIPULATIONS. 63Towards the close of the year 1850 I had

reared a ladder, full seven yards long, against astandard pear-tree, and I mounted nearly to thetop of this ladder with a pruning-knife in hand,in order that I might correct an over-grownluxuriance in the tree. Suddenly the ladderswerved in a lateral direction. I adhered to itmanfully, myself and the ladder coming simul-taneously to the ground with astounding velocity.In our fall I had just time to move my headin a direction that it did not come in contactwith the ground ; still, as it afterwards turnedout, there was a partial concussion of the brain ;and add to this, my whole side, from foot toshoulder, felt as though it had been pounded ina mill. In the course of the afternoon I tookblood from my arm to the amount of thirtyounces, and followed the affair up the next daywith a strong aperient. I believe that, with thesenecessary precautions, all would have gone rightagain (saving the arm) had not a second misad-venture followed shortly on the heels of the first ;and it was of so alarming a nature as to induce


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64 ON BONE-SETTING.me to take thirty ounces more of blood by thelancet. In order to accommodate the position ofmy disabled arm, I had put on a Scotch plaidin lieu of my coat, and in it I came to dinner.One day, the plaid having gone wrong on theshoulders, I arose from the chair to rectify it, andthe servant, supposing that I was about to retire,unluckily withdrew the chair. Unaware of thisact on his part, I came backwards to the groundwith an awful shock, and this no doubt causedconcussion of the brain to a considerable amount.Symptoms of slowly approaching dissolution nowbecame visible. Having settled all affairs withmy solicitor betwixt myself and the world, andwith my Father Confessor betwixt myself and myMaker, nothing remained but to receive the finalcatastrophe with Christian resignation. But thoughI lay insensible, with hiccups and subsultus ten-dinum, for fifteen long hours, I at last openedmy eyes, and gradually arose from my expectedruin.

I must now say a word or two of the externalsdamaged by the fall with the ladder. Notwith-


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MANIPULATIONS. 65standing the best surgical skill, my arm showedthe appearance of stiff and withered deformityat the end of three months from the accident.And now my general state of health was not asit ought to be; for incessant pain prevented sleep,whilst food itself did little good. But my slum-bers were strangely affected. I was eternallyfighting wild beasts, with a club in one hand,the other being bound up at my breast. Ninebull-dogs one night attacked me on the highroad,some of them having the head of a crocodile.I had now serious thoughts of having the armamputated. This operation was fully resolvedupon when, luckily, the advice of my trusty game-keeper, John Ogden, rendered it unnecessary.One morning, ' Master,' said he to me, ' I'm sureyou're going to the grave. You'll die to a cer-tainty. Let me go for our old bone-setter. Hecured me, long ago, and perhaps he can cureyou.

1 It was on the 25th of March, then aliasLady-day, which every Catholic in the universeknows is a solemn festival in the honour of theBlessed Virgin that I had an interview with Mr.

F


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66 ON BONE-SETTING.Joseph Crowther, the well-known bone-setter,whose family has exercised the art, from fatherto son, time out of mind. On viewing my poorremnant of an arm ' Your wrist/ said he, ' issorely injured ; a callus having formed betwixtthe hand and the arm. The elbow is out ofjoint, and the shoulder somewhat driven forwards.This last affair will prevent your raising the armto your head. Melancholy look out '. ' But canyou cure me, doctor ? ' said I. ' Yes/ replied he,firmly ; ' only let me have my own way.' ' Thentake the arm, and with it take elbow, wrist, andshoulder. I here deliver them up to you. Dowhat you please with them. Pain is no consider-ation in this case. I dare say I shall have enoughof it.' ' You will/ said he, emphatically. Thisresolute bone-setter, whom I always compared toChiron the Centaur for his science and his strength,began his operations like a man of business. Infourteen days, by means of potent embrocations,stretching, pulling, twisting, and jerking, he forcedthe shoulder and the wrist to obey him, and toperform their former healthy movements. The


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MANIPULATIONS. 67elbow was a complicated affair. It requiredgreater exertions and greater attention. In fact,it was a job for Hercules himself. Having donethe needful to it (secundum arteni) for one-and-twenty days, he seemed satisfied with the progresswhich he had made ; and he said, quite coolly,* I'll finish you off this afternoon/ At four o'clock,post meridian, his bandages, his plasters, and hiswadding having been placed on the table inregular order, he doffed his coat, tucked his shirtabove his elbows, and said that ' a glass of alewould do him good.' 'Then I'll have a glass ofsoda-water with you/ said I ; ' and we'll drinkeach other's health, and success to the under-taking.' The remaining act was one of unmiti-gated seventy: but it was absolutely necessary.My sister, Eliza, foreseeing what was to takeplace, felt her spirits sinking, and retired to herroom. Her maid, Lucy Barnes, bold as a littlelioness, said she would see it out ; whilst Mr.Harrison, a fine young gentleman who was ona visit to me (and, alas is since dead in Cali-fornia), was ready in case of need. The bone-

F 2


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68 ON BONE-SETTING.setter performed his part with resolution scarcelyto be contemplated, but which was really requiredunder existing circumstances. Laying hold of thecrippled arm just above the elbow with one hand,and below with the other, he smashed to atoms bymain force the callus which had formed in thedislocated joint ; the elbow itself cracking, asthough the interior parts of it had consisted oftobacco-pipe shanks. Having pre-determined inmy mind not to open my mouth, or to make anystir during the operation, I remained passive andsilent whilst this fierce elbow-contest was raging.All being now effected, as far as force and skillwere concerned, the remainder became a merework of time. So putting a five-pound note, byway of extra fee, into this sturdy operator's hand,the binding up of the now rectified elbow-jointwas effected by him, with a nicety and a know-ledge truly astonishing. Health soon resumedher ancient right ; sleep went hand in hand witha quiet mind ; life was once more worth enjoyingand here I am, just now sound as an acorn.

After this graphic, and yet somewhat vague as


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MANIPULATIONS. 69well as alarming description, it will sound prosaicto describe what the processes really are. Afterhaving satisfied oneself by examination and in-quiry that a given case is suited for the treatment,the first step is to feel all round the affected jointfor a spot that is painful on pressure, and in allsubsequent manipulations to be careful to fix thispainful spot by firm pressure with a thumb. Itmay be found anywhere about a joint, but morefrequently on the inner than the outer aspect ;and in each joint it has its most frequent situation

in the hip, over the head of the femur; aboutthe centre of the groin ; in the knee, at the loweredge of the internal condyle; in the elbow, overthe internal condyle of the humerus ; at the wrist,over the scaphoid or semilunar bone ; and so on.The painful spot being discovered, the limb mustbe steadied on the proximal, and grasped on thedistal, side of the affected joint, the thumb pressureapplied to the seat of pain, and the joint sharplyflexed, or flexed and extended, sometimes alsoabducted or adducted, as the case may be. Thedirection of movement must depend mainly upon


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70 ON BONE-SETTING.the direction of resistance a principle whichpresents itself to the mind of a bone-setter in theshape of the maxim that a joint must be put inthe reverse way to what it has been put out.The resistance of muscles is overcome, or at leastreduced to a minimum, by rotating the limb belowthe joint as much as possible on its axis. In thisway the muscles are thrown out of their ordinarylines of action, and are rendered almost powerless.Mr. Paget, as already quoted, says, Bone-settersviolently move the joints against the muscularresistance until the muscles are wearied andbeaten. As far as Mr. Hutton was concerned,this description is not founded upon fact, for heby his rotation manoeuvre simply evaded muscularresistance, and his manipulations were never soprolonged that muscles could be wearied andbeaten. The force, moreover, was applied in aperfectly definite way, for the attainment of adefinite end, and ceased as soon as that end wasarrived at. There was no objectless movementhither and thither ; but only a movement everystep of which was considered and planned before-


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MANIPULA TIONS. 7 1hand, like the movements of a surgeon in thereduction of an actual displacement.The cases already cited are all instances in

which freedom of action was restored by asingle operation. This, however, cannot always beaccomplished, and the manipulation must some-times be repeated again and again. In such casesMr. Hutton attached importance to the productionof sensations of tingling in the course of theaffected limb, and was not satisfied that he haddone all that was in his power until the tinglingextended quite to the tips of the fingers or toes.The instances of this kind that I can recall werechiefly of long standing, and consecutive to injuryor disease of considerable original severity.

Perhaps the most noteworthy feature of bone-setting is the ingenuity with which the leverage ofthe limbs themselves is rendered available for thepurpose of obtaining the power necessary for theaccomplishment of the object, so as to dispenseentirely with mechanical appliances. The methodsbear to those ordinarily used in anchylosis thesame relation that the reduction of a dislocated


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72 ON BONE-SETTING.hip by simple manipulation bears to its reductio'nby pulleys ; and here, I think, surgery may obtainuseful hints. It is also noteworthy, that little orno use is made of extension. Mr. Hutton used tosay,

Pulling is of little use : the twist is the

thing. And I have no doubt that this method ofevading muscular resistance might be made veryextensively useful. The precise manner of apply-ing it to each joint can only be rendered fullyintelligible by the aid of figures ; and I enterupon this part of the subject in the followingchapter.


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CHAPTER IV.MANIPULATIONS (continued].

IN the rupture of adhesions by manipulation,the first principles by which the operator shouldbe guided are to obtain sufficient firmness ofgrasp, sufficient leverage to apply the necessaryforce suddenly, and to apply it generally, inthe first instance, in the direction of flexion,before any attempt is made to restore othermovements. In their application to individualjoints, these principles require certain modi-fications of detail, to each of which attentionmay next be directed.The thumb and fingers frequently

on bone-setting by wharton p. hood

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