The Art of the Bone-Setter: A Testimony and a Vindication

by George Matthews Bennett

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.