110 MANIPULATIVE SURGERY OR BONESETTING.

expensive bismuth carbonate. The liberation of02 may be facilitated in certain cases by imme-diately following the dose of carbonate with citricacid gr. xxx. dissolved in 1 oz. of chloroform water.In cases where the hydrochloric acid in the gastricjuice is diminished, hydrochloric acid may be givenby -mouth with advantage, especially in rosacea.Powdered kaolin has been used with the idea ofcovering over abrasions of the mucous membrane.I am sceptical of its value, and I am also scepticalof the value of the various bitters very commonlyprescribed.The application of local heat to the epigastrium

is a treatment of dyspepsia hallowed by longuse. Observations by Dr. Payne and myselfhave given an indication as to how such counter-irritants are effective. Rubbing the skin over thesternum, with or without a counter-irritant, causeda profound effect on the movements of theoesophagus. In one case a sensation of " tingling,"experienced some time after the rubbing had takenplace, was associated with very considerableperistaltic activity of the cesophagus.

Local heat may be applied most simply in theform of a flannel bandage or a rubber hot water

bottle. Thermogene wool, antiphlogistine, andpoultices may be used.When pain is severe and the patient unable to

vomit, complete relief may be obtained by theremoval of the contents of the stomach by meansof a tube. In cases of gastroptosis or, as has beenalready described, in cases where the stomach isapt to undergo a sudden drop with correspondingsensations, exercise such as walking on the handsand feet strengthens the abdominal muscles.Massage of the abdominal muscles is of value, butone of the most effective of all treatments is bymeans of a belt. But it is important that con-siderable pressure should be exercised by the belton the lower part of the abdomen just above thesymphysis pubis. It may be advisable to have aconical pad made and fastened inside one of themore usual forms of belt, so that this pressure maybe exercised. It probably acts by preventing thesudden dropping of the stomach, and its value canbe assessed by an observation of Leven's that bypressing the fist into the epigastrium of thesepatients pain is produced, which may be completelyalleviated by pressing in with the other fist justabove the symphysis.

REMARKS ON

MANIPULATIVE SURGERYOR BONESETTING.*

BY

FRANK ROMER, M.R.C.S., L.R.C.P.LOND.

FROM time to time much criticism has beenpublished by the lay papers on the after-treatmentof bone and joint injuries by our profession,whilst the treatment by bonesetting or manipula-tive surgery-as it is now termed-by unqualifiedpractitioners, has been proportionately extolled.The question occasionally arises as to the probableorigin of this humble branch of surgery. Dr.Wharton Hood, to whom the profession wasoriginally indebted for the elucidation of thebonesetter's secrets, held the opinion that "' thefirst bonesetter was the servant or unqualifiedassistant of a surgeon who had known exactly whatcould be done by sudden movements and how themovements should be executed." This theory is,of course, possible. Waterton, the naturalist, whomany years ago wrote much on the subject, saysthat " this art is practised not only in England butthroughout Europe as well, and that in Spain hebears the significant name of Algebusta." As amatter of fact he does not; the name is cirujanoalgebrista, in France he is termed un rebouteur,but Waterton is correct in saying this mode oftreatment exists throughout Europe. Personally

* A Lecture delivered before the South-West London Post-Graduate Association on March 17th, 1926.

I believe that some such rough-and-ready methodof treatment has always existed, but that its utilitygot overlooked during the time surgery wasdeveloping into a definite science. As our pro-fessional ancestors progressed in their knowledgeof pathology, such a condition as tubercular diseasebegan to be more generally understood, and theimportance of quietude in this and other acutelyinflamed joints was soon realised. In consequenceof the general appreciation of the value of absolutephysiological rest in these cases, it was not longbefore it was considered essential for the treatmentof all painful and swollen joints, no matter fromwhat cause. The cult of complete rest became tobe deemed so necessary that it was never consideredadvisable to use a joint as long as the least painwas experienced on attempted movement, therebyreminding one of the boy who was forbidden toenter the water till he had learned to swim. Theuniversal adoption of these principles by the pro-fession caused anything in the way of morevigorous treatment of injuries to remain in thehands of the less educated classes who, " rushing inwhere angels fear to tread," frequently obtainedbrilliant results from their unorthodox methods.Thus it happened that many vendors of herbs andsimples resident in country places came to specialisein this business, which, unlike the majority of folk-lore remedies, contained, in the -words of The Lancet,"s ome long-forgotten truth."

HISTORY OF BONESETTING.The only book on this subject for many years was

by Dr. Wharton Hood, who, in 1871, from personalobservation of a celebrated bonesetter calledHutton, was able to disclose to us the methods

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employed. In 1880 Mr. Bennett, a very well-knownbonesetter from the Midlands, brought out a bookthe " Art of the Bonesetter," to which I am greatlyindebted for some historical information. Unfor-tunately, beyond acquiescing in the correctness ofthe movements detailed by Dr. Wharton Hood, hegives no hints as to his own procedure. He does,however, lay claim to treating recent dislocationsand fractures as well as old-standing cases ofimpaired limbs. So far as I can find out no otherunqualified man or bonesetter has ever committedhis methods and experiences to paper. In 1911and again in 1915 I published books on this subject,and quite recently Mr. T. Fisher has brought outa treatise on " Manipulation." The general publichave always shown themselves greatly interestedin the cures achieved by the so-called art of bone-setting as practised by its unqualified exponents.Doubtless this is in some measure due to an inherentbelief in all occult methods of treatment which, evenin these days, exists amongst all classes of society.At the same time a mistaken notion still leadsthem to believe that only certain individuals areendowed with some peculiar gift of healing bymanipulation. Nevertheless, credulity alone wouldnot be sufficient to keep interest alive were it notfounded on something more definite; and it mustbe granted that treatment at the hands of unquali-fied practitioners often brings about quick andpermanent cure, even in cases where the highestsurgical skill has been sought in vain. The old ideathat these cures wrought by bonesetters are broughtabout by the reduction of an overlooked dislocationstill holds good in the public mind. The historicaldiagnosis of " Bone Out " may be accounted forby the fact that these men, being for the most parttotally ignorant of the true nature of the lesion, weremisled by the crack of the rupturing adhesions,and, finding that increased mobility followed theirministrations, were honestly convinced that a bonehad been restored to its place. In parenthesisI might mention that I am not here referring to themovements connected with osteopathy. Many ofthe bonesetting fraternity still adhere to thispopular error, though, it is but fair to add, the bestknown of them hold no such mistaken view.Survival of this incorrect diagnosis has, I believe,done much to prevent medical men inquiring morefully into the meaning of these present-day cures.Satisfied that no obvious ankylosis or anatomicaldisplacement existed in some case cured by mani-pulation, they are inclined to dismiss further dis-cussion of the question. On the assumption thatthe result has been probably achieved by suggestionno attempt is made to connect it with the modernaspect of the old-fashioned bonesetting of whichthey are well informed. All the same, from thepatient's point of view, accurate diagnosis is notnearly so important as successful treatment. Itis only human that the lay mind should prefer toaccept the opinion of the man who erroneouslystates a " bone is out " and then works a speedycure, in preference to believing the doctor who

correctly maintains there is nothing anatomicallywrong, but can offer no other advice than that timewill probably bring about recovery.

FAMILY TRADITION.In all probability, not only in England but

practically all over the world, this method oftreating injured limbs by what is called bonesettinghas always been in existence. In some countrydistricts the same family for many generations pasthas had one of its members carrying on the tradeof bonesetter. Mr. Dacre Fox, writing to The Lancetin 1882, detailed three years' experience he hadwith Taylor, a celebrated bonesetter of Whitworth,Lancashire, whose family had been bonesetters formore than 200 years. The different movementsand methods of procedure were treated as businesssecrets and handed down from father to son orsome near relative who might show aptitude ordesire to take up the calling. Nearly all the present-day bonesetters can trace a relationship to a formerexponent of the art, and in many cases have madeconsiderable advance in their knowledge of thetreatment their forefathers taught. As an instanceof family tradition the celebrated Richard Hutton,after a successful career as an upholsterer inTottenham Court-road, in his late middle age tookup as a relaxation the business of his grandfather,a Yorkshire bonesetter, by whom he had beentaught. He was succeeded by his nephew, alsonamed Hutton. Hutton junior was followed indue course by a relation, Professor Atkinson, aveterinary surgeon who lived and practised in ParkLane, where his successor, and I believe relative,up to quite recently practised.

MRS. MAPP OF EPSOM.Apart from the fact that these men looked upon

their knowledge as a secret to be jealously guardedfrom any inquiries, they were usually drawn fromthe humbler and less educated classes, hence untilthe publication of some papers on "Bonesettingso called," by Dr. Wharton Hood in 1871, noliterature existed on the subject. References inthe public press, however, as nowadays, were notuncommon as far back as 1736, and the LondonMagazine brings into considerable prominence theclaims of a certain Mrs. Mapp, who lived at Epsom.Mrs. Mapp was the daughter of a Wiltshire bone-setter and speedily made a great name for herself.An article in the paper states:

" The concourse of people to Epsom on this occasionis incredible, and it is reckoned she gets nearly 20 guineasa day, she executing what she does in a very quick manner.She has strength enough to put in any man's shoulderwithout any assistance; and thus her strength makes thefollowing story probable. A man came to her, sent as itis supposed by some surgeons on purpose to try her skill,with his hand bound up and pretended his wrist was putout, which upon examination she found to be false; butto be even with him in his imposition she gave it a wrenchwhich really put it out and bade him go to the fools whosent him and get it set again, or if he would come to herthat day month she would do it herself . . . . It is furtherstated that since she became famous she married Mr. HiU

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Mapp, late servant to a mercer on Ludgate Hill, who, itis said, left her and carried off £100 of her money."

Besides practising at Epsom she used to come totown once a week in a coach and four and returnbearing away the crutches of her patients as trophiesof honour. She held her levees at the GrecianCoffee House, where she operated successfully upona niece of Sir Hans Sloane. The same day shestraightened the body of a man whose back hadstuck out two inches for nine years; and a gentle-man who went into the house with one shoe-heelsix inches high came out again cured of a lamenessof 20 years' standing and with both his legs equallength. On the other hand, one Thomas Barber,tallow chandler, published a warning to her would-be patients, from which we may deduce thatsuccess was not always achieved. The cure of SirHans Sloane's niece was the talk of the town, andMrs. Mapp became quite a famous character. Acomedy was announced at the Lincoln's Inn FieldsTheatre called " The Husband's Relief," or "TheFemale Bonesetter, and the Worm Doctor," Mrs.Mapp being present at the first night. In this playa song in her praise runs as follows:"You surgeons of London who puzzle your patesTo ride in your coaches and purchase estates,Give over for shame, for your pride's had a fallAnd the doctress of Epsom has out-done you all.Dame Nature has given her a doctor's degreeShe gets all the patients and pockets the fee,So if you don't instantly prove it a cheatShe'll loll in a chariot whilst you walk the street."

At the height of her prosperity Mrs. Mapp gavea plate of ten guineas to be run for at the Epsomraces, and the first heat was won by a mare called" Mrs. Mapp," which so pleased the lady that shegave the jockey a guinea.The fair bonesetter's career, however, was short,

and she died in poverty, according to a notice in theLondon Daily Post of Dec. 22nd, 1737. It wouldappear, therefore, that bonesetting has always beena fruitful source of copy to journalism.

Curiously enough, the word " bonesetter " hasno connexion with the surgical skill necessary toobtain good position in fractured bones. The originof the word is hard to find, but its practice has beenknown from time immemorial. Dr. Wharton Hooddefines it " as the art of overcoming by suddenflexion or extension, any impediment to the freemotion of joints that may be left behind after thesubsidence of the early symptoms of disease orinjury." It was in 1871, as I have mentioned, thatDr. Whaxton Hood published in The Lancet a seriesof papers describing the methods used by Hutton,who had a world-wide reputation.

THE MEANING OF THE MYSTERIOUS MOVEMENTS.For the first time the real meaning of these

mysterious movements referred to by so manypatients was made clear to the medical profession.The question of bonesetting at once receivedconsiderable attention in medical circles. Paperswere read at. various meetings on the subject, when-it received full discussion. Mr. Bruce Clark was

amongst the first to describe, from dissection on thejoints of amputated limbs, the real nature of theadhesions which caused the disability capable ofbeing cured by free movements. In the courseof his lecture, he advised surgeons to considerseriously the question as to whether prolonged restin all cases of injury was absolutely necessary, sinceundoubtedly it was the cause of these adventitiousbands being formed. Some years previously, SirJames Paget, in a lecture," Cases which BonesettersCure," had given similar advice by saying:" Sprains may often be quickly cured, freed frompain, and restored to useful power by graduallyincreased violence of rubbing and moving."

Mr. Dacre Fox, of Manchester, whom I havealready mentioned, about the same time contributedan interesting article pointing out that bonesettersin the north did not entirely confine their workto the treatment of old injuries, but were constantlyemployed by their clients for recent sprains anddislocations which they treated with marked success.In fact, it would appear that these men, thoughpossessing no training in surgical and anatomicalknowledge, were in the habit of rubbing and movingrecent injuries long before early movement andmassage was deemed a correct method of treatmentby the medical profession. An old-time Lancashirebonesetter, on being questioned as to the reasonsfor treating sprains in this way, replied: " Whathas been caused by violence must be cured byviolence." From this epigrammatic remark onemight almost define bonesetting as being homoeo-pathic surgery, since similia similibus curantur bestdescribes its methods. The movements adoptedare not, as some imagine, merely haphazard indirection and amount of violence; whether employedfor breaking down adhesions, moving sprainedjoints or reducing dislocations, they were the out-come of a certain knowledge, and with regard tosuch movements in recent cases of trauma theymay be considered the precursor of modern massage.This knowledge, combined with constant practice,observation, and experience, made the bonesettersconversant with the situations where adhesionswere most commonly found in the different joints,and I think it is quite feasible that besides the care-fully studied movements used by them for breakingdown adhesions they employed routine manipula-tions for reducing various dislocations, much onthe same lines that Kocher describes in his methodfor the reduction of a dislocated humerus.

Dr. Wharton Hood, Howard Marsh, and others,however, considered that any successful treatmentof dislocations at the hands of these men wasmerely a matter of luck. On the other hand,Dr. Schivardi, of Milan, in 1871, asserted that awoman, Regina Dal Cin, a well-known bonesetterof Trieste, not only broke down adhesions bymethods similar to those employed by Hutton, butsutcessfully reduced dislocations as well, some beingof long standing. She, it may be interesting tonote, was the descendant of a long line of bone-,setters, and at one time received permission to

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MAIUAIESREY RBNSTIG 1

practise in Vienna, though the permit was eventuallywithdrawn.

MODERN METHODS IN RELATION TOBONESETTING.

From this time onward the medical professionrecognised the benefits to be derived from thehitherto despised practice of bonesetting. Notonly did they adopt similar methods for treatingjoints ankylosed by adhesions, but by modifyingthe period of complete rest in sprains and fracturesthey lessened the chances of such a conditionarising. Gradually the employment of massage,heat, and electricity came to be accepted moregenerally in this class of injury, so that nowadaysit is almost universally advised as affording thebest results. The adoption of this more activemode of treating injuries has had the curious effectof reviving the cult of the unqualified practitioner.This recrudescence may be attributed to thefollowing causes. In consequence of these modernmethods practitioners have had less necessity oropportunity for breaking down adhesions, and itwould seem they have apparently forgotten thatbonesetting might occasionally prove a valuableadjunct to treatment.

Just as the majority of surgeons 50 years agoclosed their eyes to the lessons being taught byHutton, Matthews, Mason, Bennett, and a hostof lesser well-known bonesetters who were com-petently and constantly treating the old-fashionedrigid joint, so the modern practitioner is apt tolook askance at the work of the present-dayso-called manipulative surgeon who has adaptedhis treatment to the conditions existing where theutility of a joint is slightly impaired by some defect,which, though not sufficient to cause complete lackof movement, yet is capable of being both irksomeand painful. The number of patients suffering inthis way who attend the consulting-rooms ofunqualified practitioners is far greater than mightbe supposed, and the incomes earned in consequenceby some of the London bonesetters would be arevelation to the medical profession. One of thebest known amongst them informed me a few yearsago that he was occupied all day and every daytreating various forms of defective joints. It isobvious, therefore, that our profession are, to alarge extent, either chary of trying this simple formof treatment for themselves, or are ignorant of thebenefit to be obtained by its adoption, especiallyin those vague conditions of impaired mobilitywhere the patient complains more of a deviationfrom the normal than of anything markedlydefective. During my student days, though wewere taught the pathology of adhesions and thepossibility of their appearance in joints afterinjury, beyond the fact that the ensuing disabilitycould be remedied by "breaking down," noinstruction or information was vouchsafed as tothe best way for setting about the act. Dr.Wharton Hood, himself an observer of Hutton, towhom I am ever under a great debt of gratitude for

many acts of kindness, first showed me what goodresults could be obtained by forcible movementsskilfully applied in suitable cases.Mas8age.-Nowadays the value of massage in

the treatment of a trauma is well appreciated bymedical men, but I have often been impressedby the fact that, owing to want of instructionwhen students, few of them are able to give definitedirections to their masseurs. They will say," We will order massage," but they cannot go andsay when necessary to the masseur at work, " Thatis not right." Sufficient attention is not paid tomy contention that massage is a very importantfactor and, moreover, in itself is manipulativetreatment, necessary to be administered in theearliest stages of injury by one method, and in thelater stages of delayed recovery by something morevigorous. I am of opinion that our professionshould make themselves more acquainted with thetechnique of massage; they are too ready to trusttheir patients to anyone with the title " qualifiedmasseur."

BREAKING DovN FIBROUS ADHESIONS.I do not propose describing the various forms of

ankylosis, and it may be assumed that referenceis made to fibrous adhesions caused mainly bytrauma, though certain cases may be includedwhere disability has been occasioned by the so-calledrheumatoid arthritis. I have seen adhesions appearwithin three weeks of injury, but their capabilityof interfering with the normal action of a jointdepends largely on their situation. They may existwithin the joint itself, binding together the articularsurfaces and folds of synovial membrane, or beentirely peri-articular when the surrounding tendonshave become adherent to their sheaths throughtenosynovitis. The resulting disability may varyfrom complete ankylosis of the joint to a conditionwhere pain is only elicited by some particularmovement. An important point to bear in mindis that a joint need not be entirely incapacitatedby adhesions to require manipulation. Indeed,in these days of early massage and movement,complete ankylosis is rare compared to what it wasin the time when absolute rest was consideredessential for the treatment of bone and jointinjuries. Hence, it frequently happens that thepossibility of some small adventitious band isnot suspected, provided the joint moves with com-parative freedom, and it is especially in these casesthat the modern bonesetter proves so successful.Careful examination in such cases will reveala painful though comparatively slight interferencewith the normal range of movement, to cure whichforcible manipulation will be just as necessary asin joints whose action is entirely crippled byadhesions.

Unless contra-indicated, when adhesions are tobe broken down, an anesthetic must always begiven, not so much for the avoidance of pain as toensure complete relaxation of the muscles. Bydispensing with an anaesthetic the difficulties of

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MANIPULATIVE SURGERY OR BONESETTING.

the operation are increased, as it will be necessaryto overcome muscles, which the patient willinvoluntarily put into action for the protection ofthe joint, before the adhesions can be satisfactorilyruptured; at the same time, a risk is run of severelyspraining or rupturing the contracted muscles. Itis possible that where severe inflammation hasfollowed forcible movements these points havenot been observed. Where manipulation has beenproperly performed no untoward result need befeared, as there is nothing in the rupture of fibrousbands to cause inflammatory action, provided thecase is otherwise suitable.

Generally speaking, the movements should beperformed in a swift, even, and firm manner, sothat a joint undergoes the motions of its normalaction, though not necessarily to the full extentof its range. The reason of this is that the muscleswill have contracted in proportion to the limitationof movement permitted by the adhesions, and oncethat limit has been overcome, the contraction ofthe muscles will be the only impediment to thenormal range. The adhesions once ruptured, after-treatment will speedily restore the elasticity of themuscles, which might well be strained should thefull extent of movement be at once sought. Incases of long standing the adhesions yield with adistinct audible snap or crackle, others of lessduration with the noise of tearing wet parchment,whilst those of still more recent date, though givingno audible sound, can generally be felt by thefingers of the operator. Experience shows thatrapidity in the execution of the movements givesrise to far less after-pain than if the adhesions arebroken down by slow and deliberate stretching, butcare must be exercised against jerks or undueviolence. When taking hold of a limb the graspshould be just above and just below the affectedjoint, for though a more powerful leverage can beobtained by more distant grips, yet it is as well tobear in mind that other structures may be brokenbesides adhesions, whilst in the young there isdanger of separating the epiphyses.

After-pain is certain to be present in varyingdegrees, but will pass off in the course of an hour orso, and provided sufficient care has been takenin the operation no apprehension need be felt onthis point. Within a few hours the joint shouldbe gently massaged and movements aided. Oncommencement the massage must be of the lightestdescription, and should consist of gentle strokingmovements in the direction of the trunk. As thepain subsides the rubbing can be of a more vigorouscharacter, and voluntary movements of the limbaided and encouraged, but all semblance of rough-ness must be avoided. The rubbing should lastabout 20 minutes to half an hour. The mereallowing a joint to remain quiescent for 48 hours,as is sometimes recommended, is not safe; sufficienttime may thus be given to allow the freshly-rupturedadhesions to reunite. Notwithstanding the pain,every effort should be made to keep the joint free,and on no account should any bandage or splint

be applied. It will be found that the rubbing, ifskilfully performed, gives great relief from the pain,and any local application is scarcely ever requisite.

Occasionally, full movement and freedom frompain follow the manipulations, but this ideal resultis rare. More often a patient is quite unable tomove the joint beyond the extent obtained underthe anaesthetic, the explanation being that thoughthere is no longer mechanical obstruction in thejoint, the muscles from disuse are so wasted andcontracted that they are physically incapable ofnormal work. To dismiss a patient without correct-ing this condition is to court almost certain failure.Merely ordering the joint to be used is, for the mostpart, useless, as few people have the strength ofwill necessary to make muscles perform their properfunctions at the expense of pain. It is the customof a large number of operators to administer ananesthetic on two or three subsequent occasionsfor the purpose of overcoming the muscularresistance. This should never really be necessaryif the adhesions have been properly dealt with atthe time of the operation, and the most satisfactorytreatment after the first two days consists in sub-stituting for the rubbing graduated exercises bymeans of weights and pulleys. These exercises,though possibly painful, must be performed daily,when it will be found that increase of strength andmobility bring decrease of pain. Exercises shouldbe diligently persevered in till the muscles haveregained their former bulk and the joint its fullpower of movement.

SOME IMPORTANT POINTS: RADIOGRAPHY.Such are the broad principles upon which bone-

setting is based, and though, in certain particulars,the procedure which is set out differs from thatadvised by some surgeons, it embodies the experiencegained in a large number of cases in which successhas followed its adoption, and follows the techniqueused by Hutton. A certain delicacy of touch isdoubtlessly requisite properly to appreciate thatlesion, whilst the correction of it largely depends onknack, but both can easily be acquired by experienceand practice.

Before describing the various movements whichwill be required for each joint, it may be as wellto emphasise some of the more important pointsto be observed in their performance.

In the first place, an ansesthetic should alwaysbe employed even for the apparently trivial cases,as, apart from the chances of meeting with unduemuscular resistance, the pain experienced by thepatient is sometimes out of all proportion to theamount of disability present.

Secondly, the movements should be executedin a quick, smooth manner, avoiding all jerks andundue violence.

Thirdly, in seizing the limb, a short leverageshould be taken for fear of fracture.

Once the adhesions have ruptured, full movementof the joint must not be sought at the risk of over-straining the contracted muscles.

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In all cases in which diagnosis is doubtful, it isadvisable to obtain a radiograph of the joint inorder that any morbid condition may be excluded.As an example of the importance of radiography,

I will quote a case which recently came before me.A boy was brought to me a short time ago with ahistory of a strain at football some two monthspreviously, resulting in a knee in which there waslimited extension and a sensation of " nipping "in front of the internal aspect of the joint, verysuspicious of a fringe of hypertrophied membraneor possibly an organised blood-clot. I was askedif I would manipulate to reduce this and straightenthe joint, and bearing in mind my views on thispoint I advised a radiograph, and there in the middleof the joint, just on the internal aspect of thecondyle of the femur, was a distinct erosion, andthere is no question that it was a tuberculous joint.Had that joint gone before some of the unqualifiedbonesetters they would very likely have manipu-lated that joint with grave risks to the patient.In addition to the question of manipulation of ajoint, tendons and muscles are very liable to apainful depreciation of movement as a result oftrauma, which can often be rectified by this methodof treatment when less drastic efforts at obtainingrecovery have failed.

ILI.USTRATIVE CASES.Before proceeding to demonstrate the various

movements that I have found suitable for eachjoint, I will quote some cases from my own practiceas examples of the type of disability capable of beingcured by these means.A lady came to see me who had dislocated her right

shoulder five months previously by a fall out hunting.The dislocation had been reduced under an anaestheticand treated on orthodox lines. Seven weeks later thejoint was moved or " freely wrenched," as I was informed,under anaesthesia, but so great had been the pain andswelling that it was once more bound to the side. Massagewas ordered in the course of the next week, and continuedfrom time to time up to the date she was brought to see me.On examination, the arm could be moved backwards andforwards to a certain extent; rotation was entirely absentand abduction very limited, though rotation of the scapulagave the spurious appearance of fair movement. Anyattempt to obtain movement beyond these limited areascaused acute pain. Under an aniesthetic the adhesionswere broken down according to routine, but muscularshortening prevented full range of movement. Thismuscular contraction yielded to the ministrations of ahighly skilled masseuse together with graduated exercises,and the patient within 14 days regained a normal arm.The next case is that of a young man who fell on his

out-stretched hand, which was consequently severelysprained. Four months later he saw me, because, in spiteof radiant heat, massage, ionisation being meticulouslycarried out, his hand was exquisitely painful on certainmovements. On examination, there was much indurationand loss of movement between the fourth and fifth meta-carpal bones, and any attempt to move them, as in shakinghands, caused the pain. Radiograph was negative.Manipulation under anaesthesia, followed by a few days ofmassage, restored the hand to normal.As an'example of muscular lesions to which I have

already referred, I give the following exampleA man sustained a tear of the adductor muscles of the

left thigh whilst out hunting. He was treated by electrical

and other means, but in spite of massage, electrical andother forms of treatment he had arrived at a conditionwhere any attempt to sit on a horse when jumping gaverise to such pain that for the last two years he had beendebarred from the enjoyment of this sport. On examina-tion, there was induration of the adductor muscles andtenderness at the pelvic attachment. At the same timeabduction of the thigh was slightly defective as well asexternal rotation. On the assumption that this conditionwas due to a matting of the muscular fibres, and possiblythe presence of some adhesions in the tendon sheath ofthe adductor longus, I suggested stretching and kneadingof the parts. Under aniesthesia I manipulated in themanner I will shortly describe. This was followed by somemassage and some graduated exercises. At the end of tendays he was able to hunt free of pain, and continued to doso the whole of last season. He played polo all last summer,and has been hunting this season up to date in completecomfort.A lady out hunting last year fell and severely wrenched

the right lumbar region. Twelve months later she was stillunable to ride without pain, whilst any sudden jerk causedby a pulling horse caused intense pain. On examination,considerable induration in the right lumbar region. Lateralrocking, swaying of the trunk was painful and limited whentrying to lean towards the left. Pain was elicited by raisingthe arm and attempting to lean over towards the left asif a portion of the latissimus dorsi was involved in thelesion. A radiograph proving negative, I stretched thesemuscles under an anaisthetic, and, as usual, followed this bya few days massage and some graduated exercises. Threemonths later I received a letter to state that she had beenhunting up to date and " my back is now quite sound."

Now out of these examples in the first casementioned-namely, the shoulder-most peoplewould agree that there was necessity for breakingdown the adhesions, but few realise or appreciatethat the manipulation should be done methodicallywith the definite routine which I propose todemonstrate. In no case where those movementsare correctly carried out should there be more thantransitory pain, and no effusion or inflammation ofthe joint ever follow. Unfortunately the absence of astudied technique is often the cause of trouble follow-ing haphazard attempts at so-called bonesetting.The remaining cases I shall demonstrate illus-

trate my contention that our profession are apt tooverlook the value of manipulation. In the case ofthe hand, practically all movements were normaland pain only elicited by certain actions whichmerely prevented the patient indulging in boxing.Incapacity, however, still existed in spite of receiv-ing the whole gamut of treatments to be found inmassage and electro-therapeutic departments, andit was not till some adhesions were broken down bybonesetting methods that recovery took place,whilst in the purely muscular types the amount oflimitation of movement was very small and painonly brought on when strain was added to theattempted movement, such as occurred whenhunting.Some 20 years' experience in this line of work

convinces me that there is still something to begleaned from the procedure of the modern Huttonsin spite of our increased knowledge of the subject,and I counsel my profession to bear in mind to-daythe advice given by Sir James Paget many, manyyears ago, " To copy what is good in the practiceof bonesetters."

115MANIPULATIVE SURGERY OR BONESETTING.

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