Hugh Owen Thomas,and his condemning of bonesetting—“The lady doth protest too much,methinks”: A reexamination

British bonesetting in the 19th century

In 1871, the London physician Wharton Hood, who studied and practiced with the famous bonesetter Richard Hutton (1801–1871) described bonesetting as the art of overcoming, by sudden flexion and extension, any impediments to the free motion of joints that may be left behind after the subsidence of the early symptoms of disease or injury. Hood was describing forcible manipulation. ⁸ Bonesetters were empirical practitioners of joint manipulation, often with the opposition of the medical profession. The common phrase that they used to describe this treatment was that a bone was out of place, and manipulation was used to put it back in. They practiced this art in secret and passed their skills on to their sons, daughters, or other family members. They had no professional medical training; therefore, the medical profession referred to them as unqualified practitioners. ⁹

McMurray correctly points out that unlike the curriculum for the training of a surgeon, there was no line of instruction for the bonesetter, and each acted according to his belief, or because on occasion relief had been gained by some application or alteration of the position of an injured or diseased joint. He also points out that while many of the bonesetters were simply manipulators, some used massage alone, others applied poultices. ¹⁰

Leyson has reviewed bonesetting in Britain and states that some bonesetters were descendants of long family traditions of bonesetters, listing the Huttons of Westmorland, the Mathews of the Midlands, the Taylors of Witworth and the Thomas family of Anglesey. HOT came from the last family group (Figure 1). ¹¹

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Figure 1.

The reducing of a recent dislocation. Hugh Owen Thomas, third from left. Robert Jones, fourth from left. From Contributions to Surgery and Medicine. Fractures, Dislocations, Diseases and Deformities of the Bones of the Trunk and Upper Extremities (1887).

The bonesetters of Anglesey

The origins of the Thomas family date back to the shipwrecked lad that the DNA research project was so interested in. This lad was adopted by a family in Maes which gave him his name, Evan Thomas (1735–1814). He was reputed to be a man of commanding character, a good Christian, and a public benefactor. His son was called Richard, but in the fashion of the Welsh custom of adopting his father’s Christian name, he was called Richard Evans (1771–1851) of Cilmaenan. His son, Evan Thomas was born in Cilmaenan in 1804. It was this Evan Thomas (1804–1884) who was the father of HOT. This family of bonesetters were farmers and practiced the art of bonesetting when needed by the local community. HOT's father Evan Thomas was the first to practice bonesetting on a professional level in Anglesey, and in 1830 moved to Liverpool to practice as a professional bonesetter, where he was very successful. ⁵

HOT practiced with his father Evan and would have learned the art of bonesetting first hand. To understand what he did learn from his father, we must study how Evan Thomas practiced.

Evan Thomas techniques of bonesetting and manipulation

Robert Jones worked with his uncle HOT for several years. Jones stated that Evan Thomas was not the type of bonesetter such as Hutton was, whose practice has been minutely described to us by Wharton Hood and consisted almost entirely in breaking down adhesions under the pretence of reducing dislocations. Evan Thomas was conservative and never attempted to bring about motion by forcible manipulation. His cases consisted largely of recent accidents, such as fractures and dislocations, and of chronic diseases of joint and bone. HOT told Jones that his father was very skillful in reducing dislocations and rarely used an anesthetic. He treated sprained and painful joints by a moderate degree of rest by applying successive layers of pitch plaster which assumed the rigidity of cardboard. He used pulleys to reduce fractures, which he treated when length and asymmetry were restored, by well-padded wooden splints. He used slow and steady traction to treat dislocations. ² From this description we see that Evan Thomas was not an aggressive manipulator and did not use forcible manipulation. In reviewing the four malpractice court cases of Evan Thomas we find that he also applied poultices, but no forcible manipulation. ^{12 –15}

HOT techniques of bonesetting and manipulation

There is no question of the high quality of Thomas's skills in setting broken and dislocated bones and joints. Working in the neighborhood of the Liverpool docks and slums, he would see many such trauma cases, and he wrote several books of his experience and his methods of treatment. However, the fact that Thomas used techniques evolved from his father, who did not use forcible manipulation makes one question whether Thomas actually was qualified in giving an expert opinion in forcible manipulative techniques which he was so opposed to. Could his father Evan Thomas have used some forcible techniques not recorded, and HOT in turn learned these? The evidence is to the contrary. We have the statement of Jones describing Evan Thomas's nonforcible manipulations. The court cases of Evan Thomas describe no forcible manipulative techniques. HOT himself described the various types of bonesetters and their techniques, and specifically describes his father as using pitch plasters but no forcible manipulative techniques.

Apparently, Thomas did not know these treatments as well as he assumed. The flour cure he attributes to Grosvenor refers to the hair powder that Grosvenor's female rubbers used during friction massage, to prevent skin irritation. HOT fails to add that Grosvenor used forcible manipulative techniques, after friction was done. Grosvenor also identifies Taylor as utilizing similar manipulative methods as he used. HOT describes Taylor as using issue peas, a form of counter irritation but also fails to add that Taylor used manipulative techniques. ¹⁷

HOT did use some forcible manipulations of joints, for displaced knee cartilage, subluxation of the radius, and use of the Thomas wrench for clubfoot. It is ironic that a device that Thomas invented, the Thomas wrench, a modified monkey wrench, uses very forcible manipulation of the foot, more forcible that one can perform with the bare hands. Thomas was so opposed to other forms of forcible manipulation, yet used this form of foot manipulation with his wrench quite freely.

HOT stated that after studying bonesetting he came to the conclusion that there was nothing of value in it. McMurray questions if we can accept Thomas's statement at its face value, as Thomas did learn from his father the value of conservative methods of treating diseased joints. The more important question is, can we accept Thomas's total condemnation of bonesetting, by unqualified and qualified practitioners, both for inflamed and noninflamed joints?

Reasons for HOT's condemning of bonesetting

Other writers have questioned his antagonism to bonesetting. Thomas wrote that, strangely, HOT had nothing good to say of bonesetters. He found this to be surprising from a man of bonesetting ancestry, who probably knew more about bonesetters than anyone else in the country. Thomas found that why HOT should go to such lengths to denounce bonesetting remains a mystery. ¹⁸

Why the antagonism to bonesetting? There are different opinions on this.

(1) His theory of uninterrupted rest: HOT was a firm believer and follower of the principles of prolonged and uninterrupted rest, promoted by his precursors John Hunter and John Hilton.

During late years, however, in consequence of a glut of theories and methods academical, all of which on trial only giving results with practical defects, surgeons who have explored other fields have as the result of their search, advocated the treatment of articular defects by a method of adventure- bone-setting. Those who have introduced this phase of practice, seem to have overlooked the fact that bone-setting is only the past treatment of anchylosis as advocated and practiced by well known qualified specialists. All qualified and unqualified practitioners of this class practice certain flexions, extensions, twists, jerks and pushes, with passive motions and other details, which they evidently intend as giving proper dignity and importance to the proceedings; the treatment, however, which the sufferer is most in need of he seldom meets with-no motion. ¹⁹

However, he complimented his father's skills in his writings; so, his disagreements and eventual departure from his father's practice would not seem to be the cause for his condemning of bonesetting.

He also went further to condemn bonesetting by qualified and unqualified practitioners alike.

(3) Treatment of tuberculous joints: His nephew Robert Jones worked with HOT (Figure 2) and wrote that Thomas would see the results of tuberculous joints that had been manipulated and harmed. Jones wrote that it was often said of HOT that he had an unreasonable objection to moving joints, and the breaking down of adhesions was anathema to him. This he felt was because Thomas's experience of bonesetters was based on their procedures over 40 years ago, when not a week passed that he came in contact with tuberculous joints which had been forcibly moved, sometimes with tragic results.

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Figure 2.

The initial manipulation when fixing a clavicle. Hugh Owen Thomas, second from left. Robert Jones, fourth from left. From Contributions to Surgery and Medicine. Fractures, Dislocations, Diseases and Deformities of the Bones of the Trunk and Upper Extremities (1887).

Le Vay states that HOT was unfair in the bonesetting argument as he was referring to cases of tuberculous joints. However, when reading HOT's works, this was not his argument at the time.

He claimed that there was no benefit to bonesetting, and in cases that he thought that he helped he later concluded that he had not. In 1878, HOT wrote that this critical opinion of bonesetting refers only to the treatment of inflamed joints by unqualified professors, naming James Paget, and that some of them may have skillfully treated other lesions he was not prepared to deny.

Years later, his writings became even more critical of bonesetting, and not only with cases of tuberculosis or inflammatory joints. Thomas wrote that he had been fooled with his past successes with bonesetting and that no good could be achieved from this practice, whether performed by qualified or unqualified practitioners. This explanation may not be totally acceptable. Other qualified practitioners, such as Marsh, Hood, Paget, and Barwell, were quite aware of the dangers of manipulating inflamed and tuberculous joints. Their promotion of bonesetting procedures was for the cases that they felt would benefit, such as adhesions, ankylosis, and sprains, and not for tuberculous joints. All of these practitioners point out in their writings that bonesetters could select improper cases to treat with harmful results. Thomas's views were that bonesetting procedures, whether from qualified or unqualified practitioners, were useless and even harmful, not only in tuberculous joints, but in all joint problems. This goes against Thomas's own early experience in practice.

Thomas also appeared to give the impression that he felt that he was the only one qualified enough to give an accurate opinion on bonesetting, as he was trained as a qualified physician, and also learned from the unqualified bonesetter, his father. However, one of the very physicians whom he was critical of, Wharton Hood, also was a qualified physician, and also learned from an unqualified bonesetter, Hutton. The others he criticized, Brodhurst and Marsh, were qualified physicians who practiced manipulative techniques, and from reviewing their writings, they appeared quite successful at it. This did not seem to matter to Thomas as he proceeded to review their writings, and systematically discredit anything written on bonesetting.

Critical of Wharton Hood and Hutton, he wrote:

This is a baffling and untrue statement from Thomas. The evidence was not second hand, as Thomas claimed. Hood had studied and observed the bonesetter Richard Hutton treat his patients for 2 years, and had become proficient in bonesetting himself, and had also treated Hutton's patients when Hutton was ill and unable to treat them. Hood's published book on bonesetting was the first book to document the bonesetter's techniques and was reviewed and well received by various medical journals of the time. ^{21 –25} Thomas is the only one who is harshly critical of the book. As this author has practiced forcible manipulative techniques for many years, I am in a position to give an opinion, and that is that Hood’s book gives valuable information on bonesetting techniques.

HOT's denouncing of bonesetting makes one think of the Shakespearean idiom, “The lady doth protest too much, methinks.”

In referring to Hood’s book, Thomas continues with,

Not only did Hood praise Hutton the bonesetter, Marsh also did, as well as the Lancet and British Medical Journal’s obituary of Hutton. ^26,27 It is ironic that years later when Hood published his second book on the treatment of injuries, he states that the bonesetter Hutton was seldom consulted for recent injuries, and when he was, he prescribed rest, ice and evaporating lotions. The treatment of rest, which Thomas so constantly recommended, was being used by the bonesetter Hutton that Thomas so criticized. ²⁸

The nephew of Thomas, Robert Jones, was to continue promoting Thomas's work, getting the medical departments of the British armed forces to utilize the Thomas splint, which was credited with saving the lives of many injured soldiers. He truly felt that Thomas’ work was ahead of its time, and it was Jones’ congenial and persuasive personality that allowed Thomas’ principles to flourish. Otherwise, Thomas's principles would have not been adopted by the orthopedic establishment at the time that they did. However, Jones had a more positive view than his uncle had on manipulation. Jones had studied the works of Hood, Moulin, and Romer, who promoted forcible manipulation. Romer had worked with Wharton Hood for 5 years. Romer states in his book on bonesetting, that, other than a few variations, the techniques would be the same or similar to Hood. Jones repeatedly wrote and promoted the benefits of forcible manipulation, and describes many beneficial forcible manipulative techniques.

Jones did give credit to the benefits of bonesetters, and stated that when a stiff joint, which had been treated for months by various surgeons and practitioners without effect, rapidly regains its mobility and function at the hands of an irregular practitioner, the medical practitioner should be self-critical, and should ask why they missed such an opportunity. He also pointed out that the problem is not resolved by pointing out the mistakes made by the unqualified, and that the question at issue is their success.

HOT gives no explanation on why his views changed from initially finding improvement with his bonesetting treatments to later claiming that these very same patients he first treated showed no lasting benefit from his bonesetting techniques.

HOT must have known that he was being overly critical of bonesetting and that his views would be questioned. He wrote,

He felt that it was imperative that the question should have been fully debated.

All this criticism for naught

In spite of all the criticism that HOT leveled at these practitioners, they were all silent, and gave no responses or defense. Le Vay states that Thomas's angry polemics were on paper only, a quarrel in absentia, and that his personal relations with his colleagues were always courteous. One wonders if they were even aware of the criticism. This may be due to the small audience that Thomas had for his writings. In 1913, Jones wrote that the present generation of surgeons in Liverpool had no idea of the amount of interesting and original material that Thomas wrote, and this was largely due to the peculiar and almost secretive way in which his works were printed and published. The printer had a small shop on Gill Street, and very few books were sold and the remainder occupied a large room in Thomas's home. ¹⁹ Also, Thomas seldom attended any of the medical meetings or conferences. Thus, as there was no response of defense from those he criticized, Thomas's criticisms may not have even reached these individuals.

Conclusion

HOT successfully used bonesetting for fractures and dislocations but was very much opposed to forcible manipulations or ‘bonesetting’ for other joint disorders. When treating inflamed or tuberculous joints, one can understand his caution, as this could produce worsening or even disastrous results. However, HOT became dogmatic in his views on bonesetting to the point that he criticized and condemned all bonesetting, whether from qualified or unqualified practitioners, even criticizing his own past use of bonesetting. The various reasons given range from his impression that the problems were not cured totally, to his strict rules of uninterrupted rest, to treating tuberculous joints. He was severely critical of other practitioners’ writings on the subject, in spite of the fact that these writings were well received by the medical population.

I will conclude with the famous statement made by Paget ²⁹ on the subject, Learn then, to imitate what is good, and avoid what is bad in the practice of bone-setters.