Orthopedics

“ The great advance which operative surgery has made within the last forty years, and the success which has followed the removal of the head of the humerus, the whole of the elbow, the ankle, and even the knee-joint, render it imperative on surgeons of ability to endeavor to save life without the performance of so formidable an operation as that of the removal of the whole limb, more particularly when the health is good and the parts sound, with the exception of those immediately injured. ”

“ When, however, we reflect that in the living body, in cases where amputation at the shoulder-joint is required at all, the severity of the accident, or the urgency of the disease, will, in general, leave no room for selection, we shall see how utterly valueless is any knowledge of mere methods of operating, and of how much greater importance it is that we should be simply thoroughly familiar with the anatomy of the joint. ”

“ I HOPE the time is not distant when a careful study of the living model of the child and the adult, and the whole period of the development of the one into the other, will form a part of the student's ordinary course of anatomy and physiology, as such knowledge is essential to the surgeon engaged in removing and preventing deformities of the body. Orthopedic surgery as a specialty is a great evil both to the profession and the public. ”

“ There is no occasion to dissect and reflect the flap, for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place where the joint of the calcaneum with the cuboides and that between the astragalus and scaphoides ought to be opened. The surgeon will penetrate the last the most easily, particularly by taking for his guide the eminence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. ”

“ Orthopedic patients are those who have disease or disability of one or more joints or bones. The most common disease of joints is called arthritis, of which there are several kinds of varieties. The most common disability of bone during war-time is fracture. Arthritis usually prevents complete joint motion. In some instances the joint is put at rest to hasten healing. Almost all fractured bones are kept fixed by plaster casts or traction and prevented from movement during healing. ”

“ The administration of an anaesthetic, by relaxing the muscles, greatly assists the operation of reduction. The length of time that a joint has to be kept quiet after it has been restored to its normal shape depends on its form, but, as a rule, early movement is advisable. But when by the formation of the bones a joint is weak, as at the outer end of the collar-bone, and at the elbow-end of the radius, prolonged rest for the joint is necessary or dislocation may recur. ”

“ The second has to manage the limb, and on the manner in which he performs his duty much of the success and nearly all the celerity of the operation depend. While the surgeon is transfixing the anterior flap, this assistant is to support the limb in a slightly flexed position, so as to relax the muscles; the instant the flap is cut he is to extend the limb forcibly, and at the same time be careful not to abduct it in the least, but to turn the toes inward so as to bring the great trochanter well forwards on a level with the joint ”

“ When the displaced head lies against a bone, the continuous pressure produces a new osseous socket, from the margins of which osteophytic outgrowths may spring, and as the surrounding fibrous tissue becomes condensed and forms a strong capsule, a new joint results. The occurrence of these changes in the direction of a new ball-and-socket joint is largely dependent on the behaviour of the patient: a vigorous man, anxious to recover the use of the limb, will employ it with a degree of determination and indifference to pain that could not be expected in a sensitive elderly female. ”

“ Treatment.—An attempt may be made to reduce the displacement under anæsthesia, gentle traction being made in the long axis of the spine by assistants, while the surgeon attempts to mould the bones into position. No special manipulations are necessary, as the ligaments are extensively torn, and the bones are, as a rule, readily replaced. A roller-pillow is placed under the seat of fracture to allow the weight of the body above and below to exert gentle traction, and so to relieve pressure on the cord. ”

“ That the patella and articular surface of the femur are healthy. These conditions at once exclude nearly every case of disease or accident. If the joint is diseased some amputation through the thigh must be attempted; if injured, and the front of the knee is safe, it may very likely be possible to amputate below the knee. Hence this operation may be useful in cases where, for malignant disease, the whole tibia requires removal, and yet the knee-joint is sound, or for gunshot injuries, in which the tibia is splintered but the soft tissues comparatively uninjured. ”

“ In writing on surgery of the brain he records the loss of brain substance with recovery, and notes the recovery, under expectant treatment, of many patients with suspected fracture of the skull. His study of the surgical anatomy of the ribs and diaphragm as applied in opening the thorax, shows sound surgical sense. In wounds of the intestines he gives an unfavorable prognosis unless the abdomen be quickly opened and the wounds sewed up. He describes his sutures and his special needle-holder, like any modern surgeon. ”

“ The rule in surgery, to save as much of the body as possible in every amputation, was in the leg believed to be set aside by objections which militated strongly against all the{86} other operations in the leg except the one performed just below the knee. Very briefly, these were somewhat as follows:—1. Just above the ankle you have large bones with nothing to cover them except skin and tendons. 2. Higher up in the calf you have plenty of muscle, but it is all on one side, and that the wrong one ”

“ Probably his most important work is that entitled Pathological and Surgical Observations on the Diseases of the Joints, in which he attempts to trace the beginnings of disease in the different tissues that form a joint, and to give an exact value to the symptom of pain as evidence of organic disease. This volume led to the adoption by surgeons of measures of a conservative nature in the treatment of diseases of the joints, with consequent reduction in the number of amputations and the saving of many limbs and lives. ”

“ Some of the moderns manage the matter thus: Two assistants stretching the arm as aforesaid, the one holding at the armpit, and the other below at the wrist, the surgeon, standing opposite the patient, grasps the arm with the palms of both his hands near the joint, and giving orders to bind a long folded robe or broad swathe round his hands and the arm of the patient, and to pull outwards and downwards towards the hand, whilst he, following the same course, drags the parts with his hands thus secured until they pass the articulation of the joint. ”

“ This aphorism implies that not every patient with a broken knee-cap is suited for the opening of his knee-joint, or even for the subcutaneous adjustment of the broken fragments. An operative procedure which is admirably suited for one patient might result in disaster when adopted for another, and it is an important part of the surgeon’s business to know what to advise in each individual case. ”

“ When the deformity is bilateral, the patient abducts the thigh and rotates the limb outwards at the hip to disguise the deformity, and to allow the projecting knees to pass each other. He usually supinates or inverts the foot, with the object of bringing the whole length of the lateral border of the sole into contact with the ground. Flat-foot is exceptional. The boots are usually more worn along the lateral than along the medial border of the sole and heel.
No apparatus that allows of the patient walking is of any value. ”

“ The patient is placed recumbent, on a couch or on the floor, and the surgeon, sitting by his side, lodges his595 heel in the axilla, and with both hands extends the arm; after a short continuance of extension, he performs a sudden and powerful combination of both movements, and so jerks the bone into its natural position. In some recent, and in all old cases, it is necessary to apply considerable force, steadily, and for a long time, so as to tire out the muscles, and dislodge the head of the bone. ”

“ The foot must be restored and held in its normal position and measures must be adopted to quiet local irritability or inflammation, and to strengthen the muscles. The best treatment does not consist in the permanent wearing of a flat-foot support; the support should be regarded in the same light as one uses a crutch in a fracture of the leg.
As a preliminary to all treatment, the use of proper shoes must be insisted upon. A shoe should be as wide in front, as the unshod foot, when bearing the weight of the body. ”

“ If properly performed, in a tolerably healthy subject, the surgeon should not be satisfied with any results short of almost perfect restoration of motion in the joint. Flexion and extension to their full extent, with a very considerable amount of pronation and supination, are to be expected, with proper care, in a patient of average intelligence. ”

“ Before performing arthrodesis, the surgeon must decide whether the patient will be better off with a stiff joint or with a weak and movable ankle supported by apparatus. This is often a matter of social position; in the poor, an ankylosed joint is more useful and less expensive. An arthrodesis should seldom be performed at the ankle until the child has passed his eighth year, or at the knee until he has reached his twentieth year. ”

“ In the early stages of the static form attention to general health, massage and change of air, will often effect a cure. But in the more aggravated forms an apparatus is needed. This usually consists of an outside iron rod, jointed at the knee, attached above to a pelvic band and below to the heel of the boot. By the gradual tightening of padded straps passing round the limbs the bones can be drawn by degrees into a more natural position. But if the patient has reached such an age that the deformity is fixed, then the only remedy is that of operation. ”

“ When the bone has reached the edge of the acetabulum, a second assistant slips the doubled jack-towel over his shoulders, and by raising his body, lifts the femur away from the brim of the acetabulum, while the surgeon, grasping the foot and knee, makes a few movements of rotation backwards and forwards to ease the head into its socket. ”

“ This operation is done without the patient feeling it; it gives rise to no irritation, inconvenience, or danger; Nature is not interfered with in her operations; and in due time the parts which remain are separated and fall off, leaving a stump more or less good, but which will always bear the application of a wooden leg; and thus the knee-joint is saved—a saving of no small importance to the patient, and a new precept in surgery. ”

“ The surgeon being ready, an assistant draws on the pulley cord, getting gradual extension of the limb as required by the surgeon, who, keeping his hands on the hip and great trochanter, watches the progress of the head of the bone towards the acetabulum. ”

“ On the other hand, the surgeon knows only too well that the muscles of a stiffened or sprained joint, or of one that has been confined with bandages, become wasted, as do likewise muscles the nerves of which have been cut or that have been otherwise disabled. ”

“ The patient should be encouraged to move the joint from the first, beginning with the movements that put least strain upon the damaged ligaments, and gradually increasing the range. In the course of a few days he is encouraged to walk or cycle, or otherwise to use the joint without subjecting it to strain, or to a repetition of the movement that caused the accident. Alternate hot and cold douching, or hot-air baths, followed by massage, are also useful. Complete rest and prolonged immobilisation are to be condemned. ”

“ The posterior surface of the joint being exposed, the surgeon, with a strong straight bistoury, makes a transverse incision into the joint just above the olecranon. It should begin just far enough outside of the internal condyle to avoid the ulnar nerve, which the surgeon should protect by the forefinger of his left hand, and should extend transversely across to the outer condyle. ”

“ Like amputation at the shoulder, amputation at the hip has given rise to very many various methods of performance. Under the heads of single flap, double flap, oval, circular, and mixed flap and circular, at least twenty distinct methods have been put on record, and, including modifications, there are thirty-seven or thirty-eight different surgeons who have each their own plan of operation. ”

“ A surgeon may be necessary even in a case of dislocated thumb or finger, but bones out of joint are so much more easily set at first, that it is best to attempt to set them then, and the same may be said of some larger bones. ”

“ When the operation proves successful, the beneficial effect on the general health is as remarkable and rapid as after removal of the hectic cause by amputation; the pulse falls and grows firmer, diarrhœa and sweating cease, the hectic flush leave the cheek; in short, the constitution makes a complete and successful rally. It is had recourse to in order to take away disease in the following situations,—in the cancellated articulating extremity of a long bone, in part or the whole of a short bone, and in part or the whole of long bones. ”