grown its etymological meaning. It now deals with the adult as
well as the child. Until comparatively recently it embraced only
congenital deformities of children, lateral curvature, acquired de-
formities of the feet, deformities due to rickets and infantile
paralysis, and to certain types of ankylosis. More recently it has
included tubercular and other infective diseases of joints, both
in children and in adults. The experiences of the World War of
1914-8 considerably broadened its definition, and revealed the
fact that the teaching of orthopaedic surgery had been very de-
ficient more particularly in the treatment of injuries of the ex-
tremities. Visits to command depots and certain military hospi-
tals convinced the British authorities of the necessity of starting
a series of large hospitals all over the British Isles; these were
first called " orthopaedic centres " and later " special military
surgical centres." They were situated in London, Liverpool,
Manchester, Leeds, Newcastle, Oxford, Reading, Cardiff, Bristol,
Bath, Edinburgh, Glasgow, Aberdeen, Dublin and Belfast.
These hospitals were staffed by men trained in orthopaedic sur-
gery, by general surgeons and neurologists, and were equipped
with every modern facility for the practice of reconstructive sur-
gery, including physiotherapy departments, gymnasia and voca-
tional curative workshops. The group of cases treated at the
orthopaedic centres consisted of: fractures (recent, malunited
and ununited) ; paralyses due to injury of the peripheral nerves;
paralyses due to injuries of the central nervous system; diseases,
derangements and disabilities of joints, including the spine;
deformities due to the contractions of scars and to injuries of
muscles; functional diseases requiring reeducation. Later, limb-
fitting centres were attached to several of these hospitals.
The wisdom of creating these centres was soon apparent. Derelicts poured in from all parts of the country, and soldiers who had been discharged with deformity were readmitted for treatment. The value of segregating cases in masses under sur- geons specially trained for the work was clearly demonstrated. The experiment started in Liverpool with 250 beds, and the expansion was so rapid that in less than 12 months 21,000 beds were under orthopaedic control.
After the war there was a movement in all parts of Great Brit- ain to improve the training in orthopaedic surgery, and to in- crease in scope and number the special departments attached to universities and medical schools, and to simplify and make more thorough the treatment of fractures. The fact that 50% of the wounded in the war of 1914-8 received injuries resulting in im- pairment of locomotor function and usefulness of limbs, brought the importance of orthopaedic principles and methods of treat- ment into great prominence.
Orthopaedic surgery may now be said to include: (a) Congen- ital and acquired deformities of the spine and extremities; (6) infantile paralysis after the acute stage; (c) the deformities of adult paralysis; (d) stiff and ankylosed joints; (e) torticollis (" wry -neck ");(/) diseases of joints and disabilities, such as rupture of crucial ligaments, injuries to semilunar cartilage, snapping hip, slipping patellae, and those conditions which are included under the aggressive title of " bonesetting."
The war enabled surgeons to formulate conclusions based on the observation of large groups of cases, and to obtain information likely to be of great value when dealing with industrial cases. The suture of divided peripheral nerves will serve as an example. In pre-war days, an experienced surgeon in the course of a life-time rarely saw more than 20 cases. During the war many surgeons sutured over 500 nerves, and the successful issue was due largely to the experiences gained by orthopaedic surgeons in the treatment of the paralysis of infants. From the nature of the injuries and the prolonged sup- puration that followed, operation often had to be postponed for many months, and only after the removal of all cicatricial tissue was it safe to operate owing to what is called latent sepsis. Germs which remained quiescent, when disturbed by the knife assumed activity often of a very virulent type. In other cases, muscle had to be freed and developed, and diseased areas of bone drastically extir- pated before a nerve could be sutured. These operations required great delicacy and judgment. It was found by experience that in most cases it was possible to bring the nerve-ends together even after the destruction of a considerable area. This was sometimes effected by posturing the joints in order to lessen tension. In other cases the nerves were transposed from their bed and made to take a shorter course. In other instances the operation was done in
stages in order gradually to stretch the nerve. Many methods which were formerly used to protect the injured nerve from injury during healing by adhesions were discarded in favour of surrounding the sutured ends by living tissue. Nerve grafting i.e. utilizing a por- tion of a cutaneous nerve to bridge the gap in a motor nerve, proved a failure. Equally abortive were all attempts at grafting foreign material, nerve anastomosis, and the turning down of flaps. The great lesson learnt was that end-to-end suture is the only method to adopt in the immediate future.
A very remarkable adaptation of orthopaedic experience to injuries of the war was the transplantation of tendons in conditions of ir- reparable injury to the nerve. This was most useful in the cases where the musculospiral nerve was so destroyed as to render suture impossible. As a result of this injury the function of the hand was greatly impaired. The musculospiral nerve governs the motion of all the muscles which extend the wrist and the fingers. Destruction of the nerve paralysed all the muscles, and the victim, if he wished to extend the wrist and fingers, had to do it by using the other hand.
Orthopaedic surgeons nad been accustomed for many years to utilize any spare active muscles, in cases of infantile paralysis, in order to take the place and assume the action of the muscles which were paralysed. For instance, a muscle group whose function was to evert the foot (peronei), if found paralysed, would be replaced by one of the invertors of the foot (tibialis anticus). This muscle would be dissected from its insertion halfway to its origin, and taken from the inner side of the foot and planted into the bone on the outer side. The child would then be trained to use the muscle so that when it acted it would assume the function of the paralysed muscle. This principle was adopted on a very large scale in all the orthopaedic centres to supply a remedy for the paralysed extensors of the wrist and hand. Certain muscles would be taken from the front of the forearm, one of which would be attached to the paralysed thumb, another to the extensors of the wrist, and another to the various extensors of the fingers. In this way, some hundreds of cases ex- perienced a complete restoration of the function of the hand.
The influence of physiology or psychology as it affects the trans- planted muscle deserves comment. It is very difficult to explain now a muscle which has always acted as an inverter should respond to a command to evert. After a little education, however, the will becomes the master of the situation, and the transplanted tendons display an admirable functional adaptation. A few soldiers suffered from the destruction of the obdurator nerve with a resulting paraly- sis of the quadriceps a muscle whose function it is to extend the leg. In order to regain that function, two of the muscles from behind the knee are brought to the front of the thigh and fastened into the knee- cap to replace the quadriceps. In this way again, muscles, which normally bend the knee, take up a new action and straighten it.
Another orthopaedic principle derived from the treatment of in- fantile paralysis and utilized for war injuries is known as tendon fixa- tion. An example can be given by an irreparable injury of the sciatic nerve. All the muscles below the knee are paralysed. There are therefore none that can be transplanted, and the foot remains flail. In such cases, the paralysed tendons are utilized to sling the foot to the bones of the lower leg. Certain tendons in front of the foot are cut below their origin and fixed in a tunnel bored into the bone, while the tendo Achillis at the back is treated in a similar manner. The foot is thus slung into a good carrying position, and cumbersome braces discarded.
The history of damaged joints is hardly less interesting. The wounds of the war were often so extensive that joints were not only destroyed but large pieces of bone were carried away, so that the arm or leg dangled in flail fashion. As an example, the case of the shoulder will serve to illustrate our procedure in dealing with other joints. The arm lies limp at the side there is no power to lift, later- ally deflect or rotate it. Experience in treating infantile paralysis in children has supplied an idea by which the limb can be made use- ful. The procedure is known as arthrodesis. Although the arm cannot move, the shoulder-blade can. The surgeon attaches the bone of the arm (humerus) to the shoulder-blade and allows both bones to become united. The arm is fixed in the most useful position in relation to the shoulder-blade; the muscles which hitherto only moved the shoulder-blade will now move the arm also. By this de- vice the patient is able to feed himself, lift his arm from his side, put his hand in his pocket and perform many useful functions.
Again, the orthopaedic surgeon may have to deal with a stiff or ankylosed joint. In the case of the hip, shoulder or elbow, there are at his command methods to mobilize them by forming new joints. The hip-joint will serve as an example. The destroyed joint is cut down upon, the socket reconstructed, the head of the thigh-bone reshaped, and soft muscular and fascial tissue utilized as a buffer between the bones in order to imitate nature. The war has brought about the perfection of such methods, enabling flail joints to be stiff- ened, and mobilizing those which are ankylosed.;
Bone grafting has been much simplified, and has been largely used in the surgery of the jaws and in ununited fractures of every kind. Gaps of four and five inches have been remedied by this means, and certain technical details have been perfected which have given the transplanted bone greater viability. It has been most useful in frac- tures below the knee and in the forearm. Cases are on record where the graft has been broken and has united again, as in the case of a
