simple fracture. Grafts have also lived in the presence of suppura- tion. The shin-bone (tibia) is the favourite quarry from which the grafted bone is taken. A point of great interest is that the grafted bone often develops until it assumes the thickness and contour of the bone which it supplants.
No branch of surgery has been so much advanced by the war as fractures. Before the war, the treatment of fractures in England was little less than a reproach. Fractures of the femur, unless oper- ated upon, generally displayed a shortening of about two inches. This was largely due to faulty education of the student, and the early evacuation of fractures from hospital wards. There was usually no considered after-treatment. Few surgeons knew the uses of the Thomas splint which, for simplicity and efficacy, surpassed any ap- pliance in any of the armies. There was no effort in the first stage of the war to standardize this splint or to segregate fractures. This resulted in a great mortality, and filled the orthopaedic centres with appalling deformities. Fractures of the femur will serve as an exam- ple. In the early phases of the war the mortality from these frac- tures was 80%. Later, when fractures were segregated at the base and the Thomas splint applied in the firing line, this mortality was reduced to 20%. The standardization of the Thomas splint, the education of men in its use, and its application on the field of battle, secured for the fracture immobilization and simplified treatment; it minimized shock, and it prevented the perforation of vessels by securing the alignment of the broken ends. Its use had to be under- stood from the field to the base hospitals, for continuity of treatment was imperative. At the base hospital it might be necessary to apply modifications in more leisurely fashion. At a later date these frac- tures were admitted directly into orthopaedic centres, and, as a result of investigation, it was found that out of several hundreds of cases the average shortening did not exceed half an inch. These results in the British army were incomparably better than those in any of the other armies. The important lessons learnt from these expe- riences are: The necessity of better training of students, the stand- ardization of the most efficient splints, the segregation of cases under men versed in mechanical principles, and the securing of efficient orthopaedic after-care in order to obtain function.
Further experiences gained in orthopaedic hospitals included the radical treatment of the chronic sinuses leading to diseased bone. Instead of simple procedures to remove dead bone, a very extensive operation was generally performed. All unsound bone, not merely dead bone, was removed, and the edges of the large cavities bevelled down in order that the soft tissues might fill the cavity. This thorough treatment often reduced healing to weeks instead of years. Malunited fractures again formed a large group in the orthopaedic centres. Surgery has now sufficiently advanced that, under favour- able conditions, deformity should not occur. The orthopaedic teach- ing emphasizes the fact that good function is its end and any opera- tion performed should have this as its aim. Aesthetic and other objects are of minor importance. Correct alignment is the most important factor governing success. Unless this be secured erroneous deflection of body weight upon the joints above and below the fracture results. A meticulous end-to-end union with a lateral deviation is not so suc- cessful as even a little over-riding accompanied by a good alignment. Many hundreds of fractures which violated this axiom were re- broken and the limb reconstructed. Surgeons were often able to lengthen the limb by five inches or more.
Orthopaedic surgery emphasizes the after-treatment of all these chronic cases. All joints have to be kept mobile, muscle-wasting hindered, reeducation courses attended, and all the modern advan- tages of physiotherapy utilized.
Artificial Limbs. In the early stage of the war it was found very difficult to keep up any adequate supply of artificial limbs. All the English limb-making firms suffered from the fact that their staffs were at the front. The authorities were so firm that it was impossible to recall them, although the shortage of limbs had become appalling. An exhibition, to which all limb-makers were invited, was held at Roehampton House, and artificial limbs were sent by both English and foreign makers. The Amer- icans, however, were alone prepared to start work with full staffs, so that the bulk of limbs supplied were of the American pattern, and were made in ever-increasing numbers on the hospital grounds. They were strong and very reliable, and, at that time, they rep- resented all that was best and up-to-date. Later, in 1919, a parliamentary committee was constituted in England to study the question of standardizing limbs in order to lessen the cost and expedite production. After much deliberation they fixed upon certain standardized patterns suited to the more frequent sites of amputation. They were based upon the most reliable features of both the American and English types. They were manufac- tured in wood and leather with steel joints, and, although on the whole satisfactory, complaints were often made that they were too heavy. In consequence, a standardized leg has been in course of being perfected, which combines lightness with durability,
and the weight of which will not be more than four or five pounds. There can be no doubt that artificial limbs for high-up amputa- tions had previously been far too heavy, and the introduction of a light metal or wooden splint will supply a reasonable demand.
It can be said without entering into any technical details that, as an artificial limb has to transmit the weight of the body to the ground, it should be stable, painless, and permit the patient to walk in a natural, easy manner. The weight of the body in certain cases is carried directly on to the artificial limb through the end of the stump (end-bearing). In other cases a portion only of the weight is carried through the end of the stump the rest of the weight being distributed through other anatomical points (partial end-bearing). Sometimes it is transmitted through the bony points about the joint above the amputation i.e. round the hip-joint in cases of amputa- tion through the thigh (ischial bearing). The complete end-bearing distribution of weight is the ideal condition, but can only rarely be secured. It is best exemplified in a Symes' amputation which is performed when the front part of the foot is removed and the skin over the heel forms the flap. The skin has to be thick and the end of the bone expanded, otherwise ulceration may result.
While artificial legs have on the whole given very general satisfac- tion, artificial arms have been very disappointing. The leg is com- paratively a simple proposition it merely has to bear weight and perform the act of walking. The arm, on the contrary, is expected to perform diverse and complex acts. Too many arms have been merely ornamental, and have been discarded early, only to be worn for aesthetic reasons. When the war broke out only very primitive types of arms existed. They consisted of a bucket, a hinge auto- matically locking elbow and a dummy hand, which could be taken off and replaced by a hook or a ring. Later, certain arms were in- troduced which dispjayed great inventive ingenuity. These limbs were worked by certain movements of the body assisted by the stump. In an amputation above the elbow, for instance, the forearm could be fixed and supinated and the fingers opened and closed. They were, however, not a success owing to their weight and complexity, and the movements were not those which could prove useful in daily life. Mechanical arms of various types followed, some of which have proved useful. They are included in the class known as the " worker's arm," and consist of an apparatus where the external shape of the arm is sacrificed to utility. Various tools and other mechani- cal devices are attached to the end of the arm and, with training, patients are able to do very useful work. It must be admitted, how- ever, that fully two-thirds of the men have discarded their artificial arms. Doubtless, with encouragement and better and more pro- longed training, men would obtain much more satisfaction from their artificial limbs.
Temporary limbs have been employed regularly in Great Britain for the lower limbs in order to bring the leg into action at the first available moment to exercise the muscles of the stump, to avoid the evil of crutches and to allow the shrinkage of the stump to take place an essential preliminary to the final fitting of a bucket. The bucket is usually made of plaster of Paris, moulded very accurately in order that shrinking may take place from pressure. Many excellent fibre temporary or peg legs were made by amateurs and supplied by the Red Cross Society.
The Belgians and French used temporary arms in order to keep the muscles active and the joints mobile from the time the stump healed. Schools were started in order to teach the men their possi- bilities and limitations. In England, owing to rapid evacuation, very little time was spent in training men to adapt their arms to their own special trades. This is perhaps one of the main reasons of failure.
One of the most interesting developments in connexion with am- putations has been the so-called operation of cinematization of am- putation stumps. A considerable length of muscle is preserved at the time of the amputation, and the opposing groups are separated and covered with skin. By exercise these rival groups can be trained to retract often two inches, and can thus be utilized to work an arti- ficial hand by direct volition. Experiments are being continued and the prospects are encouraging.
Deformities. The aim of the modern orthopaedic surgeon is to prevent the occurrence of deformity, and to insist upon early treatment. In the case of children there are four groups of crip- ples. They consist of (a) surgical tuberculosis; (b) rickets; (c) congenital deformities; (d) deformities due to injuries and infec- tions of bone. Rickets and surgical tuberculosis account for nearly 50% of the deformities of children, while congenital de- formities and infantile paralysis will account for the remaining cases. In the group of surgical tuberculosis are included spinal caries and diseases of the various joints. Amongst the rickety cases are found knock-knee, bow-legs, spinal deviations, flat-feet, deformities of hip, etc. Amongst the congenital group there are the various types of club-feet, wry-neck and allied affections.
Most of the deformities due to these various conditions may be altogether prevented, and the cases grouped under tuberculosis
