DISCOVERY 



119 



merits of the lower limb, and the contrast presented 

 in these respects by the upper limb, which is not a 

 supporting but a prehensile organ, has led to differen- 

 tiation of the treatment meted out to the two limbs 

 for similar injuries, or diseases. Mobility in an elbow 

 is eminently desirable, whereas a fixed straight knee 

 is of far more service than an uncertain movable one ; 

 indeed, an arm is rendered useless if the elbow becomes 

 fixed in any position but a right angle (or near to it), 

 and e\'en then it is a poor imitation of the intact arm. 

 Procedures (arthroplasty) have now been devised to 

 restore mobility to a fixed joint where this is thought 

 to be desirable ; a new joint is fashioned and a 

 flap of the soft tissues, muscle or fascia, is interposed 

 to prevent reunion of the separated bones. Again, 

 when required, anchylosis (fixation) of a joint may 

 easily be brought about by the removal of a slice from 

 the end of each bone, which bones are then steadied 

 against one another till they have united ; and in the 

 lower limb such a procedure saves the child with 

 paralysis from the need for wearing heavy and 

 expensiv'e apparatus to steady the joints. 



A wide choice of operations, then, is now available 

 for the treatment of joint and bone troubles ; for the 

 linal selection from these special experience in these 

 conditions is necessary if the maximum of usefulness 

 in the limb is to be ultimately attained. 



Fractures have recently been tending to fall within 

 the special province of the orthopadic surgeon. A 

 great variety of principles has in the past been adopted 

 in their treatment. 



At one time they were kept severely immobilised 

 till union was assured. Later, Champonniere advo- 

 cated movement and massage to obviate the stiffness 

 which invariably followed from want of use of muscles 

 and joints. But except where this treatment was 

 carried out by his own specially trained masseuses, 

 it was unsuccessful, because satisfactory union of the 

 fragments was so difficult to attain. It is now recog- 

 nised that close and correct apposition of the fragments 

 does take precedence over all other considerations, 

 but that at the earUest feasible moment, slight move- 

 ments should be commenced — and the earlier the 

 better ; but no success in the preservation of healthy 

 muscles and joints compensates for such a mechanical 

 disability as a badly-set ankle. 



Owen Thomas, the founder of the Liverpool School 

 of Orthopaedic Surgery, made a great advance when 

 he devised the splints which bear his name for knee, 

 hip, and arm, consisting of wire frames to steady 

 the limb while yet permitting of an unimpeded circu- 

 lation. Splints fashioned on this principle arc to-day 

 in widespread use ; it will be seen what free access 

 there is to the injured limb for the provision of. 

 massage and other active treatment. 



The methods of Thomas were those of one who had 

 discovered by iSSo the faults of the surgeons of his 

 time, who gave insufficient rest to the limb ; and one, 

 further, who had perceived the fallacy of " manipula- 

 tions " as practised by eminent bone-setters, and 

 indeed previously by himself and his own father. 

 These splints are of the greatest use for the control 

 of the more awkward fractures, and with recent 

 improvements are extensively employed. 



Thomas's splints do not, however, provide for active 

 movement of the injured part ; and nowadays it is 

 possible by various devices to provide suitable 

 movements for injuries (including fractures) at a 

 very early date. Especially is this necessary for a 

 good result after an injury close to or involving a 

 joint. Temporary support can be provided in a variety 

 of ways until there is a minimal consolidation of the 

 repairing tissue (known as callus). This may be by 

 means of sandbags ; or merely by strapping ; or a 

 plaster of Paris encasement may be prepared to fit, 

 e.g., the leg for ankle fracture, with a hinge behind so 

 that one side of the calf muscles may receive attention 

 while the other side is supported by the splint. A 

 recent method of preserving the health of neighbouring 

 muscles in such cases as these is described later ; the 

 method, that of " graduated contractions," can be 

 applied to the injured leg, even while this plaster 

 splint is still being worn. 



We find thus a germ of truth in the teachings of 

 both Champonniere and Thomas ; one of them 

 guarded against subsequent stiffness due to neglect 

 of muscles and joints ; the other ensured sound if slow 

 bone repair. 



A radical method of assisting bone repair, mechanical 

 fixation with plates and screws, or with wire, 

 was advocated and practised originally by Sir 

 Arbuthnot Lane. Only possible with the advent of 

 Listerian surgery, it is even now limited to healthy 

 limbs ; soiled wounds necessitate complete healing 

 before such an operation can be considered, owing to 

 the extreme susceptibility of living bone tissue to the 

 poisons produced by bacteria. This embedding of 

 metal is inferior to one of the recent developments of 

 bone-grafting : the employment of bone inlays which 

 unite the two fragments. As compared with old- 

 fashioned methods of treating bone-fractures, however, 

 it was reported in 1912 by a commission of the British 

 Medical Association that, for adults. Lane's method 

 of fixation of the fragments was the most successful, 

 but that in children better results were attained either 

 by immobihsation or by mobilisation with massage. 

 A considerable number of cases was investigated : 

 2,596 treated by immobihsation ; but only 147 treated 

 by operation were at that time available. The growing 

 bones of children are liable to severe injury under 



