ORTHOPAEDICS

L’ orthopédie

Through the course of the nineteenth century the volume of medical knowledge increased and specialization in a particular field of medicine became the norm for medical doctors. One of the specialties which evolved was orthopaedics. The word orthopaedics derives from a two volume monograph by Nicolas Andry de Bois-Regard entitled L’Orthopédie ou L’Art de Prévenir et Corriger dans les Enfants les Difformités du Corps, which was first published in Paris in 1741. It was written for parents who wished to prevent and correct deformities in their children, the term ‘orthopédie’ coming from a combination of Greek words meaning right or straight child. Translated into English, it was republished in London in 1743. Over time, the term orthopaedics came to describe not only the treatment and prevention of deformities in children, but also a branch of surgery which focused more generally on disorders of the musculoskeletal system. The treatment of fractures, dislocations and joint injuries became a part of orthopaedics.

Rest versus activity

For many centuries it had been understood that when a joint was dislocated and its supporting soft tissues damaged, reduction of the bony parts was essential to recovery. Following reduction of the joint a period of convalescence was required to allow processes of healing and stabilization to take place, but during convalescence the relative value of rest and activity was not always obvious. Within the developing field of orthopaedics there were disagreements between those who emphasized the value of activity and those who emphasized the value of rest in the management of mechanical joint conditions.

Andry had encouraged moderate exercise for the promotion of health, but nineteenth century orthopaedic practitioners recognized that in acute joint conditions exercise was oftentimes painful and could result in increased inflammation. Between 1860 and 1862 John Hilton gave a series of lectures for the Royal College of Surgeons of England in which he highlighted the recuperative power of rest, arguing that rest was “the most important therapeutic agent in the cure of accidents and surgical diseases” (Hilton, 1863, p. 488). An effect of Hilton’s assessment, and the opinions of others who argued in a similar vein, was to diminish the perceived therapeutic value of movement, both through exercise and joint manipulation.

In Britain and on the European continent the contrasting teachings of individuals such as Hugh Owen Thomas, an advocate of rest, and Just Lucas-Championnière, who favoured movement, were a source of discord (Buckwalter, 1995). Even so, it is reasonable to assume that practising orthopaedic surgeons recognized that rest and movement both had a place. In the clinical setting the judgement generally came down to questions of timing and intensity. To rigorously mobilize a newly injured painful and inflamed joint made little sense, but to encourage rest in the longer term risked extending the period of disability. What was required was practical wisdom on the part of the clinician, good judgment in the context of complexity. Be that as it may, the idea of rest as a treatment became established within orthopaedics. Writing in the 1920s and reflecting on the history of orthopaedics, the surgeon Timbrell Fisher was disapproving of this fact (Fisher, 1925, pp. 3-7). As he saw it, the emphasis on rest, fear of injuring a tuberculous joint, and a reluctance to accept that any good could come of a method practised by “unqualified persons”, resulted in unwarranted neglect of manipulation in cases where it might have been helpful.

Anaesthesia

Developments in orthopaedics were paralleled by advances in the understanding of anaesthetics. Through the use of general anaesthesia joint manipulations which would otherwise have been painful for the patient were performed more comfortably by those surgeons who favoured them. Ether and chloroform were used in the reduction of dislocations and in the treatment of stiffness involving large joints such as knees and shoulders (for example see Paget, 1867). Ether and chloroform not only reduced pain, they also brought about muscular relaxation. This was of benefit to diagnosis in distinguishing muscular from other causes of joint stiffness and in treatment where in the absence of muscular resistance less force was required to mobilize the joint.

The use of general anaesthesia had advantages for practitioners of joint manipulation, some of whom came to describe themselves as ‘manipulative surgeons’, but its use was not without risk, most critically that the patient would not wake up after the operation. Had the use of anaesthetics such as ether, nitrous dioxide and chloroform been without risk it is likely that greater use would have been made of them by practitioners of joint manipulation, but as it was the risk was considerable. In 1915 William Williams Keen reflected on the early use of ether as an anaesthetic and on questions which might have haunted the minds of those pioneers who first made use of it for surgery (Keen, 1915, p.3):

“Lift the arm and it falls as if it were that of a corpse, touch the sensitive eye and the lids do not move. Cut the tender skin and it elicits no response. ‘Will he ever wake up!’ ‘May not the flickering flame of life gradually fade away for ever.’ ‘Have I not unwittingly killed this man!’”

References

Andry N. (1741). L’Orthopédie ou L’Art de Prévenir et Corriger dans les Enfants les Difformités du Corps. In two volumes. La Veuve Alix, Lambert and Durand, Paris.

Buckwalter J.A. (1995). Activity vs. rest in the treatment of bone, soft tissue and joint injuries. Iowa Orthopaedic Journal 15, 29-42.

Fisher A.G.T. (1925). Manipulative Surgery. H.K. Lewis and Co., London.

Hilton J. (1863). On the Influence of Mechanical and Physiological Rest in the Treatment of Accidents and Surgical Diseases and the Diagnostic value of Pain. Bell and Daldy, London.

Keen W.W. (1915). The Dangers of Ether as an Anesthetic. Ether Day Address, delivered at the Massachusetts General Hospital, October 1915. Press of Jamaica Printing Company, Boston.

Paget J. (1867). Clinical lecture on cases that bone-setters cure. Delivered at St. Bartholomew’s Hospital. British Medical Journal 1 (314), 1-4.