(President of the New Health Society).
SINCE the dawn of history fractured limbs were set with splints, a process which men may have learned from certain birds which try to mend their broken legs with a few sticks plastered around with mud. Method of treatment which have been employed by the medical profession since the earliest times seem hallowed by their age.
Half a century ago before the use of Roentgen rays had become established in surgery and medicine, Sir W. Arbuthnot Lane, a great surgeon, a great thinker, and a man of unlimited courage and resource, became profoundly dissatisfied with the established method of treating fractures which resulted only too often in the permanent crippling of the leg or arm treated for fracture in the usual way, It occurred to him that a complicated or a doubtful fracture should be treated not by outwards splints, allowing nature to produce a more or less correct joining of the broken bones, but by splints connecting absolutely correctly the broken bone ends by internal means joining the bones themselves by metal plates, held in place by screws, and he proceeded to do so to the amazement and dislike of his brother surgeons who considered his proceeding with dismay. They endeavoured to drive Lane out of the profession.
Undismayed by their hostility, Lane continued his work and, being convinced of the soundness of hid idea, criticized the orthodox way of treatment unsparingly and explained the advantages of his own method in numerous articles and addresses. He also wrote a brilliant, copiously illustrated volume. The operative Treatment of Fractures, issued by the Medical Publishing Company, which appeared in the second edition in 1914. I would quote from that absorbingly interesting volume some of the salient passages for the benefit of doctors, surgeons and lay readers of this magazine.
Lane has been assailed by other surgeons who were either lazy or too incompetent to carry out the Lane method in the way described and practised by its brilliant discoverer. Medical pioneers have always been attacked by their tradition-bound colleagues. Sir Arbuthnot has been one of the greatest medical and surgical leaders and it gives me particular pleasure to pay a tribute of admiration to that great man who has honoured me with his friendship. Ellis Barker J.
I HAVE examined the skeletons of many bodies in which bones, and especially the long bones, were fractured, and what surprised me most was very unsatisfactory nature of the results of treatment. Though experience had taught me to regard the statements in anatomical and surgical works with very strong suspicion. I was not prepared to find that the teaching of the causation, pathology, and the treatment of fractures and the results of such treatment, was often absolutely false in almost every detail.
It was evident that the displaced fragments of a broken bone were never or hardly ever, restored to their normal position, and that the so-called “setting of fractures” was a myth. In most cases the fracture was equally absurd, and the treatment by manipulation and splints was not based on any scientific or mechanical principle.
The conclusions which I arrived at as to the prognosis of fractures were briefly the following :-.
(1) That accurate, or anything approaching accurate, apposition of displaced fragments in a fracture was only very rarely obtained.
(2) That the treatment of fractures as it existed was a disgrace to surgical practice, because those who had sustained fractures especially of the leg, only too often experienced enormous physical disability. When dependent on labour for their income, they frequently suffered great financial depreciation in their wage earning capacity. In not a small proportion the depreciation in certain occupations amounted to a hundred per cent.
All my subsequent experience of fractures, treated by means other than operative had fully borne out the accuracy of the statements which I then made.
Age is no barrier to operation ; indeed in old people an operation is often more imperatively called for than in vigorous life for the reason that prolonged recumbency in old age is a very serious matter, often entailing of necessity a fatal result. The shock sustained from surgical interference is trivial old people bearing operation well. Alcoholic patients, in whom the soft parts about the fractures have been very severely damaged as a result of direct violence incur more risk from the injury than healthy ones so, it follows that the additional risk consequent on operation in these cases is naturally greater than healthy ones, so it these case is naturally greater than in the normal subject, not because of the operation but because of the conditions in which the operation is performed.
In other words, alcoholism and direct injury to soft parts increase the danger of fractures and also add to the risk of their operative treatment. I have found the bones of chronic alcoholics to be frequently thin and friable.
I will now relate the several steps which are involved in one operation for simple fracture. I will do so in some details, as apart from manual dexterity and skill the whole secret of success in these operation depends on the most rigid asepsis or cleanliness. The very moderate degree of cleanliness that is adopted in operation generally will not suffice when a large quantity of metal is left in a wound.
To guarantee success in the performance of these operations, the surgeon must not touch the interior of the wound even with his gloved hand, for gloves are frequently punctured especially it it be necessary to use a moderate amount of force and the introduction into the wound of fluid which may have been in contact with the skin for some time may render the wound septic. All swabs introduced into the wound should be held in long forceps and should not be handled in any way.
Some surgeons seems to have an erroneous idea that so-called rarefying ostitis may develop about screws and cause them to loosen. rarefying ostitis in plain English means “dirty surgery”, or such an insecure fixation of the fragments by wire of other connecting medium allows of movements at the junction. Rarefying ostitis is consequent upon a “defective technique”, and is a useful term to cover surgical incompetence.
The operative treatment if simple fractures was met with the most violent and virulent opposition for many years, the opponents of the suggested treatment not hesitating to employ any means, however unscrupulous, to prevent its becoming accepted. This continued till the meeting if the British Medical Association in London in 1910, when I had the honour or opening the discussion “On the Operative Treatment of Simple Fractures”.
Following on this, a Committee was appointed by the Council of the British Medical Association in response to a recommendation to that effect by the Section of Surgery. The reference to the Committee was “To report on the ultimate results obtained in the treatment of fractures with or without operation”.
The following are the main conclusions deduced from an analysis and full consideration by the Committee of the material collected by the Committees Investigators :.
“The statistics relative to the non-operating treatment of fractures of the shafts of the long bones in children (under the age of fifteen years), with the exception of fractures of both bones of the forearm, show as a rule to be improved upon materially by any other method of treatment.”.
“In comparison with the non-operative results in children the aggregate results of non-operative treatment in those past childhood (i.e. over the age of fifteen years) are not satisfactory”.
“In nearly all age groups operative cases show a higher percentage of good results than non-operative cases”.
“In order to secure the most satisfactory results from operative treatment, it should be resorted to as soon after the accident as practicable.”
“It is necessary to insist that the operative treatment of fractures requires special skill and experience, and such facilities and surroundings as will ensure asepsis. It is therefore not a method to be undertaken except by those who have constant practice and experience in such surgical procedures.”.
“A considerable proportion of the failures of operative treatment is due to infection of the wound, a possibility which may occur even with the best technique.”.
“The mortality directly due to the operative treatment of simple fractures of the long bones has been found to be so small that it cannot be urged as a sufficient reason against operative treatment.”.
“For surgeons and practitioners who are unable to avail themselves of the operative method, the non-operative procedures are likely to remain for some time yet the more safe and serviceable.”.
The number of cases operated on form but a small proportion of those who have applied for relief, and for many obvious reason. For instance, to most of the them I could promise but a slight prospect of improvement in their condition as the result of operative interference, because the displacement was of long standing, and such definite mechanical changes had taken place in the joints influenced by the deformity that it was unlikely that the patient would lose pain and disability when the fragments had been restored as nearly as possible to their normal relationship to one another.
The operative measures necessary to dissociate fragments which have become firmly ankylosed together, and perhaps to adjacent bones as well and to saw off sufficient bone from each fragment in such planes as will restore the outline of the necessarily shortened bone, are often bloody and difficult and may be fraught with danger to important adjacent vessels and nerves.
The frequent occurrence of these cases must be well known to surgeons generally, though I can readily understand any individual deluding himself into the idea that he has managed to avoid them in his practice by some skill peculiar to himself.
Considering the unfortunate physical condition of many of these patients and the misery distress, and financial loss they and those dependent on them have experienced through the gross inefficiency of the so-called science of which they are the victims, it seems little short of ridiculous to read the statements of surgeons that such mechanical disability is a rare sequence of fracture, and that it can usually be obviated by the use of massage and passive movements at an early date.
That massage and passive movements serve to diminish the disability and pain which would otherwise ensue if these fractures were left for an indefinite period in rigid casings is quite familiar to me, but to regard such measure alone as being the best scientific treatment and not merely adjuvant, suggests a want to perception of the mechanics of the skeleton.
The second group of cases, namely that of un-united or imperfectly untied fractures, is due also to the same unscientific treatment of fractures. Looking through the text- books, I find any number of reason given for non-union of broken bones, the vast majority of which appear to be utterly without foundation any experience. The surgeon is only too anxious to lay what blame he can upon the patient or his tissue, and seems inclined to regard as possible any factor other than the obvious inefficiency of his treatment.
It may be that in some few cases of simple fracture non-union result from some cause which could not be obviated by proper treatment, but I have never come across one instance in which union would not have resulted in all probability if efficient operative measures had been adopted though a very large number have come under my observation. I would also like to express an opinion on the subject differs completely from that of those who have written about them. My experience and their statements are not be reconciled, since I believe that un-united fracture is of comparatively common occurrence.
If one sees a compound fracture soon after the receipt of the injury, the skin should be efficient cleansed, and the wound opened up and swabbed out thoroughly with tincture of iodine. This drug seems to exert a maximum amount of damage to any organisms that may be present, while it does a minimum amount of harm to the tissue. In most cases it is well to wait till the wound has healed before any attempt is made to secure the fragments together by plates and screws.
Should it be advisable to secure the fragments in apposition while the wound is doubtfully or certainly septic, I employ a long plate, and secure it by screws inserted into each fragments at as great a distance as possible from the seat of fracture. By this means even if the screws are infected the damage done by the inflammatory process is separated by a considerable intervals from the opposing surface of the fragments and so it does not interfere with the union of the bones to one another.
The screws, even though infected will retain the plate in position for a length of time sufficient to ensure union. Then they can be removed with the plate. For this reason in an infected wound, or in wound that may be infected it is wise to place the plates in such a situation that they can be removed easily should this necessity arise. When there is any evidence or suspicion of infection, some arrangement should be made for drainage, which is never called for in the case of simple fractures.
I am sorry to say that the most disastrous cases of septic infection of fractures which I have had to treat have resulted from the fouling of simple fracture during the introduction of a plate.