THE PRINCIPLES OF ORTHOPAEDIC SURGERY AS THEY APPLY TO THE MILITARY NEED

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BY

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Lieut.-Col., JOEL E. GOLDTHWAIT M.C., N.A., U.S.A.

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Senior Consultant in Orthopaedic Surgery

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American Expeditionary Forces

 

THE prominence that orthopaedic surgery has assumed in this war is so much greater than is  common in civil times that it is natural for inquiry to be made for the reason for this, and in presenting them it is necessary to present the principles underlying the work of the orthopaedic surgeon which are not really different is they apply to the military needs from those practised in civil life. That the place now being occupied is proper is best shown by that which has occurred in the British army during the period of the war and to a less degree by that which has developed in the American army during this first year of its war activities.

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With the British army, starting in the beginning of the war with no representative of orthopaedic surgery, as such, upon the staff of the Medical Corps, it soon became evident that it was necessary to have men with this special training available to assist in the restoration to usefulness of many of the wounded soldiers. Naturally the man to whom the nation turned was Sir Robert Jones, and under his leadership the work has not only been developed so as to greatly benefit his own nation, but has set the standard which the American Government is trying to follow in the preparation and care of its own troops.

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That which orthopaedic surgery stands for primarily is the preservation or restoration of function in parts that may have been injured or diseased, so that not only will the disease be controlled but that there will be the least possible permanent limitation of usefulness. Medical treatment alone, or surgical treatment alone, which frequently stops with the relief of acute symptoms, many times leaves the individual with limitations of activities that could be corrected if the measures having to do with the restoration of function in the inflamed or damaged part had followed that which had been given by the physician or surgeon.

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Not only is such work possible and very much needed, but it is naturally desirable, and it is especially true in the army that the measures having to do with the restoration of function should begin at the earliest possible moment so that there may be the least possible loss of time to the service.

As an illustration, an inflammation of a joint or about the tendons, such as is so commonly a part of many of the infectious diseases, frequently results in adhesions in or about the joint or tendons that would seriously interfere with the function of the part and for which the ordinary medical or surgical treatment, which has to do largely with acute symptoms, makes no provision. Or an operation upon a bone or joint may be technically most perfect, but unless the performance is executed with reference to later usefulness, or unless the measures having to do with the restoration of function are instituted as soon as possible after the healing of the wound is completed, a result that might have been perfect may, from the point of view of function, be very poor.

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The methods of treatment having to do with the ultimate usefulness of injured tissues, especially as they have to do with the extremities, naturally involves different training from that which is expected for the regular medical or surgical work, and is so distinct that there should be no conflict of effort in the use of the methods. Naturally the treatment of acute medical conditions is carried out by internists, but it is equally natural that the restoration of the function, in parts that have been damaged, should be accomplished more rapidly and more perfectly by men who have been trained to think in terms of human mechanics and are familiar with all of the possible combinations of the elements that can bring about the greatest possible usefulness. Also, naturally, much of the acute surgery upon injured bones or joints may be and many times can best be performed by the general surgeon, but it is also natural that, as soon as the primary wound healing is established, the restoration of function in the affected part will be accomplished more quickly and perfectly by those who have been trained to deal with such problems and familiar with that which can be expected in a given case, one, or two, or six months later. It is natural that the closest possible co-operation should exist between the orthopaedic surgeon, the internist, and the general surgeon, so that the skill of each will be available, as it may be required, to save or restore the man who has been diseased or wounded.

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In the development of the work of the orthopaedic surgeon not only have the above-mentioned activities been made evident, but it has been clearly shown that the recognition and treatment of the imperfect use of the body, or parts of it, with the natural resulting strain or weakness under the stress of military activities, is not only desirable but has become a part of the activities of the department of orthopaedic surgery.

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This part of the work, which has to do with the preparation of the man for his duties and with preventing him from becoming sick or non-effective, by developing him to the greatest degree of physical fitness, is naturally distinct from that which comes after injury or disease, but is of greater importance from the numerical point of view. In this part of the work, however, the same fundamental underlying principles should be followed as apply to that which comes after injury or disease. These involve a thorough knowledge of the mechanics of the human body, of the anatomy of the structures that have to do with motion and general function, as well as of the physiological principles that have to do with their action or their restoration to usefulness. Such knowledge must be the basis of the work of the orthopaedic surgeon, and it is essential whether the special need is the correction of weaknesses that would cause trouble later, or the correction of trouble that has already occurred.

From this it is evident that the activities of the orthopaedic surgeon divide themselves into two parts, one having to do with the preparation of the men for the expected combat, and the other assisting in their recovery if wounded. The first endeavours to see that they are so trained that there will be the greatest possible vigour for the combat, and that physical defects which might have rendered them ineffective are corrected.

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The second has to do with the treatment of the men if injured, so that there will be the least possible ultimate crippling or interference with function. The first has to do with saving men for service who would otherwise be discharged as physically unfit and also, as the result of careful training, increasing the number of days that should be expected of them for active duty. The second has to do with the saving for service, men who but for such work might not have lived, or had they lived, might have been so crippled as to be of no use to the army.

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That both phases of this work are needed there can be no question. The first is shown by the large number of men with correctable physical defects that would otherwise be exempted for service in the army, and which without such treatment not only represents a great loss in needed men power but also represents a very real potential of inefficiency or disease that will be a burden to the body politic. The second is shown by the great number of wounded that are being saved for useful service for the army or nation that, but for such work, would not only be lost for service but would represent a great and unnecessary burden upon the nation.

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PRE-COMBAT

 

The first or pre-combat work involves :

 

I. Instruction in the proper use of the body in standing, walking, and other activities, so that there will be the least possible waste of energy or liability to over-strain in the performance of regular duties.

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II. Special training, through setting-up drills, orthopaedic exercises, & to overcome bad habits of carriage or body use that lead to inevitable weakness and inefficiency if continued.

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III. Instruction in the care of the feet and supervision of the shoe fitting, to ensure the least possible loss of personnel through the common foot difficulties.

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IV. Instruction of j the stretcher-bearers and ambulance corps men in the use of the standardized splints, to ensure the least possible injury to the man in his transport to the dressing or aid stations, or to the hospitals.

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Postural Training.

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To understand that which is implied in I and II, it is necessary to think of the human being as a delicately adjusted machine that naturally can do its best work only when used rightly.

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This involves a thorough understanding of the structure of the body and of the usual variations, as well as of the physiological elements, involved in proper function. It is not difficult for any one to understand that a machine of any sort will sooner or later come to grief if used wrongly, and it should be realized that this applies to the human body as well as to the device made by the man himself.

 

Great numbers of individuals are ' scrapped ' from the army or break down in civil life, not because they are sick, but because of symptoms which have developed from wrong use. These same individuals are oftentimes equal to greater than the average strain when properly trained, instead of breaking under strain that is well below the average.

 

That work of such nature is greatly needed is not to be wondered at in an army which has been recruited in a country that has directed its attention in its educational propaganda so fully to the training of the mind and has ignored so largely the principles of physical education upon which the health of both mind and body depend. In no other country has there existed so many drooped, slouched, or badly poised men and women previous to the war as in ours, and such types do not stand for physical endurance. It is obvious, however, that to give the individual a properly trained body cannot be accomplished in a day, and perhaps in this, as much as in anything else, it is shown that a great army does not ' rise up in a night '.

 

To make these men of army fitness is our task, and while much of this work should naturally have been performed in the schools during childhood, or while much of the work should be carried out at the camp, in the early part of the military training, there will, however, remain a great deal to be performed with the army in the field, to correct weaknesses that may have been overlooked or that have developed as the result of sickness or over- work.

 

In order to accomplish this work rapidly, it is necessary to have the co-operation of the man and, to secure this, practical talks should be given from time to time giving the reasons for that which is being done. With charts or tracings it is possible to demonstrate the reasons for the correct carriage, and to make it evident that there is only one right way to use the body, which is the same to-day as has been the accepted standard in all times in which attempt has been made to develop the human body to its best. It should be explained that the breathing cannot be performed best unless the chest is carried high or ' well up ', with the head erect and chin drawn in. It should also be explained that the digestion cannot be at its best unless the diaphragm is drawn up or the abdomen drawn in or held flat. It should be shown, as each individual can demonstrate, that the diaphragm or 'guts ' cannot be drawn up unless the chin is drawn in, because of the suspensory ligament of the diaphragm being attached through the pericardium to the sides of the low cervical spine. It is this that makes necessary, as well as desirable, the head erect position, and has led to the insistence that is put upon this by the athlete for running or other feats of endurance.

 

It should be explained that the spine has certain curves that are normal and that these are so formed that if the body is used properly there will be the greatest ease and spring in movement, with the muscles of the different parts of the body in such balance that action will result in the least waste of energy, and fatigue will come only after long or sustained effort.

 

It should also be explained that the bones of the feet are held together by muscles, and that only when the body is held erect are the muscles of the feet so used that strain and weakness will not result. It is easy to demonstrate that in standing erect with the chin drawn in and with the abdomen flat that the full weight is felt chiefly upon the balls of the feet and the full spring of the arch of the foot is present. It is also easy to demonstrate with each individual that if the body is relaxed, such as by simply lowering the chest or standing with the head forward, that the weight is borne upon the heels, in which position the muscles are relaxed and the spring of the arch of the foot is entirely lost. No one can stand for long in this position without weakness of the feet resulting with ultimate flat foot.

 

On the other hand, once the feet are developed, if the body is used fully erect, flat foot will not occur and use will strengthen the supporting muscles as is expected with the muscles of other parts of the body.

 

Once these things are clearly explained and the desired posture obtained, the common conditions of foot weakness or back strains, which represent the two most common results of such postural defects, will disappear. Such conditions represent weakness and not disease, and weakness largely the result of wrong use of the body. Any method of treatment of these conditions that does not recognize this must be attended by only temporary success. Such conditions should be constantly emphasized as being due to weakness and not requiring medicine.

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Once this point of view is established, it not only makes it possible to handle large numbers of men, but it at once makes them realize that the condition is not one of sickness, requiring close supervision, but is one for which they themselves are responsible and for remedying which proper physical training is essential.

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Special Training Organizations.

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Since with a large number of men the conditions of bad posture, with resulting weak backs or flat feet, are more marked than could be corrected in the ordinary routine of military life, special methods, by which groups of men can be handled, are necessary. To meet this need special training organizations should be established, and the men requiring development should be assigned to them for such period of time as may be necessary for overcoming the weakness. To them should be sent those having noticeably weak feet or troublesome, weak, or lame backs, general bad posture.

 

The medical part of the organization should be as inconspicuous as possible, and in so far as is possible the training given, or the exercises used, should be those employed in the training given in the regular military camps. For instance, squad or company drills ; bayonet drill, manual of arms, bomb throwing, route marching, and should all be used, but of course for shorter periods than would ordinarily be used in the regular training.

 

Following each period of military activity, which should be short and made as ' snappy ' as possible, should be a period devoted to some game or play in which all share and in which there is the greatest amount of relaxation from the strictness of the discipline as is compatible with the general routine. During the periods of drill, irrespective of the form, constant emphasis should be put upon the way in which the movement is made. In standing or marching, the fully erect, alert position should be insisted upon, while every special movement or exercise should be made from this position. In marching, in order to emphasize the posture, the pace should be quickened, with quick snappy action.

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In such an organization the men should be divided into four groups or companies, each having a schedule carefully planned to meet the needs of the men assigned to it. The first or junior company should have a schedule made up of short periods for military activities, with frequent periods of games and also with distinct periods for rest, the idea being to stimulate the muscles but to avoid over-fatigue. The next company, to which the men from the lower company are transferred, should have a schedule of more rigorous planning, the same being true of the third and fourth companies.

 

In the fourth company, the schedule is only slightly below that required for the full combat fitness, and it is expected here that the men will be able to march at least ten miles with full equipment without suffering strain or unnatural fatigue. Shortly after this has been reached, the men are naturally discharged back to their commands.

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The admission of the men to the organization and the transfer from one company to another, with the final discharge to their organizations, should be upon the recommendation of the orthopaedic surgeon in charge. Before the final discharge is made, the men must have demonstrated by the involuntary use of the body that the corrected habits of general posture, as well as the correct habits of foot posture, have become automatic.

 

 

 

 

 

 

 

 

 

 

 

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Such cases, without some such system of training, should not be retained in the army, as they would not be equal to the strain of combat training and to send such cases to the hospitals simply means less activity, greater weakness, with the result that after being sent back to the command the condition is really worse than it was before. Without such special training discharge from the army should be recommended for these men, but with such training they can practically all be saved for the army and between 70 and 80 per cent, can be made equal to full combat duty.

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With the experience that this work has given it is evident that flat foot should no longer be a cause for discharge from the army or exemption from the service. It should require no argument that posture such as is represented in Figs. 2, 4, and 6 is less good and represents less efficiency and alertness than Figs. 3, 5, and 7, and the fact should never be lost sight of that every individual like Figs. 2, 4, and 6 has the potential of that which is represented in Figs. 3, 5, and 7 which can be achieved by proper instruction.

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Care of the feet.

 

The importance of the part of the work that has to do with the care of the feet cannot be over-estimated and can probably only be appreciated by those having served under conditions similar to those prevailing in this war. The proper fitting or adjusting of the boots or shoes, the correction of faulty habits of use, with the overcoming of elements of weakness, as well as the direction of the hygiene of the feet, are factors upon which depend the fitness for duty of large numbers of men who would be an encumbrance to the army but for such care.

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In civil life the sizes of shoes commonly worn are as small as can be used without actual discomfort, and the socks worn are of such texture as to occupy but little space. Such covering may meet the needs of civil conditions, in which the physical activities are slight, but are not only inadequate for military needs but actually harmful since action of the muscles of the feet is interfered with. Military activities demand the hardest kind of use of the feet, and to make this possible the shoe covering should interfere the least that is possible with foot action, while there should be ample room for warm soft socks to not only protect the feet from chafing but to furnish an absorbent for the moisture that will be developed. It has been found that practically all of the men in the army need shoes that are from a size and a half to two sizes longer than had been worn previously and with relatively narrow widths. Sizes as large as this are needed especially in the winter when the use of an extra pair of socks is expected. The common habit among the men of simply increasing the width of the shoe without increasing the length is to be carefully avoided since it results in added cramping of the toes and allows the feet to spread, thus increasing the potential of difficulty that exists naturally.

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In fitting, the patient should stand with the shoe on, and there should be at least three-quarters of an inch between the tip of the great toe and the end of the upper part of the shoe when the full weight is borne upon the foot. With proper care in the fitting of the boots or shoes large numbers of men will be saved for combat usefulness that otherwise would be discarded or assigned for other duty, and since this involves a vast amount of work, if it is to be carried out thoroughly, there should be a certain number of enlisted men trained for this special task who will work under the direction of the orthopaedist.

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While this work is important for men with relatively normal feet in order to lessen as much as possible the development of later weakness, it is of greater importance for the large number of men with weak feet, which inevitably are found in an army rapidly recruited from civilians without previous training. With proper care these men can be saved for full duty, and proper use of the feet will result in the development of strength in the weak part. When the common pronation, or inward sag of the ankle is present, it is obvious that hard use will result later in an increase of the sag with development of symptoms of strain. If, however, the heel of the shoe is raised at the inner edge a sufficient amount to correct this sag so that the two malleoli are equally prominent, the element of strain is eliminated and use will result in strengthening the structures so that ultimately the special adjustment of the shoe will be unnecessary. With a simple series of wedges the exact elevation that is required in a given case can be determined, but as a matter of fact three-eighths of an inch is so commonly the amount, that it can practically be taken as a standard. The necessary alterations can be made in an ordinary cobbler's shop, and to show the need of such work in one organization alone 100 pairs of boots a day have been so treated. For each man with whom this is necessary three pairs of boots are prepared, two of which are delivered to him while the other pair is carried in the quartermaster's stores. It is expected that by the time these three pairs are worn out the feet will have so strengthened that the special need will cease to exist, and with such provision the men should have lost no time from duty.

 

Besides this type of case, there will be a certain number of men with whom the feet are so markedly spread and the cuboid bone so completely displaced to the outside that they will not be controlled by the simple raising of the inside of the heel. For these it has been found practical to use a strap to correct the spreading and to draw the cuboid in under the tarsal bones. Such a strap can be made of soft leather or webbing or canvas and can easily be provided in the cobbler shop attached at the depot or replacement division. The strap should be twenty-two inches long, an inch and a quarter wide, and should fasten with a buckle, an inch wide, commonly designated as a trouser or suspender buckle. It should be applied as a figure-of-eight (Fig. 8) about the ankle and foot, and the buckle should be placed just behind the inner malleolus where it will cause no irritation. As the strap passes under the foot its desired position is just back of the base of the fifth metatarsal bone and over the scaphoid, in which position the pressure is applied over the cuboid and the scaphoid, the two bones most displaced, and which must be replaced, before the proper strength of the foot is possible. With such a strap on, not only is marching possible but the effect of the support is to lead constantly to the correction of faulty position and in no way to interfere with the proper use or development of the muscles.

 

With a certain number of men the tarsal bones are in position and there is little if any pronation, but the front of the foot is badly spread with always more or less distortion of the toes. To meet this need a strap of similar material as that described above is provided and should be worn just back of the metatarso-phalanged articulations (Fig. 9). This strap, as also the figure-of-eight strap, should be worn over the sock. The buckle should be placed in the natural depression at the base of the fourth toe on the dorsum of the foot. With such treatment a shoe of average width will be possible, while otherwise a shoe much too wide for the rest of the foot would be required and naturally result in chafing, blisters, or strain.

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With a very small number of men, because of periarticular thickening or osseous overgrowth, it will be impossible to secure full or satisfactory function without operation. The most common conditions in which this will be required are hallux valgus and hammer toe. For the former, while the individual surgeon may be given some latitude in the selection of the form of operation, it should be fully appreciated that anything that shortens the length of the support for the arch upon the inner side must weaken the foot, and render it less good than is desired for marching.

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For that reason, the head of the metatarsal should be disturbed as little as possible, and instead of removing it entirely, as with the Heuter operation, nothing more than the prominence upon the inner side should be removed, while if it is necessary to do more in the correction of the deflected position of the toe, this should be accomplished by removing the base of the first phalanx. This should leave a freely movable tee with full length of the support for the inner side of the arch, and should give a foot that is ready for use in three or four weeks.

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* For hammer toe, the best operation consists of the removal by lateral incision of the distal two-thirds of the first phalanx. This shortens the toe enough so that it does not crowd the ends of the adjoining toes, as it otherwise would in straightening, and yet is long enough to prevent the lateral displacement of the adjoining toes, as would occur in case the entire toe had been removed.

Amputation should practically never be performed. With such an operation the tendons are not disturbed, so that full control of the toe should result and active use should be possible in a week or ten days. With such an operation no after splinting is necessary and there can be no possible relapse of the deformity.

 

Standardized Splints, their Use and Method of Instruction. At a time when it is necessary to carry on activities on such a stupendous scale as is required in the present war, it becomes necessary to standardize such activities as much as possible in order to obtain the highest possible average in the character of the service. This principle has been followed in regard to the selection of the splints that are to be used for bone, joint, or other injuries in which such articles would be required, and a standardized list has been prepared and published in the Manual of Splints and Appliances for the Medical Department of the United States Army. To obtain the best results with injuries or conditions requiring the use of such apparatus, not only is it desirable to adopt the best forms of apparatus but also to see that proper instructions are given to those who are expected to use them. It is naturally expected that the members of the Medical Corps will have such familiarity, but since their use is of the utmost importance in the transport of the wounded, it becomes necessary to instruct the stretcher-bearers, ambulance-corps men, and hospital-corps men in the use of the apparatus, with especial reference to the application under emergency conditions. The instruction and supervision of these men has been delegated to the Division of Orthopaedic Surgery, and not only should the technical use be appreciated by the men, but it should also be appreciated that all unnecessary handling of the injured part without splinting should be avoided. It cannot be too strongly emphasized that a wound which may be of moderate seriousness may become greatly increased in importance by careless or incompetent handling in the transport to or from the hospital. A fractured femur, for instance, which is always serious, may result in conditions that are very grave, with loss of leg or life, if the bone fragments are not properly splinted. Haemorrhage from torn vessels, or paralysis from damaged nerves, may be the result of injury during transport rather than the result of the original wound.

 

Thorough training of the stretcher-bearers in the application of such splints is not only important, but it should also be expected that such application will be made at the earliest possible moment. If for instance the splint can be applied before the man is put upon the stretcher, the chances of saving the life of the patient are distinctly greater than if even the least amount of transport without such splinting is allowed.

 

To meet the needs of such work careful planning of the distribution of the appliances through the combat divisions, so that they will be most practically available for use, is essential, and this as well as the supervision of the work of the stretcher-bearers and ambulance-corps men has become a part of the work of the Orthopaedic Division in the combat divisions, and the orthopaedic surgeons for such work are now a recognized part of the army organization.

 

That this work has resulted in delivering the wounded man to the evacuation hospital in better condition than would otherwise have been possible there can be no question, and the work of the stretcher-bearers in applying the splints for the arm or leg injuries in ' no man's land ' before any movement is allowed is deserving of the greatest praise.

 

After wounds or injuries have been received the duty of the orthopaedic surgeon consists in preserving as much of the tissue that has been injured as is possible and restoring the function of the part to the fullest possible extent.

 

To accomplish this the immediate protection of the part, so that there will be no unnecessary damage in transport, is naturally the first consideration, and is of the utmost importance, as has been indicated in the previous section. It should be clearly understood that the life of the patient may be lost from shock or haemorrhage, or the limb be lost not directly because of the original wound but because of the unnecessary laceration of the tissues resulting from transport. To reduce such risk to the minimum and to prevent any unnecessary injury of the tissue, as well as to ensure the least possible suffering to the patient, the injured part should be carefully splinted before transport is undertaken. For this anything that will limit or restrict movement in the injured part will be, of course, of benefit, and this can be secured in whatever way is possible in the given case. Fixation alone is of benefit, but the protection obtained in this way is less than is to be desired, since the muscular contraction that is still possible is capable of not only causing much pain but also of causing distinct injury. To accomplish the best results for the transport of such injuries, traction, which will control the contraction of the muscles better than anything else, together with the fixation provided by such apparatus, gives the best results and makes the handling of the patient for transport fairly easy. To make this possible and to easily secure both traction and fixation the apparatus that is of the greatest use is the Thomas splint, either with the full ring or with the modification having the half ring ; it is by far the best apparatus for leg or thigh injuries, while the Thomas arm- splint with the ring hinged to the uprights is best for injuries of the arm. With these two models the injuries of the extremities can be so protected that transport is attended with but little suffering or increased injury. At the time of combat such apparatus should be carried well forward with the troops so that they can be quickly available for the stretcher-bearers and ambulance-corps men.

 

The preservation of function in the injured part, as well as the preservation of as much of the injured tissue as is possible, are the two features that give justification to the orthopaedic surgeon for his position, and it should never be lost sight of that this responsibility begins at the time of the injury and not late in the course of the treatment. Too much emphasis cannot be put upon this feature, the need of which was constantly more evident as the war progressed. To prevent a man from getting a crooked leg, or a stiff joint, or from losing the leg, is much more to be desired, as well as much more economical for the nation, than to straighten the leg later or to attempt to restore motion in the joint, or to adjust the artificial member. To do this most perfectly the treatment should begin at the earliest possible moment.

 

For the cleansing of the wounds or the acute operative surgical part of the treatment, while the general principles should follow those recommended by the Inter-allied Surgical Conference, it should nevertheless be remembered that the removal of all unnecessary tissue should be most carefully avoided and that the condition of the part after the wounds have healed should never be lost sight of. It is of course desirable to cleanse the wound as perfectly as possible, and to have as little damaged tissue for possible sloughing or infection later ; nevertheless, it is to be remembered that tissue may be removed unnecessarily with resulting loss of useful functions. It should be remembered that while primary closure of the wounds is naturally desirable, it may many times be better, from the point of the greatest possible usefulness later, to make a less complete excision of doubtful tissue than would be desirable to justify primary closure, and follow the operation by use of the Carrel-Dakin solution for a few days, with the secondary or delayed closure of the wound later.

 

Such a procedure, while not as brilliant perhaps as the primary suture, may nevertheless make the difference between helplessness and usefulness later. Without such procedure the removal of an entire muscle might have to be sacrificed, while with the less radical method enough of the muscle may be preserved to be of great assistance in future activities.

 

The same principle applies to the treatment of the bone injuries, and to ensure primary closure fragments, of bone might have to be removed that could be preserved if the principles of secondary closure were followed.

 

It should be remembered that every fragment of bone that can be saved is of value in the healing and ultimate strength of the part.

 

In case the wound is of such nature at the time of the beginning of treatment that closure is impossible or unwise because of infection, the Carrel-Dakin solution should be used until the -sterilization is accomplished, after which closure in whatever manner is possible should be attempted. In the late cases with the chronic infections, the wounds should be thoroughly opened and as much actually diseased tissue removed as is possible, after which the thorough use of the Carrel- Dakin solution should be carried out until the tissues are in such condition that the evidences of infection have disappeared, when attempt at closure of the wound should be made. In the use of the Carrel-Dakin method of wound treatment it should be remembered that the success depends very largely upon the exact composition of the solution, and since there can be only five tenths of a per cent, variation in the strength of the solution, to ensure the desired result, the obviousness of the control of the dressings as well as of the solutions by skilled assistants is apparent.

 

With joint wounds if they are seen early in the first ten or fifteen hours after injury, the wound should be laid open, lacerated tissue removed in so far as is possible, as well as all foreign bodies, after which attempt should be made to close the joint with the use of active motion as early as is compatible with the wound healing. In case of infection free opening of the joint is desirable and sterilization with Carrel-Dakin solution is at times sufficient for the control, but under such conditions it many times is not possible to preserve the motion in the joint. At other times, after the joint is once thoroughly washed out, with the establishment of free drainage and with the encouragement of moderate active motion the infection is controlled and the drainage maintained. In such cases while moderate active motion may be desirable, passive motion should be avoided, since the active motion would be limited by the reflex muscular spasm as soon as the point of harmful irritation is reached, while with passive motion this protective barrier might be broken down with distinctly undesirable results.

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It should be a rule with all of the joint, bone, or muscle work that use or movement up to the limit of toleration is to be encouraged, since with such use all of the processes of blood and lymph flow, as well as innervation, are stimulated thereby, but, the use should always be active and not passive.

 

The purely operative treatment for such conditions should always be carried out with reference to the result it will present when the man is ready for final discharge as a patient, and this implies continuity in the control of the treatment. Whether one surgeon directs the work all the way through or not is immaterial, provided there is some plan by which similar methods of treatment are followed as the man is moved from one service, or one hospital, to another. Some system of constant or radial control of the entire treatment is absolutely essential if the results are to be the best that is possible, so that from the time of the inception of the wounds until the completion of all treatment, the same fundamental plans will be followed. In this way good surgery in the front is supported by good treatment in the rear with benefit to all, while without such control excellent work at the front may accomplish little ultimately because of imperfect supervision later.

 

Conversely, the best treatment at the rear will give a result much less good than was possible if the treatment at the front was not of the highest order.

 

To make the best of the wounded man or the wounded part is distinctly the function of the orthopaedic surgeon, and whether the joint is damaged or the bone injured, or the muscles lacerated, or even the limb is lost, it is his duty to see that the man is returned to duty or his home with the least unnecessary handicap.

 

All of that which has thus far been mentioned has for its first reason the saving of men for the army, but it must be obvious also that the work at the same time helps the men as individuals. The preliminary training with the better habits of carriage must make for better general health, and since, with the careless, relaxed habits of carriage which have been so commonly seen are usually associated careless mental habits as well, the physical training which insists upon alertness of body also results in much greater alertness of mind. In regard to the post-combat work, not only does such work mean saving a great number of men for useful service in the army, but it makes amends to the men for the sacrifices they may have made, in so far as it is possible so to do. It must be obvious to anyone that a man with an artificial leg can be just as useful for office work, or many details that require inactive service for the army, as the man who has not been injured. If the man is made to realize that he need not be considered unfit but is recognized as of use, there probably is nothing that will preserve his morale and set a standard that should be carried into the conditions of civil life as much as this. In other words, the work here described, while primarily military and designed for the purpose of saving the men to the army, is at the same time most broadly humanitarian and represents a square deal to the man who has played squarely to the nation.

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