ORTHOPAEDICS IN CONTINENTAL EUROPE 1900-1950 - THE CHANGING PATTERN 

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By

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HARRY PLATT

Professor of Orthopaedic Surgery

and

Director of the Department of Orthopaedics

University of Manchester 

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In the opening years of the twentieth century the practice of orthopaedics in Continental 

Europe could be seen to reflect two distinct trends in the evolution of surgical specialism. 

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In France and Belgium, and the middle European countries which looked to French surgery 

for example and precept, orthopaedics was regarded as an integral part of the surgery of 

childhood-” Chirurgie Infantile et l’Orthopedie.” In the leading university medical schools 

in France there were already professorial chairs in this subject, as indeed there are to-day.

 

Thus, continental orthopaedic surgeons who conformed to the French pattern were for the 

most part general surgeons devoting their main activities to the study and treatment of 

surgical maladies of the growth period. It Could be said in their favour that they looked at 

the child as a whole. By contrast, in Germany and in countries where German surgical 

influence was predominant, orthopaedics had long been a surgical specialism in its own right; 

but in the main it was still nineteenth century orthopaedics as practised by men who often 

had little claim to the status of general surgeon. The German orthopaedists were concerned 

primarily with the treatment of deformities resulting from crippling disease and injury in 

patients of all ages. Their therapeutic armamentarium embraced a combination of mechanical, 

re-educational and, where necessary, relatively minor operative measures. It was a field of 

practice in which there was emphasis on conservative methods of treatment. 

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In many countries both the French and German patterns of orthopaedic practice flourished side by side. But throughout Europe, at this period and for many years after, the practice and teaching of the surgery of injuries, and of the major reconstructive surgery of the locomotor system, remained within the gambit of the omnicompetent general surgeon. 

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We are therefore called upon to note the important contributions to the corpus of knowledge 

on which the art and science of present day orthopaedics is based of many whose surgical 

activities transcended the somewhat narrow scope of the “older orthopaedics.” 

 

After the first world war the change in pattern of orthopaedic practice in Great Britain, 

whereby its sphere was extended to include the treatment of fractures and allied injuries, 

inevitably began to influence the strategy of continental orthopaedics. This was one of the 

outstanding movements inspired by Sir Robert Jones, at that time acclaimed by common 

consent as the international leader. In Italy, under the guidance of the incomparable Vittorio 

Putti (1880-1940), special orthopaedic institutions and university clinics gradually assumed 

responsibility for the wider field of modern orthopaedics and the Rizzoli Institute in Bologna 

became a Mecca for young surgeons from all over the world, more especially from the 

Latin-American countries. In Holland, where the German tradition had long held sway, 

Murk Jansen (1867-1935) of Leiden encountered stiff but ineffectual opposition from some of 

the leading general surgeons of that country in his early efforts to establish the British and 

American pattern. Murk Jansen was a powerful fighter in any good cause and when in 1928 

he devoted half his private fortune to the building and equipping of the Anna Kliniek, the 

operating theatre suite on the upper floor was designed on a lavish scale. Its windows could 

be seen from many parts of the old university city of Leiden and were impishly believed by 

Jansen to provide a much needed counter-irritant to the professor of surgery as he passed on 

his bicycle to and from duties at the University Hospital! 

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Opposition to an expansionist policy was seen in its most uncompromising form in 

Germany, where in 1931 the professors of surgery issued a manifesto in which the\? defined 

the scope of the practice and teaching of orthopaedics to be followed in the university 

medical schools. For a time at least, German orthopaedic surgeons as a corporate body 

seemed willing to submit to restrictions imposed from without, and at the general assembly 

of the third congress of the Internationale de Chirurgie Orthopedique at Bologna in

1936 the German members voted as a minority bloc against the proposal to add "et de Traumatologie" to the title of the society.

 

The old arrangement of linking orthopaedics to the surgery of children still holds in 

France but is no longer sacrosanct. The first important break with tradition was seen some 

years before the second world war when Paul Mathieu was elected to a new chair of adult 

orthopaedics in the Paris School of Medicine, with his clinic at the Cochin. 

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We now face a situation in which the sphere of modern orthopaedics has become so wide 

and complex that it is questionable whether it can be encompassed adequately in the practice 

of any one man, or provided for in a balanced fashion under the roof of any single clinic or 

institution. There is to-day a real danger that the contemporary preoccupation of the coming 

generation of orthopaedic surgeons with the surgery of trauma may lead to a lessening of 

interest, and loss of skill, in the treatment of the more tedious and still unsolved problems 

we have inherited from the older orthopaedics. It may well be that we shall see the future 

emergence of two main groups of orthopaedic surgeons-the first consisting of those who 

devote the greater part of their time to the practice of cold orthopaedics with its ever

widening range of major reconstructive surgical procedures, but who maintain a firm link 

with traumatology; and a second group of those who are concerned primarily with the 

treatment of injuries of the locomotor system in large accident services, but still retain a 

link with “cold” orthopaedics. 

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LANDMARKS IN PROGRESS 

 

History has been defined as the story of the vicissitudes of human affairs. It is fitting, 

therefore, that we should chronicle the pattern of events in any special field of medicine in a 

particular epoch in terms of the actions and achievements of men who made a deep impression 

on their own generation, and whose contributions to knowledge seem likely to influence 

thought and practice in generations to come. In the field of orthopaedics we have also to 

recogn

ise that the contributions of many of its leading exponents have not been concerned 

solely with the art and science of orthopaedic practice. In all European countries, orthopaedic 

surgeons have played a prominent part in arousing public interest in the social needs of the 

crippled and deformed; they have in truth been pioneers in what is now popularly termed 

social medicine. 

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FRANCE 

In France the first outstanding figure to be noted in the opening years of the twentieth 

century is Edouard Kirmisson (1848-1927) who from 1901 to 1919 occupied the Chaire de 

Clinique Chirurgicale Infantile at the famous children’s hospital of Paris-the Clinique des 

Enfants-Malades-and was the acknowledged doyen of French Orthopaedics. His textbook 

on Acquired Deformities of the Locomotor System in Childhood and Adolescence, published in 

1902, became the standard work on this subject for the next generation. It was a companion 

volume to his earlier work on the Surgical Treatment of Congenital Deformities, published in 

1898. Among Kirmisson’s many personal communications we may note the introduction of 

osteotomy for irreducible congenital dislocation of the hip, and his recognition of the 

association of displacement of the upper femoral epiphysis with obesity of the hypopituitarv 

type. His dominant influence on the development of orthopaedics in France was seen early in his career in his share in the foundation of the Revue d’Orthopedie (1890), a journal so long 

and ably edited in our own day by Albert Mouchet. Some years later Kirmisson was the 

moving spirit in launching the French Orthopaedic Society of which he was elected the 

first president. 

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The university chair associated with the Enfants-Malades has long been regarded as the 

blue ribband of French orthopaedics and it is not surprising to find among the successors of 

Kirmisson men who attained a European reputation. Louis Ombredanne who held this 

position until 1942 is happily still with us, the elder statesman of continental orthopaedics. 

His tall distinguished figure has lent dignity and grace to the several congresses of the 

International Orthopaedic Society both before and since the second world war, and his 

election in 1948 as President-Emeritus was a fitting tribute to the qualities of his leadership. 

The design of the new surgical clinic of the Enfants-Malades has been one of his notable 

achievements and, true to the tradition of the premier French chair of orthopaedics, he has 

expounded his wide clinical experience in the pages of two comprehensive text-books-the 

classical five volume Traite de Chirurgie Orthopedique, edited in collaboration with Paul 

Mathieu (1935), and Precis Clinique et Operative de Chirurgie Infantile, of which a fifth edition, 

revised and augmented, was published last year. 

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Of Jacques Leveuf (1886-1948), who succeeded Ombredanne, there is little one can add 

at this moment to the tributes paid to him in recent memorial notices in this Journal. * ft was 

the sad fate of this man of dynamic personality to hold the coveted position at the Enfants-

Malades for a very short time, and his death at the height of his powers deprived continental 

orthopaedics of one who still had a significant message to deliver. Leveuf approached every 

subject in a critical and sceptical fashion. His brilliant and provocative studies on Volkmann’s 

ischaemic contracture, osteomyelitis, and congenital dislocation of the hip, culminating in 

his monograph Luxations et Subluxations Congenitales de la Hanche, despite the unorthodox 

views therein expounded with such vehemence, will become the base from which further 

advances will be made in these subjects in years to come. 

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From Paris we may turn aside for a moment to the great provincial medical school of 

Lyons and there take note of a man of quiet dignity and high culture-Gabriel Nove-Josserand 

(1868-1949). Nov#{233}-Josserand was brought up in the great tradition of Ollier and was appointed 

to the first professorial chair in orthopaedics in Lyons in 1921. He will be remembered in 

Great Britain as president of the second congress of the International Orthopaedic Society 

held in London in 1933. One of the subjects among many to which he applied his wisdom and 

judgment was a survey of the results of manipulative reduction of congenital dislocation of 

the hip joint in a long series of cases. With Louis Tavernier, his successor in the chair at 

Lyons, Nove-Josserand produced a monograph on malignant tumours of bone in 1927, a work 

which at that time gave a concise account of contemporary knowledge on this subject. 

Professor Tavernier, whose term of office in the Lyons chair has only recently come to an 

end, was one of the first French surgeons to deal adequately with the subject of internal 

derangement of the knee and, in collaboration with Mouchet, he published Pathologie des 

Menisques du Genou in 1927. In recent years he has made valuable contributions to the 

surgery of osteoarthritis of the hip joint with particular advocacy of the operation of 

denervation of the hip joint. 

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Orthopaedics is also indebted to the School of Lyons for the inspiring contributions of 

one who throughout his career has remained in the true sense a general surgeon-the world 

famous Rene Leriche. During his tenure of the chair of surgery at Strasbourg (1925-1939) 

Leriche became one of the great master-surgeons of Europe. His world-wide influence on 

surgical thought continues to be radiated from Paris where he now occupies the chair once 

held by Claude Bernard at the College de France. Leriche’s pioneer work on the surgery of 

the vascular system, peripheral nerve injuries, and the surgical problems of pain, has 

* Journal of Bone and Joint Surgery (1948). Obituary, Professor Jacques Leveuf, 30-B, 723. 

throughout its various phases of exposition become an integral part of the background of 

orthopaedic knowledge and practice. But it is his classic work on the physiology and pathology 

of bone which lies nearest to the heart of modern orthopaedics. Fundamental views on bone 

formation, expounded so eloquently by Leriche and his collaborator Policard in 1926, have 

not gained acceptance in their entirety, but this work indeed constitutes an epoch in the 

evolution of twentieth century orthopaedics. More recently, in his inaugural lectures at the 

College de France, Leriche reviewed in philosophic and synoptic fashion the whole range of 

skeletal disorders. 

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The foundation in the second half of the nineteenth century of the Maritime Hospital 

at Berck on the Normandy coast, under the aegis of the Paris hospital system, has been one 

of the most potent influences in determining the trend of French orthopaedic practice. For 

more than half a century this hospital of nearly one thousand beds, devoted primarily to 

the treatment of tuberculosis of bones and joints but always with a small admixture of other 

cases, has provided a unique aggregation of material and formed the basis of a continued 

stream of clinical studies from successive surgeons-in-chief and their assistants. The classic 

work of Menard in 1900 on the pathological mechanics of Pott’s disease comes first to mind; 

its significance was recognised fully by Alfred Tubby in his incomparable text-book published 

in 1912. enardremained at the Maritime Hospital throughout the whole of his long active 

career, unlike his successors who have been appointed in turn from among the Chirurgiens

des Hospitaux de Paris and have returned to the French capital after holding the Berck 

command for a limited period. Although Menard’s teaching belongs to late nineteenth century 

orthopaedics, and we are now in the era of revival of a more radical surgical attitude towards 

the treatment of surgical tuberculosis, his original observations are still of paramount 

importance. Among his most distinguished pupils who have enhanced the reputation of the 

Berck school was Jacques Calve, now living in retirement in the United States. Calve’s name 

(1910) is of course linked inseparably with Legg of Boston (1909) and Perthes of Tubingen 

(1910) in the first recognition of pseudo-coxalgie as a clinical entity. For the discovery of that much less common lesion osteochondritis of the vertebral bodies (1922) Calve’s priority is undisputable, and his further observations on this condition were presented in the essay he contributed in 1928 to the Robert Jones Birthday Volume. Calve made many important communications in the period between the two world wars, a number of them in collaboration with his pupil and assistant, Galland, a man of mechanical genius. His carefully planned technique for the relief of Pott’s paraplegia by aspirating the intra-spinal abscess by means of a curved cannula introduced through the intervertebral canal seemed at first to be a valuable addition to our therapeutic resources (1922). It was disappointing to find that after patient trial the method proved to be applicable to so few cases of paraplegia. Perhaps Calve’s most striking contribution to orthopaedic literature was his study with Galland of the pathological mechanics of Pott’s disease in the Revue d’Orthopedie. In this article we can find a masterly restatement of the basic teaching of Menard in its modern perspective and more particularly a critical examination of the rationale of the operation of spinal fusion. We must also 

remember, as Herbert Brittain has reminded us, that Calve predicted the development of ischio-femoral arthrodesis of the hip. 

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During the period under consideration many surgical pilgrims to Berck became aware of the impact on orthopaedic practice of that redoubtable and colourful personality Frederic Calot. Calot owed nothing to the Menard dynasty, or to the Paris hospital system. He had established his own independent clinic which became known far and wide as the result of his writings and more especially the attractive illustrations in his popular monograph Orthopedie Indispensable, a work published in Paris in 1909 which went into nine editions. Calot was an exponent of the injection of cold abscesses with iodoform oil. He wrote enthusiastically about the results in his own hands of the manipulative reduction of congenital hip dislocations and in this field regarded himself as a rival of the great Adolf Lorenz. His considerable experience of hip joint anomalies led him to conclude that unrecognised congenital subluxation was a basic stigma determining many affections of the hip joint at a later stage, such as pseudo-coxalgia in children and osteoarthritis in adults. Calot was the type of virtuoso to be found at every period in all branches of surgery-the man who founds no school and leaves behind no pupils; but his influence on the practice of orthopaedics cannot be discounted. 

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In due course the position of surgeon-in-chief at the Maritime Hospital provided Etienne Sorrel with a wealth of material of which he made full use during ten fruitful years after the first world war before returning to Paris to take charge of the surgical clinic at the Trousseau. 

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It was during this period that his charming and talented wife, Madame Sorrel-Dojerine, wrote the monograph on Pott’s paraplegia which will long remain a classic of orthopaedic literature. During the past twenty-five years both Sorrel and his wife have maintained a steady output of clinical contributions ranging widely over the field of children’s orthopaedics. 

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Sorrel himself has played an influential part in the affairs of the International Orthopaedic Society, and this year has attained the signal honour of being elected president of that ancient foundation, the Academie de Chirurgie de Paris. 

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The first decade of the twentieth century witnessed a number of noteworthy contributions to the treatment of fractures by Pierre Delbet (1865). It was in 1906 that this distinguished Parisian general surgeon first began to practice internal fixation of intracapsular fractures of the femoral neck by means of a screw introduced under X-ray control. At this time also Delbet was advocating early weight-bearing in fractures of the leg bones. Neither method gained immediate or universal acceptance, and it was not until some twenty years later that Smith-Petersen introduced his tri-flanged pin (1929), and Bohler in Vienna made fashionable the early ambulatory treatment of lower limb fractures. 

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Reference has already been made to the election of Paul Mathieu to the first Chair of Adult Orthopaedics in Paris, a post which he has relinquished only recently. Mathieu has been a wise counsellor in the affairs of French orthopaedics for many years and the contemporary use of acrylic-resin femoral heads in reconstructive surgery of the hip joint, in the hands of his pupils, Jean and Robert Judet, and of his successor, Merle D’Aubigne, is a development of his own earlier work in this operative field. 

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In this brief sketch of some notable events in the evolution of orthopaedics in France 

during the first half of the twentieth century it has not been possible to pay tribute to many 

who made their contribution. We do not forget the part played by such men as Frohlich of 

Nancy (1867-1945), Henri Judet (1874-1942), Le Fort of Lille, Rocher of Bordeaux and Albert Mouchet of Paris. 

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BELGIUM 

 

In Belgium, as elsewhere, modern orthopaedics exhibits the features of a mixed ancestry. 

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There is first the old French tradition of chirurgie infantile as exemplified in the professorial chair in Brussels at the Saint Pierre Hospital. This post was filled with distinction in the early part of the century by Jules Lorthioir (1864-1931), friend of Robert Jones and father of Paul Lorthioir who is well known to British surgeons by his devotion to the affairs of the International Society of Surgery and the International Orthopaedic Society. The elder Lorthioir was succeeded in 1916 by Adolphe Maffei (1872-1945), a sound practitioner and teacher of the art of orthopaedics but, above all, a man of goodwill and a delightful host who was held in warm regard by all members of the International Orthopaedic Society. Maffei suffered the cruel fate of internment during the German occupation of Brussels and he died in the notorious camp at Belsen. 

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Belgian orthopaedics also bears the imprint of the pioneer work on internal fixation of fractures by that great European surgeon Lambotte of Antwerp, the counterpart of our own Arbuthnot Lane. A delightful tribute with a pen picture of this famous veteran was given by his pupil and assistant Jean Verbrugge at the annual meeting of the British Orthopaedic Association in 1949. Robert Danis, recently retired from the chair of surgery in Brussels, is another general surgeon who throughout his career has been an exponent of osteosynthesis and has devised a variety of instruments, plates, screws and nails for this purpose. Danis has recently brought together his teaching and experience in this field of traumatic surgery in a monograph published in Paris last year-Theorie et Pratique de L’osteosynthse. 

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The Belgian orthopaedic surgeons to-day compose a small but lively body of men who reflect collectively the various facets of modern orthopaedics-traumatology, surgical tuberculosis, children’s orthopaedics and the rheumatic diseases. Prominent amongst them is the genial Jean Deichef, known far and wide as the secretary-general of the International Orthopaedic Society and a frequent and welcome visitor to this country at meetings of the British Orthopaedic Association. 

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HOLLAND 

 

The story of Dutch orthopaedics in the first thirty years of this century is, in simple truth, the story of Murk Jansen (1867-1935). It is difficult to praise too highly the achievements of this remarkable man. It was not merely that he fought for the recognition of orthopaedics as an expanding surgical universe ; it was not his superb command of many languages, wide culture, or international friendships-all these lambent qualities are still fresh in the memory of those who knew him : it was the inspiring example of a questing mind that was his outstanding gift to our generation. He was perhaps the most prolific writer of the European orthopaedic surgeons of his day. From his earliest years he became inquisitive about the genesis of congenital deformities, and to the end he held on to his theory of the harmful effects on the embryo of abnormal infolding of the amnion. Despite oft-repeated arguments his thesis gained little support ; but he was nearer than he realised to a fundamental discovery in his concept of maternal “ fatigue as the determining cause of stunting of growth in the embryo (1921). Jansen’s work on bone-formation and bone-growth was a much needed critique of the somewhat over-simplified ideas which clinicians and others had extracted from the classical studies of Culmann and Julius Wolff in the nineteenth century. Murk Jansen was 

essentially the biologist in action. As an operating surgeon, an activity to which he came late, he was largely self-taught, but his years as a teacher of anatomy guided his hands along lines of safety. It is good to know, as many of the members of the International Orthopaedic Society became aware during the congress at Amsterdam in 1948, that the Anna Kliniek is to-day an orthopaedic centre in which the whole range of modern reconstructive surgery can be witnessed. The same is true of the clinic at the Wilhelmina Hospital in Amsterdam now directed by La Chapelle. We also pay tribute to the work of Van Assen of Rotterdam, an exponent of the older orthopaedics, who died on the eve of the Amsterdam congress of which he was to have been vice-president. 

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ITALY 

 

The foundations which shaped the ultimate pattern of modern orthopaedics were well and truly laid in Italy. By the end of the nineteenth century there were two great orthopaedic institutions in Milan and Bologna. In Milan, the Istituto dei Rachitici which opened its doors in 1881 was for some years devoted to the orthopaedics of children but, as new accommodation became available, its sphere of activity was extended to deal with crippling diseases in the adult. Under the direction of Ricardo Galeazzi, a man of great personal distinction and dignified bearing, the Milan Institute became one of the little group of European orthopaedic centres which attracted surgical pilgrims during the period between the two world wars. The amazing number of congenital hip dislocations treated each year in the Milan clinic had to be seen to be believed. The treatment of this deformity was evidently regarded as an every-day affair by Galeazzi, for the subject formed the basis of few clinical studies from the Milan centre. 

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Galeazzi has been one of the comparatively few orthopaedic surgeons of high standing in 

modern times to devote his energies to the solution of that somewhat unrewarding problem, 

the correction of structural scoliosis. His first report on the results of his own carefully 

devised plan of attack was made to the German Orthopaedic Congress in 1913. A full description of the method can be found in the second edition of Jones and Lovett (1929).

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There can be no doubt that in many children, and even in adolescents with spines still plastic, a considerable degree of true correction was obtained. The method was tedious ; it demanded a great deal of time and physical labour ; and it was not free from risks. The same had been true of both the Abbot and Mackenzie Forbes methods of forced correction which in turn had had their day. Although Galeazzi belonged to a generation who had entered the practice of the older orthopaedics, he moved with the times and in due course became interested in the organisation of a centre for the treatment of industrial injuries and road accidents. One of his most instructive contributions to this field of orthopaedics was a clinical and experimental study of semilunar cartilage lesions of the knee joint in which he demonstrated how unusual types of meniscus injury could be produced by powerful violence transmitted through the cruciate ligament system. 

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The story of the foundation of the Istituto Rizzoli in Bologna has often been told-how an historic old Olivetan monastery on a hill in the outskirts of the city was purchased in 1880 by Francesco Rizzoli and adapted for use as an orthopaedic hospital. Rizzoli, who had at one time been professor of surgery in the University of Bologna, left his entire fortune for the conversion of the monastery to its new purpose and for its partial endowment-surely an example of one of the material gifts of general surgery to orthopaedics. Under Panzeri, its first director, the Institute reflected faithfully the current pattern of nineteenth century orthopaedics ; but at the turn of the century a change came over the scene with the appointment of Alessandro Codivilla, a general surgeon who was to become founder of the modern movement in Italian orthopaedics. In the short span of years allotted to him, for he died in his early fifties, Codivilla left the imprint of his teaching on almost every phase of orthopaedic practice. 

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He was probably the first to develop the technique of preserving the gliding mechanism in tendon transplantations - later to be known as the physiological method (Biesalski and Mayer) ; he was an early exponent of leg lengthening, an experiment in surgery which led him to the use of skeletal traction in the treatment of fractures ; and he set out to improve the standards of technique of amputation. At first it seemed that the early death of this great master-surgeon would slow the tempo of expansion of the field of orthopaedics; but his successor was there to hand, the young Vittorio Putti who for some years had been Codivilla’s chief assistant and was destined to outshine his master. After a brief interregnum, Putti was appointed director of the Institute at the age of thirty-one. He was born in Bologna, the son of a surgeon practising in that city; his mother was a poetess much honoured in the province of Emilia. He began the study of medicine with all the advantages of a cultured home in an ancient university city. The influence of this early background was manifest throughout his career in his love of books, his pride in the history of Italian medicine, and his ripe 

scholarship. During the first world war, under the leadership of this brilliant young surgeon, the Rizzoli Institute became a centre of reconstructive surgery and rehabilitation for military patients. By the time he had reached the age of forty, Putti’s contributions to the surgery of peripheral nerve injuries, and his work on the technique of cine-plastic amputations and on arthroplasty of the knee joint, had placed him in the front rank of European surgeons. 

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Between the two world wars the Rizzoli Institute became an orthopaedic Mecca. New buildings were added from time to time but the historic original block, which contained the beautiful library, was conserved carefully. Putti made many generous gifts from his earnings in private practice towards the cost of these extensions, and the library housed his ever increasing collection of incunabula. As a collector of ancient medical books he was soon to rank with Harvey Cushing. 

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To the Rizzoli Institute during those twenty years after the first world war, years so rich in achievement, Putti attracted a succession of talented young men, many of whom were later to take charge of new orthopaedic clinics in the smaller university cities. During their apprenticeship they enjoyed opportunities for intellectual adventure which were unique, for in the library could be found the recorded lore of orthopaedics past and present, and the facilities for clinical investigation and later for pathological and experimental research were unrivalled. 

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It could be said of Putti himself that he illuminated every subject he touched.We have already referred to his earlier contributions. To these may be added his monograph on bone tumours published in 1927 in which he recorded the results of extensive resection in cases where amputation had been regarded as inevitable ; his studies on intervertebral arthritis as a cause of the backache-sciatica syndrome recorded in 1930; and his last major work, the monograph on fractures of the neck of the femur published in 1940 in which he expounded the principles and technique of internal fixation by means of a screw which exerted an impacting and not a disimpacting force. Many other striking contributions could be cited. But it is for his work on congenital dislocation of the hip joint that Putti’s fame will endure. His first communication on the early diagnosis and treatment of the deformity in infants (1927) was a contribution to preventive orthopaedics that led to the organisation of publicity and propaganda in a population suffering a serious social problem by reason of the 

high incidence of this deformity. His superb atlas on the anatomy of the deformity based on a unique series of dissected specimens (1935) has already taken its place among the classics of twentieth century orthopaedic literature. It was left to one of Putti’s most brilliant pupils, Oscar Scaglietti, to prepare for submission to the International Orthopaedic Congress in 1939 a review of the results of manipulative reduction in 3,628 cases of congenital hip dislocation treated in the Rizzoli Institute between the years 1899 and 1938. 

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Of Putti the man, the savant and bibliophile, we have already had a glimpse. Like Murk Jansen, he was polylingual-an accomplishment that gave these two remarkable men a commanding influence in the affairs of international orthopaedics during the years between the two wars, which was indeed a golden age of orthopaedic surgery. When in the fullness of time the story of European orthopaedics in the first fifty years of the twentieth century comes to be written by those to whom the heroes of this age are no longer real men but shadowy figures in history-and if, as seems likely, it will be proclaimed the age of Robert Jones, surely with his name will be linked that of the great Vittorio Putti. 

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The prestige of the Rizzoli Institute shows no signs of decline under its new director, Francesco Delitala, who has much of the same zest for the history of medicine as his great predecessor. In Rome the development of orthopaedics has followed a less spectacular course; it has had to compete for a place in the sun with general surgery represented powerfully by such brilliant Italian surgeons as Bastianelli and Alessandri. The new University Orthopaedic Clinic, which had been opened shortly before the International Orthopaedic Congress met in Rome in 1936, is a beautifully designed and equipped institute under the direction at that time of Dalla Vedova, a man of retiring disposition but none the less an able exponent of the art of modern orthopaedics. 

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SCANDINAVIA 

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In its earliest stages Scandinavian orthopaedic practice developed largely along German lines. Special hospitals for the treatment of cripples were set up, often under the aegis of voluntary organisations. These institutions provided not only beds and out-patient clinics but workshops which became centres for the supply of orthopaedic appliances and artificial limbs for a considerable hinterland, and were used also for vocational training. 

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Patrick Haglund (1870-1937) of Stockholm was for many years the recognised leader among a small and slowly expanding group of Scandinavian orthopaedists. His earlier training had been in German orthopaedic clinics and on returning to Stockholm he began almost single handed to create an orthopaedic centre in premises which consisted of a number of houses adapted for the purpose. This was the forerunner of the modern orthopaedic hospital to be erected thirty years later on the site of the new medical centre of the Caroline Institute-the Medical College of Stockholm. In the year of opening of the new hospital Haglund reached the age of sixty-five and thus was deprived of the joy of working in an institute to the design of which he had given so much thought. To the somewhat primitive and crowded premises of the old Vanforeanstalten, Haglund had attracted patients from all over Sweden and he made good use of this material in his writings and in the training of his assistants. Haglund was a man of high culture, widely read, and a lover of music. His monograph on the Principles of Orthopaedics (1923) was a scholarly work. It was written in German and no English translation ever became available. For many years the great majority of children with congenital dislocation of the hip joint in Sweden found their way to Haglund and it was this large series of cases that formed the basis of the notable survey of late results of treatment published in 1941 by a former pupil-Erik Severin. Another important contribution which came from the old clinic was the review by Harald Nilsonne of the remarkable results of cuneiform osteotomy in an unusually large series of cases of that uncommon deformity infantile coxa vara. 

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Henning Waldenstrom, who followed Haglund as director of the new Orthopaedic Institute and in the professorial chair, held these appointments for a comparatively short term of years before reaching the statutory age of retirement ; but during that time he gathered around him a group of able young men who are now maintaining the high reputation of Swedish orthopaedics. Waldenstrom’s main clinical investigations have been centred on a study of the evolutionary changes in those affections of the hip joint in which flattening of the upper end of the femur is the final stage-coxa plana. It seems clear that by 1909 he had already recognised, independently of Legg, Calve and Perthes, that pseudo-coxalgia was a non-tuberculous lesion of the hip. In 1938 he published a brief note on a condition of the hip joint which had hitherto escaped recognition as a clinical entity and which he called coxa valga magna luxans. Now in retirement, enjoying both leisure and travel, Waldenstrom 

retains his amazingly youthful appearance, and his presence among friends and colleagues as 

President d’Honneur of the International Orthopaedic Congress to be held in Stockholm next year will be a welcome occasion. 

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In Sweden, as in every other European country, general surgeons have contributed their quota to the content of modern orthopaedic practice. In this respect Sven Johansson of Gothenburg stands out in bold relief. It is not too much to say that his pioneer work on the internal fixation of fractures of the femoral neck by the canaliculised type of Smith-Petersen pin, introduced over a guide inserted under X-ray control, marked the opening of another epoch in the long history of attempts to treat this fracture by methods applicable to fractures in other parts of the body. His monograph on the Operative Treatment of Collum Femoris Fractures (Goteburg 1934) will, in retrospect, take its place amongst our orthopaedic classics. 

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Before leaving the scene of orthopaedics in Sweden we should note the interesting work of 

Svente Orell in 1932 and later years on the use of os purum and os novum as a substitute for 

the conventional autogenous bone graft. 

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In Denmark, with its smaller population scattered throughout a group of islands, two main orthopaedic centres have been developed fully. Both are special institutions on the Swedish pattern, and the treatment of recent fractures for the most part remains the prerogative of the general hospitals. The Copenhagen Orthopaedic Hospital, now housed in a comparatively modern building, owes much of its reputation for sound orthopaedic practice during the last quarter of a century to its surgical chief Poul Guildal and his able team, among whom we may mention Sven Kiaer. The second Danish orthopaedic centre at Aarhus is a more recent development. It has grown steadily in importance and influence under the direction of a man of outstanding personality-P. G. K. Bentzon, one of the best known figures in the International Orthopaedic Society. 

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In Norway the cause of orthopaedics has been upheld loyally by V. Bulow Hansen (1861-1938) and Eivind Platou, both of Oslo. In the special field of surgical tuberculosis we must also note the name of Halfdan Sundt of Stavern to whose observations on pseudo-coxalgia we owe much for our understanding of the natural history of this hip joint affection. In Finland, Langenskiold of Helsinki has been the solitary representative of orthopaedic surgery for many years and has taken an important share in the clinical activities of the Scandinavian Orthopaedic Society. 

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GERMANY 

 

The contributions of Germany to twentieth century orthopaedic literature have been massive and important but for the most part we have to appraise their significance without more than a glimpse of the personalities behind them, for since 1914 there have been relatively few contacts between British and German orthopaedic surgeons. We have already referred to the authoritarian attempt of the German surgical hierarchy to set a limit to the sphere of action of the orthopaedic surgeons of that country. It must be recognised, however, that some of the most brilliant contributions to the surgery of the locomotor system and its scientific background have come from the German university surgical clinics. The experimental and pathological studies of Axhausen during the period 1908-1928 on bone transplantation, and his work on bone infarction in relation to osteochondritis and chronic 

arthritis, were of fundamental importance to the practising orthopaedic surgeon. We must also recall the pioneer work of Erich Lexer of Wurzburg on the transplantation of joints (1908), of Payr of Leipzig on arthroplasty (1924), and in more recent years the work of Kirschner of Heidelberg on the treatment of fractures. 

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Among the recognised leaders of pure orthopaedics, in the German sense of that term, we may single out three men for high commendation-Fritz Lange, Konrad Biesalski and Hans von Baeyer. Fritz Lange of Munich was already an outstanding figure in the world of orthopaedics in the earlier years of the century, and he now lives in retirement-a vigorous octogenarian. Despite the German tradition of conservatism in orthopaedics he was an enterprising and bold surgeon. He was probably the first to practise the operation of spinal fusion by the simple technique of wiring together the spinous processes ; later he used celluloid plates for this purpose (1910). He led the way in refinements of the technique of tendon transplantation, substituting the method of direct periosteal insertion for the attachment of tendon to tendon; and where tendons were too short to reach their new destinations he prolonged them by silk strands as, for example, in his use of the erector spinae to replace the paralysed gluteal muscles. Lange was a great teacher and he built up a large university orthopaedic clinic in Munich. In 1913 he produced in collaboration with a number of colleagues the standard German text-book of orthopaedics, Aligemeine Orthopedie und Spezielle Orthopodie (Munchen 1913), a work which in its own genre can undoubtedly be ranked with the classical text-book of A. H. Tubby. 

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Konrad Biesalski (1868-1930), trained in the clinic of Hoffa, was an orthopaedic surgeon in the true line of descent from the founders of orthopaedic institutions of the earlier years of the nineteenth century. He believed that orthopaedics was as much a sociological as a surgical vocation. Inspired by this belief, he devoted some six years from 1903 to 1909 to the compilation of a census of crippled children in Germany, and found that there were one hundred thousand such children for whom only three thousand hospital beds were available. 

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He also realised, as did Robert Jones during that same period, that the crippled child had to 

be educated as well as treated for his physical disability in the same institution. By 1913 the building of the Oscar-H#{233}lCne-Heim on the outskirts of Berlin was completed to provide three hundred beds, a school, workshops and research laboratories. This complete orthopaedic institution which supplied all the needs of its child occupants was to be the centre of Biesaiski’s activities until his death. Among the many additional responsibilities that he shouldered was the editorship-in-chief of the Zeitschrzft for Orthopidische Chirurgie. Despite his preoccupation with the educational, social and legislative needs of the cripple, Biesalski and his pupils made many valuable contributions to orthopaedic literature. The work by which he will long be remembered is his experimental and clinical study on tendon transplantation in which Leo Mayer of New York was his collaborator. (Die physiologische Sehenverpflanzung, Berlin 1916). 

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The contributions of Hans von Baeyer (1875-1941), Professor of Orthopaedics at Heidelberg until 1933, on the mechanics of muscular action, clinical kinetics and the biophysical factors concerned in the production of contractures, have perhaps not received the wide publicity that is merited by their importance. Von Baeyer’s studies were more than academic exercises : they illuminated many of the difficult mechanical problems which crippling diseases continued to present to the orthopaedic surgeon. It should be remembered also that von Baeyer devised the bifurcation osteotomy for congenital hip dislocation (1918); and that translocation of tendons was another of his ingenious ideas-for example, translocation of the flexor pollicis longus in paralysis of the thenar muscles. 

We have selected three surgeons only as profiles to illustrate the story of twentieth century 

German orthopaedics. There are others whose distinguished labours must not be overlooked: 

Schanz of Dresden (1870-1932), a resourceful surgeon and known for his subtrochanteric 

osteotomy ; Oscar Vulpius of Heidelberg, an early exponent of tendon transplantation ; Peter 

Bade of Hanover; Stoffel of Mannheim (1880-1937) who devised the operation of neurotomy 

for spastic palsy ; Schede of Dresden who prepared the German report on the results of treatment of congenital dislocation of the hip joint for the ill-fated International Congress of 1939 ; Hermann Gocht (1869-1938), pupil of Hoffa, later occupant of the chair of orthopaedics in the University of Berlin, and president-elect for the 1939 congress of the International Orthopaedic Society. The doyen of German orthopaedics to-day is Georg Hohmann, the successor of Lange in the university chair in Munich, who since the war has occupied the distinguished office of Rector of the University.

 

Hohmann’s many contributions to orthopaedic literature have been confined to problems mainly drawn from the older orthopaedics and a new edition of his well-known monograph, Fuss und Bein Munchen 1948) has recently appeared. 

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AUSTRIA 

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Adolf Lorenz (1854-1946) was a dominating figure in European orthopaedics during the closing years of the nineteenth century and by then he had standardised his manipulative technique for the bloodless reduction of congenital dislocation of the hip. It was not until 1904 that he began to travel to other countries to demonstrate his method to surgical audiences who were eager to see the master at work. In the catastrophic financial collapse of Austria which followed the first world war Lorenz lost his life savings overnight, but during the next decade he repaired his fortunes in a series of visits to the United States. His tenure of the professorship of orthopaedics in Vienna had then come to an end under the age limit and his creative work lay behind him in the past. His one remaining contribution was to popularise the operation of bifurcation osteotomy (1919). It was not his own idea, for von Baeyer had already worked out its mechanical basis, and the chief credit for the more discriminating application of this procedure to different types of hip joint affection must be given to his pupil, Julius Haas, who followed him in the university chair and filled it with distinction until he was forced out by the Anschluss. Lorenz has told his own story, and it is part of the history of European orthopaedics, in his autobiography written in vivacious fashion at the age of eighty-two (Scribners, New York 1936). He made of orthopaedics a spectacular art and his place is secure in our gallery of heroes. 

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The concentration of military orthopaedic activities in the capital of the Austro-Hungarian Empire during the first world war by which to provide for the growing numbers of amputees, and for other severely crippled men in need of physical rehabilitation, brought Hans Spitzv to Vienna from Graz where he had held the chair of children’s surgery and orthopaedics (in the French fashion) and had made a notable contribution to Lange’s text-book. In Vienna, Spitzv took charge of a large war-time hospital and began to devote special attention to the operative treatment of peripheral nerve injuries. It was a field of surgery for which he had a natural bent, for he had been engaged for some time in testing the value of anastomosis between selected motor branches of the large nerve trunks in the hemiplegic upper limb. 

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After the war Spitzv settled in Vienna and his hospital was ultimately converted into a civilian orthopaedic institution. It seemed likely at one time that Spitzy’s clinic would become a popular post-graduate school of orthopaedics, but the rise of the Bologna school and the arrival of Lorenz BOhler in Vienna soon offered more exciting prospects to the young surgical traveller. 

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Lorenz Bohler’s impact on the field of fracture surgery has been one of the dynamic events of twentieth century orthopaedics. Bohler began his medical life as a country doctor and general practitioner-surgeon. During the first world war he took charge of a military hospital at Bozen where he treated a large series of gun-shot fractures of the femur. In 1925 he was called to Vienna to organise the Accident Hospital founded and maintained by the Austrian National Insurance Company. His revival of the Lucas-Championniere-Delbet practice of early weight-bearing in lower limb fractures, his use of unpadded plaster splints and casts and the organisation of active rehabilitation programmes without the aid of apparatus, soon began to attract postgraduates from far and wide. Bohler’s major contributions to fracture surgery in monograph form are of course familiar to orthopaedic surgeons throughout the world (1929, 1930, 1932). It is interesting to trace in successive editions the guiding principles to which he always held fast during the various stages of trial and error, and the ultimate simplification of technique in the handling of certain special types of fracture. Since the war Bohler has become an enthusiastic exponent of the Kontscher method of internal fixation of fractures by intramedullary nailing (1949). The Vienna experiment, as it may be called, has proved that within the framework of comprehensive orthopaedic schemes there is a place for the accident hospital. 

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SWITZERLAND 

 

The development of Swiss orthopaedics has been based on the traditional pattern of orthopaedic institutes in the main centres providing for the surgical, re-educational and social needs of the crippled and deformed. Mechano-therapy has always been a feature of the Swiss orthopaedic clinics-no doubt an inheritance from the teaching and practice of Schultess of Zurich in the nineteenth century. Among the special institutes which to-day represent Swiss orthopaedics we may single out the Anstalt Baigrist in Zurich which has been directed for more than a quarter of a century by Richard Scherb who is to be president of the International Orthopaedic Congress next year in Stockholm. Scherb has also gained the unusual distinction for a Swiss orthopaedic surgeon of being elected to a professorial chair in his subject. He has devoted much time to the analysis of muscle action in paralysis with the aid of apparatus devised for this purpose. 

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Acute orthopaedics has remained under the wing of the great University surgical clinics at Berne, Lausanne, Zurich and Basel. In the latter centre we must pay tribute to the researches of Henschen on the physical properties of bone which have led to a better understanding of the behaviour of skeletal tissue under stress (1932-1937). Among other noteworthy contributions from general surgeons in Switzerland we may recall that Bircher was one of the early continental surgeons to deal with the problem of internal derangement of the knee (1925); and that Steinmann who also wrote on this subject in 1926 was a pioneer in the technique of skeletal traction. 

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Between the two world wars no “grand tour” of European orthopaedic clinics was complete without a visit to Leysin to see the work of that remarkable man Rollier. At the height of his activities Rollier was neither a general surgeon nor an orthopaedic surgeon in the narrowest sense of these terms. He treated surgical tuberculosis by rest and controlled helio-therapy, and in bone and joint tuberculosis used a minimal amount of mechanical restraint for the affected area. Rollier also radiated an atmosphere of cure-a vital attribute in dealing with patients who had to face long periods of relative immobility. His interest in the welfare of the victims of surgical tuberculosis extended to their rehabilitation after active treatment had been concluded, and the establishment under his guidance of what he called factories in the sun was a notable contribution to social orthopaedics.

 

SPAIN AND PORTUGAL 

 

In the countries of the Iberian Peninsula, orthopaedics appears to have developed in conformity with the usual mixed patterns. San Ricart of Barcelona has been a familiar figure at national and international congresses during the last twenty-five years despite the political upheavals in Spain, and by his qualities of mind and heart he has shown himself to be first and foremost a good European. He has for many years made a special study of amputations and of the problems relating to prostheses. 

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Bastos y Ansart, who at one time in Madrid directed a large rehabilitation hospital providing for the needs of soldiers wounded in the Spanish adventures in Morocco, has now settled in Barcelona. In earlier years many of his contributions were concerned with the general field of orthopaedics but latterly his interests have been directed towards traumatology. It is fitting here to record that from the Catalan capital British orthopaedics has acquired one of its brightest ornaments in the person of Joseph Trueta, now of Oxford. 

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MIDDLE EUROPE AND RUSSIA 

 

In the period of our review, orthopaedics in Hungary, though to some extent overshadowed by the dominating influence of the Vienna school, was represented worthily by men such as Michael Horvath (1868-1938) who directed the first complete orthopaedic institute at Budapest, and Eugene Kopits (1869-1946) who combined orthopaedics with children’s surgery and was the founder of the Hungarian Orthopaedic Society and author of the first treatise on orthopaedics in the Hungarian language. We are also indebted to Hungary for one of the most important contributions in recent times on the pathogenesis of scoliosis by A. Farkas, Uber Bedingungen und auslosend Momente bei der Skoliosenentstehung (Stuttgart 1925). 

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In the university cities of the old Czechoslovakia, orthopaedic clinics developed in accordance with the contemporary German and Austrian patterns; but during the independent life of the Czechoslovakian republic French influences also played their part. Among the leaders of modern European orthopaedics Jan Zahradnicek of Prague has for some years held a high place. His work on the treatment of congenital dislocation of the hip in infants, and on the technique of open reduction in older children, had a marked influence on Jacques Leveuf’s approach to these problems as the latter acknowledged so freely. 

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For many obvious reasons it is difficult to appraise the contributions to twentieth century  orthopaedics of Poland, Yugoslavia, Romania, Greece and Turkey but tribute must here be paid to such men as Adam Gruca of Warsaw and Dimitrijie Yovtcitch of Belgrade who in face of formidable obstacles to travel have shown by their loyalty to the International Orthopaedic Society how much they value membership in the comity of European orthopaedic surgeons. 

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For a long time we have looked at Russian orthopaedics “through a glass darkly” but we have been able to perceive clear outlines of the figure of one man-Henry Turner of Leningrad. Before the revolution of 1917, Turner had been professor of orthopaedics in the Imperial Military Academy of Medicine and he was allowed to retain this post under the Soviet Government for many years. Turner attended the International Congress of Medicine in London in 1913 and was one of that distinguished gathering of orthopaedic surgeons from many nations who were entertained to dinner by Robert Jones on a memorable evening at the Royal Automobile Club. For some years after the first world war Turner corresponded regularly with Sir Robert who was able to arrange for the publication of a number of his articles in British and American journals. His completion of fifty years of active work in orthopaedic surgery was recognised by the Soviet Government as a notable contribution to human welfare and it was commemorated, as in any capitalist country, by the presentation of his portrait painted by a leading Soviet artist! In this picture the great surgeon appears not in formal dress, nor even gowned for the operating theatre; but armed with hammer he 

stands in shirt sleeves before an anvil. In the background we get a glimpse of a workshop and of the orthopaedic appliances he symbolically forged; but there is also another human figure-a crippled boy. 

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REFERENCES 

 

BAEYER, H. VON (1933): Internationale de Chirurgie Orthopedique. Deuxieme Congres. Bruxelles: Societe Imprimerie Lielens. 

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CALVIN, J., and GALLAND, M. (1930): Physiologie Pathologique du Mal de Pott. Revue d’Orthopedie, 17, 5. 

 

GALEAZZI, R. (1927): Journal of Bone and Joint Surgery, 9, 515. 

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JANSEN, M. (1920): On Bone Formation: Its Relation to Tension and Pressure. Manchester: University Press. London: Longmans Green & Co. 

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LERICHE, R. (1939): Physiologie et Pathologie du Tissu Osseux. Paris: Nasson et Cie. 

 

LEVEUF, J. (1936): Le syndrome de Volkmann. Revue d’Orthopedie, 23, 5. 

 

LEVEUF, J. (1947): Les Lesions Initiales de L’Osteomyelite Aigue. Revue d’Orthopedie, 33, 177. 

 

LEVEUF, J., and BERTRAND, P. (1946): Luxations et Subluxations congenitales de la Hanche. Paris: Doin et Cie. 

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SORREL, E. (1921-1939): Publications sur la Chirurgie Osseuse. Paris. 

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SORREL-DEJERINE, Y. (1926): Contribution a l’etude des paraplegies pottiques. Paris: Masson et Cie. 

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