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Wednesday, 28 March 2007 15:42 |
| | THE FOUNDATIONS OF MODERN ORTHOPAEDICS | | | | It was not until the l2th century that Europe began to awake gradually from its Dark Ages. Universities and hospitals were beginning to be established, human dissection resumed and the great Greek texts were being translated from Arabic to Latin. However, until the l6th century, all developments remained within the shadow cast by Hippocrates.
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| AMBROISE PARE (1510-1590) Ambroise Pare is regarded as the most famous surgical figure of the l6th century and the father of French Surgery. He was born in Bourg Herent in France. In 1532 he became an apprentice to a Parisian barber-surgeon, then worked for four years at Hotel Dieu in Paris. In 1541, he became a master barber-surgeon and did some work as an army surgeon. In 1564, he published a monumental work on Surgery, the Dix Livres de la Chirurgie. The first part contained Anatomy and Physiology and the second, Surgery. In this, many surgical techniques were described, one of the most significant being the use of ligature for large vessels in amputations. He also used a tourniquet in his amputations, to hold the muscles retracted with the skin, prohibit the flux of blood and to dull the senses. He designed a wide variety of forceps, instruments and braces of all kinds. With the help of armourers, he made a variety of artificial limbs from iron. The majority were cosmetic, although Pare did design a scoliosis corset and a clubfoot boot. | | | |  | NICHOLAS ANDRY (1658-1759) Andry was the professor of Medicine at the University of Paris and Dean of the faculty of Physick. In 1741, at the age of 81, he published a famous book called Orthopaedia: or the Art of Correcting and Preventing Deformities in Children. By such means that may easily be put into Correcting and Preventing Deformities in Children. By such means that may easily be put into practice by parents themselves and all such as are employed in Educating Children. In this book, Andry presents the word Orthopaedic, which derives from the Greek words straight and child. Andry was interested in postural defects and this has been reflected by his famous illustration, which is known The tree of Andry. Andry believed that skeletal deformities were due to faults of posture and shortness of muscles. Some regard Andry as the Father of Orthopaedics, by many strongly disagree, believing that his work was un-scientific and that his only contribution was the use of the word Orthopaedics. | | | | 
| THOMAS SYDENHAM (1624-1689) Sydenham is likened to Hippocrates because his writings cover a large field and are characterised by good observation. Likewise, he is also known as the father of English medicine. He was born at Winford Eagle, and studied at Oxford and Montpellier. He himself suffered from gout and wrote an excellent description of the disease, detailing the attack, the changes in urine and the link with renal stones. He described acute rheumatism, chorea, and the articular manifestations of scurvy and dysentery. | | | | 
| PERCIVAL POTT (1714-1788) Pott was from London and worked in St. Bartholomew's Hospital, were he received the diploma of the Barber-Surgeons' Company in 1763. He is best known for the fracture that bears his name Pott's fracture, as he was the first to give a good description of this ankle fracture. In 1756, he received a fracture of his own. This was an oblique compound fracture of the lower third of the tibia, which was acquired after falling from his horse. He refused to be moved until he had purchased a door to be carried on, as he believed that the jolting of a carriage would have exacerbated the injury. Immediate amputation was usually conducted on such injuries, but at the last moment amputation was stopped and the limb was saved. Pott's most famous work is on the paraplegia of spinal tuberculosis, where he stressed that the condition was not related to spinal cord compression, but associated with strumous disorders in the lungs. This is known as Pott's paraplegia. | | | | WILLIAM HEBERDEN (1710-1801) Heberden was born in London were he also built up a busy practice. He is known for initiating the Medical Transactions in 1766, but even more so for his description of Heberden's nodes. | | | | 
| JOHN HUNTER (1728-1793) Hunter worked on a Lowland farm until he was 20 years of age. Until he was 32, he was a pupil and house surgeon at St. George's Hospital in London and also worked in his brother's dissecting room in Covent Garden. In the Seven Years' War, he served as a military surgeon. He set up a research centre in London's Golden Square and taught and lectured at Leicester Square until angina eventually led to his death. Hunter's contribution was immense and even stemmed through the pupils he taught (e.g. Abernethy, Chessher, Jenner and Philip Syng Physick). Hunter himself was a pupil of Percival Pott. Although he received little formal education (unlike his brother William, an obstetrician in London) Hunter put the practice of surgery on a scientific foundation and laid the framework for the twentieth century developments. His saying Don't Think, try the experiment has inspired generations of modern surgeons. | | | | Much of Hunter's knowledge may be attributed to his military experience and his experiments on animals. He described how to assess muscle power in a weak muscle. With joint injury and disease, he states that voluntary movement should not be permitted until inflammation has settled, otherwise contracture is promoted. He believed that healing depended on the body's innate power, and that the surgeon's task was to aid this. Hunter believed that bone disease often required mechanical assistance. He studied loose bodies in joints, pseudoarthroses and fracture healing, where he described the transformation from fracture haematoma to fibrocartilagenous callus to the deposition of new bone, trabeculation, reestablishment of the medullary canal and the resorption of excess bony tissue. Hunter wrote A Treatise on the Blood, Inflammation and Gunshot Wounds in 1794, and also made attempts at tissue grafting.
His collection of specimens (initially over 14,000 POT's; half destroyed in the bombing of London) is in the College of Surgeons, London. They describe the development of the various systems from the simplest (insects) to the most complex. It is a humbling and inspiring experience to visit the museum and see one mans monumental contribution to surgery. | | | | JEAN-ANDRE VENEL (1740-1791) Jean-Andre Venel was a Genevese physician who studied dissection at Montpellier at the age of 39, and in 1780, established the first orthopaedic institute in the world at Orbe, in Canton Waadt. This was the first true hospital that dealt specifically with the treatment for crippled children's skeletal deformities. Venel recorded and published all his methods and for this was known as the first true orthopaedist. He is also regarded as the father of orthopaedics, as his institute acted as a model for hospitals throughout Europe. Venel stressed the importance of sunlight and made various braces and appliances at the workshops within the institute. | | | | 
| WILLIAM HEY (1736-1819)
William Hey was born in Pudsey near Leeds. At the age of 14 he was apprenticed to a surgeon and apothecary and nearly died of an overdose of opium whilst studying its effects. He was the founder of Surgery at Leeds and trained at St. George's Hospital. Hey wrote a book on Surgery which contained several chapters on Orthopaedics. Subacute Osteomyelitis of the tibia was described and he advocated deroofing of the lesion. In 1773, Hey banged his knee getting out of the bath, and many attribute his subsequent interest in the knee to this. He coined the phrase internal derangement of the knee, and described meniscal injuries. Hey described loose bodies and introduced tarso-metatarsal amputation. | | | | GIOVANNI BATTISTA MONTEGGIA (1762-1815)
Monteggia was born at Lake Maggiore and was a Milanese pathologist who acquired syphilis by cutting himself at autopsy and became a surgeon and professor at Milan. He is particularly remembered for his description in 1814 of the fracture that bears his name, Monteggia's fracture. | | | | 
| ABRAHAM COLLES (1773-1843)
Colles was born in Kilkenny, Ireland, of humble origins. Nevertheless, he became professor of Surgery at the College of Surgeons in Dublin from the age of 29. He was the first to tie the subclavian artery, but is best known for his description of Colles' fracture, in 1814 (the same year as Monteggia).
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| BARON GUILLAUME DUPUYTREN (1777-1835)
Dupuytren was born in central France. He was kidnapped as a boy by a rich woman from Toulouse on account of his good looks. He was taken to Paris and educated, but endured great poverty throughout his studies. Dupuytren became Surgeon in chief at the Hotel Dieu and worked tremendously hard and became very rich. He was described as an unpleasant person to meet, yet his work was delightful to read. He was characterised as First among surgeons, Last among men. | | | | He was an accurate clinical observer with a great interest in pathology. Dupuytren's name is most associated with the contracture of palmar fascia and a particular ankle fracture that he described. He wrote on many subjects, including congenital dislocation of the hip, the nature of callus formation, subungal exostosis, the Trendelenburg sign, tenotomy in torticollis and he differentiated osteosarcoma from spina ventosa. | | | | 
| JAMES SYME (1799-1870)
Syme was born in Edinburgh. As a student at Edinburgh University he found a way of dissolving rubber. Syme opened a school of Anatomy and later opened a very successful private clinic. In 1833, he became Professor of Surgery in Edinburgh and held that position until his death, (he had actually made an agreement with his predecessor to pay him a pension if he resigned). Syme is known for introducing conservative alternatives to the major amputations that were carried out at the time. In 1831, he released a booklet, which detailed cases where joint excision could be used instead of amputation for grossly diseased joints, as in tuberculosis, and injured joints. In 1842, Syme described an amputation at the ankle. This amputation bears his name, as it replaced a portion of below knee amputations, which were ordinary practice at that time.
| | | | SIR BENJAMIN BRODIE (1786-1862)
Brodie was a national figure. He was a surgeon at St. George's Hospital and a friend of the Thomas family (that of Hugh Owen Thomas). He first published his book, On the Diseases of Joints in 1819, which proved to be a popular reference for many years. In 1832, he described the chronic bone abscess that has been named after him. The patient was a man of 24 who had recurring symptoms in the lower extremity of his right tibia. On examination, Brodie found a pus filled cavity, for which he believed that amputation could be avoided by trephination of that cavity. He recognised the association of arthritis with gonorrhoea and that all children's hip disorders were associated with infection. IN 1843, he introduced the Fellowship examination of the Royal College of Surgeons in order to improve the education and standing of surgeons. | | | | 
| JOHN RHEA BARTON (1794-1871)
Barton was born in Lancaster, Pennsylvania, U.S.A. He studied at the Pennsylvania Hospital and later worked for Physick (the father of American Surgery) who in turn was a student of Hunter's.It was said that Barton was ambidextrous and that once he had positioned himself for an operation, he did not move about. In 1826, he performed a subtrochanteric osteotomy of the femur for a severe flexion-adduction deformity of the hip. Barton is best known for his innovative corrective osteotomies for ankylosed joints. In 1834, Barton wired a fractured patella and in 1835, he described Barton's fracture of the wrist.
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| ROBERT WILLIAM SMITH (1807-1873)
Smith was born in Dublin, he studied and worked there. He became Professor of Surgery at Trinity College in Dublin. Smith founded the Dublin Pathological Society with Colles, Graves, Corrigan and Stokes. In 1847, Smith wrote a classic book called A Treatise on Fractures in the Vicinity of Joints, and on certain forms of Accidents and Congenital Dislocations. Here he describes the eponymous Smith's fracture, and Madelung's deformity before Madelung described it.
| | | | In 1849, he published A Treatise on the Pathology, Diagnosis and Treatment of Neuroma. This book was said to be so large that it was larger than an ordinary sized dinning-room table when opened up. Smith wrote on neurofibromatosis in great detail, much before von Recklinghausen did. | | | | 
| ANTONIUS MATHYSEN (1805-1878)
Mathysen was a Dutch military surgeon who in 1851, invented the plaster of Paris (POP) bandage which was to become so important to orthopaedic practice.
To this day, a POP cast is the mainstay of fracture immobilisation.
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| WILLIAM JOHN LITTLE (1810-1894)
Little was educated at the Jesuit seminary at St. Omer. He himself had a paralytic clubfoot. The treatment in London was amputation, however, he found a cure in Germany by tenotomy. Little was a founder of the Royal Orthopaedic Hospital. He published a detailed report, in 1862, of the then ill-understood group of deformed and partly retarded children and young adults. This type of spastic paralysis with paraplegia of the lower limbs was then called Little's disease for many years.
| | | | JOSEPH LISTER (1827-1912)
Lister studied at the University College Hospital in London. In 1853, he became Syme's house surgeon, he then married Syme's daughter, and in 1854 became assistant surgeon to the Royal Infirmary. Lister is known for the introduction of antisepsis. He first applied carbolic acid to a compound fracture in 1965. It was soon clear that the practices had had a dramatic effect in reducing in particular abscesses, pyaemia, hospital gangrene, erysipelas and amputation mortality. Lister was made a baronet in 1883, and later in his life was thought to have trialed the application of the Penicillium mould directly to wounds.
JEAN-MARTIN CHARCOT (1825-1893)
Charcot was from Salpetriere in Paris and is known worldwide as the first professor of Neurology. He wrote a thesis distinguishing gout, rheumatoid arthritis and osteoarthritis. Charcot also first described the arthropathy that bears his name. Charcot's joints. He was first to write about amyotrophic lateral sclerosis, intermittent claudication, disseminated sclerosis, intermittent hepatic fever and herpes zoster. | | | | 
| THEODOR KOCHER (1841-1917)
Kocher was born in Berne and studied in Berlin, London, Paris and Vienna. In 1872, he became Professor of Surgery in Berne. Kocher had a great interest in Anatomy and in 1870, he described his eponymous method of reducing a dislocated shoulder. Kocher wrote a remarkable book in which he detailed many useful surgical incisions that he had developed, such as his posterolateral exposure of the hip. He also developed several surgical instruments, but his main interest was in thyroid disease. | | | | 
| SIR JAMES PAGET (1814-1899)
Paget was a graduate of St. Bartholomew's Hospital in London, where he remained for the rest of his career. It was in 1877 that Paget gave the first description of what he called osteitis deformans, but what is now commonly called Paget's disease. He noted the increased incidence of osteosarcoma, the increasing head size and deformities. (One of Paget's original drawings is shown.) Paget was also a remarkable lecturer with a great interest in bone pathology. His name is also associated with other pathological processes.
| | | | SIR WILLIAM MACEWEN (1848-1924)
Macewen studied in Glasgow and had Syme and Lister as teachers. The new era of antisepsis enabled him to make many contributions to Surgery. In terms of his Orthopaedic contributions, he performed many osteotomies and developed a one-piece osteotome. Macewen's main research interest was in bone growth and in 1879 he performed the first of his pioneering bone grafts. Many of his grafts were performed on people who had had portions of their bones excised, but who had otherwise normal function. Macewen was also a pioneering neurosurgeon and cardiothoracic surgeon. He worked on cerebral tumours and abscesses and also performed the first pneumonectomy. | | | | 
| RICHARD VON VOLKMANN (1830-1889)
Volkmann was from Halle, Saxony. He was the first in Germany to institute Lister's antiseptic methods. In 1881, Volkmann published his famous paper on ischaemic muscular paralyses and contractures. Here he attributed the cause of the contractures to direct changes in the muscles produced by arterial occlusion and emphasised the early warning of preliminary weakness. These contractures are otherwise know as Volkmann's ischaemic contractures. It is interesting to note that Volkmann wrote popular poems and fairy stories and also founded a surgical journal.
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| EDUARD ALBERT (1841-1900)
Albert was born in Bohemia and studied in Vienna. He is best known for producing artificial ankyloses in paralysed limbs and wrote a paper on this in 1881. Albert performed tarsal and shoulder arthrodesis for paralysis and recurrent dislocation, and was the first to use the term arthrodesis. Albert also described synovectomy, the transplantation of nerves, sciatic scoliosis and Achilles bursitis.
| | | | HAROLD BENNETT(1837-1907)
Bennett studied at Trinity College, Dublin. He collected specimens of bone pathology and with these wrote a paper on fractures of the metacarpal bones in 1882. In this paper Bennett described his eponymous fracture dislocation of the base of the thumb metacarpal. Bennett is said to have introduced antisepsis to Dublin and to have performed many osteotomies for rickets. He became President of the Royal College of Surgeons of Ireland. | | | | 
| HUGH THOMAS (1834-1891)
If you could only read about one person in the history of Orthopaedics, then you would have to read about Hugh Owen Thomas, the father of British Orthopaedics. Hugh Owen Thomas was the eldest of five sons born to a well-known bonesetter at that time. All studied Medicine.Thomas was a thin and nervous child who was somewhat delicate. His peculiar temperament in adulthood led many to ignore him and his immense contributions to Orthopaedic Surgery during his lifetime. Hugh Owen Thomas could not even work with his father and never held a hospital appointment. He treated all his patients at his home. His practice was so busy that he started his rounds at five or six in the morning and never left his home for other than professional purposes. Thomas would designate Sunday as his free day and hundreds of patients from the country would surround his house in order to be treated.
The people of Liverpool knew Thomas as a short and quick man. A man who always wore a black coat buttoned up to the neck and a sailors cap pulled over a damaged eye. A cigarette was also seen constantly in his mouth. Despite Thomas's busy schedule, Thomas wrote prolifically in the night and developed many new techniques and surgical instruments. He believed in enforced, prolonged and uninterrupted rest for the treatment of tuberculous joints. Thomas developed a great number of splints in order to achieve this. These include, the cervical collar, metatarsal bar, heel wedge and knee splint. Many of these are still in use, such as the Thomas splint. Thomas was also able to recognise early cases of hip disease. He was the first to demonstrate concealed flexion of the hip joint and a way of unmasking this by performing the Thomas Test.
It should be remembered that Hugh Owen Thomas had studied Medicine and was interested in litholopaxy and the management of acute abdomen as well as Orthopaedics. It has been said that the medical profession might not have practised the black art of bone setting, if Hugh Owen Thomas had not graduated from a Medical school.
| | | | SIR WILLIAM ARBUTHNOT LANE (1856-1938)
Lane was a Scot from Inverness who trained and later worked at Guy's Hospital in London. Lane is known for his attempts at improving alignment of fractures by using internal fixation. He started off using silver wire, then he used steel screws and this was followed by the use of plates and screws. Lane was said to have been eccentric, regarding humans as machines and performed total colectomies as a cure for auto-intoxication. He also initiated the programmes of health education that are present today. Lane wrote columns in the newspapers, held public lectures and improved the distribution of fruit and vegetables.
FRITZ DE QUERVAIN (1868-1940)
De Quervain was born at Sion in the Valais Canton of Switzerland. He studied at Berne and succeeded Kocher as Professor of Surgery there. In 1895, de Quervain described a form of chronic tenovaginitis, which is now known as de Quervain's stenosing tenovaginitis. Like Kocher, he studied thyroid disease and is responsible for the introduction of iodised table salt. | | | | 
| FRIEDRICH TRENDELENBURG (1844-1924)
Trendelenburg was born in Berlin. He studied Medicine in Glasgow and in Berlin. Trendelenburg's name is associated with the Trendelenburg sign and the Trendelenburg gait, which he described in association with coxo-femoral incompetence in 1895. Trendelenburg also devised pulmonary embolectomy, but it was one of his pupils, Kirshner who first met success with the procedure many years later in 1924.
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| PIERRE MARIE (1853-1940)
Marie was born in Paris, he worked for Charcot and eventually succeeded him as Professor of Neurology at Salpetriere. Marie described peroneal muscular trophy (Charot-Marie-Tooth disease). He was the first to associate acromegaly with a pituitary tumour in 1886. In 1980, he described hypertrophic pulmonary osteoarthropathy. In 1898, he gave the first account of cranio-cleidal dystosis and noted the partial aplasia of the clavicles, the increased skull diameter, the disordered dentition and the failure of ossification at the fontanelles. Also in 1898, he published a classic paper on ankylosing spondylitis, which he refereed to as spondylosis rhizomelique. Marie believed that poliomyelitis was infectious.
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| LOUIS XAVIER EDOUARD LEOPOLD OLLIER (1830-1900)
Ollier was born in Vans in Ardeche and studied at Lyons and ontpellier. Ollier, like Macewen, performed pioneering bone grafts. Although both were successful, their methods and the theory behind them were in fierce opposition. In 1877, Ollier suggested that bone growth may be inhibited in order to correct certain deformities by resecting the epiphyeal plate. In 1899, Ollier first described dyschondroplasia or Ollier's Disease. Ollier researched bone growth to an enormous extent and believed that it might be possible one day to treat patients by stimulating their cartilage to ossify. | | | | 
| WILHELM CONRAD RONTGEN (1845-1923)
Although Rontgen was a professor of Physics at Wurzburg, his discovery of X-rays (Rontgen rays) and their use has provided an enormous contribution to Orthopaedics and is still of great value to Orthopaedic practice. The first radiography that Rontgen took was of his wife's hand on the 22nd of December 1895. This was allegedly her Christmas present. Rontgen received the Nobel Prize for his discovery in 1901.
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