, 1913

, Vol. VIII

only solution to this difficulty is that the general surgeons should give up these cases to the orthopedic surgeon for treatment, or learn how to apply the spica. It is to be feared he will resist either of these alternatives.

Another of the numerous facts regarding fractures which should be known to the general practitioner is that, for obvious. reasons, it is impossible to get union in good position, in fractures of the lower end of the tibia and fibula, unless the foot is held absolutely at right angles. If reposition is not affected immediately after the injury, this is not infrequently impossible without tenotomy of the tendo Achillis or heel cord.

This brings up another point which continues to be discussed in certain quarters. This is the danger of non-union after tenotomy of the heel cord. I have heard from more or less reliable sources, that this untoward event has been known to occur; but in my twenty years of practice, fifteen of which have been devoted to the study and practice of orthopedic surgery, I have never seen an actual case. There never need be any hesitancy in doing a tenotomy because one fears non-union; all one should be sure of, are the indications.

I believe the general practitioner should familiarize himself with the mechanical principles which govern the treatment of fractures. He should, at least know the comparatively simple measures, which if properly applied, are often more likely to lead to good results, than complicated operative procedures. For if he knows. these, he is at least in a position to judge whether or not, his patient is being properly cared for, should he, because he feels his lack of constant practice in these mat

ters, not care to undertake the treatment himself.

Personally I feel that because of his better mechanical knowledge, and constant practice with apparatus and bandaging, the orthopedic surgeon is better fitted to care for fracture cases than either the general practitioner or the general surgeon. I do not mean to infer that the general surgeons have not the right to treat these cases; but I feel compelled to say, that, if he does undertake their treatment he is in duty bound to study the mechanical principles which underly the procedures to be carried out. These things cannot be done intuitively; nor does a large experience in abdominal surgery make the surgeon more competent to treat fractures. Only after the general surgeon is brought to a realization of these facts, will the orthopedic surgeon be relieved of the burden of caring for the numerous failures in the treatment of fractures which come from the general hospitals.

Exactly similar conditions prevail, in the surgical treatment of diseases of the bones and joints generally. The bones and joints have mechanical functions; when they are the subject of disease, the treatment must be adapted not only to the immediate relief of symptoms, but to the future mechanical necessities. That the general surgeon does not always consider ultimate mechanical functions which these organs must perform, is born out by the fact that secondary operations are often necessary to correct deformities which should have been forestalled by proper dressings, etc., at the primary operation; by the fact that bone plugging, wiring, etc., are still constantly being discussed in associations of general surgeons, when the proper

operative procedures make these devices entirely unnecessary.

Of late years, we have had a number of rather widespread epidemics of poliomyelitis. This condition with its final results is one long familiar to the orthopedic surgeon; but, to judge from the expressed views of some of our leading neurologists and pediatrists, has until recently entirely escaped them. Hence it is, that a family, so unfortunate as to have one of its members so affected, providing they have the money to spend, hear the most diverse and and not infrequently the most antiquated notions regarding the treatment and its results. These views, only some of which can be honestly intended, not only lead to much unnecessary suffering but places the medical profession at the mercy of scoffers.

As this condition continues to be prevalent and unfortunately seems likely to remain so, it is important for the family physician to become familiar not only with the supposed etiology and pathology, but also with the practical side of this condition. He should, in a measure be able to

advise his patient or his family, regarding the propriety of the methods of treatment to be carried out.

In this connection, the family physician is, to a certain extent, responsible for the ill results and the disappointment caused by ignorant or dishonest practitioners, be they regular or irregular. He should know, for instance, that the injection of strychnine into paralyzed muscles, is not only painful, but is absolutely without benefit. I have known patients to receive these injections once or more weekly, throughout the course of an entire year and to the complete exclusion of all other treatment. As every one who takes the trouble to in

form himself, knows these injections to be useless, I consider this almost criminal.

There is no doubt that massage and electricity aid in retaining or stimulating the tone of partially paralyzed or weakened muscles; but it should be perfectly evident to every one (though it is not, or I would not speak of it) that they have no influence in restoring degenerated nerve cells. And yet in many instances these procedures receive more consideration during both the early and late stages of this disease, than more rational measures.

Long experience has taught us that contracture and deformity may, and often do occur during the initial stage of poliomyelitis. It is important to know this for several reasons. In the first place, contractures often need operative measures for their correction. Secondly, it should be more generally known and appreciated that contracture of one muscle always leads to a stretching and in the case of a paralyzed. or weakened muscle, to more or less permanent lengthening of the opposing muscles. This means that, even should there be complete recovery the stretched muscle. will, nevertheless, lose in efficiency. Hence orthopedic measures, not strychnine injections, nor massage and electricity, are the most important considerations in the early. as well as the late stages of infantile paralysis. These children should be so placed that the stronger muscles do not contract, even should this necessitate more or less complete immobilization.

Of course when one speaks of immobilization one is immediately confronted with that pernicious fallacy, that immobilization leads to atrophy which is true, and that this atrophy leads to serious consequences which is absolutely false.

There is no doubt that muscles atrophy when they are put at rest, but it is a fact

patent to every one who has eyes and a little experience, that this atrophy soon disappears when the muscle is permitted to resume its function. Indeed I have seen muscles immobilized for a number of years regain almost complete activity within a few months.

Hence there is everything to be gained by keeping children at rest during the early stages of poliomyelitis.

It should be understood that more or

less complete recovery from poliomyelitis depends, not upon the kind of treatment, but upon restoration of the cells in the spinal cord. Hence beware of the man who tells you he cures his cases of infantile paralysis.

Moreover, the recovery or the complete destruction of the anterior horn cells is entirely independent of treatment applied externally. All we can do is to retain the parts in their proper relation and improve

the mechanical conditions as we find them. If the cells recover, the muscular power will return even if the limb has been completely immobilized.

These considerations must be born in mind when the question of applying braces comes up for discussion. What applies to braces in the treatment of infantile paralysis, is equally applicable to the use of braces in other orthopedic conditions. Braces or splints of various kinds are never applied by a qualified orthopedic surgeon with the idea that they are curative. They are used principally for two distinct. purposes; either to retain a bone or joint in its proper mechanical relations, without strain, whilst nature or general treatment restores diseased parts; or to improve the mechanical efficiency of some part of the skeleton, impaired by disease or accident.

In infantile paralysis a brace is applied

to facilitate walking. to facilitate walking. It has no bearing either in curing or preventing recovery, except that by retaining the efficiency of mechanical relations, it often saves the patient the necessity of undergoing operations later on, and promotes the general well being by permitting locomotion. It is either with the intention to willfully falsify, or due to their dense ignorance, that certain individuals maintain that braces

properly applied can or will do harm. And

the claim made by some that they can cure infantile paralysis and make more or less completely walk paralyzed individuals without apparatus, is too preposterous to be excused as actuated by natural enthusiasm or philanthropic ardor.

I have only called your attention to a few very evident considerations, which the general practitioner should take unto himinordinately upon your time and patience. self. I have perhaps, encroached somewhat But I hope I have interested you at least a little. For, in principle, similar conditions apply to all the special branches of medicine.

I think the family physician should make it his duty to know the principles of the management of the treatment of patients irrespective of the nature of the illness. In this event he can become a real family adviser. It develops upon him to direct them when they need special care; and if he has their interests at heart, as he should, he will make it his business to know where and how they can best be cared for honestly and efficiently.

If he sees his duty in this light he will become a real family adviser and trusted friend, and under these circumstances I can imagine no more useful or honorable calling than that of the family physician.