Observations on the General Treatment of

Fractures.

ANSEL G. COOK, M.D., Hartford.

The treatment of fractures during the past fifteen years has not made the rapid progress that has characterized the other branches of medicine and surgery.

No great discoveries have been made, and no particularly valuable form of apparatus has been invented. Still, fractures today are better understood and better treated than ever before.

The more general knowledge of asepsis has helped; the uses and limitations of the plaster of Paris bandage have been more clearly defined, and splints and appliances of all kinds are less complicated and more efficient.

Our progress and I can honestly report progress is due rather to what we have unlearned, than to what we have learned. Fifteen years ago, all the text-books that I was able to consult, actively asserted or tacitly admitted that fixation of an injured joint produced ankylosis.

Hamilton was still the great authority on fractures, and Hamilton said, and said emphatically, that in fractures into the elbow joint, passive motion should be inflicted on the joint as early as the seventh day after the injury.

The courts of law accepted the doctrines of Hamilton as proper treatment, the text-books supported him, and the general practitioners of medicine inflicted the passive motion. This they did, conscientiously and industriously, first, last, and all the time.

A reaction, however, was beginning to set in. The younger men who had not felt the personal influence of Hamilton, followed less blindly than their elders. Early passive motion did not always prevent ankylosis. There were plenty of stiff joints in evidence, that had had early passive motion.

On the other hand, immobilization did not invariably produce ankylosis. Hamilton himself, with his long side splint, immobilized the uninjured knee and hip when he set a fracture of the femur, and these joints did not ankylose.

Orthopedic surgeons immobilized very seriously inflamed joints for long periods of time, and these joints frequently returned to their former usefulness.

Lastly, why should injured bones, muscles, ligaments, and tendons, when combined in the formation of a joint, be inflicted with early passive motion, when bones, muscles, ligaments, and tendons considered separately, were universally admitted to require rest and immobilization?

On May 24, 1894, I had the honor to read a paper before this Society, on "Fixation in the Treatment of Fractures into Joints."

I did not believe in the early passive motion of fractures into joints, and I spoke against the practice.

I have never claimed any originality for my ideas, but I was the voice of a very small and feeble minority of the members of this Society, and we had the books, the courts, our brother practitioners, and the laity, thoroughly drilled in the teachings of Hamilton, all against us.

I will quote from my original paper, a summary of the results of my investigations.

Results.

No normal joint has ever been proved to be ankylosed or even inflamed by immobilization per se. If the immobilization has been performed in such a manner as to produce interarticular pressure of the bones, or the bandage so tightly applied as to interfere with the circulation, and produce sloughing or gangrene, the case cannot be considered one of simple fixation.

"Fixation, though it does not cause ankylosis or inflammation, produces important changes in the tissues; muscles atrophy from disuse, bones become more porous and friable; blood vessels diminish in size and number, and in the young, the development of the limb is retarded.

"It seems probable that immobilization would diminish temporarily the supply of synovial fluid and render the membranes and tendons less pliable.

"I am inclined to this opinion, though Phelps, in examining dogs killed nearly five months after their joints had been carefully immobilized, found the synovial fluids undiminished in quantity, and the tendons, ligaments and membranes in all respects normal.

"A certain amount of motion is necessary for the growth and development of all the tissues of a healthy joint; when the joint is immobilized, the tissues atrophy and growth is retarded. When the joint is again used, no matter how long the period of immobilization may have been, the tissues regain their normal consistency.

"When the patient is young, and the period of immobilization has extended over months or years, the matter of retarded development may become a serious detriment to the future usefulness of the limb.

"Massage is useful in restoring atrophied but otherwise healthy muscles to their former usefulness, in breaking up minor adhesions, and in removing the products of inflammation by increasing the blood supply and thus hastening absorption.

CONCLUSION AND RULES OF TREATMENT.

First.

"That bony or serious fibrous ankylosis is the result of injury and subsequent inflammation and not of immobilization.

Second.

That early passive motion only disarranges the fragments of bone, thereby increasing the production of callous, that it irritates the injured ligaments, and by increasing the inflammation, tends to produce the ankylosis it is thought to prevent.

Third.

"Immobilization is useful only when active inflammation is present, or until the ruptured ligaments and broken bones have thoroughly united.

Fourth.

The logical treatment of a fracture into a joint, therefore, should be rest and local applications to reduce inflammation. Reduction of the fracture as early as possible, then immobilization

from three to eight

until the bones and ligaments have united weeks, or more, according to circumstances.

Fifth and Lastly.

"Passive motion, massage and use till the tissues become normal, or, if the massage fails, complete rupture of all adhesions under an anæsthetic. The factors which will ultimately determine ankylosis, are the nature of the original injury, the character and duration of the subsequent inflammation, the destruction of bone and cartilage, cicatricial contraction of the soft tissues around the joint, and the age and condition of the patient."

This paper was written twelve years ago. I am still of the same opinion, and have nothing to add or subtract, but when I first presented this subject for your consideration, it did me more harm than anything I had ever done in my life.

I was called irrational, and unfit to be allowed to treat frac

tures.

My old friend, Dr. Melancthon Storrs, labored with me in private and denounced me in public, and finally threatened that if I continued my practice of neglecting to make early passive motion in the fractured elbows I attended, the profession would not uphold me, and I would probably lose my place in this Society.

Today I again read this paper, but without fear, for now I am of the majority, and the later text-books uphold my position. Scudder says, regarding fractures into the elbow joint: sive motion should be instituted late rather than early. In most instances, it will be wise to delay passive motion until union is firm-from the fourth to the sixth week. It should be of the gentlest sort; passive motion that is painful, does harm."

Nobody will criticise this paper unless they say I am wasting valuable time, telling you something you already know. My excuse is that it is sometimes well to review the past, and that there are still living some believers in early passive motion who are as yet unconvinced.

And then gentlemen, after all I have suffered and endured, after all you have said about me and against me, you will perhaps forgive an old man if he says — I told you so.

DISCUSSION.

Dr. Ansel G. Cook (Hartford): I would like to say that Dr. McKnight was in the small and feeble minority when I read that paper twelve years ago, but he has since grown strong.

Dr. E. J. McKnight (Hartford): I don't know that I ever before had an opportunity of claiming priority in anything, but in 1879, only a few years after Dr. Cook was born (laughter and applause), I wrote a graduation thesis upon fractures involving joints, especially elbow joints, and took exactly the same view that he has taken. As that thesis was never published, I cannot accuse him of plagiarism at all. But I certainly have always held these views that Dr. Cook has advanced, and which he advanced twelve years ago. I believe we obtain much better results in delaying our passive motion in fractures involving the joints.

Dr. Leonard W. Bacon, Jr., (New Haven): Mr. President, if I may be allowed to say a word in regard to this paper. I agree with the speaker entirely that immobilization of the joints will not be likely to alter the joint structure. I remember Hupple in his celebrated text-book on anatomy, refers to the case of a woman who had a bony anchylosis of one condyle of the joint, and that continued some thirty years. And at the autopsy thirty years later (it having been completely immobilized for thirty years), it was found intact. I don't think that is the whole story by any means. The reason for making passive motion about a fracture in a joint is not on account of the joint structures as much as it is on account of the surrounding soft parts; but I think that if there is no rather prompt passive motion made about the fracture of the elbow joint, you may get a matting together of the muscles and an interference with the function of the joint that will be very considerably hindered. If you will begin passive motion early, if you put the proper interpretation on that passive motion, it will help. The passive motion that I have been accustomed to practice in fractures in the elbow joint, has consisted in changing the position in which the joint was put up; perhaps after the interval of a week, the joint is put up in a supported position. At the end of a week I take it down, very carefully flex the joint and put it up in a semi-flexed position. At the end of half a week after that, I again take the joint down and move it only a single time and again put it up in position. At the interval of a few days it is redressed and put in a flexed position. A very simple and careful manipulation of that kind can be made, and can be made early without greatly displacing the fragments, and it brings the important extra-articular structures into different relations, so that they do not get an opportunity to become firmly matted together in some one fixed position. And I am perfectly of the opinion myself, that it aids and makes the course much easier for the patient afterwards when the splints are removed, and when passive or