Russell A. Hibbs Pioneer in Orthopedic Surgery 1869–1932 9780231889964

Table of contents :
Foreword
Contents
I. Child and Student
II. Intern and House Surgeon
III. Surgeon in Chief
IV. Hospital Administrator
V. Innovator in Surgical Technique
VI. Defender of Surgical Fusion
VII. Recognized Prophet
VIII. Teacher and Medical Economist
IX. Sponsor of the Kane Fellowships
X. Man and Citizen
Russell A. Hibbs as a Sportsman
A Tribute to Russell A. Hibbs
Appendices
Bibliography
Index

Citation preview

RUSSELL A. HIBBS PIONEER IN ORTHOPEDIC SURGERY 1869-1932

RUSSELL A. HIBBS PIONEER IN ORTHOPEDIC SURGERY 1869-1932

BY G E O R G E M. G O O D W I N

NEW Y O R K : M O R N I N G S I D E

HEIGHTS

COLUMBIA UNIVERSITY 1935

PRESS

CoprmioHT 1935 COLUMBIA UNIVERSITY PRESS PUBLUHXD I935

P U N T E D I N T H E U N I T E D STATES O F AMERICA

TO BENJAMIN P. FARRELL SKILLED OKTHOPBDIST FOR M A N Y YEARS T H E LOYAL A N D D E V O T E D F R I E N D OF RUSSELL HIBBS

FOREWORD This story of the life of Russell Aubra Hibbs has been undertaken because it is believed that his name w i l l have an important and permanent place as a contributor to the development of orthopedic surgery. The story of his accomplishments in the field of creative surgery, in hospital organization, and in medical education is easily told. Every one w h o had anything more than casual contact w i t h him was impressed by the vividness of his personality. Because his personality was exerted so intensely and was so active an influence in the crusade he carried on for the help of the cripple, in the healing of his patients, and in the inspiration of younger medical men, its delineation is equally as important as the story of his surgical accomplishment; but the portrayal of a personality of as many colors as his is a difficult task. While this task has been undertaken not without misgivings, the author hopes that he has performed it w i t h some measure of success. The material for the writing of these chapters has come from various sources, among them standard textbooks on orthopedics, orthopedic literature, the Annual Reports of the New Y o r k Orthopedic Dispensary and Hospital, and Hibbs's personal papers and correspondence. I am indebted to many of his lay friends and medical colleagues w h o have been kind enough to give me, either by personal communication or by letter, their impressions of him and of his work. ^ , , ( j . M . CJ. NBW YORK CITY AUGUST 1 5 ,

1935

CONTENTS Russell A. Hibbs RUSSELL A .

HIBBS,

Frontispiece PIONEER IN ORTHOPEDIC

SURGERY,

by George M. Goodwin

i

I. Child and Student

3

II. Intern and House Surgeon

8

III. Surgeon in Chief

17

IV. Hospital Administrator

13

V. Innovator in Surgical Technique

. . .

VI. Defender of Surgical Fusion

40

VII. Recognized Prophet

46

VIII. Teacher and Medical Economist IX. Sponsor of the Kane Fellowships

. . .

56

. . .

63

X. Man and Citizen RUSSELL

A.

HIBBS

AS A

71 SPORTSMAN,

by Samuel

W .

Lambert A

81

by Karl Vogel A P P E N D I C E S : O R I G I N A L P A P E R S , by Russell A. Hibbs 1. A Method of Lengthening the Tendo Achillis Figures: 1. Lines on which the tendon is to be incised; z. Mechanism of elongation after incision. 1 . An Operation for Stiffening the Knee Joint Figures: 1. Space on the femur and the tibia prepared to receive the patella; z. Patella in place; 3. Periosteum of the patella stitched to that of the femur and tibia T R I B U T E TO R U S S E L L

19

A.

HIBBS,

87 93 95 99

X

CONTENTS

3. An Operation for Progressive Spinal Deformities Figures: ia. Scheme of using spinous processes for solidifying posterior aspcct of vertebrae; ib. Lateral view showing fusion of spinous processes; 1 . Anteroposterior view, showing fusion of spinous processes (Case I); 3. Case I after operation; 4. Case II before operation; 5. Case II after operation; 6. Case III before operation; 7. Case III after operation. 4. A Preliminary Report of Twenty Cases of Hip Joint Tuberculosis Treated by an Operation Devised to Eliminate Motion by Fusing the Joints Figures: 1. (A) Antcrosuperior spine; (B) skin incision; i. (A) Tensor femoris muscle divided; (B) vastus muscle divided; (C) gluteus medius and minimus muscles; (D) trochanter and shaft; (E) chisel line cut in trochanter and shaft; 3. ( A ) Tensor femoris muscle divided; (B) vastus muscle divided; (C) gluteus medius and minimus muscles which were cut through anteriorly and above trochanter; (D) in ia, za, and 3a, trochanter turned up with lower end under iliac bone flap; (E) raw bone superior surface of neck of femur; (F) head of femur in acetabulum; (G) capsule of joint. BIBLIOGRAPHY

104

113

131

RUSSELL A. HIBBS PIONEER IN ORTHOPEDIC SURGERY BY

GEORGE M. GOODWIN

I CHILD AND STUDENT T H B S B arrived in New York one day early in 1893 a tall, rangy young Kentuckian. His manner of speech, characterized by something of a drawl, the inflections of his voice, and a certain courtliness of manner stamped him as a Southerner. His name was Russell Aubra Hibbs and he was, by right of a diploma from the University of Louisville, granted him three years before at the age of twenty-one, by profession a doctor. His boyhood had been spent on a farm near the little hamlet of Birdsville in southwestern Kentucky. The frontier had moved far westward by the time of his birth, but in that rural community there still lingered much of the atmosphere of the days of the log cabin. The Hibbs home was a large, rambling white house, situated on a small knoll overlooking the Ohio River, and from the verandas could be seen and heard the lazily active river traffic, with the deep toned whistles of freight and passenger boats and occasionally the shrill notes of a steam calliope belonging to the passing show boat. Russell's father had been born in the district, as had his father before him. James Lacy Hibbs was a successful farmer and occupied a respected position in the community. In the absence of banks, he acted as the local banker. Transactions between him and his neighbors

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CHILD AND STUDENT

were based on verbal agreements, since it was his reputation that his word was as good as his bond. His cash on hand, sometimes amounting to several thousand dollars, found a repository in the bosom of his wife's dress. Mr. Hibbs took an active interest in the affairs of the local church and served a term in the Kentucky legislature. Lacy Hibb's wife, Russell's mother, Emma Lena Branch, had been born in North Carolina in 1815. Her father, a Virginian, of French descent, had been a physician as well as a bishop in the Methodist Church. She bore James Lacy Hibbs ten children, of whom Russell was the youngest. A woman of great strength of character, she carried on the duties of a large rural household with remarkable efficiency. Her children idolized her. Russell's boyhood was like that of most boys bred at that time on farms in such districts. In his early years, his brothers being considerably older, he played with the Negro boys of his age on the place, who were the children of former slaves of his mother's family. There was much work to be done, and he was always eager to undertake the share in it which his age warranted. It was a proud day for him when he was permitted to follow the plow, and, the work completed, the ache in his young limbs was eased by the observation of the straightness of his furrows. His parents saw to it that, while he developed a sense of responsibility as to a share of the farm work befitting his years, he also had plenty of opportunity for play. As a consequence, he rode horseback as soon as he could straddle a horse, and spent much time in roaming the countryside, whipping a favorite

CHILD AND STUDENT

5

stream for fish or tramping the fields with his gun for game. So he developed a love for the outdoors; for the rest of his life, he never lost the thrill which the feel of a gun or a rod gives the true out-of-doors man. Rainy days found him in the country store at Birdsville. Here he listened to the neighborhood gossip and to discussions on politics. He never tired of observing the seemingly endless resources of the store's stock and the operations of the storekeeper in weighing and measuring goods. In later years, when he stole away from his work to fish and hunt, he was wont to visit with the country shopkeeper in the locality, and often said that it was his ambition, when he retired from his profession, to conduct a country store of his own. Lacy and Emma Hibbs made every effort to obtain for their children the best education available in the region at the time. At first Russell attended the local ungraded country school. Later, he went to Bethel College at Russellville, Kentucky, and finally he entered Vanderbilt University at Nashville, where he was graduated in 1888 with what would now be considered the equivalent of a high-school diploma. After graduation from Vanderbilt, he decided upon medicine as a career. Lacy Hibbs had brought up his sons with the idea that it was his responsibility to provide them with the best education and training he could gain for them. When he had done this, the elder Hibbs felt that his responsibility was ended and that thereafter they must look out for themselves. The sons accepted this attitude, without question, as just and right,

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CHILD AND STUDENT

and it served to stimulate their ambition and selfreliance. His father encouraged Russell in his ambition to be a doctor, and Russell therefore enrolled at the University of Louisville, and was graduated, after two terms of six months each, in the year 1890. Today, so short a course would seem to be only a very rudimentary medical education. Such, in fact, it was, since it consisted chiefly in attendance at lectures on basic subjects—anatomy, physiology, medicine, surgery, and therapeutics. After graduation, Russell Hibbs's great desire was to go to one of the country's large cities, where he might avail himself of the opportunity for further education and satisfy his youthful ambitions. Bred in the tradition that when a man comes of age he must fend for himself, he made it his immediate consideration to earn enough money to enable him to achieve this end. For a few months he practiced in his native Birdsville, but he soon found that the members of the community in which he had been reared were slow to take a young doctor seriously and to become his patients. For this reason he harkened to the dictum of Horace Greeley to " G o West, Young Man," and decided to try his luck in Texas. He arrived in Texas with but a small sum of money, and found that the most necessary prerequisite for a doctor entering upon practice was a horse. Fortunately, he was taken to board by a Mr. Milsap, a Texan farmer, who, when Hibbs's funds were exhausted in the purchase of a saddle, loaned him a horse. For Mr. Milsap Hibbs formed a strong affection. With this kindly older man, the young doctor had long discussions on a variety of

CHILD AND STUDENT

7

topics, particularly on religion and the Bible, and his affection for Mr. Milsap mitigated somewhat the homesickness from which he suffered, recurrently and with great intensity, for several years after leaving home. For two years Hibbs made his sick rounds in this rural community, on horseback, carrying his medicine and instruments in his saddlebags. At the end of this time, he had saved enough to make a journey to New York, where he arrived in 1893, unknown and with funds sufficient to maintain him for but a short time. Arriving at the Grand Central Station, the young doctor appealed to a cabby to find him a hotel at which to lodge. Settling himself and his bag in the hansom, he prepared to view the city, but in this he was disappointed, for the cabby deposited him on the opposite side of the street, at the old Grand Union Hotel.

II INTERN AND HOUSE SURGEON H I B B S now found himself in New York—a graduate of a little-known medical school in a city where hospital positions and internships were sought after and quickly occupied by the many graduates of the local medical schools. He was even without the usual letter of introduction from some physician at home to a medical acquaintance in New York who might give him advice, and was feeling somewhat at a loss when, looking through a current medical journal, his eye struck an advertisement for qualified medical graduates to act as interns at the New York Polyclinic Hospital. Hibbs presented himself to the medical head of the Polyclinic Hospital, Dr. John Wyeth, and, to his great relief, received an appointment as an intern. He was assigned to duties on the obstetrical service, which consisted, for the most part, in delivering women in their homes in the tenements of the district, but, in addition, provided accommodations for a few in-patients in a nearby building owned by the hospital. The young doctor received as compensation for his services his lodging and four dollars a week. Three dollars, as he told a fellow intern, went for food, and one dollar for washing, leaving him richer only in experience. But courses were given at the hospital for the instruction of post-graduates in numerous subjects, and Hibbs

INTERN AND HOUSE SURGEON

9

had the privilege of attending such courses as he desired. Anxious to improve himself, and eager to learn, he attended lectures and clinics whenever freedom from his own duties permitted it. He was popular with his fellow interns, with whom he enjoyed discussing their mutual problems. The favorite forum for these discussions was a French restaurant in the neighborhood, where members of the group repaired for a table d'hôte dinner on Saturday night—provided that they were fortunate enough to be able to scrape together the sixty-five cents necessary to pay for this weekly feast. Hibbs had worked for a year at the Polyclinic when an opening presented itself at the New York Orthopedic Dispensary and Hospital for a physician to act as Superintendent ^and house surgeon. At the time, Hibbs had no special leaning to orthopedics, but he felt that he had obtained all he could from his position at the Polyclinic and decided to apply for the position. Dr. Wyeth gave him a letter to Dr. Newton M. Shaffer, surgeon in chief at the Orthopedic, who approved his application for the position. The New York Orthopedic Dispensary and Hospital had been founded in 1868, largely through the efforts of Mr. Theodore Roosevelt, father of President Theodore Roosevelt. One of Mr. Roosevelt's daughters suffered from Pott's disease, and the attending physician in the case was Dr. C. Fayette Taylor, a leading New York orthopedist and the inventor of a number of orthopedic appliances. (Some of the braces devised by him are still in use and are called by his name.) Dr. Taylor drew the

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INTERN AND HOUSE SURGEON

attention of Mr. Roosevelt to the great need in the city for institutions for the treatment of the crippled children of the indigent poor. Mr. Roosevelt immediately interested himself in the problem and, with the help of Messrs. James Brown, John C. Aspenwall, and Howard Potter, raised sufficient funds to establish an orthopedic dispensary under Dr. Taylor, in a single room rented in a building on Broadway between Thirty-fifth and Thirtysixth Streets. By 1873, t he dispensary had so fully demonstrated its usefulness that it was able to obtain funds to purchase a house on 59th Street near Lexington Avenue. This house, originally a dwelling, was converted into an out-patient clinic and a hospital with accommodations for twenty to thirty children as in-patients. In the basement was housed a well-equipped shop where braces and orthopedic appliances could be manufactured on the premises. It was at this stage of the hospital's development that Hibbs assumed the duties of house surgeon and superintendent. In the planning of the hospital, scant attention had been paid to some of the minor details of hospital arrangement. For this reason, the young house surgeon found himself lodged in a small hall bedroom, furnished only with a bed and one or two chairs, and without even a place to hang his clothes. This last deficiency was corrected later by the gift of a wardrobe from the board of lady supervisors. The condition of his living quarters, however, made little impression on Hibbs, since he was experiencing an

INTERN AND HOUSE SURGEON

Ii

awakening interest in the problem of the cripple. The crippled child is quick to arouse the compassionate interest of the observer, and Hibbs felt immediately such an interest. Through the doors of the hospital there paraded daily a seemingly endless line of the maimed, some withering away from chronic bone disease, others deformed or lamed, and many in pain. Among them were a liberal number of humpbacks, the treatment of whose condition the young physician was to revolutionize. This was different from the life of a rural practitioner in Texas. Here the disparity between the work to be done and the time and facilities for doing it was a problem to challenge the thought and tax the energies of any man. Here, indeed, was a task in the dedication to which a man would find interest and satisfaction. Hibbs continued his duties as house surgeon and superintendent at the New York Orthopedic for four years, with steadily increasing interest and enthusiasm. At this time an unfortunate dispute arose between him and the surgeon in chief, Dr. Shaffer. Dr. Shaffer was one of the leading orthopedists in New York and was physician and friend of many influential families in the city. He was a man of strong personality, had written a great deal on orthopedic subjects, and was well known in orthopedic circles throughout the country and even abroad. In speaking of his experience at this time, Hibbs said in after years that he soon discovered in Dr. Shaffer an inclination to be jealous of his subordinates, and a tendency to discourage any initiative

INTERN AND HOUSE SURGEON or assumption of responsibility upon their part. Hibbs for this reason lost respect for him. As superintendent of the institution Hibbs was responsible to the lay trustees for the conduct of the administrative details of the hospital and to the surgeon in chief for the medical^care of the patients. The organization of the New York Orthopedic Hospital at this time was similar to that of other privately endowed hospitals today. The administrative policy of these hospitals is usually in the hands of laymen who themselves supply the funds for their support or who obtain from their friends contributions to the hospital endowment. These lay trustees rule the hospital, have authority over the medical staff in everything except matters of medical policy, and may appoint or dismiss members of the medical staff at their discretion. The medical board, or staff, while its contribution to the hospital is a matter of service rather than money, considers its contribution equally important to that of the trustees and often find its subordination irksome. For this reason, the members of the medical staff are jealous of their right to direct the medical policy of the hospital, and are inclined to resent any interference in the details of medical management. Occasions arise when the authority of the two boards overlap. Under these circumstances, a hospital superintendent, responsible to both boards, naturally may find his position difficult if the two boards are in disagreement or issue conflicting orders. Hibbs now found himself in just such a situation. While Dr. Shaffer was away on his vacation, the execu-

INTERN AND HOUSE SURGEON

13

tivc committee of the board of trustees directed him to make certain changes in the conduct of the brace shop. Hibbs, sensing that Dr. Shaffer might resent any change being made without his being consulted, insisted that the committee notify the acting chief surgeon of the changes, and then transmitted the order to the brace shop foreman as directed. Dr. Shaffer learned of the change on the first day after his return to the hospital and became incensed that the change had been made without his authority. He immediately sought Hibbs out, reprimanded him personally, and accused him of disloyalty to his fellow members of the medical personnel in transmitting the order. Hibbs was not the man to accept an unjust reprimand in silence, and he hotly denied that he was personally responsible for the order which offended Shaffer or that he had been guilty of any disloyalty. Shaffer thereupon brought Hibbs before the trustees on charges of insubordination and impertinence. A committee of the trustees appointed to hear the charges against Hibbs refused to consider the charge of insubordination, since the insubordination had consisted in transmitting one of the board's own orders. In considering the charge of impertinence, the members of the committee had only the words of the two principals in the dispute. To Shaffer's accusation of impertinence Hibbs replied that he had simply made a statement of fact and denied being impertinent. The committee, after hearing the principals and their witnesses, found the charges against Hibbs not substantiated and refused to

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INTERN AND HOUSE SURGEON

dismiss him. This angered Dr. Shaffer, and he tendered his resignation. The whole affair was regrettable, and Hibbs was fortunate, under the circumstances, in not having come out the loser in the dispute. Shaffer, as has been said, was influential in both the medical and lay circles of the city and was well known as an orthopedist. His connection with the hospital lent it a certain amount of prestige, and the trustees might easily have found it expedient to let the surgeon in chief have his way and to dismiss the young and unknown house surgeon. But in their visits to the hospital members of both the board of trustees and of the board of lady supervisors had had frequent opportunity to observe and talk to the young house-surgeonsuperintendent. They recognized the earnestness and seriousness with which he dealt with the problems of the crippled patients. At the same time, his seriousness was never dull, and was often lightened by his quick appreciation of the really humorous or droll. For these reasons, the trustees were attracted by his personality and inclined to be friendly toward him. Dr. Shaffer, on the other hand, had successfully used the threat of resignation as a weapon to gain his ends on two previous occasions, and there existed on the part of some of the trustees a feeling of impatience with him. Dr. Shaffer's resignation, probably to his surprise, was accepted. For this he blamed Hibbs, and this influential orthopedist became Hibbs's unrelenting enemy. This enmity was to have unpleasant consequences for Hibbs later on.

INTERN AND HOUSE SURGEON After Dr. Shaffer's resignation, the trustees considered for a long time the selection of his successor. From the first, a group favored the appointment of Hibbs. Among these was Mr. Osgood Welsh, the treasurer, who had formed a liking for Hibbs at their first meeting, had assumed the role of an older counselor, and had seemed to sense a brilliant future for him. He strongly urged Hibbs's appointment as surgeon in chief. After a great deal of deliberation, the trustees compromised by offering Hibbs the position not of surgeon in chief but of surgeon in charge. This offer Hibbs refused in the following letter: I appreciate highly the honor conferred upon me by your action in placing me in charge of the medical work of the Institution, but I deprecate any change in the title of the office. In my relation to you, and to the work itself, the matter of title is altogether immaterial, but it is evident to me that the effect of the proposed change upon the Institution and upon its medical head, whoever he may be, has not been fully considered. No matter whether or not it was so intended by you, the change carries with it the suggestion, to the staff and to the outside world, of a lack of full confidence in the wisdom of the selection of the man. It reflects upon the Institution and the man, thereby infringing the dignity and impairing the usefulness of both. I am fully persuaded that it is your desire to insure to me all the advantages that justly attach to the office of Medical Head of the Orthopedic and that on further consideration of the subject you will appreciate the serious conditions that control me in my attitude toward the question of title. This action, by which Hibbs, a man of thirty-one years of age, dictated the terms under which he would

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INTERN AND HOUSE SURGEON

assume the directorship of an institution, was unusual. Many men would have been content with the honor, though it might temporarily be a diluted one. But he felt that if he must assume the full responsibilities of surgeon in chief, it was only his right that he should have the full title. It was characteristic of him, all his life, to think a situation over, and, having decided after due deliberation that a certain course of action was the right one, to pursue that course without compromise and regardless of consequence to himself. The board of trustees, after consideration of his letter, appointed him surgeon in chief of the hospital on December 17, 1900. With his appointment as surgeon in chief at the New York Orthopedic, Russell Hibbs began a career in which, for over thirty years, he was to devote himself with the enthusiasm and tireless effort of a crusader to the improvement of the lot of individuals crippled by bone and joint disease. This effort was directed toward the enlargement of hospital facilities for this class of patients, toward improvement in the method of their treatment, and toward the better instruction of young physicians in the art of orthopedic surgery.

Ill SURGEON IN CHIEF Hibbs came to the New York Orthopedic, as has been said, the hospital building was a converted private dwelling and, as a hospital, had many defects. At the time, the facilities for the hospitalization of cases of chronic bone disease, considering the incidence of such disease in the city's population, were exceedingly limited. The general hospitals, for the most part, devoted themselves to the care of the acutely ill. It was felt that a hospital did the largest good by caring for the largest number of cases. Patients with acute disease required hospitalization only for a number of days or weeks, while the orthopedic case required months or even years of treatment; for these reasons, a number of acute cases could be treated in the time consumed in the treatment of one orthopedic case. The general hospitals, therefore, excluded or sharply limited the number of such cases admitted. At the New York Orthopedic, when Hibbs took charge, there were accommodations for some thirty children in the wards and no accommodations for adults whatever. Hibbs saw, every day, numerous patients, in need of hospitalization, turned away for lack of accommodations, and he set himself resolutely to the task of remedying this condition. WHEN

As we have said, the New York Orthopedic was representative in its organization of the usual privately

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SURGEON IN CHIEF

endowed hospital. The trustees of these h o s p i t a l s laymen of social and financial prominence—have, as a rule, a fine sense of the responsibility of their class toward the less fortunate members of their community. The contribution of their time and funds to the conduct of a hospital is a charitable accomplishment which affords them considerable satisfaction in discharging their obligations as members of the community. To the ordinary trustee, the hospital is an institution supported by voluntary contributions and conducted w i t h out profit for the purpose of caring for a certain number of sick individuals annually. As a trustee it is his concern as a business man to see to the economic and useful expenditure of the hospital funds. The actual work of the hospital is done by the members of the medical staff. These physicians are in constant contact with the patients and are familiar with their illnesses and the personal problems resulting from them. The relation of the trustees to the hospital work is largely impersonal, while that of the staff physician is intensely personal. At the time at which Hibbs took charge of the medical work of the New York Orthopedic, the trustees were proud of, and, for the most part, satisfied with, the bit their hospital was doing in the care of the crippled population of the city. They did not sit in the clinic with Hibbs every day, and see case after case needing hospital treatment returned to their homes for lack of beds in the hospital. They could not envision the difference it would make in the lives of these individuals if they could receive adequate treatment.

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19

Hibbs set himself to the task of educating these trustees, and any other laymen whom he could interest in the matter, as to the institution's great opportunity for larger service. Many of his patients were suffering from bone and joint tuberculosis, and Hibbs, discouraged by the results so far obtained in the treatment at the hospital of tuberculous cases, felt the results would be improved if the patients could be placed in healthful surroundings in the country. In this conviction he was strengthened by observing the attention which was coming at this time to the fresh-air treatment of pulmonary tuberculosis, so successfully applied by Dr. Edward L. Trudeau. It was customary at the time to hold an annual meeting at the hospital at which were present members of the board of trustees and members of the board of lady supervisors. There were also often present interested friends of members of these boards. At these meetings, reports dealing with the hospital activities of the current year were read by the president of the board of trustees and by the surgeon in chief. At one of these meetings, a year or two after his appointment, Hibbs pointed out with emphatic earnestness the need of the hospital for a country branch to which patients might be sent to have the benefit of healthy outdoor surroundings. Among those present at this particular meeting was Miss Emily A. Watson. She was impressed by Hibbs and expressed an interest in what he had said, and invited him to call upon her to discuss the subject. Miss Watson was a lady of considerable wealth, and

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doubtless had been exposed to the importunities of representatives of various benevolent causes for financial aid. While she was philanthropically inclined, she had definite views as to wise and useful ways of applying her philanthropy. Hibbs accepted her invitation to call with high hopes of gaining her aid. Doubtless his attractive personality made a favorable impression upon her and inclined her to be friendly to his cause, and he pleaded that cause with a persuasiveness bred of his sincere conviction that philanthropy could nowhere be better applied. As a consequence of this meeting, Miss Watson, in her own behalf and in behalf of her sister, Mrs. Harry Walker, offered the hospital fifty thousand dollars for the erection of buildings to start a branch in the country. To Hibbs's disappointment, however, the hospital trustees refused to accept a gift of this kind, since, without addition to the hospital resources to support such an establishment, they felt unwilling to commit themselves to undertaking it. Nevertheless, Hibbs succeeded in keeping Miss Watson's interest in the project alive, and after long consideration she decided to add to the original offer the sum of some four hundred thousand dollars as an endowment fund for the support of her gift. The hospital then purchased forty acres of land in White Plains, and upon this was erected a building designed in accordance with Hibbs's ideas. This building was opened in 1904, four years after Hibbs's appointment as surgeon in chief, and contained accommodation for fifty children. Miss Watson maintained her interest in the institution for the rest of her life, and, until advancing years pre-

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il

vented it, made it her custom to be present and observe the progress of the work when the chief surgeon made his weekly trip from the city to make rounds. One wonders whether the chief surgeon tired at such times of such frequent accounting of his stewardship, especially when it conflicted with his purely medical duties; if he did, he must never have shown signs of weariness, because Miss Watson, as time went on, increased the endowment to approximately a million and a half dollars. The country branch, when opened in July, 1904, had a capacity of 50 beds for children. In 1908 it was enlarged to a capacity of 140 beds, and in 1924 30 more beds were added for adults, making the total capacity 165 beds. An aspect of the problem of the cripple to which Hibbs had given a good deal of thought was the cripple's education. The duration of the period of active disease was usually so long that it often extended through school and adolescent years. This interfered with, often precluded, any schooling, and after the disease became quiescent the individual faced life with no means of livelihood, and, frequently with some residual physical handicap. It was not strange, therefore, that his morale had undergone so much deterioration that he had an inclination to become simply a charge upon his family or the community. Hibbs felt, therefore, that the cripple, during his hospitalization, should not be deprived of facilities for education and training; and he also had a very strong conviction that after discharge from the hospital he should not be segregated in special classes or

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SURGEON IN CHIEF

groups, but should take his place as naturally as possible among his normal fellows. The plans for the country branch of the hospital for this reason included an industrial school. During their residence, the children received not only the ordinary schooling available to their more fortunate fellows, but were also instructed in some trade. This industrial school was continued until, in later years, improvement in orthopedic methods so reduced the length of stay of the patients that its continuation was unnecessary.

IV

HOSPITAL ADMINISTRATOR WITH his appointment as surgeon in chief at the New York Orthopedic, Hibbs's life became an exceedingly busy one. The work at the hospital made great demands upon his energy, and his private practice, for which he had opened an office, made increasing demands upon his time. At this time, too, his work was increased by the foundation, at his instigation, of an orthopedic clinic in Orange, New Jersey. The history of this clinic was somewhat as follows: Hibbs had made a number of friends in this locality, the chief of them being Mr. Edwin Lamson of Summit. To this group of friends he pointed out the lack of facilities for orthopedic treatment in the region. He volunteered to conduct a clinic himself, and his friends rented a single room in a building at Orange, where, one day each week, Hibbs did his work. The success of the clinic led to the foundation of the New Jersey Orthopedic Dispensary and Hospital at Orange; here Hibbs continued his work for two years, or until he was able to select competent physicians to replace him in active charge of the work. Coincident with Hibbs's appointment as surgeon in chief at the New York Orthopedic Hospital, there had been an awakening of interest in all departments of the hospital. The trustees, in response to his constant preaching and explanation, soon came to have a better and

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more intimate understanding of the worth of the service the institution was rendering, and the necessity and opportunity for much greater service. Evidence of their response was their readiness to accept the administration of the large country unit, as well as a more interested attitude toward the routine work of the hospital. The medical staff found Hibbs's interest in the problems of diagnosis and treatment infectious, and were stimulated to greater effort. As time went on, it became apparent that he was possessed of the rare ability of maintaining a continued enthusiasm for his work and of imparting that enthusiasm to his co-workers. The Country Branch opened its doors in 1904. In the next ten years, a revolutionary change occurred in orthopedic methods—a change in which, as will be seen later, Hibbs played a leading part. When the Country Branch was opened orthopedic treatment was largely concerned with the application of various types of braces for the immobilization and support of joints. In the next ten years, this method of immobilization began to be replaced by the introduction of operative methods. As the number of surgical operations performed increased, the city hospital assumed added burdens. The patients were operated upon there and sent to the country for convalescence. It soon became apparent to Hibbs that to do justice to the work the hospital should have better and more modern equipment. Besides this, the number of patients visiting the out-patient department had grown so much that the space available for their treatment had become entirely inadequate.

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Not long after the Country Branch had been opened, therefore, Hibbs began to preach the need of a larger city hospital. He seldom lost an opportunity to point this out to the trustees, individually and collectively, or to any other interested laymen. In his annual report for 1908 he said: It seems to mc that the time has arrived in the history of the Orthopedic Hospital when some definite movement should be put forth to make its quarters reasonably comfortable and adequate for the work we are endeavoring to do. I can assure you that orthopedic work is in itself difficult enough, but to get men and women to show continued enthusiasm, and to have a controlling factor in their work high scientific spirit, where they are forced to work at such a tremendous disadvantage, is extremely difficult. If I fatigue you with suggestions and burden you with problems, may I say that if you will stand day by day in the dispensary and see child after child brought to us suffering from crippling disease, whose lives we may transform, you will find there instead of fatigue an inspiration; and see instead of burdens opportunities for service to future citizens. It is probable that the trustees did at times become "fatigued" with Hibbs's suggestions, and "burdened" with his problems, but in him the cripple had an indefatigable advocate. Where the cripple was concerned he had the spirit of a crusader, and he preached his needs with the fervor of an evangelist spreading the gospel. As time went on, and the results of the new methods of treatment which he introduced became apparent, he had, to the advantage of his appeals, a record of cures brought about in half the time formerly required.

HOSPITAL ADMINISTRATOR This record served as evidence for the practical person that the money contributed to the institution was being spent to very useful pruposes. The response to his appeals for a new city hospital was disheartening at first, and Hibbs had many discouragements. At every opportunity, however, he continued his pleas. Gradually the trustees became convinced, and finally they entered upon an ambitious campaign to raise the funds for a new hospital—a campaign which reached fruition on January 31, 1916, when a new hospital building was opened at 42.0 East Fifty-ninth Street. Hibbs took an active and interested part in planning the new hospital. He met frequently with the architects, and consulted with the heads of the various departments to learn their needs. With the building committee of the board of trustees he went over the details of the plans again and again, until they were satisfactory. The new hospital, upon its completion, was simple in architecture, provided wards with an abundance of fresh air and sunshine, and stands today as a model of modern hospital architecture, in which every available foot of space is used to advantage. The new building had accommodations for eighty children, ten men, and ten women patients in the wards, a large out-patient department, and a well-equipped operating suite. To be sure, the endowment fund for the maintenance of the hospital at its completion was a half-million dollars short of its goal, but this probably caused the trustees more uneasiness than it did Hibbs. One suspects that after the years of effort, often discouraging effort,

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to obtain this much-needed hospital equipment, Hibbs felt that, having obtained this much, he might rest, and let necessity spur the trustees on in obtaining the stillneeded half-million dollars. At the same time, he had an abiding and unquestioning faith that if an institution demonstrated its usefulness and provided helpful service to human suffering, funds for its support would be forthcoming from somewhere. Numerous experiences had acted to give Hibbs this faith. Money not infrequently came, when the hospital needed it most, in unexpected ways. One such experience will illustrate this. Hibbs, on one occasion, was called in consultation to see a case at Saranac. While there, he volunteered to see a young woman who, for a long time, had been bedridden with Pott's disease. She had become something of a personage in the village because of the cheerful way in which she accepted her lot. Her bedroom was situated on the ground floor of the cottage, and she had arranged a series of mirrors which acted as improvised periscopes by which she could see, from her recumbent position, what was going on in the streets and so know when to wave to her friends. Hibbs's reaction to an interesting and courageous personality was always immediate and sympathetic. After examination, he vouchsafed that he could do a great deal for her if funds could be provided for her transportation to New York. This was eventually arranged; he performed a fusion operation on her spine; and, with aftercare in the city hospital and country branch, she was restored to health. This girl was the daughter of one of three Irishmen who

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had emigrated to the States together, and were firm friends. Her own father had died, but the other two had, for friendship's sake, kept a kindly eye upon her. One of them, who lived in New York, visited her frequently in the wards of the hospital, and saw the way in which she and her ward mates were treated. Two or three years later, the hospital received unexpectedly a bequest of two hundred and fifty thousand dollars. Inquiry revealed that one of the three Irishmen above mentioned had prospered in this country. He had been informed by the friend who had visited at the hospital of the treatment afforded their old comrade's daughter, and, as a consequence, had made this unexpected bequest. The deficit in the endowment was overcome before very long, and in 1915 a pavilion was opened for the accommodation of private patients. The hospital then became a completed unit. It had already assumed a foremost rank among the institutions of the country devoted to orthopedic work, having attained and deserved this rank not because of its growth in physical equipment alone, but also because, with this physical growth, there had developed, under Hibbs's administration, a high standard of quality in the surgical work performed, as well as a remarkable efficiency in the executive management of the hospital.

V

INNOVATOR IN SURGICAL TECHNIC the period of the growth of the New York Orthopedic Hospital under the inspiration of his leadership, Hibbs was introducing new methods of treatment which were profoundly to influence orthopedic surgery. He belonged to that rare class of individuals who are possessed of originality of mind and technical imagination. The first of his papers to evidence these qualities was one on a method of lengthening the Achilles and other tendons, read before the New York Academy of Medicine in 1900.* The influence of short calf muscles upon foot disorders had been recognized for a long time: the shortness of these muscles keeps the patient from bending his foot upward upon the leg beyond a right angle, and this shortening results in a painful disturbance of the function and structure of the feet. The condition is often referred to as "muscle-bound foot." DURING

A t the end of the nineteenth century, various methods were in use in the treatment of this condition. Hibbs's predecessor at the New York Orthopedic, Dr. Shaffer, had designed a machine to stretch the muscle by the application of traction to the foot. Commonly, however, the condition was treated surgically, simply by cutting the tendon straight across. After this, the divided ends • For this paper, sec Appendix 1.

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of the tendon separated, and it was expected'that nature would unite these ends by the growth of new tissue, and that this strip of new tissue would provide the needed length. A number of these cases had been operated upon in this way at the hospital, and Hibbs found on reexamining them that the operation had failed to accomplish its purpose and that in many cases the patients' conditions had been made worse. Upon operating on some of the cases, he found that the new tissue connecting the divided ends was not unyielding or tendinous, and that the function of the tendon was much interfered with or lost. Hibbs considered for some time a way in which the tendon could be lengthened without completely dividing it, and finally arrived at a method of making incisions in the tendon so that it would unfold and thus lengthen itself. He did this by making an incision through two-thirds of the width of the tendon from one side and then turning the knife upward from this incision and cutting the tendon a certain length longitudinally. A quarter of an inch from this last incision another incision was made through two-thirds of the width of the tendon from the opposite side and then the tendon was split downward from the end of this incision to within a quarter of an inch of the first. When incisions are made in a tendon in this way, the tendon unfolds itself, and can be made the desired length by varying the size of the longitudinal incisions. Hibbs found this a satisfactory method. Other methods have since been designed and are now in use, but the

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introduction of Hibbs's method had a great deal of influence in the abandonment of the old method of simple division. The second of Hibbs's original methods of treatment, upon which he reported to the Academy of Medicine in 1910, was a method of stiffening the knee joint.* A not infrequent consequence of infantile paralysis is an abnormal mobility of the joints governed by the paralysed muscles. This may occur in any joint, and is particularly a handicap when the knee is affected. The knee becomes flail-like, and the patient cannot bear his weight upon the leg without the aid of a brace. Before this time, stiffening of the joint had been attempted by surgical procedure. This procedure, excision, usually consisted in removing the crucial ligaments, denuding the bones forming the articulation of their cartilage, bringing the denuded bone ends together, and fastening them with nails or pegs. The knee was then placed in a cast until the bone surface had grown together—a period usually of a year or more. This method of stiffening the knee, Hibbs found, was not very successful, because the loss of the ligaments resulted in deformity, and because the removal of a sufficient amount of cartilage caused so much shortening of the leg that a disability resulted which was as great a handicap as the flail joint. Hibbs therefore sought for a method of stiffening the knee which would not be attended by the disadvantage of the method of excision. * For this paper, see Appendix r .

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The knee is constructed of the ends of the thigh and shin bones—the femur and tibia, respectively—which roll upon each other. In front of these bones is the kneecap, or patella, which also takes part in the articulation. The joint surfaces of these bones are covered with cartilage. The ends of the shin and thigh bones are connected by two rounded bands—the crucial ligaments. Hibbs decided that the joint could be stiffened by a method other than excision. In order to do this, he removed the cartilage from the tibia and femur just in front of their centers, carefully preserving the crucial ligaments, and into this space he mortised the kneecap, or patella. In this way the patella formed the nucleus for the growth of a strong and firm bony bridge between the two large bones. Four to six ¡weeks after the operation, he allowed his patients to walk in plaster, and in five to seven months the patients were able to walk with all support removed. By this operation, Hibbs succeeded in giving to the patient, who, as a consequence of infantile paralysis, had an unstable knee, a strong and stiff joint upon which he could bear his weight without the aid of a brace. A few years after the opening of the Country Branch, Hibbs began to realize that the treatment of tuberculosis by the combination of life in healthy outdoor surroundings, heliotherapy, and the application of braces did not accomplish what he had expected of it. The patients at the Country Branch had every advantage of this method of treatment. Their surroundings were excellent. The braces or apparatus which they wore were under con-

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33

stant supervision. Hibbs had a natural mcchanical sense and an aptitude for the use and application of mechanical apparatus, and exercised the strictest care in the use of such apparatus, never countenancing slipshod methods in himself or his assistants. Yet he found that a very large percentage of these patients with joint tuberculosis remained at the Country Branch for five, six, or seven years, and still were not cured. Eventually he began to express the opinion that tuberculous disease of a joint was never cured unless the motion of the joint was completely eliminated. There was nothing revolutionary about this opinion, since the whole effort in the treatment of tuberculous joints at the time was to obtain immobilization. But Hibbs went further in his thought than this, and expressed the opinion that immobilization must be permanent and must be absolute and that this absolute immobilization could not be accomplished by the external application of braces, casts, or other apparatus. The only hope of accomplishing the desired complete and permanent immobilization, he felt, lay in finding a way to do it surgically. Hibbs had found a successful and satisfactory way completely to immobilize a knee joint. Many of his cases suffered from tuberculosis of the spine or Pott's disease, and his mind kept dwelling upon the problem of a way in which to immobilize the joints between the vertebrae. For months he concentrated on this problem, and his absorption in it so compelled his attention that his friends often noticed him in seemingly abstracted

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moods. He frequently talked the problem over with his friend Dr. George S. Huntington, then professor of anatomy at the College of Physicians and Surgeons, Columbia University, and Dr. Huntington, a man of keen scientific spirit, encouraged him to come to his laboratory and do some experimental work upon cadavers. This Hibbs did, and perfected a technic which he believed would accomplish the immobilization and fusion of tuberculous vertebrae.* The spinal column is constructed of a number of individual vertebrae superimposed one upon another. The vertebrae are cylindrical bodies with flat opposing surfaces covered with cartilage and articulating with each other. At each side, at the posterior aspect of the vertebra, a curved plate of bone extends backward. These plates form an arch and join behind to form a solid process of bone protruding backward toward the skin of the back and this is called the spinous process of a vertebra. The vertebral bodies sit one upon another, forming a bony column, while the superimposed arches of the vertebrae form a bony tunnel or canal which houses the spinal cord. Tuberculosis attacks the bodies of the vertebrae, which it may destroy and cause to collapse, giving the characteristic humpback. In this process the spinal cord may be injured. Hibbs sought an operative technic which would utilize the healthy arches of bone behind the diseased vertebral bodies to build a bridge or splint of bone which would immobilize and support the diseased vertebral bodies and cause them to fuse together. * For the technical description of this operation, see Appendix 3.

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35

The tcchnic which he used in his first operation on a case of Pott's disease consisted in fracturing the spinous processes of a number of vertebrae at their bases. In this way, he was enabled to bend one spinous process down upon the fractured base of the spinous process next below, which in turn was bent down upon the process next below it. He included in the operative work the spinous processes of vertebrae above and below the diseased area, so that the bony splint would be anchored to healthy vertebrae above and below. After completing this part of the operation he sewed back the periosteum, or fibrous covering of the bones, which he had carefully preserved, over the fractured spinous processes. It is important to understand that the bony splint which Hibbs aimed to secure was not formed with the completion of his operation, but that his operation initiated and induced a production by nature of a shaft of new bone along the line of the fractured spinous processes. Hibbs did this first operation, called a fusion operation, on a nine-year-old boy on January 9, 1 9 1 1 . After the operation the boy was kept prone in bed with a brace for eight weeks; for the next four weeks he was allowed to sit up in bed; at the end of twelve weeks he was allowed to walk; and at the end of another month the brace was entirely removed. One may imagine the interest with which Hibbs and his colleagues at the Orthopedic observed the boy's progress, and their gratification at seeing the operation eventually accomplish the end at which he aimed. The boy was entirely restored to health, and now is the strong and robust

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driver of a heavy truck, the brakes and steering wheel of which he manipulates without difficulty. As he performed more operations of the kind, Hibbs elaborated upon his original technic. Instead of using the spinous processes alone, he gained greater strength for the vertebral fusion by chipping a piece of bone from the side of each vertebral arch and bringing this chip down on the next arch below, at the same time elevating a chip from this lower arch to. the one above. He did this on both sides of the vertebral column, at the same time inducing a fusion of the lateral articulations by denuding their surfaces of cartilage. As a consequence of this technic, a growth of new and solid bone occurred along the spinous processes behind, and laterally along the vertebral arches. Careful follow-up of cases of Pott's disease (tuberculosis of the spine) treated by this operation convinced Hibbs of the superiority of this method of treatment over the old treatment of mechanotherapy. This conviction became still stronger after a lapse of years permitted judgment as to the permanency of the cures, and after the low operative mortality in a large series of cases showed the safety with which the operation could be performed. Since it was possible by this operation to build a bony splint to immobilize and support a vertebra or several vertebrae, Hibbs recognized that the operation would be useful in the treatment of other conditions than tuberculosis. He applied it successfully in the treatment of vertebrae fractured or dislocated by accidental injury, securing, in this way, immobilization which was in-

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37

herently difficult to obtain by mechanical measures. He also applied it to lateral curvature of the spine, a condition—frequently encountered in orthopedic practice— which is usually the consequence of infantile paralysis. The mechanical method of treatment usually consisted in the application of longitudinal and lateral traction upon the spine by the use of straps, buckles, and pulleys, but Hibbs, recognizing that his fusion method would be useful here, soon adopted a method of obtaining the maximum correction possible by the application of a plaster jacket, equipped with hinges and turn buckles, and then maintaining this correction by means of a fusion operation. Hibbs was one of the first to emphasize the rôle played by unstable vertebrae in the causation of pain in the back and legs. The favorite site for this instability is the fifth lumbar vertebra, which articulates or moves upon the sacrum as a fixed base. The vertebral articulations are complicated mechanisms, and it is not surprising that congenital imperfections in their development should lead to faults in this mechanism. Such faults sometimes result in a slipping of one vertebra upon another, under strain which gives rise to attacks of prolonged pain or backache. For a condition of this kind Hibbs found his fusion operation the ideal method of treatment, and reported its successful application in many cases. The success which he had attained in the treatment of Pott's disease through absolute immobilization by oper-

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ative methods had convinced Hibbs and made him assert without reservation that the right way to treat any tuberculous joint was to render it absolutely immobile by surgery. After he had demonstrated the usefulness of fusion in Pott's disease, he immediately began to fuse the knee for tuberculosis of that joint. Stimulated by the success of fusion here he sought a method of fusing the hip joint. The thigh bone, or femur, consists of a shaft of bone at the upper extremity of which is a thickened prominence called the trochanter. From the inner side of this shaft, near the trochanter, the neck of the femur extends inward and upward at an angle, ending in a rounded head which articulates in a saucerlike depression in the pelvic bone. The pelvic bone flares upward from the hip joint for three or four inches. Hibbs sought to build a solid bony shaft, external to the articular surface of the joint, which would immobilize the hip and transmit the weight from the pelvis to the femur and relieve the diseased hip joint of the burden of weight bearing. The technic which he finally evolved for this consisted in lifting a flap of bone from the trochanter and turning it upward, while, at the same time, elevating a bone flap from the pelvic bone or ilium above. He then laid th e flap from the trochanter of the femur up under the flap from the ilium and stitched them against each other with a covering of periosteum. By the use of this technic, he found, he could satisfactorily fuse the hip joint—the largest joint in the body. In this way he successfully

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treated a large number of cases of tuberculosis of the hip joint.* With the discovery of a method of fusing the hip joint, Hibbs completed his contribution to the technical development of orthopedic surgery. There remained the task of convincing others of the truth of his conviction that tuberculous joint disease could be cured only by absolute immobilization of the joint and that this could be best accomplished by surgery. * For the technical description of this operation, see Appendix 4. A list of other papers by Hibbs will be found in the Bibliography.

VI

DEFENDER OF SURGICAL FUSION HIBBS'S experience as a pioneer was not unlike that of other pioneers in medical history. The medical profession, taught by the experience of frequent disillusionment, is always conservative in the acceptance of novel methods and theories. Hibbs's principle of absolute immobilization by fusion for tuberculosis of joints met with frank skepticism, often amounting to hostility, in many quarters. In addition to the natural professional conservatism, there were several other reasons for this. At the time when Hibbs began to adopt his fusion methods, orthopedic practice was for the most part in the hands of men who were by training brace-makers and not surgeons. The attitude of these men might be summed up in a statement in one of Dr. Shaffer's reports to the trustees of the New York Orthopedic Hospital:

To the legitimate orthopedic surgeon therefore, operative work takes a secondary or minor position, just as the mechanical part takes by far the more important place; and in true orthopedic surgery, operative work, per se, has no real status. Hibbs was a good operator. He had a facility in the use of his hands and gained the satisfaction in performing delicate manual work which marks the true craftsman. The Hibbs fusion operation required a skillful technic which many were unqualified by training to adopt. The

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lack of training which prevented their adoption of the Hibbs method prejudiced many men, unconsciously perhaps, against it. For years they had treated their cases by the use of braces or other mechanical appliances. They might admit that such treatment consumed years, as Hibbs said, but to agree with Hibbs that few if any cases were cured in this way seemed to be a contradiction of their accustomed conceptions. Besides this, Hibbs, in accomplishing a cure, permanently sacrificed the motion of an affected joint, and to their minds the object of treatment was to preserve or restore motion, not to sacrifice it. Hibbs had no inclination to indulge in personal controversies with the opponents of his method and recognized the futility of wordy arguments or debates. He knew that the only way he could effectively prove his contentions was by the accumulation of proven facts through careful and accurate observations on the results of his work. He set himself, therefore, to the accumulation of these facts. The study of a disease or of methods of treating diseases by the systematic and prolonged observation of large groups of cases in a comparatively recent method of medical investigation. Formerly, conclusions were often drawn from the observation of but a few cases, and such conclusions were often misleading. Modern hospital organization has made possible the inclusion of a large number of cases for the purpose of investigation, which, with the aid of efficient follow-up departments, may be kept continuously under observation for long periods.

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Numbers alone do not, of course, insure the value of the conclusions of an investigator, but accuracy and carc in observation, coupled with a large amount of clinical material, form a basis for reliable judgments. Hibbs recognized the truth of this and very carefully organized a hospital system to follow up his cases and prepare accurate statistics. Cases which were operated upon were carefully studied before operation, and were brought back at intervals for observation, long after their discharge. At these follow-up visits careful records, including tracings and Xrays, were made of the patient's progress. The building of the Country Branch had given him an unusual opportunity to study the effects of mechanotherapy upon joint tuberculosis, and in one of his annual reports he expressed the conclusions which he drew from this study as follows: The study here has led to a new conception of the disease and a complete revolution in the treatment. Children under treatment in the old conditions in the city hospital and dispensary had no continuous observation of the individual case for long periods and, therefore, no complete knowledge was obtained in these cases of the course of the disease or the influence of the treatment upon it. The long observation of these cases which was possible at the Country Branch has given unmistakable evidence that few got well by the established methods of treatment and that the diagnosis was always uncertain in all joints except the spine. The method of treatment consisted in the application of braces and supports of various kinds in an attempt to protect these joints from mobility. They do not accomplish this purpose to such a degree as to effect cure quickly without deformity and we find it can not be accom-

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plishcd except by operation. After the diagnosis is made, the operation is performed and the patients when convalescent are sent to the Country Branch, where they remain for from one year to eighteen months, when cure is complete, and they are sent back to the normal life fitting their age. Under the older methods they remained often for from five to seven years in the Country Branch and were not cured. The majority of cases discharged as cured under the old methods have come back to the city hospital for operation in later life. At intervals after his adoption of the fusion operation for tuberculous joint disease, Hibbs published the results he had obtained by this method. In 1918 he reports the results in 2.10 cases of Pott's disease. Three and onehalf to seven years had elapsed since the operation. In this series no deaths had occurred from operation: 157 (74.7 percent) he classified as cures, 2.2. (10.4 percent) as doubtful cures, and 31 (14.7 percent) were dead of intercurrent disease or tuberculosis of other organs. In 1918 he read before the American Orthopedic Association a paper giving the results of treatment of a third group of cases numbering 2.86 operated upon by members of his staff. In this group he reported cures in 74.6 percent, a failure to cure in 3.1 percent, and an operative mortality in 0.9 percent. The remaining patients had died, in a majority of instances from tuberculosis of other organs. In 1916 he reported that 154 knee joints had been fused at the New York Orthopedic, and that in no instance had there been a recurrence of the disease in these joints. In cases of knee-joint tuberculosis treated conservatively at the Country Branch, he found that only zo percent were cured.

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He summarized his experience in tuberculosis of the joints of the lower extremities treated by fusion operations as follows: In no instance has there been recurrence of disease in any of these fused joints, and the limitation of the patient's activity which might have been expected has not been experienced. On the contrary they all engage in most activities with greater freedom, no pain, less fatigue, and more confidence than before fusion had taken place. This is especially true of children, and particularly the hip, the ankle and the tarsal cases. Because of the compensation which takes place in the lumbar spine after hip fusion, in the tarsal joints after ankle fusion, the patients arc almost entirely free from any handicap in ordinary activity. In the knee cases the chief disadvantage is experienced in sitting. Of still greater importance is the fact that these patients have been freed from the constant danger of life by extension of the active disease from the joint, as well as from the necessity of years of treatment in hospital or clinic. In making the statement that there had been no recurrence of disease in any of these fused joints, Hibbs did not mean that he was successful in accomplishing the fusion of every joint upon which he operated. Faulty operative technic, or poor reparative power of the patients' tissues, or both, resulted not infrequently in failure of fusion to occur. Under these circumstances, the disease was not arrested or cured. Successful fusion occurred in slightly over 70 percent of the cases of vertebral and hip-joint tuberculosis, and in a still higher percentage of the knee cases. He believed that in the hands of qualified surgeons this should be the normal expectation of success. In his experience, mechanical therapy did not approach such a degree of efficiency.

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45

While Hibbs was preaching in this way the efficacy of fusion operations for tuberculous joints, he was also expressing opinions as to the diagnosis of these conditions which in some quarters were considered as radical as his attitude toward treatment. He insisted that it was necessary to diagnose joint tuberculosis accurately, and believed that this could be done in joints of the extremities only by opening the suspected joint and obtaining a piece of tissue for microscopical examination, or by inducing tuberculosis in guinea pigs by injection of pus from the joint or by implantation of suspected tissue. In early stages of the disease, mistaken diagnoses, he said, were frequent. Harm was done by treating cases as tuberculosis which in fact were not tuberculous, and failure to make the diagnosis early, which was often difficult, allowed the development of a destructive lesion more difficult to cure. While some might consider it a radical practice to resort to this method of diagnosis, he considered it a much safer policy to make a positive diagnosis early than to allow a tuberculous process, with its menace to the joint and to the general health, to progress because of uncertainty as to diagnosis. Despite these reports of Hibb's on the results of the application of truly surgical methods to orthopedic disease—reports founded on careful and painstaking study and observation—it may be said that orthopedists in general were slow to accept or even to admit merit in his ideas and methods. In large part, this was the result of the spirit of conservatism, but it is probably also true that, in lesser degree, Hibbs was handicapped by his relationship with the American Orthopedic Association.

VII

RECOGNIZED PROPHET THB American Orthopedic Association is one of a number of similar associations or societies found in the United States and Canada today. They differ from the national and county medical societies in that the membership is restricted to men who have achieved distinction in the various specialties which the associations represent. Designedly, the criteria of membership are ability, contributions to the advancement of surgical and medical knowledge, and worth of character. On the whole, these considerations are predominant in the recruiting of an association's membership, but there not infrequently enters an element of politics. Dislike or jealousy on the part of some of the members will sometimes exclude a good man while another may be admitted whose chief distinction is the friendship of a member or group of members. Hibbs's name first came up for admission to the American Orthopedic Association in 1902.. Dr. Newton M. Shaffer, Hibbs's predecessor at the New York Orthopedic, was a member and had been a founder of the Association; and Hibbs's replacement of Dr. Shaffer at the hospital had created resentment and prejudice toward Hibbs among a group of influential members of the Association. It was their impression and feeling that Hibbs's course in achieving his position had been un-

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fair to his colleague and not altogether honorable. As a consequence the committee on nominations rejected Hibbs's application for membership. While Hibbs was disappointed, he was inclined at first to take the attitude that if certain members of the Association did not desire his membership it was not for him to try to force himself upon them. But upon reflection, and after consultation with his friends, he felt that an injustice had been done him, and that the only way in which he could defend himself against accusations which he considered baseless and false was by reapplying for membership. This he did, at the same time supplying his sponsors with evidence to clear him of the accusations which had been made against him. To his sponsor, Dr. A. B. Judson, the members of the consulting staff of the New York Orthopedic wrote the following letter: Dear Doctor : We recall distinctly the circumstances which led the Board of Trustees of the N e w York Orthopcdic Dispensary and Hospital to accept the resignation of the Surgcon-in-chief, Dr. Shaffer, in November, 1898. All the facts were placed before the Medical Board and we, having been acquainted with these facts, were of the opinion and are still of the opinion that Dr. Hibbs' course was entirely honorable; and we have approved of the action of the Board of Trustees in appointing Dr. Hibbs to the position of Surgeon-in-Chief.

This letter was signed by the following members of the consulting staff: Wm. T. Bull, Richard H. Derby, Charles McBurney, Thomas E. Satterthwaite, and Abraham Jacobi.

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Notwithstanding this statement, made by this group of physicians, each of whom was a man of reputation and note, the group opposed to Hibbs succeeded, a year or two later, in preventing, a second time, his election to the Association. Several years later, in 1914, his friends again insistently advocated his election. By this time, the record of his accomplishment in the orthopedic field was so good that opposition of necessity narrowed itself to strictly personal grounds; but his opponents remained relentless in the opposition and when Hibbs's sponsors insisted upon a vote from the floor while the Association was in executive session, twenty-two members voted for his election and twenty against. Not having obtained sufficient votes for election, his candidacy was rejected for the third time. This experience naturally had its effect upon Hibbs. He had been excluded from an association of orthopedists on the ground of being disloyal and unfair in dealing with his colleagues. He felt entirely blameless of any such accusations, and he considered that the defense which he had presented should have convinced any fair-minded person that this was so. Yet the assertions of his enemies had been given credence, and he knew that many outside of the American Orthopedic Association, who had heard only one side of the story, would be inclined to be prejudiced against him. He felt a certain bitterness about it, and he was, as a consequence, sometimes inclined to sense hostility in other men when actually none existed. In another way, the experience had a fortunate effect upon him, since it stimulated him to greater effort to

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prove his worth. His resentment and bitterness would perhaps have been greater, had he not been reassured, as time went on, by his increasing success as a surgeon and as a hospital organizer. The orthopedists included in the membership of the American Orthopedic Association undoubtedly exercised a strong influence on American orthopedics, and it is probable that an element in the opposition to Hibbs's ideas and methods had its origin in a personal animosity on the part of a group of these members. But Hibbs had available to him more than one forum for the expression of his opinions. In 1915 he was made chairman of the Orthopedic Section of the American Medical Association, and his articles frequently appeared in the journal of this and other associations. Ten years after Hibbs did his first fusion operation on a spine, a large group of orthopedists remained skeptical as to the efficacy of the fusion operation, opposed it, and preferred to continue treatment of their cases by mechanotherapy. But Hibbs's reports and those of others on their results compelled these conservatives to have good reason for their opposition. In 1913 the American Orthopedic Association appointed " a commission to investigate the results of ankylosing operations of the spine." The commission made no attempt to compare the relative influence of mechanical and operative treatment, because in the majority of cases, they asserted, the two methods were combined. They prefaced their report with the following statement:

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The Commission has been greatly handicapped by the laxity of methods which individual members of the Association have pursued in keeping proper records of their cases. The situation is the same with regard to the hospitals with which the members are connected. With few exceptions the proper data necessary to the work of the Commission has been unobtainable. The follow-up system in most hospitals has been woefully lacking, practically does not exist. In one hospital only, and that served by a man not a member of the Association have complete data been obtainable and furnished the Commission. On perusal of this report the reader has the feeling rather of being left in the air. The commission seemed to recognize certain merits in the ankylosing operations, but evidently was unprepared to give them anything like unqualified approval. In discussing the report one of the members of the Commission had this to say: I think we must draw the conclusion that simply an operation alone will not suffice to cure Pott's disease and we must keep up mechanical treatment until the bodies of the vertebrae becomc fused if we want to cure these cases. This was an expression of a compromise which perhaps satisfied the conservatives, but only made Hibbs and his followers impatient. Hibbs had stated in his reports that operated patients were kept in bed for six weeks after operation and wore a brace for twelve to eighteen months afterwards. After this the patients returned to active life. In his experience, patients treated with mechanical methods alone had to continue the treatment often as long as from five to seven years and were then not cured. The one hospital referred to in the report which had

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an efficient follow-up system and presented complete data was the New York Orthopedic! The report of this commission was read and submitted at the meeting of the Association held in Boston in June, 1911. At this same meeting Hibbs was unanimously elected to membership. His election occurred without his seeking it and came as a surprise to him. The matter came up in an executive session of the Association, and, while one or two might have remained irreconcilable in their opposition, the feeling of the members was so predominantly and insistently favorable that they found it expedient not to continue their opposition. One of his friends notified Hibbs of his election by telegram. He was at first moved to decline to accept membership in an Association which on three occasions had refused him membership. He had gained success without help from the Association. In earlier years, membership might have meant much more to him, but now his name was known, he was professor of orthopedic surgery at one of the country's best medical school s and director of one of the best orthopedic hospitals, in the visitors' book of which appeared the names of visiting physicians from all over the United States, from Canada, South America, and Europe. Upon further consideration, however, he decided that to accept was a bigger thing than to decline, and therefore accepted membership. The membership of the Association had changed; most of the group who had used the Association to indulge their personal animosity toward him were no longer members. A large group, per-

RECOGNIZED PROPHET haps, still disagreed with him as to the merits of operative treatment in orthopedics but their disagreement was an honest difference of opinion to which they were of course entitled. He received cordial letters of congratulation from many members of the Association upon his election. From Dr. R. B. Osgood, the President, came this letter: June 4th, 1 9 1 1 DEAR DR.

HIBBS:

I am more pleased than I can tell over your unanimous election to the American Orthopedic Association which occurred today. I feel the Association has done itself a too long delayed honor. It has been one of those unfortunate things that happen when the ordinary safeguards of election becomes an obstacle to the will of the overwhelming majority. I am sure you will realize that this has been the situation for many years. That this action was taken while I was President, though without any initiative on my part or any influence, is a source of very great satisfaction. Cordially (.Signet0

R . B . OSGOOD

From Dr. Joel Goldthwaite, a former president, he received this letter: June 7, 1 9 1 1 M Y D E A R DOCTOR :

I am delighted that at the last executive meeting of the Orthopedic Association the Association honored itself in electing you a member of its body. The election was from the floor and unanimous. I simply want you to know how very happy I am personally to feel you arc a member and to asure you that as far as my own interests arc concerned this would have been brought about

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many, many years ago. It is a relief to know that this whole situation seems to have changed. With my best wishes and with most cordial appreciation for all you have done to help the work of the Special Commission* of which I have had the Chairmanship, I am Very sincerely yours, (.Signed)

JOBL E . G O L D T H W A I T E

While the predominant reaction toward Hibbs's fusion methods was hostile, there were from the first many orthopedists w h o welcomed this new trend in orthopedic practice. It is difficult to maintain an enthusiastic interest in patients suffering from chronic disease whose treatment extends over a period of years. A method of treatment which reduced this time had great appeal and promised a change of mental attitude toward the sufferer. It permitted the development of an enthusiastic surgical interest afforded patients suffering from acute illness. As time went on, more and more visiting physicians appeared at the hospital to learn the technic by seeing Hibbs or his associates, Drs. B. P. Farrel, and A . DeF. Smith perform operations. When, in 19x8, Hibbs read his last paper, on the spine fusion operation for vertebral tuberculosis, before the American Orthopedic Association, the current editions of textbooks on orthopedic surgery gave descriptions of the operative technic and the results of the operations in the hands of different men. But they still gave precedence and more space to the discussion of the treatment by mechanical therapy. Approval of the operative method, * N o t the Commission which investigated the results of ankylosing operations on the spine.

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by these authors and by many other orthopedists, was qualified particularly as regards its application to children. In this last paper Hibbs was emphatic in disagreeing with this viewpoint and worded one of his conclusions as follows : Any treatment to be most effective in vertebral tuberculosis must be applicable to children, as most cases occur in childhood. This scries and the previous one offer abundant proof that children are the most favorable cases for operation. Fusion takes place more rapidly in them and their recuperative powers arc better.

It is probably fair to say, however, that at this time most of the younger men in the orthopedic specialty, and the progressive type among their seniors in this country, had accepted the principle that the absolute immobilization necessary to cure a tuberculous joint could best be accomplished by surgery. Hibbs had preached this principle for twenty years. At first, his voice had been that of one crying in the wilderness. In general, the profession had been inclined to regard him as a radical. Undeterred, he had continued to preach the principle of surgical immobilization, and now at last he had the gratification of seeing his preaching receive acceptance.

VIII TEACHER A N D MEDICAL ECONOMIST THUS far, in considering Hibbs's carccr, wc have discussed his work as a hospital organizer and as a contributor to the development of the new orthopedic surgery. The third phase of his career has to do with his work as a teacher. In 1911 Hibbs was approached by Dr. W. M. Polk, Dean of the Cornell Medical School, to learn whether he would accept, if it were offered him, the Professorship of Orthopedic Surgery at that school. At the time discussions were going on between Hibbs, as representative of the New York Orthopedic Hospital, and authorities at Columbia University, looking toward an alliance between the two institutions which would open the hospital to the medical students of that university for teaching purposes. In one of his papers under the date of May 2.5, 1911, the following note occurs: Called upon Dr. Polk this morning and declined the offer made as described above, stating that I felt that I was t o o far committed w i t h the prospective alliance w i t h Columbia. He replied that he thought I had done perfectly right. Thus closes a pleasant episode.

Eight years later, Hibbs was appointed Professor of Orthopedic Surgery at Columbia University. His immediate effort was to secure the allotment of more time to the students for the study of this branch of surgery.

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He maintained that, considering the comparative incidence of orthopedic conditions in general surgical illness, the teaching of orthopedics deserved a more important placc in the curriculum than it was customary for medical schools to afford it. In this he had the strong support of Professor Huntington, who persuaded Dean Samuel W. Lambert and Dr. Adrian V. S. Lambert, the Professor of Surgery, to adopt this point of view. The course as organized under Hibbs assumed a much greater importance than it had previously had. In one of his papers, he summarized as follows his aims in the teaching of orthopedics at the medical school. Most mcdical schools now devote some time to the teaching of this department of surgery, some more than others, for instance at the College of Physicians and Surgeons of Columbia University, the third year student is given seventy hours of bedside work in the hospital and is examined on it and the fourth year class in small sections is given thirty hours of bedside work in the hospital. No more attempt is made to make specialists in orthopedics than the work required in general surgery is designed to make general surgeons. The purpose is to give each student the principles of diagnosis and treatment of various conditions peculiar to this branch of surgery, certainly the least that a well educated man should have. In doing this the student is given some conception of the wide field of usefulness which is open to him in this branch of surgery and he is in a better position to choose, when the time comes to make a choice, the special work most suitable to his inclination and equipment. The promise for the future here is in the hope that among the graduates of all the schools thruout the country, some each year will choose this branch of surgery as their field of service,

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in the sure confidcncc that it offers opportunity for a wide reach of surgical attainment and professional advancement. Hibbs was a popular lecturer at the medical school, although he was not a systematic one. His assistants often collected for him cases illustrating the subjects to be covered at a certain lecture, but when the lecture came, as often as not he became interested in a particular case and devoted the hour to it, forgetting entirely the outlined plan of the lecture. He had the knack of dramatizing his subject and imparting to his students something of his own enthusiastic interest. He succeeded in showing the students that the practice of orthopedics was not simply a matter of the patient application of plaster and braces, as it had once been, but a truly surgical art. Many students had their interest in orthopedics awakened by his lectures and after graduation selected this branch of medicine as a career. Hibbs exerted his most intense influence as a teacher upon the smaller group of men who in successive years made up the intern staff of the hospital or who became junior members of the attending staff. Among his staff and among his patients there were many to whom Hibbs reacted with an immediate feeling of sympathy and understanding. With them he took pleasure and interest in talking of their lives and of his own. With others he did not feel this sympathy, or, where it had existed, some incident would occur to disturb it. Then his relation with them became one either of respectful formality or of superficial pleasantry. He was quickly aware of qualities which appealed to him in

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other men, and formed intuitive judgments of their characters which he seldom found reason to change. With the members of his staff he was an exacting taskmaster, but they recognized that he was equally exacting of himself. In his relations w i t h them he showed an open-mindedness in the matter of suggestion, was enthusiastic in his praise of well-accomplished or original work, and never harbored any jealousy. On the mediocre man who refused to recognize his mediocrity and to try to rise above it, Hibbs wasted little time. Laziness, conceit, or dishonesty on the part of an assistant irritated him and often aroused in him a fiery temper. He could reprimand a culprit for mistakes arising from such qualities with the blunt directness of an army colonel. To the men of his staff Hibbs preached his creed of service. He pointed out to them that above all else they must strive for excellence in their art. The acquisition of skill and knowledge in his work, with the opportunity which it afforded for service, was the most satisfying attainment a man could gain. He preached this creed at a time when the tendency in America, too often, was to measure a man's ability in terms of his financial success. That man to whom financial success was the primary motive, and to whom service and excellence of service was a lesser consideration, had little respect from Hibbs. Let a man be interested above all in preparing himself for skilled and useful service to his fellows, and Hibbs was confident that his material success would take care of itself and be sufficient.

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He pointed out that, to the physician, there are two rewards for his service. First, there is the satisfaction of obtaining relief or cure for his patient, and, second, the financial reward which comes from the sale of his services. In discussing their careers with young men, he insisted that the true physician, the physician who truly deserved the respect of his fellows, was he to whom the satisfaction of relieving suffering in others transcended all other rewards. The ideal physician, he insisted, was primarily interested in the care of the sick. When he observed a patient, his first consideration ought to be how he could relieve that patient of discomfort and make him better. The satisfaction of intellectual curiosity as to diagnosis or the nature of the morbid process, the seeking of self-glory in a distinguished contribution to medical science, or the thought of financial reward must always be subservient to a sincere desire to relieve suffering. As for living up to such an ideal, in one instance a man might suffer from the distraction resulting from the lack of funds, or, in another instance, from a too great readiness to sacrifice the opportunity for improvement in training and knowledge for financial advancement. It was always a source of great satisfaction and pleasure to Hibbs to find, among the successive groups of interns at the hospital, individuals in whom he discerned outstanding qualities of character and ability. In these he took, and made them feel, his personal interest. Often he invited them into his office, where he had long talks with them about their futures, and discussed with

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them what was worth while in medicine and in life generally. To these men, today, one of the most vivid of their memories of Hibbs is the recollection of him at one of these interviews. Seated at his desk in the long white coat which he wore at the hospital, his eyes afire, emphatic in tone and gesture, he kindled their ambitions and encouraged them to aspire to the ideal. If Hibbs preached an idealistic creed to the young men who came under his influence, he was not impractical in his idealism. He had a high regard for the value of the service rendered by a skillful physician as considered in the light of a purchasable commodity, and in comparison with any other commodity or service an individual might buy. To his mind no laborer was so worthy of his hire as the able physician. In the last decade there has been increasing discussion of medical economics. More and more the sentiment is being expressed that it is unfair for the public to expect the medical profession to assume, by the donation of their services, a large share in the burden of caring for the sick poor. There are undoubtedly advantages to a physician in his connection with a first-class hospital. His standing in the community is enhanced, and he has facilities for the study and treatment of disease not easily available elsewhere. On the other hand, if he has a large private practice, the time devoted to hospital work, if he is conscientious, may entail either a financial sacrifice or an imposition on his physical resources; if he is young, and has a small practice, he must, for the sake of his bread and butter, neglect his hospital work if it conflicts

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in time with his private practice. Hibbs considered and maintained from the time of his appointment as surgeon in chief in 1900 that the traditional policy in effect in private hospitals of accepting the services of their medical staffs without compensation was wrong. He admitted that there was a class of men whose interest in their work was so keen that its quality was uninfluenced by whether they did or did not receive financial remuneration for it, but held that not to admit that most men derived the greatest satisfaction from work for which they received compensation was contrary to any just understanding of human nature. The traditional policy was an injustice to the physicians who of necessity must give first consideration to the work of private practice. Soon after the founding of the hospital, Dr. C. F. Taylor had advocated the payment of salaries to the physicians working in the dispensary. In response to this plea, the trustees agreed to pay these physicians the sum of twenty-five dollars a month. Hibbs maintained that this salary was entirely inadequate, and that not only these physicians should be paid but also the physicians attending the in-patients. In effect he said to the trustees: "Gentlemen, you pay your janitors, your cooks, your scrubwomen—in fact every one about the hospital but the men for whose work the hospital actually exists. Such a condition is unfair and economically unsound." No doubt to most of the trustees this was a novel attitude. Compensation of their physicians was a new conception in the economic organization of private hospitals. Some of the trustees felt that the adoption of such a

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schcmc would bankrupt the hospital. Hibbs continued his campaign, however, and maintained that, before endowment funds were sought for any other purpose, an endowment should be obtained for the specific purpose of paying the hospital physicians. Such an endowment was eventually obtained, and the New York Orthopedic assumed among private hospitals a unique position in its relation to its staff. The surgeon in chief, the associate surgeons, and the dispensary physicians all received compensation for their hospital work. While the rate of compensation was less than that received for the same time spent in private practice, it was still sufficient to make these men regard their salaries as important and substantial additions to their incomes. This arrangement, in the experience of the New York Orthopedic Hospital, has acted to make the physicians feel an increased responsibility to the hospital, has placed the surgeon in chief in a position where he can demand attendance regularly for a specified number of hours a week, and has resulted in greatly increased efficiency in the work of the staff.

I X

SPONSOR OF THE KANE FELLOWSHIPS W B H A V B seen that in the course which he gave at Columbia Hibbs had no intention of making an orthopedist of the medical student, but merely sought to instruct him in the general principles of orthopedic diagnosis and treatment. It was also his aim to attract students to the specialty. In circles of medical education there is going on at present much discussion of the qualifications which make a man eligible to call himself a specialist. It is unquestionably true that specialism has been abused by the enrollment, in the various specialties, of men not sufficiently qualified by training or experience. Hibbs frequently saw p atients whose suffering had been increased or who had wasted much time for want of skillful or proper treatment. In some instances, this resulted from the inadequate qualifications of their physicians to care for them, in others from the reluctance of their physicians to refer them to better qualified men because of the personal financial loss entailed. Examples of the former saddened hi m and made him feel the responsibility of orthopedic 1 eaders in providing good orthopedic training for young men; examples of the latter he condemned in unvarnished and expressive language which left his hearers in no doubt as to the intensity of his indignation.

The pursuit of a two-year internship gives young men

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an excellent beginning for their training, but Hibbs felt that, at the end of that time, they still lacked adequate experience and sufficient breadth of judgment to justify their going out into the country as specialists, particularly into communities where the continued guidance and advice of older men were not available. Yet the preparation for a medical career is a long and expensive one. The student's pre-medical education, his attendance at medical school, and his internship in a hospital consume, usually, about ten years, and he is not ready to engage in practice until he has reached, on the average, the age of twenty-eight. Longer to delay entrance into practice is an economic hardship and strain which few men can sustain. Hibbs appreciated this and appreciated also that while he had succeeded in obtaining a salary of twelve hundred dollars a year for young men working in the hospital outpatient department, this was not sufficient to finance their setting up in practice or to allow them to do their work without the distraction of financial anxiety. In considering the situation, Hibbs's mind turned to the possibility of obtaining a fund to endow or support young men while they continued their preparation for specializing in orthopedics. In 192.6, Mrs. John I. Kane had died and left a large estate, the residue of which was to be given to such charities as her executors selected. These executors were Messrs. C. L. Carpenter, D. K. Jay, E . J . Hancy, and W. M. Cruikshank. Hibbs had the opportunity of conferring with these gentlemen, and laid before them his ideas as to the bene-

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fits which would result in the establishment of paid fellowships which would enable promising young men to pursue their studies and to secure further and necessary experience under proper guidance before going into private practice. He pointed out that many men who were inadequately trained were going out of hospitals as specialists in orthopedics and other branches of medicine. Many of these men, he knew, would welcome the opportunity of gaining larger experience before beginning practice, but found it impossible to do so because of the lack of financial resources. After several conferences with Hibbs and after visiting the hospital to familiarize themselves with the work done there, the Kane executors offered the hospital the sume of five hundred thousand dollars as an endowment for the purpose proposed by Hibbs. The latter considered, however, that such a sum would be insufficient to accomplish what he intended, and, to the consternation of some of his advisers, refused the offer. The executors then reconsidered the matter and decided to grant the full sum which he requested. On December 5, 1917, Mr. Robert S. Brewster, President of the Board of Trustees, who shared Hibbs's interest in the hospital and his concern for the welfare of the cripple, rejoiced in forwarding to Hibbs a letter which he had received from these executors, which read, in part: DEAR M R .

BREWSTER:

Under the will of the late Mrs. John I. Kane, her residuary estate was left to her executors in trust to give the same to

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charities selected by them. Wc, the Trustees under her will, after hearing Dr. Hibbs and visiting your hospital, have decided to offer the New York Orthopedic Dispensary and Hospital $1,000,000.00 on the following terms: (A)

That it should be treated as a separate fund and called the "Annie C. Kane" fund. (B) That the income therefrom be used to pay adequate salaries to certain selected young surgeons who, having finished their interneship, and showing promise of further development, may continue their training in the hospital undisturbed by any consideration other than those pertaining directly to the care of the sick. It is not our desire to prescribe too much in detail, nor impose too severe limitations on the use of the income. Our object is to make it possible for your Board to retain the interest and devotion of competent men relieving them of economic pressure for three to five years at the best period of their lives in order that the strength of your staff may be increased and that it may be possible for you to send out to other communities men who have had the advantage of better and longer training under the proper leadership. In the next few weeks, an arrangement for the setting up of the fund was completed, and its creation w a s announced in the newspapers in February, 192.8. A t the time the following editorial appeared in the N e w Y o r k Times, under the heading, "Endowment of T a l e n t " : The million dollar gift from the estate of the late Mrs. John Innes Kane, for the creation of fellowships to enable a few of the most promising young surgeons to continue their hospital work beyond the period of interneship or to undertake research or experimental work, is noteworthy even in these days because of the purpose to which it is to be devoted. It is virtually an endowment of talent in one field of the science and art of

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surgery. Most young men entering upon a profession arc under such heavy economic responsibilities that they have to be thinking of the financial returns for their service, with the result that they can give little time to keeping abreast of progress in their profession, much less to making advances themselves in it. This endowment permits from three to five years of added study or hospital experience for eight students each year free of anxiety as to the means of livelihood, for the stipends are sufficient to afford a living even in great centers and also for those w h o have married and thus given hostages to fortune. This gift deserves cspecial notice and commendation not alone for what it has made possible in one branch of surgery, orthopedics, but also because it shows what needs to be done in other fields, particularly in promotion of health. A few years ago a notable thing was done in the endowment of an eminent opthalmologist, Dr. Wilmer, and the building of an institute about him. There is need of this sort of endowment of other men w h o have attained highest skill. But there is an even wider need of endowment at the other end of the line, an endowment of young men of high promise, that they may carry into their several professions at the very beginning of their careers the full measure of what has been learned by those who have gone before, and so be able themselves to lead in further advances. Benefit will accrue not alone to those who have the temporary stipends, but to the communities which they will come to serve directly and to the wider circle which will profit by whatever contributions these talented few make to the science to which they devote their all. It is through such endowments as this that the discoveries and achievements of one generation may become the prompt possession of the next. It is through the recognition and setting apart of the skill that can minister most effectually to human ills that the whole race is ultimately to have advantage. The endowment of young Dr. Banting,

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after his discovery of the cure of diabetes by insulin, is but a recognition after the fact of the potential value of such financing of young talent. The acquisition of the Kane fellowships by the New York Orthopedic Hospital gave Hibbs great satisfaction. The work of the hospital necessarily benefitted by the provision it made for the enlargement of its staff. Through these fellowships, men whose financial resources would otherwise have prevented it were given opportunity for obtaining mature experience and skill. Orthopedics in the previous twenty-five years had undergone a transformation. In 1900 the specialty had been almost entirely devoted to mechanotherapy. In 192.8, when the Kane fellowships were established, a grasp and knowledge of surgical technic was as essential for the orthopedist as it was for the general surgeon. But educational methods and facilities had lagged behind the progress of the art, and the number of men with the modern training was inadequate for the needs of the crippled population. By means of the Kane fellowships the New York Orthopedic was placed in a position to send out each year into other communities men with the new training. The foundation of the Kane fellowships was Hibbs's last important contribution to orthopedics. Chance had led him into orthopedic work. The observation of a class of patients suffering from deformity and disease of the bones and joints had led him to realize that such patients were handicapped not only by their physical disability, but also by the inadequacy of facilities for their treat-

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mcnt and the inefficacy of such treatment as was then practiced. He had devoted himself to the task of obtaining for the crippled patient more than a compassionate sympathy on the part of the community. He had striven to gain for them an interested attitude on the part of the public in providing them with adequate hospital facilities, and the same enthusiasm in their treatment on the part of the profession as was afforded patients suffering from acute disease. Under his influence, the hospital with which he was connected had expanded and grown and developed the same atmosphere of spirited interest and accomplishment which is present in hospitals devoted to the care of acute illness. By this example, had been demonstrated the great usefulness of an institution adequately equipped for the care of orthopedic patients. Discouraged with the results of the time-honored methods of treating the cripple by mechanical appliances, Hibbs had abandoned these methods, had adopted a treatment founded on the principle of joint fusion by surgical methods, and had devised a technic of his own to accomplish fusion of the vertebral joints, the knee, and the hip. He had demonstrated that in this way the time required for accomplishing a cure could be reduced from a matter of years to a matter of months. The introduction of surgical methods in the practice of orthopedics had created a demand for men trained in the performance of a specialized surgical technic. Facilities for such training had been limited. Then, as far as the New York Orthopedic Hospital was concerned, the Kane fellowships had offered a means of supplying such facili-

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tics and an example for other institutions to follow. The Kane Foundation insured the development of young men, trained in skillful administration to the needs of the crippled patient, who would continue to carry on his work, and thus served as a fitting climax to Hibbs's career.

X MAN AND CITIZEN PBRHAPS, in this narrative of Hibbs's accomplishment in the fields of surgery and hospital administration, too little has been said of his personal qualities. Certainly, to those who knew him, his traits of character and personality were as unusual as were his abilities. Indeed, it was his personality which made him a master of the art, just as his creative and technical gifts made him a master of the science, of medicine. The art of medicine deals with the imponderable reactions of a sick man's mind to pain and to fear, to despair and to hope. In dealing with his patients, Hibbs never lost sight of the importance of these reactions to the progress of their disease. The process of the successful healing of a diseased bone or joint apparently gave him less pleasure and interest than did the transformation of the patient's personality when relieved of pain and incapacity. At stated times, he walked the wards of the hospital with his staff and discussed the problems of diagnosis and treatment of the individual cases. On these rounds he never had time for more than a word of encouragement for the patient under discussion, but he took great enjoyment, whenever time permitted, in strolling about the wards informally and alone, and at these times he was quick to sense the discouragement of one patient or the excess of self-pity in another, or to observe the drawn look of long-continued pain on the face

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of another. At the beds of such patients he was wont to stop and talk, leaving them better for having expressed themselves to an understanding listener or for having had an appropriate word of advice or encouragement. Combined with the predominantly serious vein of his nature was a lighter side which manifested itself in the quick appreciation of humorous things and the quiet utterance of some humorous remark of his own. He enjoyed the subtleties of a refined wit or humor, and, at the same time, often found amusement in more obvious humor, such as that of a comic strip. Occasionally an incident in the joint life of Messrs. Mutt and Jeff would amuse him so much that he would cut the strip from the paper and carry it about with him, to chuckle over it again and again when he showed it to others. In many ways, his personality seemed full of contradictions. At the hospital and in relation to his work, he was quick in his decisions, and seemed alive with force and driving power. In the small affairs of everyday life unconnected with his work, he often seemed indolent and lacking in decision. If something needed to be done about his home by a masculine hand, he set his hand to it only after prolonged procrastination convinced him that the task was not to be avoided. He could carry on over long periods of days crowded with hard and worrisome work, apparently enjoying it all, and then go on a vacation and lead an utterly lazy life, the while reflecting on the doubtful merits which accrued from a strenuous existence. At one time, he might take an intolerant view of some act or viewpoint of another, and at another

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time be unexpectedly tolerant. His changes in mood, from deep seriousness to almost flippant lightheadedness, were as conspicuous in their contrast as were his periods of talkativeness and his times of inarticulate silence. Hibbs was reared at home in a religious atmosphere, where he daily took turns with other members of the family in reading passages from the Bible. He seems never to have been mentally disquieted by the conflict of science and religion. He retained throughout his life a firm faith and a reliance upon a spiritual relationship with his Creator. It was this, perhaps, which made him so humble as far as his own achievements were concerned. He served for many years as a vestryman at the Church of the Epiphany. Toward the end of his life, formal religion seemed to mean less to him than it had in his earlier years, and his religion probably found its most satisfactory outlet in the healing of his patients. Inherently, Hibbs was of a sensitive nature. This made him feel very deeply the criticism of others, particularly the reflections cast on his personal integrity in the unfortunate affair of the American Orthopedic Association. But he disguised this sensitiveness from the outside world, and only his intimates knew the depth of it. The intensity of his interest in his work, and the demands of his work upon his time and energies, precluded any great activity on Hibbs's part in other directions. It is wrong, however, to give the impression that his life was all work and no play. The number of his intimate friends were few, but he was always interested in his fellow humans. Wherever he went, he was apt to find

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some personality which appealed to him and interested him, and he took great enjoyment in conversing and exchanging ideas with such acquaintances. With those whom he liked he was always ready to indulge in some good-natured raillery, or, better still, to have a long conversation on some worth-while topic—politics, philosophy, or religion. In 1904 he married Miss Madeline Cutting of Pittsfield, Massachusetts. In one of his addresses to young graduates in medicine, Sir William Osier urged them to start their careers by "marrying the right woman." Hibbs's marriage, a union which was to continue for twenty-eight years, proved the wisdom of Sir William's advice. There existed between Russell and Madeline Hibbs, for the rest of his life, an ideal relationship and a complete congeniality. For the first two or three years after their marriage the couple found it necessary to practice a strict economy to live within their income. After this the income from Hibbs's practice increased steadily, and thereafter they were never subjected to the distraction of financial anxiety. Soon after their marriage, Mrs. Hibbs acted as one of the representatives for Bishop Greer at the newly established children's court in New York. At the time, the Catholic and Jewish communities were represented in the court, and made provision for taking and caring for children of their faiths whose home environment was unsatisfactory. The fact that no adequate provision was available for Protestant children was drawn to the at-

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tcntion of Bishop Grccr, Protestant Episcopal Bishop of the New York diocese. As a result of the necessity for an additional home of some kind for the Protestant charges of the children's court, pointed out by the committee, of which Mrs. Hibbs was a member, such a home was established. A large tract of ground in Dutchess County was acquired; and cottages, schools, and other physical equipment were erected for the housing, education, and occupational training of children which the court found it necessary to remove from their homes. This institution became known as Hope Farm. Hibbs shared Mrs. Hibbs's interest in the development of Hope Farm, followed Bishop Greer as president of the institution upon the latter's death, and succeeded in imparting to the supporters and workers of the institution a stimulus somewhat akin to that which he had given to the New York Orthopedic. Mrs. Hibbs was always keenly interested in her husband's orthopedic work. In her he found one to whom he could confide his aspirations and plans, and gain sympathetic encouragement, or, when need be, wise criticism or counsel. As has been said, Hibbs's interest in his own particular sphere of endeavor was so intense that it left little room for outside activities. Mrs. Hibbs saw to it, however, that he obtained evenings of relaxation at the theater, the opera, or musical concerts, which he very much enjoyed. He usually left home in the evening with an air of self-sacrifice, but, having arrived at the play or the opera, enjoyed himself. He liked best, however, to remain home

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and read a good book aloud with Mrs. Hibbs. For this reading, he usually chose some book of biography or philosophy, or, occasionally, a novel. The love of fishing and hunting which he acquired as a boy Hibbs retained throughout his life. He always found it difficult to refuse an opportunity for a few days of hunting or fishing, and frequently stole away on such excursions. Several years after their marriage the Hibbses became members of the Huron Mountain Club and built a cabin in the club reservation on the shore of Lake Superior. Here they spent many summers in tramping the woods and fishing, and Hibbs came to love this wooded lake country so much that each year in the Spring, when he was tired from a winter's work in the city, he found himself yearning to return there. At Huron Mountain, Hibbs formed many friendships. With the sons of the members he was an especial favorite. He had a sense of fun and an aptitude for droll banter which made him an enjoyable companion on a camping trip, while, at the same time, he exercised on these boys and young men an influence like that which he exercised upon his staff in stimulating their ambitions and helping them to fasten upon a wholesome sense of the values of life. The Hibbses never had any children of their own, but one of the young doctors at the New York Orthopedic, Herman L. von Lackum, who had served his internship at the hospital and had afterwards become a member of the attending staff, came to occupy almost the position of a son in their household. Von Lackum was possessed

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of unusual technical ability and a sound surgical judgment, and Hibbs took great interest and pride in his development; von Lackum, in return, had a graceful and thoughtful way of relieving the older man of some of the burden of his routine work. Von Lackum was a member of the aviation squadron of the National Guard, and his flying disturbed both Dr. and Mrs. Hibbs, who frequently tried to dissuade him fron continuing it. In 1918, while he was piloting his plane to the summer training grounds, the plane crashed, and von Lackum was instantly killed. His death was a great shock and sorrow to Hibbs. It was the first time that personal sorrow had touched him so closely, and it was months before he could even refer to von Lackum without showing emotion. During the World War Hibbs served as a major in the medical corps. In addition to carrying on the work at the New York Orthopedic, undermanned by the demands of the war on its personnel, he journeyed to Washington each week to lecture at the Walter Reed Hospital to the medical officers receiving training in orthopedics. The end of the war found him worn out, and he suddenly lost his voice. He consulted a laryngologist, who diagnosed his condition as tuberculous laryngitis, and advised him to give up all work and to go away. Recognizing the gravity of the condition, the Hibbses went to their cabin at Huron Mountain, and here Hibbs spent six weeks, lying in the fresh air, nursed by Mrs. Hibbs. At the end of this time, he had gained thirty pounds in weight and had entirely regained his voice. In fact, his quick and thorough recovery pointed

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to a mistaken diagnosis, and he therefore returned to New York and resumed all of his former duties. During the next ten years, he led an unusually active life. In 19x8, on the occasion of a routine examination of his eyes, his oculist discovered some small retinal hemorrhages. This condition of his eyes, combined with a moderate elevation in his blood pressure, indicated the beginning of an arterial degeneration. Hibbs was advised to reduce his pace and to take longer and more frequent vacations. He followed the advice as to vacations, and went to Europe for a short period during each succeeding winter; besides this, he began spending his week ends at a small country house which he and Mrs. Hibbs owned at Bedford in Westchester County. When he was in town, however, his friends noticed very little slowing of pace. A slow pace was not his habit. In the latter part of May, 1932., he suffered one night a distressing attack of breathlessness. To his medical advisers, it was apparent that he had had a coronary occlusion or accident to one of the arteries of his heart. He was sent to bed, in the hope that his heart would at least partially repair itself, but, as the weary summer dragged on, it became more and more apparent that his heart was damaged beyond repair. He made a good patient despite discomfort which at times was acutely distressing. He had spent his life in overcoming obstacles, and this lifetime habit made him take a sanguine view of his illness. He longed to return to his cabin at Huron Mountain, and for a while it seemed that he might re-

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cover sufficiently to gain his wish, but this was not to be, and he died on the sixteenth of September, 1932.. As the crippled patient sits today in the waiting room at the New York Orthopedic Hospital, unconscious of the part Hibbs's life has played in bettering his expectation of relief from his handicap, his eye meets these words: In Memory of Russell A. Hibbs, M. D. 1869-1932. For thirty-three years Surgeon-in-Chief of this hospital who devoted his life to the betterment of the crippled poor, and whose Vision, Faith and Courage inspired all who worked with him. Into this building his genius breathed life and a soul.

RUSSELL A. HIBBS AS A SPORTSMAN BY SAMUEL W. LAMBERT

IT HAS been said that the medical profession chooses a hobby as a follower of outdoor sport in agreement with the specialty in medicine of each individual—that physicians w h o elect a medical career are found among the ranks of anglers rather than in the more strenuous hobby of hunting with the rifle and shotgun, in which sport many surgeons are experts. Of course such a classification is never exact or rigid. Russell A. Hibbs as a boy was raised in the country of his own state, Kentucky, and he never lost the zest for the sports of the woods and fields. His temperament made him a very enthusiastic sportsman. His character and method of thought were philosophical and analytical to minute detail. His enthusiasm for improving education in his specialty, for developing methods of training experts in orthopedic surgery, was transferred to both the branches of outdoor sport which he followed with eagerness and a really excited furor. He was a keen fisherman for trout, and one of the "shootingest" gunners for ducks that has ever come to my notice or with whom I have shot side by side. One of his fellow anglers, who has waded the streams of the eastern Adirondacks in friendly rivalry, claims that his enthusiasm upon the hooking of a particularly lusty brown or an American speckled trout would bring forth a noisy acclaim intended to attract his companion and to express a mutual triumph, no matter upon which line the strike might have occurred. Of late years, he limited his fishing to the tribu-

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taries of Lake Champlain and the streams of the northern peninsula of Michigan, where he was accompanied on all vacations by his wife, who is also an ardent angler. I never fished with him, but I have shot ducks in his company, and a more cheering and cheerful companion to the "missingest" gunner of all the large tribe of the ducking fraternity could not be found. He could calm the mind and salve the feelings of anyone, no matter how great the error or how stupid the performance of his companion. The case and accuracy of his own performance was a pleasure to sec, a stimulus to better work and a lesson in humble demeanor. One of his fellow members in the Toussaint Club on Lake Erie has expressed to me his pleasure in enjoying the companionship of Russell Hibbs, both after a successful morning on the marsh and on the journeys to the Club, and in returning to New York after a few days' sport with the "English" ducks of the north shore of Ohio. Russell Hibbs exemplified the mentality of the successful medico on a holiday. Sitting in a duck blind is no place for noisy conversation or active muscular demonstration of medical and surgical problems. The ducks are keen of sight and hearing, and capable of profiting from the slightest hints of the presence of the enemy, man. The solitude of a lone fisherman or gunner might seem a bore to many activeminded physicians, but it was not so with Russell Hibbs, and I am sure that he worked out the details of his plan for the education of specialists in his own field and for the organization of the Orthopedic Dispensary and Hospital, which Dr. Goodwin has so clearly described, very largely while on his short and longer vacations on

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85

trout stream and duck marsh. M y testimony on this point comes from the duck blinds of the South Side Club of Long Island, where after I had sat w i t h Hibbs for periods of an hour or more, he would come out w i t h a whispered sentence or t w o relative to his o w n work and career as a hospital director and expert in medical education which would lead to long subsequent conference of advantage to me, at least in studying the never-finallysolved questions of the education of the young doctor during both his school work and his graduate study. While Russell would be sitting quietly on the watch for the approaching bird, w i t h every sense of sight and hearing on the qui vive, his brain would be at work also on the deeper problems of education w h i c h meant so much to him and led so surely to his successes in developing his specialty. This mental activity, disconnected from but coincident w i t h the acute attention of his physical powers, was his habit whether he watched the flight of birds in association w i t h a kindred spirit, or if he fished along some rapid mountain stream for the wary char or trout. While he was seemingly intent on his sport, his mind was at work on the serious problems of the hospital and his teaching,—a dual existence in w h i c h he excelled in both at one and the same moment. Cato's characterization of his friend Publius Cornelius Scipio Africanus, as quoted by Cicero, applies to the mental status of Russell Aubra Hibbs: Numquam se minus otiosum esse quam cum otiosus ncc minus solum quam cum solus csset. That he was never less idle than when he was taking a vacation, and never less alone than when alone.

A TRIBUTE TO RUSSELL A. HIBBS BY

KARL VOGEL

IN THE death of Dr. Russell A. Hibbs the art of surgery has lost a great leader, who in an especially difficult field opened pathways that have led to progress in directions hitherto held to be impassable. His colleagues realize the importance of the advances for which he was responsible and his students will miss the inspiration of his teaching and example, but his patients of all degree mourn the kindly friend whose supreme skill banished pain and brought strength and function back to twisted limbs and crippled bodies. As with many who have risen to great heights, the beginnings of his upward path were steep and arduous. Though success and fame were not too long delayed in coming to him, they had been preceded by a period of hard and self-denying country practice in a remote part of Texas, where the young doctor from Kentucky rode on horseback over lonely trails to visit his scattered patients. Coming to New York in 1893, unknown and without influence, six years later at the early age of thirty his ability had made him Surgeon-in-Chief of the New York Orthopaedic Hospital, a post he was to hold until his death. His inventive genius ranged the whole field of orthopedics, and his international reputation rests on many contributions covering a wide variety of subjects. Notable among these are his improvements in the treatment of tuberculosis of the joints, his method of treating diseases and injuries of the spine by the operation of NOTE;

This article is reprinted from the New York Times, September 18, 1 9 3 1 .

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spinal fusion, and his operations on the hip, knee, ankle and other joints. He was deeply interested in the problems of medical educations and during his many years as Professor of Orthopaedic Surgery in the College of Physicians and Surgeons of Columbia University strove constantly to impress on his students his own high conception of the medical calling. Through his instrumentality the Annie C. Kane Fund established fellowships enabling young doctors to continue their medical training during the first years after finishing interneship at the New York Orthopaedic Hospital. Giving unstintingly of his time to the needy, he was especially concerned with the care of children and as President of Hope Farm directed a community home for children at Millbrook. His major activities, however, centered about the New York Orthopaedic Dispensary and Hospital and the Country Branch at White Plains, the development and management of both of which formed the chief interest of his professional life. He was as great an administrator as he was a surgeon and the magnificent new buildings of the hospital, completed in 1916 and since enlarged, in planning and organization are largely his creation. As Surgeon-in-Chief he was also director of the hospital and developed it into an institution unique in its efficient management. He was simple and direct, strong in faith, singularly humble in regard to his own achievements and deprecating all praise, deliberate in forming an opinion but in-

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flexible in pursuing a course he felt was right. Unceasingly interested in the pursuit of knowledge, he was an indefatigable reader, nearly always of books on serious subjects. His life was devoted to his work and he conceded little time to relaxation, except when occasional hunting and fishing trips gave opportunity for indulging his love of outdoor life and exercising his unusual ability as a sportsman. The dominating quality that set him in a class apart was his idealistic attitude toward his calling, which he regarded as an obligation and a privilege, together with his feeling of deep responsibility to his patients. Unsparing of himself, he was a strict taskmaster to others and exacted full performance from his subordinates, but his personality and example inspired them, from the highest to the lowest, with a loyalty and devotion such as arc rarely seen. Strikingly handsome, tall, of forceful presence and compelling eye, his appearance intimated strength and authority, but with his patients, and above all with children, who received so much of his time and effort, he was all charm and kindliness and tender sympathy. His outlook on life and his contacts with his fellow beings were tempered with a grace of humor and a quiet wit that delighted all who felt its touch. The gratitude and affection, almost adoration, with which his patients regarded him and which have been most touchingly expressed since his death, are proof of how much finer than mere material success the rewards of the medical profession sometimes can be. But more farreaching than the good that any one man, however

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eminent, could do in caring for individual patients or in acting as teacher or consultant, is the importance of the great institution to which he imparted the momentum and guiding force, and something of his own rare spirit, and which remains and will continue to carry on the work to which his life had been devoted. In the New York Orthopaedic Dispensary and Hospital the memory of Russell A. Hibbs will always live. It is a monument in his honor more enduring than brass and worthy of the highest ambitions to which a mortal can aspire.

APPENDICES ORIGINAL PAPERS BY

RUSSELL A. HIBBS

I LENGTHENING THE TENDO ACHILLIS* Dr. R. A. Hibbs presented five patients affected with talipes equino-varus, the result of infantile paralysis, on whom he had performed a new operation, as follows: The tendo Achillis, having been exposed by a parallel incision i j ^ inches in length, made to its outer side, was cut transversely within J^ inch of its insertion, through two-thirds of its substance, and, with the turned knife, it was then split upward a certain distance. A quarter of an inch above the end of the longitudinal cut another transverse cut was made from the opposite side through two-thirds of the substance of the tendon, and, the knife being turned, the tendon was again split to within %

6 FIG.

I.—Lines on which the tendon is to be incised.

inch of the first transverse incision. Thus, the tendon was severed in such a manner as to secure its lengthening and at the same time to preserve its continuity. In Fig. i the first transverse cut would be from E to C, the first longitudinal from C to D, the second transverse from G to B, and the second longitudinal from B to A. When traction * Reprinted from the Medical News, L X X V I (1900), 631-33.

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LENGTHENING THE TENDO ACHILLIS

was applied lengthening would occur as shown in Fig. z and it would be equal to the sum of the two longitudinal cuts minus the sum of the two laps of inch each. In Fig. i if CD is ^ inch, B A inch, A to EC inch, andD to G B J4 inch, then the lengthening would be Yi, inch plus % inch minus ¡ n c h pl u s XA inch, or i inch minus y 2 inch, or inch. It is a matter of choice whether the longitudinal or the transverse cuts be made first, but E

C

0

G

Fio. 1.—Mechanism of elongation after incision.

it is important that the skin incision should be to the outer side of the tendon in order to prevent the scar from falling directly over the tendon, which might be rubbed by the shoe. Dr. Hibbs has learned since operating by this method that it has been practised in a case of traumatic equinus by Sporon, a Dane (Hospitals tidendc, 3d series, Vol. I X . , No. 50, 1891). C A S E I.—In a girl eight years old, a short tendo Achillis had prevented flexion of the right foot within 10 degrees from a right angle. It w a s lengthened by this method on September 1 1 , 1899, and the foot was fixed at a right angle. In t w o weeks slight voluntary motion w a s allowed and the muscle received daily exercise w i t h some resistance from the attendant. After }/i inch lengthening had been secured there was positive resistance to any further flexion of the foot than was allowed by the lengthening. The child walked with strong control of the os calcis.

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97

CASB II.—In a girl twelve years old flexion of the left foot was impossible within 15 degrees from a right angle. The tendon was lengthened % inch on July 6, 1899. With suitable aftertreatment the result was an excellent position of the foot with strong action of the muscles of the calf. CASB III.—In a girl fourteen years old flexion of the right foot was prevented within 10 degrees from a right angle. The tendon was lengthened 1 i n c h e s on June 16, 1899, an unusual amount in order to relieve extreme valgus, with resulting good control of the os calcis. As the valgus was recurring a tendon grafting would be done. CASE IV.—In a girl eight years old the left foot was inflexible within 45 degrees from a right angle, appearing to be almost in a straight line with the leg. The tendon was lenthened inches on June 16, 1899, and the foot fixed at a right angle. It was believed that an ordinary tenotomy would have been followed by loss of usefulness of the calf-muscles. It was seen, however, that this action was excellent. CASB V.—In a girl fourteen years old the right foot had been inflexible within 15 degrees from the right angle and the tendon was lengthened % inch on June 16, 1899, and the foot fixed at 90 degrees. The muscle and tendon showed enough strength to sustain the weight of the body on tiptoe and this had been true of all the cases presented. In no case had an effort been made to correct the equinus beyond a right angle. Further correction might be desirable in congenital, but not in acquired equinus. That the strength of a tendon lengthened in this w a y is not seriously impaired is proved by the observation that in every case there had been resistance to the carrying of the flexion beyond the limit allowed by the operation and also by the ability of the muscle and tendon to sustain the body on tiptoe. The process of repair had been

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rapidly completed after operation by this method, which presented obvious advantages over those in which sutures were applied to the tendon. But the greatest advantage had been found in the readiness and certainty with which the desired amount of lengthening could be exactly secured. A perfect gait required the "spring" or elastic quality imparted by the muscles which enabled the anterior part of the foot to sustain the weight of the body in walking. Without this power the gait would be that of one who had a wooden foot or a foot affected with talipes calcaneus. In equinus following infantile paralysis it is probable that the muscles are more shortened than the tendon and, as lengthening the muscles is generally impossible, operative relief has to be sought by lengthening the tendon. In operating, however, it is important, on the one hand, to avoid leaving the tendon so long as to impair the action of the muscle, and, on the other hand, to avoid leaving it so short that the equinus will not be sufficiently overcome. This method enables the operator to maintain exactly the proper relation between the length of the tendon and that of the muscle. By subcutaneous tenotomy the equinus is readily corrected, but in many cases the result is a serious defect in the gait from undue lengthening of the tendon and resulting shortening and inefficiency of the muscle.

2.

AN OPERATION FOR STIFFENING THE KNEE JOINT* W I T H REPORT OF CASES FROM THE SERVICE OF THB N E W Y O R K ORTHOPAEDIC HOSPITAL

The operation of stiffening joints has been done very generally during the past few years in cases of infantile paralysis, especially in the joints of the foot and ankle when the permanent damage to muscle and ligamentous structure has been such as to make necessary the indefinite use of apparatus to prevent deformity and secure function. The knee joint, however, I do not believe has been stiffened frequently enough, especially among the classes of people we see in the dispensaries, w h o are, in most instances, wage earners, and the necessity of wearing some form of brace permanently is troublesome and expensive to them. This is probably due to the fact that attempting to stiffen this joint by the old method of doing practically an excision, has not been very successful. In the first place, the removal of a sufficient amount of cartilage from the femur and tibia to secure bony surfaces for approximation shortens the leg about inches, w h i c h w i t h the shortening already present in these cases, is a * Read before the Orthopaedic Section of the N e w Y o r k Academy of M e d i cine, October r i , 1910, and here reprinted from Amah of Surgery, LIII ( 1 9 1 1 ) , 4°4-7-

IOO

STIFFENING THE K N E E JOINT

serious consideration. And in the second place, the removal of the ligaments makes difficult the prevention of deformity during the long period, a year or more, before there is solid bony union. This led me on January 1 5 , 1909, to perform an operation which obviates these disadvantages. It was that of mortising the patella, after it was denuded of its periosteum and cartilage, into a space prepared for it by the removal of the cartilage, just anterior to the center of the tibia and femur. It will be found that such a space may be sccured without injury to the crucial ligaments or to the epiphysis of either bone. With the patella in this position, a perfect bony bridge is thus formed between the tibia and the femur. There w a s some question in my mind as to the nutrition of this bone in its new position, so that in the first few cases the upper attachment of the patella ligament and periosteum was left intact, in order to leave undisturbed the subperiosteal vessels. Later this precaution was considered unnecessary and was discontinued. The patella in the first three cases was put in transversely, and in the next four, horizontally. In all these cases, in from five to six months there was solid bony ankylosis, which has been maintained a sufficient length of time since the removal of support to consider it permanent. (The first case, with a description of the operation, was reported to the Boston Orthopaedic Club, March i 4 ,

1909.) It then occurred to me that if the patella was placed horizontally in a space prepared for it, and then if the

FIG. 1—Space on the femur and the tibia prepared to receive the patella, (A) Crucial ligaments unimpaired.

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101

periosteum was carefully preserved in its removal from the patella and brought down over the freshened area and stitched to the periosteum around the edges of the tibia and femur, there would be reproduced from this periosteum new bone, so that our bony bridge would be larger and stronger. In the last three cases this procedure has been adopted, as shown in Figs, i , i , and 3, and in each case there has been a reproduction of bone from this periosteum, as has been unmistakably shown by X-ray pictures. The advantages of this latter procedure are obvious. In the first place, there is less likelihood of the patella slipping out of its bed, and, in the second place, there is secured, through the reproduction of new bone, a larger and stronger bony bridge, and the weight may be safely borne on the leg earlier with advantage, and all support removed sooner. These cases have walked in plaster at the end of from four to six weeks, and all support has been removed at the end of the fifth to the seventh month. Except in the three last cases, all support was removed at the end of the fourth month. It is important to note what an adequate bony bridge the patella makes, and, in addition, how far beyond the edges of the patella (Fig. 3) the periosteum extends when stitched to the periosteum of the femur and tibia, which measures the extent of the new bone produced. This operation would seem to be an ideal one in such cases as are here reported, and in addition it would seem helpful in excision cases for disease of the knee joint

I OI

STIFFENING T H E K N E E JOINT

when the patella is healthy, to utilize it and its periosteum in this w a y , as a bridge between the two bones. The operation, in all these cases, has been done through a transverse incision just below the patella. The periosteal and skin sutures were of ten-day chromic catgut. The wound was closed without drainage and a plaster spica applied. The wound was dressed through a window on the tenth day, and in every case found to be completely healed. The ages of these patients have been from thirteen to seventeen years. I believe, however, that younger children could be operated on with equally good results. CASB I.—Ethel H., aged thirteen years. Infantile paralysis. Loss of control of right knee. Operation.—January 15, 1909, patella mortised into the joint transversely. Ligaments unimpaired. Wound closed without drainage. Plaster spica applied. Walked in plaster after ten weeks, and in six months all support removed. Result, complete bony ankylosis. CASE II.—Mary H., aged fifteen years. Infantile paralysis. Loss of control of right knee. Operation.—March 1 , 1909; walked in plaster, April 19, 1909. Walked without support in 5 m o n t h s . Result, complete bony ankylosis. CASE III.—Kenneth W., aged fourteen years. Infantile paralysis. Loss of control of left knee. Operation.—April 30, 1909; walked in plaster, June 30, 1909. In seven months walked without sypport. Result, complete bony ankylosis. CASE IV.—Annie H., aged sixteen years. Infantile paralysis. Loss of control of right knee. Operation.—September 15, 1909. Result, patella slipped from its bed and became adherent to the femur. The second operation was on October 18, 1910, the patella being replaced horizontally. January 10, 1 9 1 1 , the ankylosis is firm, though short plaster still worn.

FIG. 2—Patella in place, (A) Femoral periosteum; (B) tibial periosteum.

A

B

FIG. 3—Periosteum of the patella stitched to that of the femur and tibia, (A) Line of suture of patella periosteum to femoral periosteum; (B) line of suture of patella periosteum to tibial periosteum.

STIFFENING THE K N E E JOINT C A S B V . — S a r a h W . , aged seventeen years. Infantile paralysis. Loss of control of right knee. Operation.—September 30, 1909; walked in plaster, Octobcr 13,1909. All support removed in six months. Result, firm bony ankylosis, patella put in the joint horizontally. C A S E VI.—Mary S . , aged thirteen years. Infantile paralysis. Loss of control of left knee. Operation.—Octobcr 1 1 , 1909; walked in plaster November 3,1909. All support removed after five months. Result, complete bony ankylosis. C A S E VII.—Isaac S . , aged fifteen years. Infantile paralysis. Loss of control of left knee. Operation.—November 1, 1909. All support removed in five months. Result, complete bony ankylosis. C A S B VIII.—Concetta S., aged sixteen years. Infantile paralysis. Loss of control of knee. Operation.—November z6, 1909; periosteum of the patella preserved and stitched, as shown in the illustrations. In four months all support was removed. Result, complete bony ankylosis. C A S E IX.—Emma T . , aged fourteen years. Infantile paralysis. Loss of control of right knee. Operation.—-July i i , 1910; operation, as in Case VIII. Walked in plaster September 17, 1910. In four months all support was removed. Result, complete bony ankylosis. C A S E X.—Rachel G., aged twelve years. Infantile paralysis. Loss of control of right knee. Operation.—July 2.1, 1910, as in Case VIII. Walked in plaster, September 17, 1910. All support removed in four months. Result, complete bony ankylosis.

3 AN OPERATION FOR PROGRESSIVE SPINAL DEFORMITIES* A P R E L I M I N A R Y R E P O R T OF T H R E E CASES F R O M T H E S E R V I C E OF T H E O R T H O P A E D I C H O S P I T A L

The treatment of Pott's disease or humpback by immobilization of the diseased joints has long been the accepted method, and is accomplished by various mechanical means, braces, plaster of Paris, etc. That much success has been obtained in the prevention of deformity and the cure of the disease by these means, there is no question. That there is still much to be desired is equally unquestionable, because these various means do not secure absolute immobilization, and for this reason it is necessary to continue treatment for long periods of time, and in almost every case the deformity increases more or less. The treatment of lateral curvatures is still more unsatisfactory; the deformity is more complication and its cause less definitely understood. In these, in spite of the best efforts by means of support to the column and the development of muscles, in a very large percentage of cases the increase of the deformity is progressive. In the spine affected by tuberculosis, it is the body of the vertebra which is destroyed, and, in consequence of this destruction of bone, the deformity appears, and is, •Reprinted from the NewYorkStati

Journal

of Medicine,

XCIII (1911), 1013-16.

FIG. la—Scheme of using spinous processes for solidifying posterior aspect of vertebrae. (A) Base from which spinous process has been removed; (B) process touching A; (C) tip of process touching (D) base of next process removed; (E) tip of last process removed touching bare bone at the base of (F) the process of a healthy vertebra to which anchorage is made.

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105

in the very large percentage of cases, a purely kyphotic curve. It is very rarely that the spinous or lateral processes are affected. One of the reasons why the disease is so persistent in its destructive effect on the bodies of the vertebrae is because of the motion which takes place between them, and while the various methods of treatment limit the motion, none absolutely prevents it. In the light of our present knowledge and experience, the greatest need in the treatment of this disease, both from the standpoint of shortening its duration and preventing deformity is the perfection of a method which will absolutely immobilize the spine throughout the diseased area and make the development of deformity impossible. The writer has done an operation for stiffening the knee joint, which consists of removing the patella from its periosteum and putting it in the joint after a space is freshened in the bones to receive it, the periosteum then being stitched to that of the tibia and femur. In these cases the patella was not absorbed, but formed a bridge between the tibia and femur, and the periosteum reproduced in every case new bone sufficient to make a large bony bridge and a perfectly safe bony ankylosis. This operation led to the conception that if the periosteum of the spinous processes was carefully removed, and the processes were divided at their base and placed longitudinally in the interspinous space touching with either end the base from which the processes were removed (see Fig. ia), and then the periosteum brought back and sutured, a similar condition would be produced. That is,

io6

PROGRESSIVE SPINAL DEFORMITIES

the process would become adherent to the base at either end, thus filling up the interspinous gap with solid bone, and thé periosteum would reproduce more bone so that there would be secured a fusion of the posterior aspect of the vertebra by a bridge of bone which would increase in size and strength so that absolute ankylosis would be secured. It was thought that if a bony bridge could be established, its size and strength would gradually increase to meet the force exerted upon it, as is the case with the fibula when it is utilized to take the place of the tibia. This, it seemed, would be sufficient to prevent the kyphotic curve, while in the lateral curvature cases, in which the deformity is more complicated, it was thought necessary to do an arthrodesis in the articulation between the lateral processes, thus giving a cantilever support. Through the kindness of Professor George S. Huntington, of Columbia University, I was given the privilege of doing this operation three times on the cadaver, in the fall of 1910, and I am indebted to him as well for many helpful suggestions. I have since done it upon three patients, all with Pott's disease of the spine. A sufficient time has elapsed only in one case to give positive proof that the condition which we attempted has been produced. The X-ray pictures, Figs, i b and 2., made by Dr. Caldwell, show the continuous bone formation between the vertebrae, three months after operation. One is a lateral view and the other an anteroposterior one. Of course the report of these cases, as stated before, is

FIG. lb—Lateral view showing fusion of spinous processes (Case I).

FIG. 2—Anteroposterior view, showing fusion of spinous processes ( C a s e I ) .

PROGRESSIVE SPINAL DEFORMITIES

107

preliminary, as there are many questions which arise that cannot now be answered: for instance, the earliest age at which the formation of this mass of bone may be expected, its effect on the future progress of the deformity, etc. The youngest patient was seven years old. The processes in this case were sufficiently ossified and long enough to fill the interspinous space. It is believed that in still younger children it will be successful. The traumatism of the operation will hasten ossification and increase the activity of new bone formation from the periosteum. In the very young, however, I think it will be necessary to graft bone from the leg. This is a perfectly practical procedure. No case of lateral curvature has yet been done, but I propose to do exactly this same operation, and if it is not sufficient, to do an arthrodesis between the. lateral processes, as already suggested. This operation was done through a longitudinal incision directly over the processes; the ligament was split, and the periosteum of the processes removed very carefully and retracted with the muscles. The processes were divided at their base, as closely as possible, without opening the canal, then they were placed longitudinally so that there was fresh bone contact, one end, the proximal, touching the lower part of the fresh base from which the processs was removed, and the distal end in contact with the upper part of the base from which the next process was removed, and so on throughout the diseased area, so as to ankylose the diseased one to healthy vertebrae above and below.

io8

P R O G R E S S I V E S P I N A L DEFORMITIES

The periosteum was then brought back and sutured with chromic catgut, and the skin closed with silk, without drainage. Only in the first case were any bone sutures used, as it was thought unnecessary. The ordinary sterile dressings were applied. The wound in each case was found completely closed at the first dressing, on the eleventh day. The first patient got up at the end of five and a half weeks, and all support was removed after three months. C A S E I . — E . Q . , American, male, aged nine years. Entered ward of N e w Y o r k Orthopaedic Hospital, December z j , 1910. Lumbar Pott's disease. Patient had moderate kyphos involving last dorsal and upper four lumbar vertebrae. Disease was quite active, as shown by intense spasm of muscles, occasional pain, protective gait. Indeed, he was admitted for rest because of acute symptoms, as there was no thought at that time of operating on him. Patient was kept on back in bed, wearing a spinal assistant; under this treatment he became free from pain and had no night cries at the end of t w o weeks. General condition good. Temperature normal. X ray showed disease to have almost completely destroyed the bodies of the second and third lumbar vertebrae. January 9, 1911, under gas and ether, an incision was made in the median line of the back from the eleventh dorsal to last lumbar vertebra, d o w n to the periosteum. The periosteum was then divided over the tips of spinous processes, and stripped down to the base of spinous processes, the interspinous ligaments being split in median line, thus leaving a continuous layer of periosteum and ligament on either side of spinous processes. The last dorsal and three upper lumbar spinous processes were thus denuded. The four respective spinous processes were then fractured by means of a small bone chisel, close to their bases.

FIG. 3—Case I after operation.

PROGRESSIVE SPINAL DEFORMITIES The third lumbar spine was then placed longitudinally so that its apex rested on the upper part of the base of the spinous process of fourth lumbar spine; in this position a No. x chromic gut suture was passed through the end of the third and body of the fourth lumbar spines, thus fastening the two processes together. In like manner the second lumbar was fastened to the third, the first to the second, and the last dorsal to the first lumbar. The reflected periosteum was then brought together over the spinous processes and sutured with a running chromic suture, No. i , and reinforced in three places with silk sutures. The skin wound was closed with silk. The wound was dressed and a plaster spica applied from knees to axilla, the spine being kept in slight overextension while plaster was applied. Patient was put to bed on back. On the first night after operation patient suffered severe pain which was difficult to control, even with opiates. January u , 1 9 1 1 , pain still severe and plaster was amputated at groin; this gave him very little relief. January 13, entire plaster jacket was removed. Wound found to be in excellent condition, with primary union. The wound was dressed and a modified spinal assistant applied. At no time after this did the patient have the slightest pain. It is evident that the pain and discomfort were due to the overextension of the spine, and the pressure of the plaster. The temperature rose to ioo° F. on the day following the operation. On the third day after operation, the temperature dropped to normal and has remained so. Patient was kept in bed, until February 2.0. At that time he was in excellent condition and seemed to have bony union in spine. He was allowed up on that date, wearing a brace, with no adverse effect. After getting up he continued to improve and on March 10, 1 9 1 1 , was transferred to the country branch. April 5, 1 9 1 1 , all support was removed. There was solid bony fusion of the posterior aspect of the vertebra. This is

no

PROGRESSIVE SPINAL DEFORMITIES

absolutely demonstrated by X-ray pictures made by Dr. Caldwell. (See Figs, ib and i . Fig. 3 is a photograph after the operation.) CASB II.—W. M., Italian, male, aged seven years. Entered ward of New York Orthopaedic Hospital, December 31, 1910, with dorsolumbar Pott's disease of two years' duration. Patient had moderate kyphos extending from tenth dorsal to fourth lumbar vertebra. Back was very painful, spasm of back muscles very acute. He also had double psoas spasm which caused flexion deformity of both thighs of about 90°. Slight thickening in left inguinal region. Patella reflexes exaggerated. Patient was put at rest on back and extension applied to both legs. General condition remained good and at the end of one week he had no pain and flexion of thighs was entirely reduced. Psoas spasm still present and patella reflexes + . Patient continued gradually to improve and by the middle of April, 1911, psoas spasm was very slight. Patella reflexes were normal. April 16, 1911. Under gas and ether a spinal operation was performed. Incision was made over the kyphos from tenth dorsal to fourth lumbar inclusive. Periosteum and ligaments were stripped back as in Case I. Spinous processes were found to be quite large and almost completely ossified. The bases of the spinous processes (tenth dorsal to fourth lumbar inclusive) were then fractured with a small bone chisel, and placed so that the base of the fourth lumbar remained in contact with the lower part from which it was removed and the tip was placed in contact with the spinous process of the fifth lumbar, the third against the fourth, second against the third, etc., until the bridge was formed of continuous bone. The processes were not sutured in place as in the preceding operation, as it was thought that the close adjustment and suture of periosteum and muscle would hold them in place. The periosteum was then brought back over the bone and held with deep continuous chromic gut sutures. The skin wound was closed with silk without drainage.

FIG. 4—Case II before operation.

PROGRESSIVE SPINAL DEFORMITIES

HI

Having in mind the extreme discomfort that the preceding patient had experienced from the plaster jacket, a modified spinal assistant was applied with perineal straps. The patient was placed in bed on the back. Patient had some discomfort for the first twelve hours after operation, but not severe enough to require any attention. On the following day he was free from pain and at no time since has he had the slightest discomfort. General health good. Preceding the operation, temperature had never gone above 5° F., minimum being 97.50 F. Since operation the temperature has never gone above 98.6° F., minimum being 98° F. The wound was dressed on the tenth day and the sutures were removed, union being found perfect. (Fig. 4 is a photograph before, and Fig 5. after operation.) A sufficient time has not elapsed to make a final report. This will be done later. CASE III.—Mrs. B., American, aged twenty-five years, mother of two children. Entered ward of New York Orthopaedic Hospital, March 13, 1 9 1 1 , with dorsolumbar Pott's disease, of five years' duration. Marked kyphos involving ninth dorsal to second lumbar vertebra inclusive. Patient had considerable pain when in erect posture and intense muscle spasm of back; psoas spasm on left side; large fluctuating abscess in left inguinal region, which had burrowed under Poupart's ligament, and extended down the anterointernal aspect of thigh about six inches. General condition good, temperature normal. Patient was kept at rest in bed until April 17, 1 9 1 1 , when it was decided to operate on her spine. The abscess during this time had remained about the same. April 17, 1 9 1 1 , under gas and ether an incision was made over the kyphos, down the spinous processes, the same technique being observed as in Case II. The last four dorsal and three upper lumbar spines were then fractured as in the preceding operations. The periosteum was then closed over the spines with continuous chromic gut sutures, reinforced at intervals

ill

PROGRESSIVE SPINAL DEFORMITIES

with deep silk sutures. Skin was dosed with silk, dressing applied, and the spine immobilized with modified spinal assistant with perineal straps. The patient being very heavy, she was put on a Bradford frame to facilitate moving her. She had very little pain after operation and slept during the first night without opiates. After the first twenty-four hours after operation; the patient had no discomfort; temperature normal; the abscess had given her no discomfort and was slightly diminished in size. The wound was dressed on the tenth day, and sutures were removed; union by first intention. The most striking feature of the operation is the marked reduction in the kyphos. This patient is still in the recumbent posture. (Fig. 6 is a photograph before, and Fig. 7 after the operation). It is too early in this work to reach any final conclusion as to its value. It seems, however, that this method may possibly do much in the prevention of kyphotic curves and shorten the duration of the disease, saving the patient at the same time the necessity of wearing an apparatus for years. In the lateral curvatures, it would seem to offer a means of preventing a progress of that distressing deformity. * Russell A. Hibbs, "An Operation for Stiffening the Knee Joint," Annals of Surffry, March, 1 9 1 1 ; reprinted as Appendix i .

FIG. 6—Case III before operation.

I o tu,

4 A PRELIMINARY REPORT OF TWENTY CASES OF HIP JOINT TUBERCULOSIS TREATED BY AN OPERATION DEVISED TO ELIMINATE MOTION BY FUSING THE JOINT* An attempt has been made by the operation described to produce a fusion of the hip joint by an extra-articular method, similar to that used in the treatment of tuberculosis of the vertebral articulations. Many attempts have been made to fuse this joint by operative procedures designed to secure bone contact between the head of the femur and the acetabulum. In most instances these attempts have failed; certainly this has been the experience of this clinic, f Most cases of hip-joint tuberculosis begin in early life, before ossification of the head of the femur or the acetabulum is complete. This would seem to make fusion at that age by such means difficult, if not impossible, while at a later period, when ossification is more complete, both the head of the femur and the acetabulum have been so profoundly affected by the disease and by the atrophy of disuse that, though contact may be secured, sufficient bone growth will rarely take place to produce a solid fusion of the joint. * Read before the American Orthopaedic Association, April 1 7 , 1916, and here reprinted from The Journal of Born and Joint Surf try, VIII (192.6), 5 1 1 - 3 1 . f B. P. Farrell, " A n Attempt to Fuse the Hip Joint for Tuberculosis; A Report of the End Result of Ten C a s e s , " / . Bom & Joint Surg., V I I ( J u l y , 1 9 1 5 ) ,

563-69-

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Therefore it would seem that some other means must be used, one which is outside the joint and makes contact of healthy bone with continuity of the periosteum. This has been done in these twenty cases by transposing the trochanter so that it makes contact with the ilium above and with the femur below and at the same time secures continuity of periosteum. An incision is made through skin and subcutaneous tissue from two inches behind and above the anterior superior spine, down over the great trochanter, three inches on the shaft of the femur. The deep fascia is split, the tensor fascia femoris retracted medially, and the fiber of the gluteus medius and minimus separated by blunt dissection, exposing the capsule. The periosteum of the femur is incised along the line of the base of the trochanter, elevated and retracted medially; the anterior three-fourths of the trochanter with two inches of the cortex of the femur is separated with a chisel, leaving the muscle and periosteal attachments undisturbed (Fig. 1). The capsule is split, the superior aspect of the neck exposed, and the cortex removed. A mass of the ilium including the upper rim of the acetabulum is elevated without disturbing the muscle or periosteal attachments or breaking loose the mass above. The trochanter is now transposed by turning its lower end up under the elevated mass of the ilium, its base making snug contact with the cancellous bone of the neck, the cortex having been removed. The periosteum of the transposed bone is sutured to that of the iliac mass above and to that of the

FIG. 1—(A) Anterosuperior spine; (B) skin incision.

FUSING THE HIP JOINT

XI

5

femur below. The mass is also caught by the tip of the remaining one-fourth of the trochanter; when the thigh is abducted fifteen degrees and flexed thirty degrees, it is held securely in place. The muscles and fascia are closed with sutures of plain catgut, the subcutaneous tissues with plain gut, and the skin with silk. A double spica plaster is applied, which has already been prepared and bivalved. By this means direct and massive bone contact has been secured between the ilium and the femur, with continuous periosteum which produces a situation favorable to bone growth, and essentially similar to the situation produced by spine fusion, where the continuity of bone and periosteum is primarily of healthy bone which first becomes fused; ultimately, however, fusion of the diseased bodies takes place. It was hoped that in the case of the hip the primary fusion would by of the transposed trochanter, ilium and femur and ultimately of the head and acetabulum as well, finally showing a massive area of fusion which is necessary to stand the force exerted upon it by the long femur CFigs- x a n < l 3)This technic was developed on the cadaver in the Department of Anatomy at the College of Physicians and Surgeons, Columbia University, in 192.x. The first case operated on was on April 5, 192.3. In looking up the literature in preparation of this report it was found that a somewhat similar procedure was reported by J . Hass.* Our work was completed without knowledge of this fact. • J . Hass, "Extraartikulare Ankylosierung dcr Hufte. Ztntralbl. f . X L I X (Oct. 7, 1 9 1 1 ) , 1466-67.

dir.,

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In the first twenty cases only has sufficient time elapsed since operation to make possible any fair estimate of the result, and even in these the report must be considered as preliminary. A longer time must have elapsed and a larger number of cases be studied before any final conclusion may be reached as to the value of the operation. Of these twenty cases eighteen, or 90 percent, are definitely fused, as determined by stereoscopic X-ray pictures, careful examination for mobility, and the disappearance of all spasm or symptoms of active disease, with unrestricted activity in the use of the leg for varying periods of time, from two and one-half years to six months in the most recent case. One patient was four years old, one six, and three were nine years old. The other fifteen varied up to thirty-one years, the oldest patient. Much interest lies in the results in the younger patients, because, to be of the greatest service, any such operation must be applicable to young children, at which age most cases of the disease begin, and when compensation in the use of a stiff hip is easily attained. The sixyear-old child, the second case operated on, has a firmly fused joint in good position. There is no evidence of activity of the disease, and her general condition is excellent. At the time of operation, the disease was advanced and very active. The youngest patient was a girl four years of age. The technic in this case was faulty in that the osseous center of the transposed trochanter was not placed in contact with the denuded bone of the neck, although it was firmly fixed in the ilium. The result at the end of a year was a well developed block of living

FIG. 2—(A) Tensor femoris muscle divided; (B) vastus muscle divided; ( c ) gluteus medius and minimus muscles; (D) trochanter and shaft ; (E) chisel line cut in trochanter and shaft.

FIG. 3—(A) Tensor femoris muscle divided; (B) vastus muscle divided; (c) gluteus medius and minimus muscles which were cut through anteriorly and above trochanter; (D) in la, 2a, and 3a, trochanter turned up with lower end under iliac bone flap; (E) raw bone superior surface of neck of femur; (F) head of femur in acetabulum; (G) capsule of joint.

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bone, firmly incorporated with the ilium but not attached by bone to the femur. A revision was undertaken by which a bridge of bone was made to fill the gap. Subsequent X rays have shown a progressively increasing mass of bone with ultimate firm union of the femur to the pelvis. This case demonstrates the possibility of transposing the trochanter and having it incorporate itself with the surrounding bone while remaining viable. The three nine-year-old cases have all achieved a firm, bony arthrodesis and arrest of disease. The fusion which has taken place in these cases appears to have been primarily of the transposed trochanter, ilium, and neck of the femur, but finally of the remaining head and acetabulum as well. This process is very similar to that which takes place in vertebral tuberculosis, in that the fusion is primarily of the healthy bone of the posterior elements of the vertebrae and finally of the diseased bodies. With two exceptions the disease in this series of cases was of long standing and the destructive process was extensive. The average duration before operation was eight and one-half years. In one case it was twenty-six years, in one sixteen years, in another fifteen years, and in two thirteen years. Two patients had had symptoms for only six months, and in these the diagnosis was proved by exploratory operation. Since contact of bone between the head of the femur and the wall of the acetabulum is not depended upon, the difficulty of doing the operation is not increased by the disease of these elements. On the contrary, proximity of the trochanter to the ilium makes

n8

FUSING THE HIP JOINT

the procedure easier. The trochanter itself was extensively diseased in one case, but the result was in no way compromised by this fact. In all of the cases, the disease was active as evidenced by pronounced muscle spasm and limitation of motion. X rays at the time of operation showed more or less extensive destruction of the head and neck of the femur and of the acetabulum. The general condition of the patient was good in seventeen, fair in two, and poor in one. Several of the cases had had sinuses which were healed at operation. One of these sinuses began to discharge slightly after operation but is now closed. Two sinuses open at the time of operation have since become healed. The one death in the series occurred in the case of a colored man twenty-one years old. He had pleurisy a few months before operation and was in poor condition. The disease in his hip was active and a large abscess was present. He succumbed to miliary tuberculosis nine months after operation. Several sinuses were discharging and the hip was not fused. These twenty patients had been treated in this hospital for an average of about six years and some of them had been treated for years in other hospitals. Six had been cared for at the Country Branch of the New York Orthopaedic Hospital for periods of from three to seven years. The majority of them had worn apparatus for many years. This group is quite typical of the cases of hip-joint tuberculosis seen at this clinic and illustrates the hopelessness of dealing effectively with this condition by the old conservative methods.

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In the main the same technic was used in all of these operations, but minor modifications and improvements were made until the procedure described above was arrived at. In twelve cases the wounds healed by primary intention. Six developed small sinuses in the wound, all of which healed at the end of a few months. One had a severe operative infection, still has two sinuses discharging profusely and the result of the fusion is doubtful (Series 19, Case 2.2.385). One developed sinuses in the wound and died of miliary tuberculosis nine months after and the hip was not fused (Series 5, Case 67557). A rather severe postoperative reaction with shock occurred in two cases. After that a plaster spica was prepared before operation, bivalved and warmed while the operation was being done. This eliminates all delay and manipulation while applying the plaster after the operation and substitutes a dry, warm plaster for a wet, cold one. This, together with improvement in the technic, has done away entirely with shock and the course after the operation has been smooth. Immobilization in plaster spicas was continued for an average of ten months. Walking in the plaster spica was started at about the ninth week in the earlier cases and at the end of the twelfth week in the later ones. It is customary to change the bivalved plaster into which the patient is placed after operation for a more permanent one at the end of the third week, at which time the wound is dressed. A problem arose in some of the older cases of long duration in which the hip was badly flexed and adducted

IUD

FUSING THE HIP JOINT

with slight mobility at the time of operation. A number of these were left practically in this position because it seemed inadvisable to traumatize the joint to the extent necessary to accomplish correction. In one case, the adduction has been corrected by a subtrochanteric osteotomy, and this procedure will be necessary in one other. Since no attempt was made to open the old joint cavity, it was difficult in some cases to obtain tissue from a region in which the disease was active. Twelve positive reports for tuberculosis were received from the laboratory. In eight the examination was doubtful, although in practically all a guinea pig inoculation, as well as tissue section, was carried out. With the long duration of the disease, X ray and clinical findings all corroborating the diagnosis, there seemed no doubt whatever as to the character of the lesion in any of the cases. C A S E HISTORIES CASE I.—H. H., 18307, a boy, eighteen years old at time of operation. Pain and stiffness started in right hip at two years of age. He was admitted to the New York Orthopaedic Dispensary and Hospital three and one-half years before operation. The right hip was flexed 40 degrees, adducted and internally rotated. Motion was slight. A discharging sinus was present and still was active at the time of operation. X rays showed complete destruction of the head of the right femur and a remnant of neck still in the acetabulum. A hip splint was applied and was worn for three and one-half years. Operation for hip fusion was performed on April 5, 1913, and the leg was placed in a plaster spica in 10 degrees flexion and slight abduction. The wound healed by primary union. Walking in plaster was started two and one-half months after operation.

FUSING T H E HIP JOINT

12.1

The patient remained in the hospital for three months, and the last plaster cast was removed at the end of eleven months. The hip seemed perfectly solid eight months after operation. The last X ray showed solid union of the transposed trochanter to the ilium and femur. The sinus is closed and there is no evidence of active disease. CASE II.—A. S., 60963, a girl six years old, was first treated at the clinic three months before operation. The history of limp, pain and stiffness in the left hip extended back four years, the onset being at two years. There was marked atrophy of the left lower extremity with extreme muscle spasm which greatly limited motion in the hip. X ray showed disappearance of the joint space and destruction and cavitation of the wall of the acetabulum. She had worn a plaster spica for seven months and a Taylor hip splint was applied at the time of admission. Hip fusion operation was performed on April 1 1 , 1913. The patient was transferred to the Country Branch of the hospital, where she still is, although there has been no sign of active disease for two and one-half years. The plaster spica was removed thirteen months after operation, at which time the hip appeared to be firmly fused. X rays show the trochanter in the new position with much new formed bone around it. The child runs and plays actively, with no pain or spasm. She has learned to compensate for the stiff hip in a remarkable manner. CASB III.—A. E., 19900, a boy seventeen years of age. Symptoms began in the right hip at four years of age, and he first came to the Orthopaedic Hospital for treatment at eleven years of age. He wore a hip splint for two years and the condition then became quiescent for four years. The symptoms returned about three months before operation. X rays then showed a loss of substance both of the acetabulum and head of the femur. The hip was flexed and markedly adducted. At operation, July 10, 192.3, it was felt that the adduction could not be overcome without unwarranted trauma and the hip

Iii

FUSING THE HIP JOINT

was put up without changing this deformity. The patient remained in the hospital two and one-half months, at which time weight-bearing was begun. The hip seemed firmly fused at the end of four months and the plaster was removed. In December, 1915, a sub-trochanteric osteotomy of the right femur was done in order to correct the adduction. X rays show the transposed trochanter in the new bed with abundant new bone around it. The hip is solid and there is no pain or muscle spasm. CASB IV.—M. D., 15831, a girl seventeen years old, came to this clinic at the age of two years with limitation of motion and muscle spasm about the right hip. She was treated for ten years with a Taylor hip splint. In 1913 she still had slight muscle spasm and pain in the hip, which was flexed and adducted about 10 degrees with approximately 10 degrees of motion in flexion and extension. The X rays showed a deepening and erosion of the acetabulum and only slight destruction of the femoral head. The operation was performed on September 18,19x3. The hip was placed in a plaster spica in flexion and abduction. Weight-bearing was begun in two months. She remained in the hospital two and one-half months and the plaster was removed in ten months. The X rays show apparently complete arthrodesis. All muscle spasm and pain have entirely disappeared. CASE V.—E. M., 67557, a colored man aged twenty-one years, began to have pain and stiffness in the left hip three months before admission to the hospital. He was in poor general condition and had had pleurisy with effusion during the past year. No signs of active tuberculosis could be found in the lungs. There was marked muscle spasm and limitation of motion in the left hip. A fluctuating swelling over the anterior surface of the hip was aspirated, and thin pus was obtained from which a positive diagnosis of tuberculosis was made. X ray showed slight thinning of the joint space and a small trans-

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lucent area in the roof of the acetabulum. Operation for hip fusion was performed on December 4, 192.3, six months after onset of symptoms. An abscess was found overlying the joint. The general condition remained poor after operation. Sinuses formed communicating with the abscess. The patient was discharged from the hospital four and one-half months after operation. He was later admitted to Sea View Hospital, where he died from general miliary tuberculosis nine months after operation. The hip had not become fused. CASE VI.—S. D., 3912.3, a girl nine years old, began to have pain, stiffness and limp in left hip when three and one-half years old. She came to the New Y o r k Orthopaedic Hospital for treatment when five and one-half years old, and wore the regulation Taylor hip splint for two and one-half years while receiving dispensary treatment. A t the time of operation, December 14, 192.3, she still had muscle spasm and pain. The hip was flexed 50 degrees and adducted 15 degrees. About zo degrees of motion was present. The X ray showed almost complete destruction of the head and neck of the femur, with the remnant of the neck in an eroded acetabulum. Following operation, she was in shock, from which she rapidly recovered. At the end of three weeks she was transferred to the Country Branch of the hospital, from which she was taken against advice eleven months after operation. Walking was started two months after operation. The hip seemed solid six months after operation, but the plaster was not removed until thirteen months. The hip was perfectly solid and there is absence of pain and muscle spasm. The X ray shows the trochanter solidly fused to acetabulum and femur. CASH V I I . — W . B . , 2.2.654,

a m a Q

t w e n t y - t w o years old, began

to have symptoms in left hip when fifteen years old. One year later he came to the New York Orthopaedic Hospital for treatment and was eared for in the dispensary for four years, during which time he wore a brace. His symptoms then disap-

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pcared and he was free from pain, etc., for one and one-half years, when they rccurred. Before operation he had pain and muscle spasm. Motion was limited to about 5 degrees. X rays showed marked destruction of the acetabulum and a spicule of the neck remaining. A sinus which had been discharging was closed. The hip was flexed 45 degrees and adducted. Operation was performed on February 15, 1914. No attempt was made to correct the adduction. He remained in the hospital three months, and the plaster spica was removed in thirteen months. The hip is firmly fused and the X ray shows union of the trochanter to the neck and ilium. All symptoms have disappeared. C A S E V I I I . — V . C., 1 7 1 7 1 , a boy fourteen years old, first had symptoms in right hip when seven years old. T w o and a half years later he came to the hospital for treatment and was sent to the Country Branch of the hospital for three and a half years, when he was discharged, apparently cured. One year later he again had pain, muscle spasm, etc., in the hip. There was about 10 degrees each of flexion and adduction. The X ray picture was that of deepening and erosion of the acetabulum. He was operated upon February 19,1924. An abscess was found in the trochanter, but this was employed in the usual way regardless of the pathological condition. The patient walked at the end of two months and left the hospital three months after operation. Fusion seemed to be complete in five months and the spica was removed in nine months. The joint has remained perfectly solid and free from symptoms. X rays indicate that bony fusion has taken place.

CASE I X . — R . G . , 41771, a girl nine years of age. Stiffness in right hip and limp began when she was five years of age. She was brought to the hospital six months later, and was treated for three years at the Country Branch. When discharged, the hip was quiescent, but symptoms reappeared in six months and the disease appeared to be slowly progressing. The hip was

FUSING THE HIP JOINT

12-5

flexed xo degrees, adducted 10 degrees, and very little motion was present. X rays showed marked irregular destruction of the head and neck of the femur and obliteration of the joint space. She was operated upon March 9 , 1 9 1 4 , and has remained in the Country Branch since then. She started to walk in plaster two months after operation. The hip appeared to be solid in eight months and the plaster was removed in ten months. The child is now very active and has no symptoms whatever in the hip. X ray shows a large bridge of bone between the acetabulum and femur. CASE X.—T. S., 3031, a boy seventeen years old, began to have pain in the left hip and limped at four years of age. He came to this clinic three years later, and was treated for three and one-half years at the Country Branch, at the end of which time he was apparently cured. He reported for six months longer at the dispensary. He was free from symptoms for six years more. Then following a fall the hip again became active and he was found to have only slight motion and muscle spasm. A healed sinus was present. X rays showed slight erosion of the head of the femur and obliteration of the joint space. The operation was done on March 14, 1914, thirteen years after the onset. Weight-bearing was started nine weeks later. The hip seemed solid in eight months, and the plaster was removed at the end of one year. At the time, a sinus was discharging, but it soon closed and has remained so. The patient is active and well; the hip is solid and there are no evidences of active disease. CASB XI.—R. M., 7 1 7 1 1 , a girl four years old, began to have pain and stiffness in the right hip at three and one-half years. She was taken to the Orthopaedic Hospital three months later. All the typical signs of tuberculosis of the hip were present. The X ray showed nothing definite. An exploratory operation was performed, and the diagnosis of tuberculosis of the hip was established by section of tissue and guinea pig

11.6

F U S I N G T H E HIP JOINT

inoculation. On June 17, 19x4, six m o n t h after onset, a hip fusion operation was performed, and she vas sent later to the Country Branch of the hospital. T h e traisposed trochanter fused firmly to the ilium, but failed to uritc with the femur because the technic had been faulty and good contact had not been established. In April, 192.5, a second operation was performed and pieces of bone were turned up from the femur to make contact w i t h the transplanted trochinter. This resulted in a complete bony bridge w h i c h has stcidily grown larger. The h i p is n o w solid and is free from symptoms. CASB XII.—J. M . , 4151, a boy fifteen years old, was first seen in this clinic w h e n four years old. He had then had pain, stiffness, and limp in right hip for six month;. He was treated in the dispensary w i t h a brace w h i c h he wort eleven years, until the time of operation. The disease was then slightly active as evidenced by pain and muscle spasm. A tery slight range of motion was still present and there was a marked flexion and adduction deformity. T h e X ray showed destruction of the head and neck of the femur, erosion of the acetabulum and slight upward displacement of the shaft. Hr was operated upon July 9, 19x4, and the hip was placed in flexion and slight abduction. He stayed in the hospital for three months, at w h i c h time union seemed firm and w a l k i n g was begun. The spica was removed at the end of eight months. The hip has remained solid w i t h no symptoms of activity. It is in a position of flexion and slight adduction. T h e X ray now indicates bony fusion. CASE X I I I . — F . C., 43748, a girl nine years old, first had evidence of tuberculosis in right hip when ¿ve years old. She came to the N e w Y o r k Orthopaedic Hospital four years after, w i t h the typical findings of atrophy, musclc spasm, great limitation of motion and w i t h the hip in flexion and adduction. The head and neck of the femur were destroyed and the acetabulum was deepened. A discharging sinus was present. She had worn a brace for three years. A hip fusion operation was performed on

FUSING THE HIP JOINT

12-7

August ix, 1914. Weight-bearing was started in three months, and the hip appeared to be solid in seven months. The plaster spica was left on for seven months. The patient has remained at the Country Branch of the hospital since operation, although she is entirely free from symptoms. The hip seems firmly arthrodesed and X rays indicate that this is so. There is still a slight discharge from the sinus. CASB XIV.—I. S., 7 7 7 5 1 , a girl fifteen years of age, began to have pain, stiffness and limp in right hip when five years old. She first came to the Orthopaedic Hospital ten years later, having been treated elsewhere in plaster for two years and with a brace for eight years. The disease appeared to be moderately active and well advanced. The hip was adducted and flexed and very little motion was present. X ray showed marked destruction of the head and neck of the femur and enlargement of the acetabular cavity. Two healed sinuses were indicated by scars. Operation was performed on November iz, 1924. Walking was begun in plaster at the end of three months. Fusion seemed firm at the end of seven months, and the plaster was removed in nine months. She stayed at the Country Branch of the hospital for thirteen months. A sinus appeared after operation but closed at the end of three months. The hip is solidly fused in good position and gives no symptoms. X ray shows fusion of the femur to the ilium through the transplanted trochanter. CASB XV.—P. L., 1 7 4 9 3 , a boy twelve years old, began to have symptoms in right hip when five years old. One year later he came to the Orthopaedic Hospital and was sent to the Country Branch, where he stayed for five years. One year after discharge from the hospital he still had pronounced muscle spasm and limitation of motion, although he had worn a brace for six years. The joint was in good position, flexed 20 degrees and abducted in degrees. About 30 degrees motion was possible. The X ray showed under-development and decalcifi-

ii8

FUSING T H E HIP J O I N T

cation of the femur with cystic areas in the head and neck. He was operated upon November 19, 1924, and later was sent to the Country Branch of the hospital where he still is being kept under observation. He began to walk in plaster three months after operation. The hip appeared to be firmly fused at the end of seven months and the plaster was removed at the end of nine months. The hip is now flexed and slightly adducted. Fusion is firm, as indicated both by physical examination and X rays. There arc no symptoms of disease in the joint. CASH XVI.—A. L., 51971, a boy fourteen years old, first had pain and stiffness in right hip when five years old. He applied for treatment at the New York Orthopaedic Hospital seven years later. There were several draining sinuses about the hip, which was flexed and extremely rotated. Motion was limited to about 30 degrees, and muscle spasm was present. The X ray showed decalcification of bone, deep cavitation of the acetabulum, and marked destruction of the head and neck of the femur. A hip fusion operation was done on December 16,1914. Weight-bearing was begun three months later, and the hip seemed to be solid eleven months after operation. The plaster was removed thirteen months after operation. The X ray shows a bridge of bone from the ilium to the femur and the hip appears to be solid. The sinuses still are discharging. There is no muscle spasm or pain. CASE XVII.—E. G., 5x861, a girl sixteen years of age, was admitted to the New York Orthopaedic Hospital in 19x1, having had pain in left hip and leg for six months. There were atrophy, muscle spasm, and limitation of motion. The X ray showed bone decalcification and thinning of the joint space. A hip splint was applied, and at the end of a year the pain was gone and the muscle spasm had almost completely disappeared. Several months later, the symptoms recurred, and the pain became very severe and persistent. Operation was performed January 9, 1915. She was allowed to walk in plaster four

F U S I N G T H E HIP J O I N T

12.9

months later. A sinus appeared after operation w h i c h healed two months later. The hip appeared to be solid at the end of six months, and the plaster was removed in seven months. She remained at the Country Branch of the hospital for eleven months after operation. The hip is now firmly arthrodescd in flexion and abduction and there is complete freedom from pain. The X ray shows bony fusion of the femur to the ilium through the transplanted trochanter. CASE X V I I I . — A . K . , 68695, a man thirty-one years old, began to have symptoms of tuberculosis of the left hip when he was five years old. For the intervening twenty-six years he was treated at the dispensary. There were intermittent periods of activity and for a total of sixteen years he wore braces and plaster casts. A t the time of operation there were still pain and muscle spasm. The hip was flexed 35 degrees and slightly adducted. Motion was practically nil. X rays showed cavitation of the acetabulum and erosion of the head of the femur. He was operated upon February 1 7 , 1 9 1 5 , and was allowed to walk three months later, at which time the hip seemed firmly fused. A sinus which formed in the incision was healed at the end of t w o months. The plaster was removed eight months after operation and the patient was discharged from the Country Branch of the hospital at the end of nine months. Fusion is solid, as indicated both by X ray and physical examination and all symptoms of activity have gone. CASE X I X . — A . L . , 2.1385, a boy twelve years old, had limp and stiffness in right hip when two years of age. He came to the N e w Y o r k Orthopaedic Hospital three years later at the age of five, and was treated for seven years in the Country Branch of the hospital, during all of which time he wore a brace. The disease in his hip progressed steadily although his general condition was good. A t the time of operation the hip was flexed and extremely rotated and only about 5 degrees of motion was present. The femoral head and neck were gone, and

FUSING T H E HIP JOINT the acetabulum was deepened and elongated. Operation was performed February 18, 191.5. There was a severe postoperative reaction and it was found that the wound was infected. This infection extended to the bone and an osteomyelitis ensued. There are still draining sinuses and the result is doubtful, though it is hoped that fusion will take place. C A S E X X . — J . B., 41140, a boy ten years old, had onset of symptoms in the right hip when five years of age, and was taken at once to the New York Orthopedic Hospital. He was admitted to the Country Branch six months later and remained there five years, until he was operated on. During all of this period he wore a brace. His general condition was good, but he continued to have muscle spasm and limitation of motion in the hip and the X ray showed increasing cavitation of the acetabulum and disappearance of the joint space. Operation was performed on February 2.0, 192.5. A rather severe infection ensued but the wound finally closed completely. Weightbearing was started in three months, and the hip appeared to be solid in four months. The plaster was removed in ten months. The patient is being kept under observation at the Country Branch of the hospital. The X ray shows bony fusion of the femur to the acetabulum and clinically all signs of disease have disappeared.

BIBLIOGRAPHY [The following is a list of Dr. Hibbs's paper in chronological order.] A Report of Six Cases of Mastoid Disease Operated upon at the Polyclinic Hospital by Professor E. B. Dench. N. Y. Polyclinic, II (1893), 174-76. The Modern Treatment of Wounds. Transactions Texas State Med. Assn., X X V I (1894), 117-30. A Case of Quintet Labor with Photographs of Children and Placenta. Am. Med. Surg. Bull., X (1896), 167. The Treatment of Abscess in Connection with Tuberculous Joint Disease. N. Y. Med. J., L X V (1897), 661-65. The Relation of Suppuration to Shortening of the Limbs in Tuberculous Diseases of the Hip Joint; a Study of One Hundred and Six Cases. N. Y. Med. J., LXVIII (1898),. 650-54. A Study of Shortening of the Tibia and Femur in Fifty Cases of Tuberculous Diseases of the Hip Joint. N. Y. Med. J., L X X (1899), 87^79. An Operation for Lengthening the Tendo Achillis, with Report of Ten Cases and Illustrations. Med. News, L X X V I (1900), 631-34. Published also in Lancet, London, X I (1900), 1170. A Report of Two Cases of Haemarthrosis of the Knees. N. Y. Med. J., LXXIII (1901), 91. A New Incline Plane and the "Camp Stool Cover Rest." Am. Med. J., II (1901), 848. The Management of the Tendency of the Upper Fragment to Tilt Forward in Fractures of the Upper Third of the Femur. N. Y. Med. J., L X X V (1901), 177. The Management of the Tendency of the Upper Fragment to Tilt Forward in Fractures of the Upper Third of the Femur; a Reply to the Question of Priority Raised by Dr. N. M . Shaffer. N. Y. Med. J., L X X V (1901), 314.

BIBLIOGRAPHY Subcutaneous Division of the Tcndo Achillis for the Relief of Equinus Following Infantile Paralysis. N. Y. Med. J., L X X V I (190z), 89-100. The Orthopedic Hospital Pelvic Rest. N. Y. Med. J., L X X V I I (1903), 118. The Tendo Achillis Shortened for the Restoration of the Function of the Calf, Lost as a Result of a Previous Tenotomy. N. Y. Med. J., L X X V I I (1903), 773-76. Suture of Popliteal Nerve; Perfect Restoration of Function. J. Nerv, and Ment. Dis., X X X CI9°3)> 565. Two Cases of Congenital Elevation of the Shoulder, with a Review of the Reported Cases. Med. Ree., LXIV (1903), 168-71. In collaboration with Dr. H. Correl-Loewenstein. Ein Fall von angeborenem Hochstand der Schulterblätter und eine Zusammenstellung und Klassifikation der bisher veröffentlichten Fälle. Arth. f . Orthop., etc., Wicsb., XI (1904), 40-50. Translation of the above; in collaboration with Dr. H. Carrel-Loewenstein. The Treatment of Knee-joint Disease. Internat. Clin., Phila., Fifteenth Series (1905), No. i, pp. 1x5-33. The Treatment of Joint Tuberculosis in the Open Air in a City Hospital. N. Y. Med. J., L X X X I I I (1906), 393. A Method of Lengthening the Achillis Tendon and Other Tendons. Internat. Clin., Phila., Sixteenth Series (1906), No. 1, pp. 79-81. Suggestions in the Treatment of Hip-Joint Disease. Internat. Clin., Phila. and Lond., Sixteenth Scries (1906), No. 4, pp. 178-85. An Original Method of Operating for Congenital Dislocation of the Hip; a Preliminary Report of Cases. N. Y. Med. J., L X X X V I I (1908), 767-71. An Operation for Stiffening the Knee-Joint; with Report of Cases from the Service of the New York Orthopaedic Hospital. Ann. Surg., LIII (1911), 404-7. An Operation for Progressive Spinal Deformities; a Preliminary Report of Three Cases from the Service of the Orthopaedic Hospital. N. Y. Med. J., XCIII (1911), 1013-16.

BIBLIOGRAPHY

J

33

An Operation for Pott's Disease of the Spine. N. Y. State J. Med., XII (1911), 501-4. An Operation for Pott's Disease of the Spine. J. Am. Med. Assn., L I X ( 1 9 1 1 ) , 433-36. A Further Consideration of an Operation for Pott's Disease of the Spine; with a Report of Cases from the Service of the New York Orthopaedic Hospital. Ann. Surg., L V ( 1 9 1 1 ) , 681-88. Muscle Bound Feet. N. Y. Med. J., C (1914), 797-99. Anteversion of the Neck of the Femur in Connection with Congenital Dislocation of the Hip. J. Am. Med. Assn., L X V (1915), 1801-1. The Problem of the Chronic Cripple. A. Am. Med. Assn., L X V I I (1916), 985-86. Development of the New York Orthopaedic Dispensary and Hospital. Am. J. Care of Cripples, V (1917), 2.01-1. Tuberculosis of the Knee Joint in the Adult in Which Operations Were Done Eliminating Motion by Producing Fusion of the Femur and Tibia; a Report of Five Cases from the Servicc of the Orthopaedic Hospital. N. Y. Med. J., CV (1917), 9 1 1 - 1 5 . The Treatment of Deformities of the Spine Caused by Poliomyelitis; a Report of Eight Cases in Which Fusion Operations Were Performed. J. Am. Med. Assn., L X I X C I 9 I 7)» 787-91. Treatment of Vertebral Tuberculosis by Fusion Operation; Report of Two Hundred and Ten Cases. J. Am. Med. Assn., L X X I (1918), 1371-76. Treatment of Vertebral Tuberculosis by Fusion Operation; Report of Two Hundred and Ten Cases. Transactions Section Orthopedic Society, Am. Med. Assn., 1918, p. 119. An Operation for "Claw Foot." J. Am. Med. Assn., L X X I I I (1919), 1583-85. Fracture-Dislocation of the Spine Treated by Fusion. Arch. Surg., IV ( 1 9 1 1 ) , 598-613. A Report of Fifty-nine Cases of Scoliosis Treated by the Fusion Operation. J. Bone and Joint Surg., VI (1914), 3-37. Surgery of the Spine. J. Industrial Hygiene, V (1914), 315-18.

!34

BIBLIOGRAPHY

End-Results in Treatment of Knee Joint Tuberculosis. J . Am. Med. Assn., L X X X V (19x5), 1189-92.. In collaboration with Dr. H. L . von Lackum. A Preliminary Report of Twenty Cases of Hip Joint Tuberculosis Treated by an Operation Devised to Eliminate Motion by Fusing the Joint. J . Bone and Joint Surg., VIII (19x6), 5"-~33Orthopedic Surgery and the Graduate Nurse. Am. J. Nursing, X X V I (19x6), 697-99. Some Aspects of the Problem of Joint Tuberculosis. South. Med. J., X X ( 1 9 1 7 ) , 178-80. Joint Tuberculosis. Med. J . Australia, I (192.7), 810-12.. In collaboration with Dr. A. DeF. Smith. Treatment of Vertebral Tuberculosis by the Spine Fusion Operation; a Report of T w o Hundred and Eighty-six Cases. J . Bone and Joint Surg., X (19x8), 805-14. In collaboration with Dr. J . C. Risser. Developmental Abnormalities at the Lumbo-Sacral Juncture Causing Pain and Disability; a Report of One Hundred and Forty-seven Patients Treated by the Spine Fusion Operation. Surg. Gynec. and Obstet., L X V I I I (192.9), 604-11. In collaboration with Dr. W. E. Swift. "Orthopedics," in Outline of Preventive Medicine for Medical Practitioners and Students, prepared under the auspices of the Committee on Public Health Relations, New York Academy of Medicine. Editorial Committee: Frederic E. Sondern, Chas. Gordon Heyd, E. H. Corwin. New York, Paul B. Hoeber, Inc., 19x9. The Treatment of Tuberculosis of the Joints of the Lower Extremities by Operative Fusion. J. Bone and Joint Surg., X I I ( i 9 3 ° ) . 749-54"Diagnosis of Various Lesions of the Spine," in Surgical Diagnosis, edited by Evarts Ambrose Graham. Philadelphia, W. B. Saunders Co., 1930. Scoliosis Treated by the Fusion Operation; an End-Result Study of Three Hundred and Sixty Cases. J. Bone and Joint Surg., XIII ( 1 9 3 1 ) , 91-104. In collaboration with Drs. J . C. Risser and A. B. Ferguson.

INDEX American Orthopedic Association, Hibbs rejected for membership in, 47, 48; influence of, on American Orthopedics, 49; commission of, to investigate ankylosing operations of spine, 49750; Hibbs elected to membership in, 51 Aspinwall, Mr. John C., executor of Kane estate, 10 Bethel College, Hibbs a student at, 5 Birdsville, birthplace of R. A. Hibbs, 3. 5

Bone, use of grafts of, 107 Boston, Orthopedic Club of, 100 Brown, Mr. Jas., a founder of New York Orthopedic Hospital, 10 Bull, Dr. Wm. T., consultant at New York Orthopedic Hospital, 47 Caldwell, Dr. E. C., radiologist, 106 Caipenter, Mr. C. L., executor of Kane estate, 64 Columbia University Medical School, Hibbs appointed professor at, 55 Cornell University Medical School, Hibbs offered professorship at, 55 Cruikshank, Mr. W. M., executor of Kane estate, 64 Derby, Dr. R., consultant New York Orthopedic Hospital, 47 Farrell, Dr. B. P., associate of R. A. Hibbs, 53, n j Ferguson, Dr. A. B., 134 Follow-up system, at New York Orthopedic Hospital, 45,51 Fusion operations, sit Operations Goldthwaite, Dr. Joel E., letter of congratulation to Hibbs on his election to American Orthopedic Association, 52. Greer, Bishop David Hummell, 74, 75

Hancy, Mr. E. J., executor of Kane estate, 64 Hass, Dr. J . , devises operation for fusion of hip joint, 115 Hibbs, Emma Lena Branch, mother of Russell, 4, 5 Hibbs, James Lacy, father of Russell, 3. 5

Hibbs, Madeline Cutting, wife of Russell, 74-78 Hibbs, Russell A.: birthplace, 4; childhood and education, 4—6; 'actices in Texas, 6; intern at New ork Polyclinic Hospital, 9; house surgeon at New York Orthopedic Hospital, 10-14; Surgeon in Chief, 16; secures funds for country branch, 10; founds New Jersey Orthopedic Hospital, 2.3; campaigns for new hospital, 15; devises new operations, 19, 31, 35, 38; reports on results of his operations, 43-44; opinions on diagnosis of joint disease, 45; rejected for membership in American Orthopedic Association, 46-48; Chairman, Orthopedic Section, American Medical Association, 51; Professor of Orthopedic Surgery at Columbia, 55-57; influence on his staff, 57; his creed of service, 58; advocates payment of staff physicians by hospitals, 60-61; secures fund for fellowships, 64-70; traits of character, 71-74, 83-85; President of Hope Farm, 75, 90; Major U. S. Army Medical Corps, 77; death, 78 Hip joint, fusion of, see Operations Hope Farm, 75 Huntington, Dr. George S., 34, 56

?

Jacobi, Dr. Abraham, consultant at New York Orthopedic Hospital, 47 Jay, Mr. D. K., executor of Kane estate, 64

I36

INDEX

Jndson, Dr. A. B., sponsors Hibbs's election to American Orthopedic Association, 47 Kane Fellowships, 65-67 Kane, Mrs. John I., 64; Annie C. Kane fund, 66 Knee joint, stiffening of, let Operations Lackum, Herman L. von, Hibbs's associate at New York Orthopedic Hospital, 76, 134 Lambert, Dr. Adrian V. S., concurs in Hibbs's plan of teaching orthopedics, 56 Lambert, Dean Samuel W., concurs in Hibbs's plan for teaching ortho cdics, 56, on Hibbs as a sportsman, 1-85.

r

McBurney, Dr. Charles, consultant at New York Orthopedic Hospital, 41 New Jersey Orthopedic Hospital, founded by Hibbs, 2.3 New York Orthopedic Hospital, founding of, 9; organization of, 17-18; Country Branch of, opened, 10; industrial school of, 1 1 ; new hospital building of, opened, 16 New York Polyclinic Hospital, Hibbs an intern at, 8 New York Timti, comments on Kane Fellowships, 66 Operations: tendon lengthening, 19, 30, 95-98,131-33; stiffening of knee joint, 31, 43, 99-103, 133; fusion of spine. Î5-37. 43. « J . ' î î . i } * . iJ4; fusion of hip, 38, 113-30, 134 Osgood, Dr. Robert B., letter of congratulation to Hibbs on his election to American Orthopedic Association, 51 Polk, Dr. W. M., 56 Potter, Mr. Howard, a founder of New York Orthopedic Hospital, 10

Risser, Dr. Joseph, devises turnbuckle for use in treatment of lateral curvature of spine, 37, 134 Roosevelt, Mr. Theodore, a founder of New York Orthopedic Hospital, 9 Satterwaite, Dr. Thos. E., consultant at New York Orthopedic Hospital, 47 Shaffer, Dr. Newton M., surgeon in chief New York Orthopedic Hospital, 9; dispute of, with Hibbs, n-i3;resignation of, 14; method of lengthening tendons, 19; attitude toward operative surgery, 40 Smith, Dr. A. DeF., associate of R. A. Hibbs, ^3, 134 Spine, fusion of, ue Operations Swift, Dr. W. E., 134 Taylor, Dr. C. Fayette, instrumental in founding New York Orthopedic Hospital, 9; advocates payment of hospital physicians, 61 Tendo Aibtiltt, lengthening of, sa Operations Trueleau, Dr. E. L., advocate of freshair treatment for tuberculosis, 19 Vanderbilt University, Hibbs graduates from, 5 Vogel, Dr. Karl, tribute to Hibbs by, 87-91 Von Lackum, Herman L. see Lackum, Herman L. von Watson, Miss Emily A., supplies funds for country branch, 19-11 Walker, Mrs. Harry, shares in Miss Watson's gift, 10 Welsh, Mr. Osgood, advocates Hibbs's appointment as surgeon in chief, 1 0 Wyeth, Dr. John, Superintendent of New York Polyclinic Hospital, 8, 9

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