No scalpel required: When orthopaedic surgery was conservative

In his 1914 presidential address to the American Orthopaedic Association, Gwilym G. Davis, MD, described the field as follows: “Radical procedures characterize general surgery, whereas

conservation is the watchword of the orthopedic surgeon.”¹ Conservative surgery was an ideology many elite surgeons applied at the time to separate themselves from their barber-surgeon past—to distance themselves from the image of the rash, careless, bloodthirsty hatchet men who recklessly chopped off limbs. By contrast, the modern, scientific surgeon demonstrated restraint, precision, and educated judgment in his practice. William H. Halsted, MD, FACS, epitomized this notion of conservative surgery in this era. Although he readily operated, removing cancerous breasts, chest muscles, and lymph nodes, he did so with a meticulous control of bleeding, using only the finest possible sutures.

Conservative in orthopaedic circles, however, frequently meant refraining from operating altogether, or, to use the words of orthopaedists themselves, it meant privileging “dry” surgery over “wet” surgery—manipulative surgery over operative surgery. The orthopaedists’ commitment to conservative surgery increased with the outbreak of World War I, a time when the gold standard of care was nonoperative bracing and months of physical and vocational therapy.²

H. Winnett Orr, MD, FACS, whose collection of some 2,600 volumes of rare books and miscellanea on permanent loan o the University of Nebraska Medical Center, Omaha, from the American College of Surgeons Archives, was among these surgeons. In his memoir of the Great War, Dr. Orr described his devotion to “the development of what Sir Robert Jones, Bt, KBE, CB, FRCS, called an ‘orthopaedic conscience,’” of treating all forms of “disability and deformity…even when the patient himself had given up hope.”³ Sir Robert, along with his uncle and mentor Hugh Owen Thomas, KBE, CB, FRCS, had an international reputation for developing a new brand of orthopaedic surgery in Britain, defined not by the knife, but by nonoperative rehabilitation techniques, or what they called “curative workshops” (see Figure 1).²

After the Great War, Dr. Orr applied the principles of conservative orthopaedics at home, particularly in fracture care. At the Nebraska Orthopaedic Hospital, Omaha, where he worked for 50 years, he developed variations on the Thomas Splint, a method of external fixation and traction that drastically reduced mortality rates among soldiers, especially individuals with femur fractures (see Figures 2 and 3). Although operative techniques of internal fixation would eventually come to dominate fracture care worldwide by the late 1960s, the ongoing coronavirus 2019 pandemic has forced many surgeons to reconsider older approaches in an effort to alleviate overcrowded operating suites and mitigate the risk of viral transmission among both patients and surgical staff.⁴

References

1. Gwilym G. Davis. President’s address. Am J Orthop Surg. 1914;12(1):1-4.
2. Linker B. War’s Waste: Rehabilitation in World War I America. Chicago, IL: University of Chicago Press; 2011.
3. Orr HW. An Orthopedic Surgeon’s Story of the Great War. Norfolk, NE: Huse Publishing Company; 1921:13.
4. Iyengar K, Vaish A, Vaishya R. Revisiting conservative orthopaedic management of fractures during COVID-19 pandemic. J Clin Orthop Trauma. 2020;11(4):718-720.