Ronald FURLONG1909–2002

Ronald FURLONG

1909–2002

Ronald Furlong, the pioneer of hydroxyapatite- coated hip replacements, died on August 12, 2002 at the age of 93. He is buried in Weggis, Switzerland, which fittingly reflects his strong professional and cultural links with the continent.

He was honored by Pope Pius XII with a special blessing for his work among the civilian popula- tion in Milan at the end of World War II. He was the “discoverer” of Küntscher, the nail and then the man. In Italy with the Royal Army Medical Corps (RAMC), Furlong developed a particular expertise in plating fractures of the femur and, at the base hospital in Caserta, accumulated a per- sonal series of 200 cases. After the Allied Army took Italy, he was responsible for inspecting a German military hospital. Here, he recognized something very unusual in the treatment of a frac- tured femur and, at the end of the war, was instructed by Whitehall to find out about this new device. After a hair-raising journey through war-torn Europe, he eventually located Professor Küntscher in Kiel via the good offices of Profes- sor Böhler (a friend of Ronnie Furlong’s old chief, Rowley Bristow), whom he found in hiding in Vienna. The currency for this extraordinary adventure was cigarettes and the mode of trans- port a jeep. He returned to Britain much impressed by Küntscher’s work, together with a precious trefoil-shaped intramedullary nail, which he personally delivered to Maurice Down of Down Brothers, the famous old British manu-

Jules FROMENT

1878–1946

Jules Froment was Professor of Medicine at Lyons, and devoted his life to neurology, com- bining diligent observation, a philosophical ap- proach and debating skill.

Graduating in 1906 with a thesis on disease of the heart in thyrotoxicosis, he remained at Lyons until the Great War. After a year at the front, he joined a nerve injuries unit at Rennes, and later was at Paris with Babinski. During this time he evolved a series of tests for nerve dysfunction, the best known being his sign of ulnar nerve weakness; another was loss of the hollow of the anatomical snuff box in radial nerve injury.

After the war he ran a Red Cross Hospital in Lyons, and the encephalitis epidemic of 1918–1922 provided another intellectual chal- lenge. In 1926 he nearly died as a result of being severely injured by one of his patients.

Froment pointed out the difference between

a pinch grip and grasping, both of which are

impaired by a low ulnar nerve palsy due to weak-

ness of adductor pollicis. He introduced a test to

show this. Today it is used to assess flexor polli-

cis brevis.

facturing company. It was then marketed worldwide.

Later in his career he would once again turn toward continental Europe for inspiration and assistance in developing his own ideas. He was one of the very few British surgeons to be a per- sonal friend of Professor Pauwels and one of only five people to be awarded the Pauwels Medal for biomechanics. Pauwels spoke only German and wrote only in “High German” so, in his early sixties, it was back to school for Ronnie Furlong, this time language school. It is a tribute to his remarkable intelligence that it took only 3 months of early-morning daily German lessons for him to master the language. Within a year, together with his friend, Paul Maquet, one of Pauwels’ disciples and the pioneer of the understanding of the leg alignment in knee surgery, he was translating the works of Pauwels, Braun and Fischer into English. Rather remarkably, these translations sold well in Germany, as the text was more com- prehensible when written in English than in the complexity of classical German! During early 1960, I can recall the often animated debates on biomechanics that would take place among Messrs Furlong, Maquet, Kummer, the distin- guished anatomist and pioneer of comparative biomechanics from Cologne, and Bombelli, the Italian guru of proximal femoral osteotomy.

Debate would switch from English to German and, to a somewhat bewildered senior registrar, the resultant force was undoubtedly to be reck- oned with. Finally, it was the link with the German faciomaxillary surgeon Dr. Osborn that would introduce hydroxyapatite coatings and revolutionize prosthetic fixation.

Furlong’s career was extraordinary in the true sense of the word, for nothing about him or what he did was ever ordinary. To start with, it was long, very long; indeed, it probably qualifies for the Guinness Book of Records. Will orthopedic surgery or, indeed, any branch of medicine, encounter again a doctor who spends 70 years in active practice? As with most aspects of this remarkable life, his medical career started with a touch of color. Born in 1909, he grew up in south London, being educated at Eltham College. At the age of 16 there was, it seems, a sharp disagree- ment between Furlong senior and the house master, who had taken exception to finding young Furlong with his feet up on the mantelpiece while some prospective parents were being shown round the school. Consequently, one week Furlong junior was a schoolboy and the next,

apparently, a medical student. Whether the Dean of St. Thomas’ comprehended that he had ad- mitted a 16-year-old is not recorded, but Ronald probably appeared far older. He was physically a giant of a man, tall, broad shouldered, undoubt- edly handsome and always elegant; even as a schoolboy he doubtless had an imposing style.

Anyway, if Furlong had decided he was coming to St. Thomas’, that was it and the Dean, poor man, was probably not given an option to refuse.

He qualified at the age of 22 and fully justified his early admission, winning the Cheselden Medal for Surgery. As was possible in those days, he passed his primary before he qualified in 1931.

By the age of 24 he was FRCS. It seems unlikely he ever actually applied for a job; certainly he never seems to have attended an interview. He was appointed a house surgeon to Sir Max Page, a fine clinician who clearly had a tremendous impact on young Furlong. He appointed himself to his next post, informing Rowley Bristow at a garden party that he proposed to come and work for him. Bristow was the first orthopedic consult- ant at St. Thomas’ and had been placed there by his mentor, Sir Robert Jones. Even though the First World War had given a great boost to ortho- pedic and trauma surgery, the specialty was, in the 1930s, still tiny. Such expansion that had occurred was largely due to the personal influence of Sir Robert, who had an honorary appointment at many hospitals, one of which was St. Thomas’.

Max Page and Bristow remained lifelong heroes.

From the former Furlong learned the art of clini- cal surgery and, from the latter, the art of leader- ship. He duly became registrar and then chief assistant.

The medical world of the 1930s was very dif- ferent from today. All doctors worked extraordi- narily long hours but the pace of life was far less frenetic. I recall a beautiful summary over coffee in the surgeons’ room in classical Furlong style:

“The biggest inconvenience in the life of a Harley Street surgeon was that the dining room also acted as the patients’ waiting room so that lunch, by necessity, had to finish by ten minutes to two.” In those pre-antibiotic days, long-stay patients were lodged in a country hospital and there were several of these around London, for example Stanmore, Black Notley, Royal Sea Bathing at Margate and Lord Mayor Treloar’s at Alton.

On Fridays, the “great man” from Harley

Street/Teaching Hospital would come down in his

Rolls Royce, do his ward round, then operate on

Saturday morning. Sir Reginald Watson-Jones of

the London Hospital went as far as Oswestry.

Each great man usually had his country house near his country hospital. Rowley Bristow lived in a Victorian mansion at West Byfleet and his hospital was the Church of England Home for Waifs and Strays at Pyrford, later renamed the Rowley Bristow Hospital. The day-to-day running of these hospitals was the responsibility of the registrar and chief assistant. Ronnie Furlong’s formative years were therefore spent between St. Thomas’ and Pyrford and periods out

“on loan” to other friends. In Furlong’s case, it was to Sir Harold Gillies, the pioneering plastic and hand surgeon. Furlong was a beautiful surgeon to watch and much of the polish came via Sir Harold. Ronnie Furlong was to achieve inter- national acclaim in this field. One of the pleasures of my registrar years was watching him do a now unfashionable operation of fasciotomy for Dupuytren’s contracture. He was brilliant with the tenotome and had no fear of digital nerves. He himself had a Dupuytren’s contracture in his left little finger. Rowley Bristow had accounted for a digital nerve and the situation had eventually been rescued by Sir Archibald MacIndoe. However, Furlong thereafter had a touch of numbness on the ulnar side of his little finger, but it made no dif- ference to his technical excellence!

The second phase of his career was wartime experience. As with many others who lived through the war, he never spoke about it and it was only when I read The Times obituary (August, 28, 2002) that I learned of his blessing from Pius XII and the fact that he was one of the first, if not the first, orthopedic surgeon to use penicillin. He had met Sir Alexander Fleming in Italy and had, with characteristic style, told Fleming, he was most impressed with “that tea stuff you are playing with.”

The third phase was his establishment as a leading clinician and one of the best second opin- ions in the country. He did not even know he had been appointed as a consultant at St. Thomas’

until some weeks after the appointments commit- tee, for he was still too busily engaged in his RAMC duties, including, of course, charging around Europe seeking Küntscher. As standard practice, he was sent off on a Fellowship before starting his post. Some things do not change and finance for Fellowships was just as problematic as today. Waiting at Waterloo to catch the boat train to Southampton and thence America, he observed a shadowy figure in a mackintosh walking towards him. Being rather short sighted,

it was only when the figure drew close that he rec- ognized that it was George Perkins (the second orthopedic specialist to be appointed to St.

Thomas’ and, later, Professor of Surgery). Perkins thrust his hand into his mackintosh pocket, took out a large wad of pound notes, thrust them into Furlong’s pocket and wished him “bon voyage”!

Willis Campbell, Stirling Bunnell, Albee, Sorrell and, I believe, Risser were part of the itinerary.

He was, I understand, meant to come back as an expert in spinal fusion and scoliosis, but spinal surgery never fired his imagination.

The 1950s and 1960s were, by Furlong’s stan- dards, relatively quiet. He was acclaimed for his excellent monograph on hand injuries, published in the mid-1950s, but much of this was based on his wartime experience. He had a fine command of both written and spoken English, with an extraordinary ability to summarize complex con- cepts in a brief sentence. His hospital notes were always a delight to read. As a registrar in the follow-up clinic, what more did you need to know about a patient than the simple statement “sciat- ica—all over the body!” My own favorite story of the Furlong diagnostic acumen was the tale of the butterfly, which was recounted to me by David Gruebel-Lee, chief assistant to Furlong and later consultant at Frimley Park Hospital. He was doing a clinic at the Queen Victoria Hospital, East Grinstead (Furlong had sessions at St. Thomas’, the Rowley Bristow Hospital, Pyrford, and East Grinstead) when in came a lady in her thirties.

She did not have too much the matter with her;

indeed, it was apparent that she had really just called in to pay her respects to Mr. Furlong.

Having passed the time of day, she departed, leaving David Lee somewhat puzzled as to why she had such a thick folder of orthopedic notes.

These related to her time as a child and early

teenager when she had been seen by many of the

distinguished colleagues of the day, including

several well-known opinions in Harley Street,

whose letters of explanation often ran to a page

or more. David Lee eventually came across the

Furlong contribution, which merely amounted to

a single line: “Doesn’t want to be a butterfly in

the school pantomime.” It was of course a case of

teenage anterior knee pain compounded by the

problems of being a teenager. Furlong stories

were legion. I never knew him miss a case of alco-

holism; “My boy,”—all registrars were referred

to as boys—“if a spouse specifically requests a

single room for her/his husband/wife you can

with confidence write down ‘alcoholic’.” His

memorable phrases, combined with a sharp diag- nostic acumen, made Furlong a fine teacher.

Consider the case of the 16-year-old boy found languishing under the chest physicians for 6 months, with the physique of a 10-year-old, hor- mones all awry and scattered bone cysts. The answer—miliary tuberculosis. Why? “Two ele- phants (in this case three) parading down the Strand are likely to belong to the same circus.”

With his turn of phrase and ready wit he was a brilliant teacher of undergraduates. Personally, I resolved to become an orthopedic surgeon fol- lowing my first Furlong outpatient session as a student. Seminar sessions and problem case learn- ing were not the order of the day but “theater”

was. The outpatient teaching room in the old Victorian south wing was indeed like a theater with banked rows of seats. The finalists sat in the front with the rest of us behind. Enter then this broad, elegant, imposing man, an object flew across the room toward the captain of rugby, accompanied by the cry “Catch it.” “What is it?”

“A patella, sir,” came the reply. “That, my boy, is the nearest you’ll get to a Nightingale knee for the next two hours!” The only surprising thing to me was that all St. Thomas’ students didn’t take up orthopedics. However, in the early 1960s, every- one thought orthopedics was going out of busi- ness. Antibiotics would clear tuberculosis and vaccination would remove polio, while trauma was still largely treated conservatively. Those who wanted to do proper surgery would go for general surgery, for it was the age of pursuing cancer cells with a knife. How wrong they were;

orthopedics was about to change, for joint replacement was arriving.

The 1950s and 1960s had seen Ronnie Furlong achieve “clinical excellence.” An ordinary man would have been well content with what he had achieved and would have looked forward to retirement 5 or 6 years down the line, for RJF, as he was often known, was approaching 60. Two factors were to be the spark; one was emotional, the other professional. Ronnie Furlong lived for orthopedics, indeed I doubt if there was a single day in the 70 years in which he practiced that orthopedics did not govern his way of life. If he went abroad it was to see some distinguished col- league and if he stayed at home, he would sit and think. However, he required a soulmate who was equally dedicated. He found such a person in his third wife, Eileen. It was a partnership that achieved great things together: the formation of the joint replacement instrumentation (JRI)

company; the first hydroxyapatite-coated hip, inserted on September 9, 1985, when Ronnie Furlong was 77; the opening of a factory in Sheffield with its remarkable expertise in high- tech coatings; and the Queen’s Award for Techni- cal Achievement in 1993. To obtain this award you not only have to have the ideas but are required to show these are economically viable and can generate an export industry. It is an extraordinary achievement for a surgeon to form a company that is the recipient of this award.

The last 5 years of his St. Thomas’ career had been the period of enlightenment. Ronnie Furlong had a great respect for Charnley, with whom he had served in the war, but he did not feel com- fortable with a 22 mm femoral head. He tried the McKee, but inserting the large socket seemed too destructive. He did not take to the Ring. The 32 mm head of what was then called the Müller–Charnley seemed to him a practical solu- tion. His surgical eye was also attracted to the Müller instrumentation. So began another voyage of discovery on the continent. However, he was not satisfied purely with technique; he wished to understand the theory. This took him in search of Pauwels, much as many years before, he had searched for Küntscher, only this time language, not war, was the problem. As we have already noted, he was to master German without diffi- culty, just as he was to master the knowledge of biomechanics. For those of us working in St.

Thomas’, it was a remarkable period, for not only was it the first UK hospital to do the Müller hip, but the second to adopt the AO system of fracture fixation (Batten of Birmingham was the British pioneer of AO), and the second UK hospital to do a knee replacement (Michael Freeman at the London Hospital was the first; while at St.

Thomas’ we took up the Gunston). All this was done with a staff of two consultants, two senior registrars and a registrar, with two other senior registrars on rotation to Southampton and New York and one other registrar on rotation to the Princess Margaret Hospital in Swindon. It was certainly an exciting time to learn orthopedics.

The final phase of Furlong’s career, the era of originality and creativity, was to last a very long time. Joint Replacement Instrumentation, known by its initials JRI, grew out of necessity, his mother-in-law declaring that, while her son-in- law could be arrested for importing contraband, at her age she had no wish to join him and that

“In future, neither I nor my skirt will be employed

to cover illegally imported Müller replacements.”

Up to that point, the eccentric method of restock- ing St. Thomas’ was as follows: Jim Lovegrove, RJF’s loyal theater assistant, would announce:

“The stores are getting low.” RJF would then inform the team that he would be absent from the next clinic while the Mercedes, wife Eileen and mother-in-law were driven at speed across Europe to Berne. The return journey was nonstop, espe- cially through customs! If they had been appre- hended, the resulting court case would have been legally interesting, for St. Thomas’ never paid for the implants, which were therefore charitable gifts from RJF himself.

Joint Replacement Instrumentation gradually metamorphosed from an import company to man- ufacturing. Interestingly, the first implant it made was the Gunston knee. The first implant to carry the Furlong name was the straight stem hip replacement, which has several features in com- mon with the Exeter hip. The Furlong HAC hip was quite different and, while some hold that

“the jury is still out,” the evidence to date in the opinion of this author is that it will not only stand the test of time but will prove a major orthopedic milestone. It is a combination of British design, technical expertise and metallurgy with German chemistry. The late Dr. Osborn was a German maxillofacial surgeon and, as is so often the case, new materials in orthopedics have once again entered via our “dental” colleagues. Needless to say, in characteristic Furlong style, the inspiration for the design, with its proximal fill to control rotation and its intramedullary stem, came not from expensive testing in biomechanical labora- tories but from observation of a glass stopper in a wine decanter in RJF’s sitting room! The story of JRI, the glossy adverts, the Sheffield factory plus the Queen’s Award are very well recorded in the obituary published in Orthopedic Product

Ronnie Furlong fully deserves the accolade of

“Master Surgeon,” for he was a fine diagnostician with great technical skill. He had flair, charisma and, in addition, late in life displayed remarkable originality. As Professor Müller once remarked,

“Ronnie, we all stop but you go on and on.” His ideas on fixation and hip replacements will remain a landmark even when technology ad- vances. He was a great European surgeon, a great British surgeon and to undergraduates and gradu- ates alike, a great St. Thomas’ surgeon.

Riccardo GALEAZZI

1866–1952

For 35 years Professor Galeazzi was Director of the Orthopedic Clinic in the University of Milan, and his example and leadership, both in clinical surgery and in research, were a tremendous stimulus to orthopedic progress throughout Italy.

Under his guidance, the Instituto dei Rachitici grew from small beginnings to become an impor- tant orthopedic hospital, and his influence was largely responsible for the inception and devel- opment of rehabilitation centers for the care of the crippled and injured.

His many scientific writings testify to his eru- dition and wide culture; especially to be remem- bered is his great work on scoliosis, to which he devoted a large part of his professional life.

Notable also were his studies of skeletal tuber- culosis, acute arthritis of infants, and juvenile osteochondritis. He made contributions to the treatment of chronic arthritis of adults, to the pathology of osteitis fibrosa, and to the patho- genesis of achondroplasia. He made experimental studies on bone grafts and on epiphysial cartilage transplants, and he was able to review more than 12,000 treated cases of congenital dislocation of the hip. In the field of operative surgery, he intro- duced original techniques for the treatment of poliomyelitic disabilities, congenital foot defor- mities, recurrent dislocation of the shoulder and of the patella, and torn cruciate ligaments of the knee.

Among his many activities he found time to

direct for 35 years the Archivio di Ortopedia, the