William Thomas Gordon PUGH1872–1945

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Who’s Who in Orthopedics

a seeker after high places. He was not a “committee man” but could be irritating and irrepress- ible in committee, usually presenting some aspect of the subject normally ignored yet worthy of further consideration.

His originality and personality brought numer- ous overseas visitors to Bristol and many were privileged to be entertained by K.P., with Joanna his wife and the seven children, at The Chalet, their country resort with a few acres of woodland, perhaps to participate in a barbecue or in the felling of trees, but certainly in some vigorous open-air occupation that was so dear to his heart.

Others might meet the Pridies in the Isles of Scilly, where swimming and boating were the regular holiday activities based on their diminu- tive holiday abode on St. Mary’s.

Kenneth Pridie, Lecturer in Orthopedic Surgery at the University of Bristol and Senior Orthopedic Surgeon at Bristol Royal Hospital and Winford Orthopedic Hospital, died suddenly on May 4, 1963, at the age of 57 years while reading a paper to the South-West Orthopedic Club meeting at Exeter. He had had to reduce his activities since the ﬁrst evidence of cardiac insufﬁ- ciency in 1962 and appeared to be doing well until shortly before his death, when friends were alarmed by news of heart failure, but he insisted on giving his paper on anterior fusion of the cervical spine.

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William Thomas Gordon PUGH

1872–1945

William Thomas Gordon Pugh was the Medical Superintendent of Queen Mary’s Hospital for Children, Carshalton, from 1909 until his retire- ment in 1937. Originally a physician, he became interested, of necessity, in children’s orthopedics, and during those 28 years established and directed one of the ﬁrst two long-stay children’s country hospitals in the south of England. Both Pugh and his hospital became well known for the manage- ment of skeletal tuberculosis and poliomyelitis.

Pugh is best remembered for his “traction by suspension” and for his “Carshalton carriages,”

which were the tools he used to diminish the destructive changes so manifest in tuberculous joints treated without traction.

William Thomas Pugh was born in 1872 at Hodley, a village in Montgomeryshire. In 1899 he adopted by deed poll the additional Christian name of Gordon. He was educated at Ardwyn School, Aberystwyth, University College, Aberystwyth, and the Middlesex Hospital Medical School, where he was entrance scholar and subsequently Lyell Gold Medallist in prac- tical surgery, Senior Broderip Scholar and Governors’ Prizeman. He qualiﬁed in 1894 and graduated the following year with ﬁrst-class honors in surgery and honors in medicine and obstetrics. After the customary junior appoint- ments at his teaching hospital and in children’s work, he joined the fever service of the Metro- politan Asylums Board in 1897. The following year he gained the MD and in 1907 became

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Superintendent of Gore Farm Hospital (now the Southern Hospital) at Dartford in Kent. During 1905 he had described a simple staining tech- nique, using toluidine blue in absolute alcohol and glacial acetic acid, for the detection of the diphtheria bacillus by demonstration of its Babès- Ernst bodies or polar granules.²

In 1909, as a result of his expressed views on the need for children’s country hospitals, he was appointed ﬁrst Medical Superintendent of the Children’s Inﬁrmary at Carshalton, which was, with royal approval, redesignated Queen Mary’s Hospital for Children in 1914. Here he remained for the rest of his professional career. He retired in 1937 and died at Boscombe, Hampshire, 8 years later.¹By 1919 his reputation was so established in orthopedics that he became a member of a select orthopedic club in company with McRae Aitken, Blundell Bankart, Rowley Bristow, Reginald Elmslie, Laming Evans, William Trethawan, Jenner Verrall and Thomas Fairbank.

In 1926 Pugh was president of the orthopedic section of the Royal Society of Medicine. He was an early member of the British Orthopedic Association, and in 1935 he was elected to the Fellowship of the Royal College of Surgeons of England.

When Pugh arrived at Carshalton, the hospital, which had been completed by the Metropolitan Asylums Board in 1907, consisted in the main of 24 single-storey ward blocks with over 900 beds. The buildings were originally intended for a convalescent fever hospital but had never been occupied. They were situated in 136 acres of parkland on the Surrey Downs. Pugh modiﬁed some of the ward blocks in order to provide an operating theater, gymnasium and appliance workshop.³ The reduced bed complement was made up by constructing verandahs around the courtyards on the south side of each ward block in which 300 children might live, day and night, summer and winter, continuously in the open air.

Children who required prolonged inpatient treatment were accepted from the whole of the London area on the authority of the boards of guardians and the London County Council. Under Pugh’s guidance, special units were set up within the hospital to care for children with skeletal tuberculosis, poliomyelitis, cerebral palsy and rheumatic fever. The undulating countryside provided ideal conditions for the open-air treatment of skeletal tuberculosis so popular at that time. In addition, enforced rest, adequate diet and conservative surgery, which included the aspira-

tion and incision of abscesses, were the mainstays of treatment. Pugh accepted a trial of heliother- apy (sunshine) and phototherapy (carbon arc lamp), but was not convinced of their efﬁcacy;⁴ however, he was more impressed with the use of radium in the treatment of tuberculous cervical adenitis.⁵

Gordon Pugh is best remembered in orthopedic circles for his methods of overcoming deformity and of maintaining enforced rest of the tuberculous hip and spine. In 1924 he introduced into England “traction by suspension” for the treatment of tuberculosis of the hip at the suggestion of Dennis W. Crile of Chicago.⁶The method had first been described by Josse of Amiens in 1836 for the treatment of fractures of the femur, and Pott and Petit had experimented with inclined planes and gravity in the eighteenth century.¹⁰ Pugh had not been satisfied with the ability of weight traction to abolish deformity caused by spasm around an inflamed hip joint.

The original apparatus used at Carshalton consisted of a fracture board and mattress on which the child was placed with the feet towards the head of the bed. Skin extension was applied direct to the affected limb, the extension straps were secured to the fracture board and, by attaching it to the head rail, the child was tilted head down by about 30 degrees. Lateral rotation of the limb was prevented by a sandal attached to a horizontal wooden bar, and a further wooden bar was placed under the mattress at knee level to prevent backward subluxation of this joint. One night of “traction by suspension” usually sufﬁced to correct hip deformity caused by muscle spasm. The child was allowed relatively free mobility on the bed but was prevented from turning over by a chest band.

Pugh had difficulty in finding a suitable skin extension to withstand prolonged traction. Ini- tially, and with success, he used two large mole- skin plasters, which enveloped the thigh. These were later replaced by two layers of stockinette fixed to the thigh by zinc–gelatin paste, which gave fewer skin complications.

Pugh also modiﬁed Robert Jones’ abduction frame to give traction by suspension in patients with advanced tuberculosis of the hip in whom the desired result was ankylosis in the best position rather than a mobile joint, as was often obtained by “Pugh’s traction” in early cases. In the early 1920s, the ﬁrst tip-up hip carriage was produced and this was essentially the fracture board on wheels, elevated to 30 degrees from the horizontal.

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For the treatment of spinal caries, Pugh advo- cated prolonged recumbency to prevent the collapse of the diseased vertebral bodies until union had been achieved. There were no shortcuts:

“There had never yet been devised a jacket or splint . . . which was capable of relieving the diseased vertebral bodies of an erect child from superincumbent weight.”⁷ He believed that recumbency could prevent deformity in the early case but did not think that hyperextension at the seat of disease, as practiced by Gauvain, could produce correction if deformity was already present. Pugh argued that hyperextension opened up a gap between the vertebral bodies, which interfered with bone healing. The lesion would then heal with ﬁbrous tissue, which allowed recurrence of the deformity on assumption of the upright posture, despite the support of a jacket or brace. He was also against posterior spinal bone grafting as a method of shortening the duration of recumbency. He regarded the procedure as per- formed in the 1920s and 1930s as unsuitable for children. The operation was often done while the disease was still active in an endeavor to reduce weight on the weakened vertebral bodies by bracing the posterior elements together. Pugh argued that the center of gravity for the body was well in front of the spinal column and that if recumbency was discontinued before healing was well advanced, collapse of the vertebral bodies could occur anteriorly. Furthermore, the graft prevented telescoping of the vertebrae and main- tained the space between them with a persistent abscess and further sinus formation.⁷Pugh was in advance of his time and his views on spinal grafting—in those days always posteriorly—proved correct. Pugh attempted to neutralize the deformity after arrest of activity by encouraging the compensatory curvature in the healthy region of the spine. He had observed that in two-thirds of his children, spinal caries developed before the age of 6 years, when the shape of the spine was readily modiﬁed.⁷

Pugh developed the Carshalton carriages for the recumbent treatment of vertebral caries.⁸They were made in the hospital workshop and consisted of a metal spinal frame mounted on a wooden carriage. On them, children could be immobilized for months or years with little supervision, but could exercise the limbs and share in the social and edu- cational amenities of the hospital. Constructed of gas piping, the frame was shaped individually for each child to produce the appropriate compensatory spinal curvatures. The child was secured to

the frame with a waistcoat of crash towelling and a folding leg piece was incorporated to rest the knees in slight ﬂexion and prevent equinus deformity of the foot. When there was clinical and radi- ological evidence of healing, many children were then treated for a further lengthy period, often months or years, in a molded jacket of nonﬂam- mable celluloid.

Renal infection and lithiasis were, at one time, common complications in recumbent children and the carriages were modiﬁed in the early 1930s to allow 30 degrees of tilt of the frame to either side, thus elevating each kidney in turn to improve urinary drainage. This, in addition to a high ﬂuid intake, restriction of dietary oxalate and oral administration of potassium citrate, solved the problem. In 1933 Pugh introduced a second hip carriage in which the spinal frame was mounted on rollers on a backward inclined slope to produce traction by suspension. As on the spinal carriage, a rotary device was incorporated.

This carriage was developed to allow the child to lie in the more comfortable horizontal position.

Elmslie had reported that poliomyelitis was the commonest single cause of crippling in children in the London area,⁹ and in 1924 the London County Council designated 50 beds at Queen Mary’s Hospital for the treatment of this condi- tion in the second stage, that is, from the loss of muscle tenderness until the disease became stationary. Pugh did not believe in outpatient treatment, as was commonly practiced then, and insisted that adequate supervision with rest, splin- tage, muscle training and re-education could be done only in hospital. In some cases he consid- ered that heat, massage and electrical stimulation were beneﬁcial, although he was fully aware of the dangers of fatigue. All treatment was under the supervision of two gymnasts. An outdoor heated swimming pool was constructed for the use of these patients in 1927. Children in the later stages of the disease were also admitted for oper- ative correction of their deformities and for stabilization procedures, and many of these were done by distinguished visiting orthopedic surgeons such as the redoubtable Willie Trethowan from Guy’s.

Although skeletal tuberculosis is now uncom- mon in the United Kingdom, Pugh’s “traction by suspension” remains of considerable value for the treatment of children with transient synovitis of the hip, Legg–Calvé–Perthes’ disease, coxa vara,¹¹and fractures of the femoral shaft, and pro- 282

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vides a memento of “Pugh of Carshalton,” who devoted his life to the care of crippled children.

References

1. D’Arcy Power, Le Fanu (1953) 2. Pugh (1905)

3. Pugh WTG (1926) 4. Pugh WTG (1925–1926) 5. Pugh WTG (1937) 6. Pugh WTG (1926–1927) 7. Pugh WTG (1925) 8. Pugh WTG (1921) 9. Pugh WTG (1922–1923) 10. Rang (1966)

11. Wastson-Jones (1952)

foreign editor of The Journal of Bone and Joint Surgery since January 1928.

Bologna was a Roman city. The Cathedral of San Pietro e San Paolo, built in part from the Roman remains, was erected in the fourth century.

The city has long been a seat of learning, and legends attribute the founding of the famous Uni- versity of Bologna to Theodosius the Great in 425 A.D. Among the students of this university were Dante (1265–1321), Petrarch (1304–1374), and Luigi Galvani (1737–1798), the discoverer of galvinism. One of the most famous professors was the anatomist Marcello Malpighi (1628–1694). In 1262 the students of the university were said to number nearly 10,000. The student population has decreased, but the medical school of the university is still outstanding.

The Istituto Ortopedico Rizzoli is situated on a hill on the outskirts of this fascinating old city and occupies the picturesque buildings of a Benedic- tine monastery known as San Michele in Bosco.

The early years of this institute for crippled children were not noteworthy, until Alessandro Codivilla, modest and skillful master, became its director and surgeon-in-chief. This great general surgeon, after excelling in the surgery of the gastrointestinal tract and the brain, devoted his talents to orthopedic surgery, and the “Istituto”

became world-famous. Codivilla made original and important contributions to the surgery of fractures and the methods of tendon transplantation, and to the development and standing of the specialty.

At his death in 1912, Codivilla was succeeded by Vittorio Putti, the son of a well-known surgeon who was for many years professor of surgery in the University of Bologna. Putti had ﬁrst become identiﬁed with the Istituto Ortopedico Rizzoli in 1903, when Codivilla had appointed him as an assistant. Following 2 years of study in European clinics, he returned to the institution in 1909 as vice director, and in 1914 became director and surgeon-in-chief of the Istituto. He was also professor of orthopedic surgery at the University of Bologna.

In 1922 he opened the country branch, which provided for the care of 100 cases of surgical tuberculosis, and as director of this hospital (Isti- tuto dio terapico Codivilla di Corona d’Ampezzo) in the Dolomites, he found frequent escape from his very strenuous city life.

A brilliant student, a wide reader, an able administrator, a resourceful and skillful surgeon with a mechanical bent, he enhanced the 283

Vittorio PUTTI

1880–1940

Vittorio Putti was professor in the University of Bologna, surgeon-in-chief of the Istituto Ortopedico Rizzoli, a founder of the Société Internationale de Chirurgie Orthopédique et de Traumatologie and president of its 1936 Congress, Honorary Member of the British Orthopedic Association, the American Orthope- dic Association, Corresponding Member of the American Academy of Orthopedic Surgeons, and many other national organizations. He was a bib- liographer, medical historian, orthopedic investi- gator, and teacher of surgeons. He had been a