Jones made orthopaedics a specialty in the United Kingdom

Sir Robert Jones laid the foundation for orthopaedic treatment, training and thinking.

Issue: Issue 1 2003

--- Sir Robert Jones

When Sir Robert Jones received his medical training, orthopaedics meant little more than taking care of disabled children, usually through mechanical means. Through his determination, Victorian work ethic and vision, however, orthopaedics in the United Kingdom was expanded to include the treatment of adults, the inclusion of all disorders of the musculoskeletal system, and their surgical and nonsurgical management.

Although Jones died nearly 70 years ago, his legacy lives on. “All are aware that he is the founder of our specialty in this country,” said Nicholas Barton, FRCS, emeritus consultant orthopaedic surgeon, Nottingham University Hospital. Barton is a member of the British Orthopaedic Association (BOA) with a keen interest in the history of orthopaedics in his country. He noted, however, that there is probably no single figure “quite so dominant” in the history of American orthopaedics as Jones. “I never knew him, of course, but I did meet patients and physicians who did, and they all thought he was wonderful.”

Tremendous contributions

Among his accomplishments, Jones was instrumental in the founding of the BOA and was the first to use the x-ray for diagnosis in England. He is also partially responsible for the close relationship between British and American orthopaedics, which contributed much to the betterment of the specialty in both countries. Jones also set up an organization of hospitals that were founded by his disciples following World War I.

His contributions to surgical orthopaedics include bone grafting, various combinations of tendon transfers to correct paralytic hand and foot deformities, a proximal femoral osteotomy procedure, the operative removal of torn menisci, and the description of the avulsion fracture of the base of the fifth metatarsal. In addition, he investigated early interpositional arthroplasty by placing gold foil between the damaged femoral head and acetabulum of an arthritic hip.

“Jones was fortunate to enter practice as aseptic (thermal sterilization) procedures rendered bone and joint surgery-safe,” said John Kirkup, MD, FRCS, honorary archivist of the BOA. “But his methods maintained a sound balance of conservative and radical treatment.”

Jones was born in Rhyl, North Wales, in 1858. He entered Sydenham College in London at the age of 12 and remained there until he was 17. Following his graduation, he went to live in Liverpool with his uncle, Hugh Owen Thomas, the famous pioneer of early English orthopaedics, and attended the Liverpool School of Medicine. Jones was qualified as a doctor in 1878 and began working as his uncle’s assistant in his huge outpatient service.

Thomas, who came from a family of bonesetters, combined secrets passed down for generations with contemporary medicine to establish a practice that was famous for treating a variety of orthopaedic conditions nonsurgically on an outpatient basis.

Under his uncle’s tutelage, Jones learned the medical principles and work ethic that would stay with him throughout his career — most importantly, to work constantly and quickly.

Advocate of rest

Thomas strongly advocated the use of rest and immobilization for the treatment of fractures and tuberculosis of the bones. This went against the conventional wisdom of the day, which usually consisted of excision or amputation for chronic bone disorders. Thomas invented many splints, which he manufactured in his own shop, to allow for proper rest and immobilization. In addition, Thomas’ strong commitment to his community led him to offer free clinics to the city’s poor on Sundays, something that Jones would continue long after his uncle’s death.

Jones then went on to work as a general surgeon in Liverpool’s Stanley Hospital. While there, he published his first article in 1883. “Ununited fractures of the humerus, radius and ulna successfully treated” turned out to be a prediction of his future interest and success. In 1888, he was appointed the chief surgeon for the Manchester Ship Canal, a massive public works project that employed 20,000 workers. He organized hospitals that treated more than 3000 injuries; Jones himself treated more than 300 of those injuries.

It was during this period that the close relationship between the orthopaedic communities of the United States and Great Britain was forged. Liverpool was a common point of entry for foreign travelers to England. The clinics of Thomas and Jones were some of the first stopping points for American surgeons entering the British Isles. They were impressed by what they saw, and many took word of Jones’ work back to America.

According to Kirkup, Jones befriended John Ridlon of Chicago and Joel Goldthwaite of Boston and came to greatly admire the rapid evolution of the new specialty of orthopaedic surgery in the United States. Kirkup said that Jones’ attempts to have orthopaedics recognized as a specialty in his own country “met with misguided opposition.”

Philanthropic orthopaedist

Jones was also a world-class philanthropist. As orthopaedics in the late 19th century primarily dealt with children stricken with tuberculosis and deformities stemming from polio, Jones’ earliest involvement revolved around the treatment of children. He was instrumental in securing wards for orthopaedic treatment in hospitals in and around Liverpool as well as founding the Royal Liverpool Country Hospital for Children.

Around the turn of the century, Jones developed a relationship with Dame Agnes Hunt, who was disabled from a childhood bout with osteomyelitis of the hip. Hunt founded the Baschurch Home, a convalescent center for disabled children. Upon meeting Jones for the first time, Hunt wrote: “When I saw Robert Jones, I marveled no more, for you could not spend five minutes in his presence without feeling that all was well in this best of all possible worlds.”

Following her successful treatment by Jones, Hunt regularly brought children from Baschurch to his Nelson Street clinic for treatment. Eventually this alliance would result in the Robert Jones and Agnes Hunt Orthopaedic Hospital at Oswestry, which continues to serve England and Wales.

A proving ground

World War I proved to be not only a major event in the history of the nation; it also became a proving ground for Jones and the principles he had learned earlier from his uncle. When the war began in 1914 he was 57, but he volunteered immediately and rose to the rank of Major General and Inspector of Military Orthopaedics.

On touring many field hospitals, Jones was aghast at the treatment many soldiers received. In response, he published books and articles on military orthopaedics and stressed the risks of and proper treatment for fractures and promoted the use of the Thomas splint over plaster of Paris immobilization for fractures of the lower and middle third of the femur. The use of his uncle’s splint for the emergency treatment and transport of soldiers with fractures due to gunshot wounds reportedly reduced the mortality rate from 80% to 20%. “Later, this was adopted by American surgeons and even the French,” Kirkup said.

Further strengthening the ties between the early English and American orthopaedists, Jones sought help from his American friends with the war effort. “Before the United States entered the war, he had persuaded Goldthwaite to send volunteer orthopaedic surgeons from the U.S.A. to assist in the many hospitals Jones established for rehabilitating severe deformities, chronic infections and nerve injuries, etc.,” Kirkup said. “He placed Robert Osgood of Boston second in command and they became excellent friends as well as a very powerful team.”

After the war, those who served under Jones had some of the first specialty training in the new”orthopaedics.

“His disciples who worked with him in the First World War went out into the country after the war and established orthopaedic hospitals,” Barton said. Fracture services and trauma care were eventually added to orthopaedic treatment.

At this time as well, at the urging of Osgood, he founded the BOA and became that organization’s second president, holding the office for five years, longer than anyone since. He was eventually named life president emeritus.

Jones’ Victorian work ethic remained with him through the rest of his life. Observers noted his tremendous schedule, which would include 20 to 30 surgeries daily. For his many achievements, Jones has been called the greatest orthopaedic surgeon that the world has ever seen. Contemporaries noted, “When Jones operated, time stood still.”

Time stood still

Jones’ most enduring quality, however, was his charming personality. According to the History of the British Orthopaedic Association, “Victorian values, especially the work ethic, combined with an extraordinarily attractive personality, lay behind his success. Not only did he enjoy his work, but he organized what he did with such remarkable efficiency that he encompassed more than seems possible.”

His charm was said to overcome not only his contemporary physicians but patients as well. One anecdote describes his exchange with a mother who wanted her child’s bowlegs treated, but who demanded that the child’s legs not be broken. “Tut, tut, what put that in your head? But you wouldn’t mind a little fracturing?” Jones asked. “Certainly not!” the mother replied.

Kirkup said: “Jones was said to be a kind friend to all; patients adored him and he had no enemies. Nevertheless, he had great persuasive powers and moved politicians, the army high command, philanthropists, etc., into action.”

Throughout his life, Jones lectured and published texts and articles on fracture care, various surgical procedures and the promotion of orthopaedic training and orthopaedic programs in hospitals. In a 1957 article in the Journal of Bone and Joint Surgery, his writing style was described as “eloquent, intimate and often adorned with flashes of delightful humor. He wrote with ease and rarely found it necessary to correct his first draft.”

Jones’ works could educate surgeons while explaining the plight of orthopaedic patients. A brief summary of his papers and texts include The Cure of Crippled Children, 1919; Injuries of Joints, 1915; and Notes on Military Orthopaedics, 1917. His textbook Orthopaedic Surgery, 1923, is said to be the first to have dealt systematically with the diagnosis and treatment of fresh fractures.