History of orthopedic surgery, November 10, 1987

Dr. R. Palmer Howard: Welcome to the headquarters of the American Association of History of Medicine. We have such a crowd that we expand right through the back of the door. [inaudible 00:00:12] I want to welcome you all. I know that some of you are seniors in the field of orthopedics, and some have just begun. [inaudible 00:00:27] I believe they are equally, physicians. In this day and age, we'd like to welcome members of many of the health professions. Since we're about [inaudible 00:00:47] one pronged or two pronged snake, as the emblem for Hippocrates [inaudible 00:00:54] In particular, we have a guest all the way from the University of Shanghai Medical School, Dr. Yang. [inaudible 00:01:08] This is a very auspicious meeting. Most of you didn't know that you were starting in at such a time, because officially this minute book goes back to the first, shall I say, official meeting of the society. Appropriately, the speaker was John Martin, Suggestions for an Approach to the Study of the History of Medicine. A very good beginning, although by now we may want to reach more of an [inaudible 00:01:59] with our present speaker. That was on November the 9th, 1978. Today we start the 10th year of this society. I may say, credit goes to John Martin, and to his colleagues at that time. And to Bob Rakel, really a more, to some of us who are a little bit old in the top of the head as well as the whole head probably, but a new group. Today, then, we have the pleasure of hearing the History of Orthopedic Surgery. Appropriately, I believe our speaker would be proud to say that a share of his education and inspiration came from Dr. Steindler, the first professor of Orthopedics at the University of Iowa. Dr. Ponseti, Emeritus Professor of Orthopedics, who came to us from Spain, will present the History of Orthopedic Surgery. Dr. Igncio Ponseti: Thank you Dr. Palmer. There will be an exhibit, that Mr. [inaudible 00:03:37] has arranged carefully, here in the rare book library. Most of the books I am going to refer to here in the History of Orthopedics are in the library. We are very fortunate indeed to have such a treasure here in our midst. It has been a great pleasure for me in the past two or three weeks to put together this few pages on the history of our specialty, because I have been able to go to the real sources. The word orthopedia was used for the first time as the title of a book published in 1741 by Nicholas Andry. Nicholas Andry was Professor of Medicine at the University of Paris. He formed the word orthopedia out of two Greek words, orthos meaning straight, free from deformity and paidios, a child. Professor Andry writes, out of these two words I have compounded that of orthopedia, to express in one term the design I propose, which is to teach the different methods of preventing and correcting the deformities of children. There are two small volumes in this work. In the first volume of the book there is depicted a crooked young tree attached to a straight staff to exemplify his ideas, his philosophy. According to Andry, posture and proper muscle balance play a major role in the symmetrical development of the skeleton. Andry studied deformities of the spine, of the head, and neck, and of the extremities. In the absence of trauma or destructive disease he says, "crookedness of the spine derives from asymmetrical pull of the muscles of the trunk." In the prevention of the deformity, great attention is paid to postural training when sitting and standing. Proper posture, and regular, adequate exercises are to be considered a necessary part of every child's upbringing. Andry advised parents not to bind their babies too snugly, to prevent a narrow chest and short clavicles. See, this philosophy of Andry is very mechanistic. The clavicles won't grow if you tie the bandage of the baby too tight. The child should be fitted with a corset when getting up after an illness requiring prolonged bedrest. Andry observed that the proportion of the length of the trunk to the legs changes with age, and that supportive apparatus may be necessary during fast growth in adolescence to prevent spinal deformities. Originally, the orthopedist was concerned primarily with the care of the crippled child. A concern for the crippled developed gradually only after the radical philosophical and scientific revolutions that occurred in the Renaissance. In the middle ages, the deformed and the lame were ostracized from society and considered unfortunate incurables. The crippled was not considered a social problem until the 17th century. In 1601, England established the Poor Relief Act, the first statute enacted by a European government specifically mentioning the cripple and providing to some extent for his care. Thus, the cripple came into community consciousness as a public charge, and the medical profession gave its attention to the cure, prevention, or relief of the lame and deformed body. Many crippling deformities are congenital, but others are secondary to skeletal trauma, infections, tumors, or are related to poor nutrition, or indeed to poor medical care. The orthopedists gradually have enlarged their field of work to include adults as well as children. The Medical Academy of Orthopedic Surgeons now has over 12,000 members. Now the specialty occupies a prominent role in all modern hospitals throughout the world. The Academy defines the orthopedic surgery as the medical specialty that includes the investigation, preservation, and restoration of the form and function of the extremities, spine, and associated structures by medical, surgical, or physical means. The Academy's seal of office is the crooked tree in Andry's book. The orthopedists of the 17th and 18th century had a large body of knowledge on crippling deformities gathered by Greeks, Romans, and Renaissance physicians. The books of the School of Hippocrates on fractures, and on articulations, contain excellent discussions on the clinical aspects and treatment of fractures and of dislocations. A carefully prescribed method of traction were used for reduction of fractures of the long bones. The traction was maintained during the application of firm bandages, or splints, until the part was adequately supported. It was important to obtain proper alignment and proper length of the thigh bone, for example. Hippocrates says, "For the arm, when shortened, it might be concealed, the mistake will not be great, but the shortened thigh bone will exhibit the man maimed." Early mobilization of the fractured extremity was recommended. "It should be kept in mind," he added, "that exercise strengthens and inactivity wastes." The diagnosis and treatment of dislocations were as carefully studied as were fractures. The description of shoulder dislocation and their care have become classic. Reduction of the shoulder dislocation was effected by traction on the arm, with counter traction applied to the axilla using the heel of the operator, as we do even today. Clubfoot was recognized as a congenital deformity, and treatment was said to be most effective when applied at the earliest possible time. Repeated manual correction was attempted, with strong bandages applied during the process. Overcorrection was said to be essential and the foot was to be maintaining in the position over a long period of time. Later, especially devised shoes were to be worn to prevent a relapse, which they knew was more than likely to occur. Deformities of the spinal column were intensively studied. The deformity could be caused by fractures, and dislocations of the vertebrae, or by disease. A possible relationship between the spinal gibbous and pulmonary disease was first suggested in the Hippocratic text on articulations. Of course, final confirmation of this did not come until the 19th century. The Greeks knew that there are many varieties of curvatures of the spine, even in persons who were in good health, for it takes place from natural conformation and from habit, and the spine is liable to be bent from old age and from pains. The serious consequences and the possible progression of a spinal deformity, whatever its etiology, were fully appreciated. Although the treatment of a spinal deformity was considered to be usually ineffective, it was always assiduously attempted. Various methods were devised with a view to reducing the visible deformity. The patient was placed in traction on a bench, and compression was applied on the gibbous. The extension bench described by Hippocrates has been copied and modified throughout the ages, even into recent times. This is illustrated in the book by [inaudible 00:11:46] here, because we don't have the original illustrations from the proprietary books. Galen contributed greatly to understanding of muscle contracture, and on the significance of nerve fibers entering each muscle. "The principle of motion comes from the brain," he says, "and travels through the nerves." He called the nerve impulse a vital humor. Galen's contributions to the clinical practice of orthopedics were few, and he followed Hippocrates, whose practice he emulated. He's believed to have coined the words kyphosis, lordosis, and scoliosis to connote those deformities described in the Hippocratic texts. After Galen, there is nothing of importance in the orthopedic literature until the 11th century, when students from all parts of Europe went to Salerno, in Southern Italy, where great stress was laid on the study of anatomy as an essential basis for surgical practice. From Salerno came Roger of Parma, who wrote, towards the end of the 12th century, the first great book on surgery in Western medical literature. In it is found much of the Greek material, with little trace of Arabian influence. From Salerno, surgery moved up the Italian peninsula to the newly created University of Bologna in 1113. Bologna today still ranks as a foremost center of orthopedic surgery. In Bologna were devised effective and simple braces, such as spinal supports and splints for fractured femurs. Saliceto wrote in 1275 in Bologna, his important book on Chirurgia, which is considered to be the best work on anatomy before the Renaissance. Saliceto preferred much the scalpel to the cautery, and insisted upon cleanliness when operating, and on the avoidance, when possible, of trauma and manipulation. In Bologna was taught the fundamental doctrine of antisepsis as practiced by the Hippocratic school, as well as the avoidance of wound contamination. Guy de Chauliac was professor at the University of Montpelier, and wrote in his book La Grande Chirurgie on the use of weights and pulleys for continuous traction in the treatment of fractures of the femur. We have this book here. During the 15th and 16th centuries there was a complete review of anatomy based upon meticulous dissection of the human body. Leonardo da Vinci, who lived from 1452-1519, was the leader of the scientific method of research which culminated in the work of Vesalius. Leonardo was a student, and later an instructor of anatomy, and he made many original observations concerning the origin, insertions, and functions of the muscles of the human body. He evolved two important principles of muscle function, mechanical leverage and synergistic action upon which muscle balance depends. Leonardo worked assiduously for many years with his teacher, a very prominent anatomist, Marcantonio della Torre. Leonardo's Quaderni d'anatomia were lost for 200 years. In the 18th century William Hunter discovered some of them in the British libraries, and more were discovered in Norway. Most are now in the Royal Library at Windsor. We have here excellent copies of these books. Great anatomists contributed to the advance of this science, and among them is Vesalius, Falopius, Servetus, and Eustachio. Vesalius' work at Padua, De humani corporis fabrica, published in 1543, published in 1543, is a landmark in the history of medicine. Books one and two, on bones, ligaments, and muscles have figures of superlative excellence and accuracy. You will see some of them in the exhibit. He published his book, by the way, when he was 29 years old. Following the Renaissance, many hospitals were built in Europe to house the sick and the crippled. Skeletal deformities were treated by massage, manipulation, and braces. Francis Glisson wrote in 1650, we have here the edition of Glisson from 1682. He wrote an important monograph on rickets. Glisson also described patients with achondroplasia which he considered to be fetal rickets. In his monograph, there is a clinical description of infantile scurvy. Spinal deformities were apparently very common, and most were thought to be due to rickets. Spinal caries is often termed Pott's disease. Pott in 1779 did not describe the disease or its tuberculous nature, however, but only the deformity and its sequelae. The tuberculous nature of the gibbous had been surmised by Hippocrates, and also by Galen, and was finally established by Delpech. The pathology of the 1900s, or the 1800s. Although much effort was devoted to the treatment of skeletal deformities with orthopedic apparatus, real progress would come only from the discoveries in anatomy, physiology, chemistry, pathology, and from the understanding and control of infectious diseases. I will review briefly the most important discoveries in these fields relevant to modern orthopedics. Hieronymus Fabricius studied at Padua, where he succeeded his master Gabriel Fallopius as teacher of anatomy and surgery. Fabricius, who lived from 1537-1619, was the author of the first illustrated work on embryology. He observed the valves in the veins, which this will be illustrated in the exhibit here. We have his excellent book on embryology. We left open I think pages on the valves in the veins. He described an apparatus for the correction of torticollis, and another for the gradual reduction of a gibbous. He did not accept the Hippocratic suggestion of forcible correction of spinal deformities, and advocated the use of gentle manipulation with repeated adjustments of the spinal brace. William Harvey studied under Fabricius. His discovery of the circulation of the blood in 1628 had been paved by the discovery of the valves in the veins by Fabricius, and by that of the lesser circulation by the Catalan Servetus. Harvey's work was the basis of modern rational medicine. An excellent book. With a rudimentary microscope, the Dutch Anton Van Leeuwenhoek observed the striped character of muscle and its sarcolemma. Toward the end of the 17th century, Baglivi noted the existence of two types of muscle tissue, the striped and the smooth. This century saw the rise of the physical sciences, and physicists were successful in giving mathematical expression to mechanical events. The Italian physicist Alphonso Giovanni Borelli was a pupil of Galileo. In his book De Motu Animalium, which we have here, published in Rome in 1680, Borelli investigated the action of muscle contraction on bones of man and of animals. His analysis evolved into a system describing the mechanics of motion, of walking, running, jumping, weightlifting, bird flight, fish motion, and insect creeping. He was a representative of the iatrophysicists, who explained animal activity and physiology as rigid consequences of the laws of physics and mechanics. Thus, heartbeat was a simple muscular contraction, and the circulatory system was hydraulic in principle. Thomas Sydenham of London, in the second part of the 17th century, studied the natural history of disease, thus reviving this interest of the Hippocratic school of medicine in early Greece. He described accurately gout, as well as scurvy, which was frequently epidemic at that time among the crews of sailing vessels. Clinical teaching was first instituted at the University of Leyden in 1636. The medical school attained a reputation which rapidly surpassed even that of Padua. Herman Boerhaave was first appointed as teacher in Leyden in 1701, and established the modern method of bedside teaching and medical instruction. Clopton Havers of London studied in the University of Utrecht, another famous Dutch university of that period, and applied himself to the investigation of bones and joints. His book The Osteologia Nova contains the first description of the microscopic appearance of the articular cartilage and the internal architectural of bone, including the first account of the vascular canals of long bones known, as the Haversian canals. He did not recognize, however, their vascular contents. Although he was a contemporary of Harvey, Havers did not comprehend the new theory of circulation, but retained the traditional conception of animal spirits. Havers made original observations on the structure of cartilage and on the presence of mucilaginous material in the cells of the synovial membrane. Albrecht Von Haller studied at Leyden with Boerhaave in 1763. He wrote a most comprehensive treatise of on Elements of Physiology of the Human Body, which appeared in the the 18th century. It has eight volumes, and we have all of those volumes in our rare book library. Haller investigated the tendency of the muscle fibers to shorten with any stimulus, and afterwards to expand again to its normal length. This capacity for contraction Haller called irritability, and a very slight stimulus produces a movement altogether out of proportion to itself, and continues to do this repeatedly as long as the fiber remains alive. Haller noted that stimulus of the muscle contracture came by the nerves. Haller also showed that the tissues are not in themselves capable of sensation, but that the nerves are the sole channels or instruments of this process. In his other book on Experiments on the Formation of Bone, published in 1763, Haller described the growth of bone in the fowl embryos and young chicks. That's a very detailed study which we have here. The bone forms not from the periosteum he thought, but from the soft cartilaginous tissue, and from those tissues that surround the primordial nucleus of ossification. Haller also studied healing fractures in chickens and pigeons, and observed the exceptional vascularity of the reparative tissues about the fracture, and finally ascribed actual osteogenic properties to the newly formed vessels. To Haller, who lived almost a century before the introduction of cellular histology, bone was a substance deposited in tissue, rather than the product of local cellular activity. In the 18th century, a new chapter of physiology was opened by the extension of the knowledge of electric phenomena to the living body. Galvani, of Bologna, while investigating the susceptibility of nerves to irritation in 1791, showed a correlation between muscle twitching and simultaneous contact with both iron and copper plates. He was, in fact, of course producing an electrical current. Volta, of Pavia, demonstrated that the muscle can be thrown into continuous contraction by repeated electric stimulations. Duchenne de Boulogne published in 1855 his basic book on the L'electrisation Localissee, electrification of the muscles, where he described with utmost precision the action of muscles as detected by localized electrical stimulation. He opened a new chapter in muscle physiology, pathology, and treatment of paralysis. Post mortem examinations were rarely done before Giovanni Battista Morgagni, who was Professor of Anatomy at Padua for 56 years. In his 79th year, in 1761, Morgani published his vast experience on the clinical history of the patient, the history of his disease, and the events in connection with his illness and death. In his book, which we have here, De Sedibus et Causis Morborum, on the seats and causes of disease, conditions of the organs at some 700 post mortem examinations are minutely described. The findings are correlated, as best he can, with the clinical history. Morgagni introduced the necessity of basic diagnosis, prognosis, and treatment on a knowledge of anatomical lesions. The study of the anatomical specimens was introduced into surgery by John Hunter in London. With Hunter, who lived from 1728-1793, surgery begins to be a real science, replenished with ideas drawn from comparative anatomy and pathology. Hunter's approach was based on Hippocratic principles, since he stated that, "the only rational means of treatment are those which are based on the natural recuperative power of the body." He ruptured his achilles tendon while dancing, and observed that the proximal portion was retracted to a considerable distance, and the gap between the ends became breached by simple connective tissue which supplied sufficient strength to restore good function to the ruptured tendon, and he went back to dancing. His monument is the Hunterian Museum in London, based on his specimens, of which a few somehow survived German bombing in World War II. Rudolph Virchow, in the 19th century, exerted a very important influence on medical thought. His achievement was the extension of the cell concept to diseased tissues. His Cellular Pathology, published in 1858, analyzed such tissue from the point of view of cell formation and cell structure. He described the underlying genetic identity of bone, cartilage, and connective tissue cells. A great achievement in this time, and named osteoid, the tissue seen in rachitic bone. Virchow's work complemented the pathological studies of Morgagni and John Hunter with histological observations. In 1736 John Belchier reported to the London Philosophical Society, that when madder was fed to pigs and their bones were later examined, newly formed bone was stained red while established bone remained unstained. Before Belchier, Duhamel had made similar observations in France, but not as carefully as Belchier explained them afterwards. This experiment became fundamental to all later research on bone growth and development. In more recent times, the dye alizarine, first extracted from madder, has supplanted the root in the laboratory. While studying osteogenesis, John Goodsir from the University of Edinburgh, observed in 1845 that the formation of osteoid tissue and callus was a direct effect of the activity of the osteoblasts. Many osteoblasts were observed in the periosteum. Later on, William Macewen from the University of Glasgow thought that the periosteum possessed no osteogenic property. Whereas Ollier in Lyon, France, in 1867, shortly after, demonstrated the importance of the osteogenic property of the periosteum, and thought that it was important not to damage this structure during surgery for internal fixation of fractures. A breakthrough in the history of medicine occurred in 1796 when Edward Jenner demonstrated that a condition known as cowpox gave immunity for smallpox. Vaccination opened a new world with the study of immunity to disease. One and a half centuries later, infantile paralysis was controlled with a vaccine, and the orthopedic surgeons were freed from a great load of work in their practice. Indeed we were almost left without work for a while. The germ doctrine of disease has been the center of the triumphs of medicine during the last 100 years. The work of Pasteur, Koch, Hansen, and Ehrlich as the founders of bacteriology is well known to all of us. Many infectious diseases were associated with their organisms at about the same time, towards the last quarter of the 19th century. It was then too, that the scientific study of immunity took great strides, and many infectious diseases were well studied, and some were controlled with active or passive immunity. With Lister's development of antisepsis, and later on asepsis, surgery was finally made safe. The discovery of ether anesthesia in 1846, and 25 years before, by William Morton made surgery painless. Improved surgical techniques and applied bioengineering have changed the practice of orthopedics in the past 50 years. Probably the most successful innovation has been the improvement of the hip arthroplasty with a total hip replacement, designed by Professor John Charnley of the University of Manchester, in England. Charnley replaced the head of the femur with a metallic prosthesis of a small size to reduce the moment of frictional force. This prosthesis is used in combination with a low friction plastic socket. Charnley developed a self curing acrylic cement to anchor both the femoral replacement and the acetabular acrylic socket. In developed countries, total hip replacement is used very often for the treatment of patients with osteoarthritis of the hip, and other hip ailments. The operation has been very successful in providing relief of pain and good hip motion for several years following surgery. Internal fixation of the skeleton for treatment of fractures has been greatly perfected with the use of plates, and screws, and other devices made of inert metallic alloys. The three-phlanged nail, devised in 1931 by Smith Petersen of Harvard, represented an important advance in the treatment of fractures of the neck of the femur. Intramedullary nailing for fractures of the shaft of the femur with the Kuntscher nail was extensively used during the second World War. It is a successful method of treatment of femoral shaft fractures in clinical practice. Internal fixation of shaft fractures interferes, however, with the natural fracture callus formation and delays the healing of fractures. In the hands of a good surgeon, internal fixation of articular fractures improves greatly the results.Internal fixation of fractures not involving the joints is possibly not much better than the judicious application of plaster or Paris bandages, which can successfully immobilize the injured extremity and allow for weight bearing and functional use of the injured extremity. Plaster of Paris, by the way, was first introduced by Mathijsen in 1852, a Flemish army surgeon. Plaster of Paris successfully replaced traditional splints made of a mixture of egg white, gum, and resins, which had been used since Hippocrates. When I came to Iowa City in 1941, a large number of patients in the Orthopedic Department had diseases which are today practically unknown, namely residuals of poliomyelitis, tuberculosis of bones and joints, and osteomyelitis. Skeletal tuberculosis decreased considerably in Iowa during the 30's, owing to the destruction of cattle infected with tuberculosis. The disease was nearly completely eradicated in the late 40's with the advent of streptomycin [inaudible 00:34:45] and so on. Osteomyelitis was also controlled in the 40's with the advent of penicillin, although it is still seen, mainly as a complication of compound fractures. Poliomyelitis disappeared in this part of the world in the early 50's with the advent of the polio vaccine. The orthopedists have to deal now with a number of poorly understood disorders of growth and development of the skeleton, degenerative arthritis, and congenital deformities. We know very little of the nature of congenital deformities such as club foot, congenital dislocation of the hip, and the cause of idiopathic scoliosis. Henry Mankin, Professor of Orthopedics at Harvard, has stated that future changes in orthopedics will be based in biology, and more specifically in our ability to understand and alter the basic unit, the cell. Much effort is being devoted to the study of the skeletal connective tissue cells and their matrices. The electron microscope, x-ray diffraction, and other instrumental analyses have allowed detailed examination of cells, cell organelles, and extracellular matrices of fibroblasts, chondrocytes, osteoblasts, and osteocytes. Much has been learned of the function of these cells and of the composition of the extracellular matrices, particularly of collagen and of proteoglycans, through the efforts of biologists and biochemists, but much remains to be done. Great advances in genetics have made possible the understanding of different inheritance patterns that work in gene disorders affecting the musculoskeletal system. Many familiar diseases treated by orthopedic surgeons, such as congenital dislocation of the hip, club foot, and even idiopathic scoliosis are probably multifactorial in character. Osteoporosis has been recently studied extensively, owing to the prevalence of this disorder in the aged population. Certainly the disease is multifactorial. The disorder can be partially controlled with adequate intake of calcium, vitamin D, and the encouragement of maximum physical activity. Fractures in the aged are usually related to osteoporosis, and constitute a major orthopedic problem in our aging society. Through the centuries, orthopedic surgery has been of utmost importance to the army surgeon. I should like to conclude this talk with a very brief review of the history and treatment of war wounds. The introduction of cannon shot in the 14th century marked the beginning of a new type of war wounds, often with extensive injuries to the skeleton. In Spain during the siege of Malaga in 1487, Queen Isabella organized the first field hospitals, known as ambulances, set up in support of armies in action. Ambrose Pare made the greatest contribution to surgery in the 16th century. He served three kings of France, and wrote an important treatise on surgery, the Ten Books of Surgery. He possessed great surgical skill. He advocated the introduction of maggots in suppurating wounds when he was acting as a surgeon in the army of Henry II. He published the first case of a bullet embedded in the spinal cord. He described the use of ligatures of the veins and arteries when amputating an extremity. Pare insisted upon the necessity for cleanliness in all operative work, and recommended the enlargement of the wounds and the removal of all foreign bodies. He used traction for reduction of fractures, and splints for their immobilization. He devised a large number of corrective apparatus, such as corsets of metal to be used for spinal deformities, splints for fracture work, walking splints for hip disease, and several types of shoes for clubfeet. It was not until 1731 that Mareschal founded the Academy of Surgery in Paris, which 11 years later obtained the same rights and privileges as the Faculty of Medicine. Under his influence there were founded in Russia, and in Austria, educational institutions for military doctors, which contributed greatly to the diffusion of medical knowledge among the surgeons of that day. The medical services in the armies of Napoleon were efficiently organized by two notable military surgeons, namely Pierre Percy and Dominic Larrey. Larrey was gifted with great manual dexterity, and operated with extreme rapidity. The wounds were debrided widely, but the death rates in the hospitals in the Napoleonic Wars in 1813 and 1814 exceeded 28%. During the Franco-Prussian war of 1870, Ollier made his first observations on the treatment of wounds by the use of the occlusive method. This method was essentially the same as that which half a century later was to be made known by Orr throughout the world. At this time Joseph Lister introduced antisepsis, and later asepsis, and made possible the exploration of new fields of surgical technique. John Hunter considered that war wounds vary considerably. His book on war wounds by the way, we have it here in the exhibit. The small wound of entry of a bullet, Hunter says, may not need to be debrided. Whereas a large wound must be explored and thoroughly cleaned. In World War I, the surgeons at first tended to make wide incisions for debridement, and used a variety of antiseptics. Carrel and Dakin used continuous hypochlorite irrigation, by which a sterilization of the wound was achieved with a minimum of disturbance of the healing process. Secondary suture was used on a wider scale, often with disastrous results, with later sepsis. In the later stages of the war, two surgeons from the United States, William Baer and Winnett Orr, began detailed studies of certain therapeutic principles, which at that time were not generally known or accepted. In Spain, the war of 1936-1939 made possible a larger scale practical application of the suggestions put forward by these American surgeons. Orr stated that rest is as important to the healing of the wounds of soft tissues as it is for the healing of broken bones. To evacuate soldiers with open wounds and fractures from Europe to the United States, Orr dressed the wounds with Vaseline gauze, and covered them with a plaster cast applied to the affected extremity. In most instances, when the soldiers arrived in the States, the wounds were much improved or healed. Following the war, Orr published his cases of compound fractures treated by wound excision and immobilization in plaster. He extended these principles to the treatment of osteomyelitis. In the Spanish War, Trueta introduced Orr's technique with some minimal modifications that decreased mortality in the hospitals to 0.6%. This was without antibiotics. The wounded extremity was thoroughly washed with soap and water with a nail brush until the wound itself was bleeding. The skin edges of the wound were excised, as well as old contused tissue, and the wound was widened as much as required for proper drainage. Nonviable muscle and cellular tissues were thoroughly removed, as well as all foreign organic matter. Once the fracture was reduced, the wound was dressed with gauze and the extremity was immobilized in a plaster cast, including the two adjoining joints. In wounds with deep cavities, drainage was arranged by opening up the aponeurotic planes and the intermuscular spaces. This drainage was maintained open by the insertion of a sterile gauze or a rubber tube. Retained discharge, which is the result of bad drainage, may bring about disaster. This same treatment was widely used in World War II, and in Korea, and in Vietnam. The use of antibiotics in these last wars greatly enhanced survival rate in these wars and made successful delayed primary wound closure and early skin grafting of the wounds, feasible. Thank you very much.