JBJS | Advancing the Science and Art of Orthopaedics : Lessons from History*

The Journal of Bone & Joint Surgery, Volume 82, Issue 12

The Orthopaedic Forum | December 01, 2000

Advancing the Science and Art of Orthopaedics : Lessons from History*

Joseph A. Buckwalter, M.D.†

Iowa City, Iowa
*First President-Elect's Address. Read at the Annual Meeting of the American Orthopaedic Association, Hot Springs, Virginia, June 17, 2000.
†Department of Orthopaedic Surgery, 01008 JPP, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242. E-mail address: joseph-buckwalter@uiowa.edu.

The Journal of Bone & Joint Surgery. 2000; 82:1782-1782

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Introduction

Introduction | References

President Herndon, Second President-Elect Simon, members of the American Orthopaedic Association, and guests: it is a great honor to be elected President of this Association. I am pleased to accept this distinguished office, but the honor is not mine alone. It also belongs to those who made this possible: the teachers, physicians, and scientists who inspired and prepared me to contribute to the profession of medicine; my faculty colleagues at the University of Iowa, who taught and supported me; my children, Jody, Andrea, and Abigail, who have made being their father easy; and my wife, Kitty, who has encouraged and guided me for nearly thirty years.

One of the pleasant tasks of the presidency is selecting the topic for the President-Elect's address. In 1887, the founders of the American Orthopaedic Association dedicated their new Association to advancing the science and art of orthopaedics^14,98. Their choice of this purpose, more than a century ago, may seem unimportant now, but thoughtful consideration suggests otherwise. Today, I appreciate the opportunity to comment on the role of science in the development of medicine, orthopaedics in particular, and on the importance of a commitment to advancing the science and art of orthopaedics for our future.

At the time that this Association was founded, the American public and medical profession did not recognize orthopaedics as a medical specialty and physicians in the United States did not enjoy their current high social and economic status^14,31,92,127. Most physicians in the United States learned medicine and received the title of doctor from proprietary schools. To make the largest possible profit, these schools maximized the number of students and minimized the quality of education. Few faculty members had more than a high-school degree. The schools were not affiliated with academic institutions; they had few if any educational requirements for their students and made little or no effort to include science in their curricula. Substantive basic or clinical medical research did not exist in the United States. The public accepted multiple health-care providers, including chiropodists, homeopaths, folk-medicine practitioners, patent-medicine salesmen, bone-setters, and brace-makers, as equals of physicians in education, qualifications, and the results of treatment^{14,31,98,126,127}. There were no established standards or qualifications for surgical practice. Most physicians practicing surgery had limited knowledge of surgical anatomy and pathophysiology and rudimentary technical skills and instruments; as a result, operations often led to disappointing if not disastrous results. Even the most desperately ill patients avoided surgeons and surgery, and only the strongest could reasonably expect to survive a major operation⁹⁸. A small number of American physicians recognized the limitations of nineteenth-century medical education, research, and practice in the United States and improved their knowledge and skills by studying in Edinburgh, London, Paris, Glasgow, Vienna, and Berlin. Physicians and scientists in these cities were making rapid progress in basic and clinical research, but new European ideas and practices passed slowly to America, and most physicians in the United States did not believe that science had a role in guiding medical practice. Partially because they had little understanding of science, American physicians and surgeons tried to attract patients by advertising and providing a range of unproven treatments - treatments that were often worthless and, in many instances, dangerous^31,50,126.

The founders of the American Orthopaedic Association deserve great credit for recognizing that the development of the specialty depended on the integration of science into practice and for establishing a national Association committed to advancing the science and art of orthopaedics. Viewed in the context of the time in which they lived and its place in the history of medicine, their choice of this single, substantive, enduring purpose for their Association demonstrates remarkable wisdom. They must have understood well how medicine had developed over the past centuries and seen clearly where it should go. Like the founders of this Association, knowledge of our place in history helps us to understand and meet the challenges and opportunities that face us.

Western medicine has passed through four ages, each distinguished by a different preeminent intellectual framework that guided medical practice: supernaturalism (mysticism, superstition, and religion) (3000-450 b.c.), theory (450 b.c.-1500s), original research (1500s-late 1800s), and science and technology (late 1800s-present). Recognized medical practice began in antiquity in the age of medicine that was dominated by the belief that supernatural forces caused disease and healing. Religion, mysticism, and superstition, combined with empiricism, provided the sources of medical knowledge. Medical practice consisted primarily of attempts to manipulate or invoke supernatural forces. During the rise of the Greek civilization, the age of theory began and then extended for more than 2000 years, until the initial stage of the age of original research in the late Renaissance. In the last decades of the nineteenth century, at about the time of the founding of the American Orthopaedic Association, medicine entered the age of science and technology.

Hippocrates (460-377 b.c.), and the unknown individuals who contributed to the development of Hippocratic medicine and the writings that have passed through history as the work of Hippocrates^32,33,57,58, rejected supernatural forces as the basis for medical practice, bringing to an end the age of western medicine⁶² that was dominated by mysticism, superstition, and religion^{30,33,57,58,76,86,91,92,99}. Based on their understanding of the natural world, they used their exceptional skills in observation, logic, and philosophy to create theories that explained health, disease, and healing. They advanced the powerful idea that diseases had natural, discoverable causes and that treatments should be based on an understanding of these causes. This striking break with the past occurred almost simultaneously with other historical intellectual accomplishments. As Hippocrates and his colleagues started a new age in medicine, their contemporaries, Aeschylus (525-456 b.c.), Aristophanes (448-388 b.c.), Aristotle (384-322 b.c.), Euripides (480-406 b.c.), Herodotus (484-425 b.c.), Pericles (495-429 b.c.), Plato (427-347 b.c.), Socrates (469-399 b.c.), Sophocles (496-406 b.c.), and Thucydides (460-400 b.c.), started new ages in architecture, government, historiography, literature, and philosophy¹⁰.

For the Greeks, the natural world consisted of four elements, each with specific properties: earth (dry and cold), fire (dry and warm), air (moist and warm), and water (moist and cold). All matter, including living tissues, consisted of combinations of these basic elements: bone consisted of two parts earth, two parts water, and four parts fire, and blood consisted of equal parts of all four elements⁸⁷. Based on their understanding of the nature of matter, they identified four bodily fluids, or humors, each with the same properties as the corresponding four elements: black bile (earth), yellow bile (fire), blood (air), and phlegm (water)^86,87,92,103. Black bile came from the spleen and stomach; yellow bile, from the liver; blood, from the heart; and phlegm, from the brain. Health depended on equilibrium among the humors. Illness resulted from a systemic or localized disturbance of this equilibrium due to unhealthy winds, climates, waters, or places that caused undue concentration or corruption of one of the humors^53,87. Treatment of diseases and injuries consisted of restoring the balance among the humors^{31,66,76,86,87,92}. Accumulation of blood and phlegm in the joints caused arthritis and should be treated by enemas and suppositories, pneumonitis with hemoptysis should be treated by letting blood from the arm veins until the patient was as bloodless as possible, and wounds should be treated by enemas and fasting⁵⁹. The comprehensiveness of the humoral theories, their derivation from the accepted understanding of the natural world and from observations of patients, and their concept of health as homeostasis gave them great appeal. Lack of understanding of the value or methods of testing theories by experiment made them impossible to refute.

Few records of the outcomes of Greek and Roman medical care exist, but it is unlikely that many patients benefited from treatment based on the humoral theories, and in at least some cases it must have made them worse. About fifty years after the death of Hippocrates, in 323 b.c., Alexander the Great became ill after an evening of eating and drinking. His most expert physicians attended him, but his condition, despite their treatment, deteriorated steadily, and he is reported to have said shortly before his death, "I die by the help of too many physicians."⁹² Frequent results like this led to widespread doubt concerning the efficacy of medical practice. Cato (234-149 b.c.) urged Romans to "beware of doctors" for they bring "death by medicine."⁹² In the first century a.d., the Romans decorated monuments to Alexander the Great with the inscription "it was the crowd of physicians that killed me."⁹²

Given this level of skepticism, medicine based on the humoral theories might have faded away sooner rather than later, except for the appearance of the single most remarkable and influential physician in history, Galen (129-200 a.d.)^{9,30,31,33,45,66,77,91,92,125}. Galen was born in Pergamon, originally a Greek city, then a Roman city during the rise of the Roman Empire, and then a Turkish city after the fall of Rome. At the urging of his father, Aelius Nicon, a prominent Greek architect and builder with interests in mathematics, logic, and astronomy, Galen studied Hippocratic medicine at the Aesculapian in Pergamon. Following completion of his medical education, he visited Smyrna, Corinth, and Alexandria to observe medical practice before returning to Pergamon. At the age of twenty-eight, the president of the gladiatorial games appointed Galen surgeon for the gladiators of Pergamon. Five years later, Galen moved to Rome, where he developed a large and lucrative medical practice and became Marcus Aurelius's physician and advisor.

Nothing impressed Galen as much as his own ideas. In one of his more than 350 publications^33,45,80,104, he explained that he had developed a successful dressing for wounded nerves and tendons and that recognition of this accomplishment, along with his special talents, had led the president of the games to select him as the surgeon for the gladiators^80,92. Galen was also impressed with his own clinical skills: among his other achievements, he reported that, whereas many gladiators had died in previous years, not one of those treated by him had died⁸⁰. This is an impressive record, given the severity of the injuries suffered by the gladiators treated by Galen, including penetrating wounds of the brain, heart, lungs, and abdominal and pelvic viscera; traumatic amputations; and mangled limbs⁸⁰.

Like the Hippocratic physicians, Galen prided himself on his clinical observations and his diagnostic and prognostic skills⁴⁴, but, unlike his predecessors, he conducted original, planned investigations. Because Roman law kept him from dissecting humans, he learned anatomy primarily by operating on his patients to drain abscesses, debride wounds, and amputate limbs, and by studying human bones and dissecting animals, primarily apes¹⁰⁴. To discover the function of organs, he performed vivisections^80,85,92,104. The Greeks and most Roman physicians believed that arteries contained pneuma, a vital essence present in the air that was inhaled by the lungs and then passed through the left ventricle to the arteries. Galen ligated the aortas of living animals proximally and distally and then opened the ligated vessels to show that they contained blood, not pneuma. By ligating ureters, he proved that urine comes from the kidneys, refuting the previous belief that the bladder produced urine. Observation of the effect of cutting the phrenic nerve in living animals led him to understand how the diaphragm expanded the lungs⁸⁵. He showed that cutting the spinal cord caused paralysis of muscles, cutting the optic nerve caused blindness, and cutting the recurrent laryngeal nerve, now named Galen's nerve, kept pigs from squealing^80,85,92,104. When he exposed the heart in living animals, he observed that expansion of the aorta and a pulse in the peripheral arteries immediately followed the contraction of ventricles, but he failed to recognize that the heart pumped blood through the arteries¹⁰⁴.

Based on his experience treating the ghastly wounds of the gladiators and his investigations of anatomy and physiology in animals, Galen wrote comprehensive descriptions of human anatomy, physiology, and pathology^{50,66,76,80,90,92,104,125,127}. He stressed that surgeons should study anatomy since if "a man is ignorant of the position of a vital nerve, muscle, artery, or important vein, he is more likely to maim his patients or destroy rather than save life."¹⁰⁴ He emphasized that surgeons needed to know the location of the major arteries and avoid transecting them because "nothing upsets any operation like haemorrhage."¹⁰⁴ He recommended that muscles be divided parallel to their fibers because transverse incisions led to paralysis of the muscle distal to an incision across the muscle fibers¹⁰⁴. To be sure that others knew of his work, Galen spent much of his income employing scribes to record and reproduce records of his observations and theories. Since he did not perform human dissections, he based his descriptions of human anatomy, physiology, and pathology on his dissections and vivisections of animals and his clinical experience. When these sources failed him, he used his imagination. He reported that the liver produced blood from ingested food and that other organs, including the heart, consumed blood^91,92. According to his studies, veins, including the vena cava, originated in the liver and extended peripherally to other organs, including the heart, whereas arteries originated in the heart and, like the veins, extended to other organs. To reach the tissues, blood flowed back and forth like the tides in separate venous and arterial systems. He expanded the humoral theories and never conceded that he could not explain the cause of any disease; he reported that an excess of yellow bile, black bile, phlegm, or blood could cause fever and that excess black bile caused cancer⁹². Unlike the Hippocratic physicians, who emphasized the power of nature to heal and the spontaneous resolution of many diseases, Galen, without any cautions, recommended treatment of diseases and wounds by starving, purging, and bleeding^{30,33,49,50,57,85,92}.

One of his most illogical and dangerous recommendations was that hemorrhage should be treated by bleeding^80,92. How could someone as intelligent, experienced, and skilled in original investigations as Galen make such a mistake? Why did he not test the effects of bleeding in an animal? The answer is that he interpreted what he observed to fit what he believed. Some of his patients survived venesection treatment of hemorrhage and may have temporarily become calm as a result of anemia or hypotension. The placebo effect created by the drama of a confident, charismatic physician slitting one of their veins and draining a pint or more of their blood may have also convinced some patients that they had received effective treatment. When one of his patients recovered from an illness or injury, Galen assumed that his treatment was responsible for the recovery. This was Galen's great error: interpreting his observations to confirm his theory. In his defense, no one used a controlled clinical experiment to test a theory or to evaluate the effect of a treatment until Galen had been dead for more than fifteen centuries, and, despite the apparent absurdity of treating hemorrhage by bleeding, medical authorities still recommended this approach 300 years after Galen's death⁸⁰.

Galen's reputation and extensive writings helped to pass his ideas and practices on through the centuries^92,116. Instead of seeking new information through observation or experiment, those who followed him expanded the humoral theories to explain personality characteristics; moods and emotions; health and disease; and the roles of the moon, the planets Jupiter, Mars, and Saturn, the stars, and the Apostles Mark, Peter, John, and Paul^{76,80,87,92,103,116}. During the terrifying black-plague epidemics that devastated Europe in the fourteenth century, doctors treated plague victims by bleeding, purging, and blistering¹¹⁶. In the Middle Ages, physicians performed dissections guided by simultaneous readings from Galen. When examination of internal organs directly contradicted Galen's descriptions, the dissectors assumed that the body was abnormal^50,85,92. Despite common sense, the dismal results of medical treatment, and contradictory physical evidence, the humoral theories and Galen's descriptions of human anatomy, physiology, and pathology guided European medical practice into the eighteenth century^{9,31,50,66,80,92}.

In the early 1600s, English physicians brought the Hippocratic-Galenic theories of medicine and the treatments based on those theories, including bleeding, blistering, purging, and inducing vomiting and sweating, to the first permanent European settlements in Virginia³¹. As the population of the American colonies grew, most of the colonial physicians and surgeons learned medicine through proprietary apprenticeships or taught themselves, a system of education that passed on the humoral theories as the basis for medical practice⁹⁸. A prescription from a North American physician in 1720 for the treatment of a patient with joint pain consisted of purging twice on the first day, bleeding twelve to fourteen ounces on the second day, and purging twice more on the third or fourth day³¹. It seems likely that more than a few patients reported relief of their arthralgias after enduring this treatment, due to the placebo effect or out of fear of being told they needed another, similar prescription. Results like this apparently encouraged physicians to believe that purging and bleeding did some good. Others were not so easily deceived, and colonial records list multiple examples of patients suffering and dying from excessive purging³¹.

More than any other individual, Benjamin Rush (1745-1813), humanitarian, political activist, and one of America's most prominent and influential physicians, established the humoral theories as the basis of medical practice in North America^{31,33,49,50,92}. A gifted and motivated student, he graduated from the College of New Jersey at Princeton, later Princeton University, at age fifteen. He started his long and successful medical career at age sixteen by apprenticing himself to Dr. John Redman, one of the founders of Philadelphia's College of Physicians, and by attending lectures on anatomy and medical practice. After nearly six years of apprenticeship, he decided to seek a more rigorous medical education and moved to Edinburgh, where he received a medical degree from the University of Edinburgh in 1768. In the next year, he visited London and Paris, where he attended medical lectures, including presentations by William Hunter (1718-1783)^31,125, before returning to Philadelphia in 1769 to establish a practice serving the poor of the city. At age twenty-four, he became the youngest member of the College of Philadelphia faculty and the first chemistry professor in the colonies. Over his long career at the College of Philadelphia, later the University of Pennsylvania, Rush became one of the most respected physicians in the United States. He personally taught more than 3000 medical students, who spread his ideas to every part of the country, and eighteenth and early nineteenth-century American physicians almost universally accepted, or at least did not question, his observations and recommendations^31,97. In 1837, a group of his former students founded Chicago's Rush Medical College in his honor.

Rush did not restrict himself to practicing and teaching medicine; he used his talents and influence to help to provide medical care for the poor, to promote better education for women, and to reform the prison system^31,92,120. A well respected American patriot, he was one of four physicians to sign the Declaration of Independence and served as a member of the Continental Congress of 1774. Rush did not hesitate to publicly challenge accepted practices. He vigorously opposed capital punishment and slavery. In his efforts to end slavery, he published a pamphlet condemning the slave trade and helped to organize the first antislavery society in North America, serving as its President.

Despite his intellectual ability, education, and willingness to question established ideas and practices, he accepted the humoral theories of health, disease, and healing as the basis for medical practice and did not consider subjecting them to scientific tests^33,50,92. He hypothesized that most diseases resulted from excessive vascular tension that must be relieved by purging and bloodletting³¹, and he stressed that desperate diseases require desperate remedies, a modification of the Hippocratic aphorism that "for extreme diseases, extreme methods of cure, as to restriction, are most suitable."^50,58 He urged physicians to bleed, purge, and force vomiting until the disease was cured^31,125. Unfortunately for thousands, possibly tens of thousands, of patients, Rush estimated that the normal blood volume was more than double the actual amount and recommended relieving patients of 80 percent of their blood³¹. When violent purging caused rectal bleeding, he argued that the treatment was doubly effective³¹. During the 1793 yellow-fever epidemic that killed thousands of people in Philadelphia, Rush heroically treated large numbers of patients, frequently more than 100 a day, with aggressive purging and bloodletting^{31,96,120,125}. Some of them survived, and he concluded that "not less than six thousand of the inhabitants of Philadelphia were saved from death by purging and bleeding."¹²⁰ He interpreted the survival of some of his patients as supporting his version of the humoral theories³¹ - an example of Galen's great error. Like the Hippocratic physicians and Galen, Rush and most eighteenth and nineteenth-century physicians based their medical practices on theory and experience, and they did not consider subjecting their theories or practices to scientific tests. Their evaluations of their clinical results illustrate a deception that has led physicians and surgeons to repeat Galen's great error; few things improve the apparent results of a treatment, when administered and evaluated by a physician who believes in that treatment, as much as the absence of a comparison or control group.

The lack of records of the outcomes of medical practice from the late 1700s and early 1800s makes it difficult to assess the consequences of Rush's teachings on health care in the United States, but many people suffered and died under the care of physicians following his recommendations¹²⁵. On December 14, 1799, in George Washington's home, Mount Vernon, Washington awakened his wife, Martha, between two and three in the morning to tell her that he had a sore throat and a fever^31,42. Soon after daybreak, his overseer opened one of Washington's veins with a lancet and allowed the blood to run freely until about a pint had been taken. Later that morning, Washington's physician treated him with bleeding, blistering, leaches, enemas, and emetics. When the former president didn't improve, his physician bled him again. Washington still did not improve, and new physician consultants were called. They made the diagnosis of quinsy (a severe form of tonsillitis or pharyngitis) and then bled Washington for the fourth time, draining his circulation of another thirty-two ounces of blood. This time his blood came "thick and slow."⁹² Following this last venesection, the doctors gave him calomel (mercurous chloride) and other purges. Late in the afternoon, Washington requested that he be permitted to die without further interruption. Yet the doctors continued to apply blisters and poultices to his legs and feet. Washington died that evening, possibly, like Alexander the Great, the victim of too much attention from his physicians.

Despite frequent bad results, medical practices based on the humoral theories continued into the twentieth century in the United States. In 1893, six years after the founding of the American Orthopaedic Association, the great physician William Osler (1849-1919) noted that pneumonia is one of the diseases in which timely venesection saves life, and early twentieth-century textbooks recommended venesection for the treatment of serious illness³¹. As a result, at least some American physicians were still relying on theories based on ancient concepts of the natural world that had never been subjected to scientific examination and that were implausible at best. Since thoughtful people knew that most operations and aggressive purging and bleeding did considerable harm and little if any good, it is not surprising that Americans did not have high regard for surgeons and physicians in the late nineteenth century and that a variety of alternative medical sects, including Thomsonians, Homeopaths, and Eclectics, appeared and prospered³¹. It is surprising that the public and the state and federal governments were not more aggressive in condemning and trying to control physicians.

While nineteenth-century American physicians based their medical practice on theories first developed in ancient Greece, the age of original research was underway in Europe. Between the mid-1500s and the mid-1700s, three individuals, Andreas Vesalius, William Harvey, and Giovanni Morgagni, showed that Galen's descriptions of human anatomy, physiology, and pathology contained fundamental errors, and Morgagni effectively disproved the humoral theories of disease. Robert Boyle discredited the foundation of the humoral theories, the concept that matter was composed of various combinations of earth, air, fire, and water. These individuals differed in personality, scientific methods, and the subjects they studied, but they had in common the ability to make accurate observations and to interpret these observations independently of existing theories and their own beliefs; they did not fall into the trap of Galen's great error. Their specific results advanced science and medicine, but their challenges to established theories made the greater contribution - they broke Galen's hold on the minds of physicians and medical scientists.

Andreas Vesalius (1514-1564)^{4,9,30,50,77,92}, the son of a Belgian apothecary, studied Hippocratic and Galenic medicine at the University of Paris. He learned anatomy under the direction of Jacques Dubois (also known as Jacobus Sylvius), one of the most prominent and respected university faculty members. Dubois taught his students that the structure and function of the human body could only be understood by studying Galen's writings³³. In 1537, Vesalius moved to Padua, where he completed his medical education and then became professor of anatomy and surgery at the University of Padua. Initially, like Dubois, he taught anatomy from Galen's texts and even contributed to an edition of Galen's anatomical descriptions^33,46, but, to improve his ability to educate his students, he began to dissect humans. The differences that he noticed between Galen's descriptions and the structure of the body convinced him that Galen had not studied human anatomy. Surprised by these observations, Vesalius made arrangements to receive a steady supply of the bodies of recently executed criminals, and he meticulously dissected each body. His work aroused so much local interest that the authorities delayed executions until Vesalius was ready for the next body. In his text De Humani Corporis Fabrica Libri Septem (On the Fabric of the Human Body)^33,119, based on his dissections, he presented detailed descriptions of the musculoskeletal and nervous systems, blood vessels, and viscera, and he corrected more than 200 of Galen's most egregious errors⁸⁵. Made confident by his dissection of multiple bodies, Vesalius did not hesitate to point out that generations of physicians had followed Galen, often "against reason"⁹², and he commented that he could not "wonder enough at my own stupidity and too great a trust in the writings of Galen."⁹²

Although his work proved that many of Galen's descriptions of the human body were wrong and thereby encouraged others to question the foundations of Galenic medicine, Vesalius accepted Galen's teaching that the liver produced blood, and he did not question the Galenic description of two separate vascular systems. Like Galen, he failed to consider the possibility that the heart pumped blood through the arteries and that blood returned to the heart through the veins.

William Harvey (1578-1657) not only considered this possibility; he proved that it was true. The son of an English farmer^{9,30,33,50,61,77,92}, Harvey received his medical education at the University of Padua, where he studied under the direction of Fabricius ab Aquapendente (1537-1619), an anatomist and surgeon who dissected animals to discover how organs worked and attempted to relate the structure of organs to their function^36-38,43,92. Fabricius had observed that limb veins had internal valves^33,38,92, and he prepared a drawing, later reproduced by Harvey, showing that blood in the superficial veins of the human forearm flowed from the wrist toward the elbow^33,38. Yet Fabricius interpreted these observations as compatible with Galen's description of the tidal flow of the blood, explaining that, by hindering the flow of blood, the valves ensured an even distribution of blood and prevented inundation of the distal portions of the extremities^9,54,85.

Encouraged by exposure to the experimental approach of Fabricius³³, Harvey began investigations of the structure and function of the heart while in Padua. He then returned to England, where, in addition to becoming one of the royal physicians for James I and then for Charles I, he studied the action of the heart in living animals. His observations of heart motion and movement of blood through the arteries and veins convinced him that the heart pumped blood into the arteries, that the pulse resulted from the pumping action of the heart, and that the blood returned to the heart through the veins. More important than Harvey's observations was his development of quantitative evidence to support his hypothesis^85,92. He determined that each contraction of the human left ventricle pumped at least two ounces of blood into the aorta. Given a heart rate of seventy-two beats per minute, the heart would pump at least 540 pounds of blood into the aorta per hour, more than three times the weight of the average human. This calculation showed that Galen was wrong; the liver could not possibly produce 540 pounds of blood per hour from ingested food^85,92. If the liver did not produce the blood that appeared in the heart, it must be coming from the veins. To prove that the blood passed from arteries to veins in humans, Harvey applied a tourniquet to the distal arm tightly enough to stop arterial blood flow in the forearm and hand. Then he loosened the tourniquet slightly to demonstrate that, as the pulse returned, the forearm veins become increasingly distended if the tourniquet was tight enough to prevent venous blood flow. He confirmed Fabricius's observation that limb veins had valves, but, unlike his teacher, Harvey emphasized that the valves only allowed blood to flow back to the heart. He did not discover the capillaries, but he assumed that undetected connections existed between the arteries and veins⁹. Like Vesalius, Harvey had great confidence in the accuracy of his observations and apparently gained considerable satisfaction from pointing out that he was right and Galen was wrong. In his book Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (An Anatomical Disquisition on the Motion of the Heart and Blood in Animals) (1628)^54,55, dedicated to Charles I, he described how beating hearts "impelled" blood in a circle created by the arteries and veins, refuting the Galenic theory that blood flowed back and forth in the veins and arteries like the tides.

Shortly after Harvey's death, Marcello Malpighi (1628-1694), professor of theoretical medicine at the Universities of Pisa and Bologna, used a microscope to see "tiny tracts" connecting arteries with veins in the lung⁸¹. His description of these pulmonary capillaries, in his book De Pulmonum Substantia & Motu Diatribe) (1663), provided the evidence that confirmed the circulation of the blood^{9,33,61,81,92}.

Less well known than Vesalius and Harvey, Giovanni Morgagni (1682-1771)^30,50,77,92 used meticulous, well documented clinical-pathological correlations to discredit the humoral theories of disease. Born in the small northern Italian town of Forlêª Morgagni moved to Bologna at age sixteen to study medicine under the direction of Antonio Valsalva (1666-1723), one of the great anatomists and a former student of Malpighi^33,118. After six years of working as Valsalva's assistant and several years of practicing medicine in Forlêª Morgagni assumed the position of junior professor of theoretical medicine at Padua. Four years later, he became professor of anatomy, the position previously held by Fabricius and Vesalius.

During his more than fifty years at the University of Padua, Morgagni became convinced that postmortem examination of a patient's body could demonstrate changes in organs responsible for the symptoms and signs of disease. He studied the clinical course of patients with multiple disorders, including cirrhosis, cancer, pneumonia, and atherosclerosis, and performed nearly 700 autopsies with the intention of identifying the lesions responsible for the clinical manifestations of these diseases. He demonstrated that abscesses, neoplasms, tuberculosis, aneurysms, and other lesions occurring at specific sites were consistently associated with specific signs and symptoms. Based on these observations, he developed the hypothesis that abnormalities in organs, not humoral imbalances, caused disease and death. Near the end of his career, at age seventy-nine, he published his observations in De Sedibus, et Causis Morborum (On the Sites and Causes of Disease) (1761)^33,83, a book that identified the tissue lesions responsible for many common diseases and included case histories that demonstrated the relationships between clinical symptoms and signs and the underlying lesions. The overwhelming evidence carefully collected and analyzed by Morgagni made the humoral theory of disease indefensible.

Although it was not appreciated at the time, Robert Boyle (1627-1691)^61,103, an English scientist, made an even more fundamental challenge to the humoral theories of health and disease 100 years before Morgagni published De Sedibus, et Causis Morborum. Most modern physicians learn Boyle's name when they memorize Boyle's law (the pressure of a given mass of an ideal gas is inversely proportional to the volume if the temperature remains constant; P = constant/V) in chemistry and physics classes. Perhaps more important than his study of the behavior of gases was his discrediting of the idea that matter consists of earth, air, fire, and water, which had led to the humoral theories of health, disease, and healing. Boyle recognized that matter consists of a range of elements and that each element is composed of identical "corpuscles," or atoms, and in his book The Sceptical Chymist (1661) he advanced the concept that matter is formed from chemical compounds that in turn consist of combinations of elements¹⁰³.

Despite the publication and general acceptance of the well documented scientific observations of Vesalius, Harvey, Morgagni, Boyle, and others, medical practice changed little in the seventeenth and eighteenth centuries. Physicians and surgeons continued to base diagnosis and treatment on modified versions of 2000-year-old humoral theories along with other untested ideas and empiricism. Perceptive individuals in Europe and the United States questioned the validity of medical knowledge and expressed concern about the results of medical practice. Moliç±¥'s (1622-1673) popular plays Love's the Best Doctor, The Doctor in Spite of Himself, and The Imaginary Invalid exposed physicians' explanations of human illness and treatment of disease as ludicrous and promoted the widely accepted view that doctors did more harm than good. Voltaire (1694-1778) noted that "doctors are men who prescribe medicines of which they know little to cure diseases of which they know less in human beings of which they know nothing."¹²⁴ In America, newspapers routinely reported disastrous consequences of medical and surgical treatments and printed poems and stories ridiculing physicians³¹. Some colonial governments attempted to stop the most dangerous medical practices by establishing minimal requirements for physicians. A 1760 New York medical licensure law noted that "ignorant and unskillful persons" were administering medications and practicing surgery and thereby endangering the lives and limbs of their patients³¹. In 1806, Thomas Jefferson, then the third president of the United States and a respected scholar and amateur scientist, noted that "Harvey's discovery of the circulation of the blood was a beautiful addition to our knowledge of the animal economy, but on a review of the practice of medicine before and since that epoch, I do not see any great amelioration which has been derived from that discovery."⁹²

If publication of basic scientific evidence that discredited the humoral theories of disease and public recognition of generally poor results of medical care did not affect how physicians treated their patients, what finally freed medical practice from ancient theories? More than anything else, realization that the application of results of original clinical research could save lives and restore function led physicians to accept the importance of subjecting theories and practices to scientific tests. Many individuals contributed to the understanding of the power of original clinical research between the mid-1700s and the late 1800s, but three stand out: James Lind, John Snow, and Joseph Lister. All three trained as surgeons, and Joseph Lister spent much of his career improving operative treatment of diseases and injuries of bones, joints, and musculoskeletal soft tissues^39,47,92.

James Lind (1716-1794)^23,77,90,92 learned medicine as an apprentice to an Edinburgh surgeon and then entered the Royal Navy as a surgeon's mate in 1739. He distinguished himself by his clinical skill and dedication to the welfare of the sailors, and in 1747 he was promoted to the rank of naval surgeon. Like other naval surgeons, he observed that more sailors died from scurvy than from wounds, infectious diseases, and all other causes combined and that the disease only occurred during long voyages. Sailors and naval surgeons accepted death from scurvy as a risk of serving on ships. More than half of the men accompanying Vasco da Gama on his first voyage around the Cape of Good Hope (1497-1499) died of scurvy. Nearly 150 years later, during a four-year British voyage around the world (1740-1744), 997 of 1955 men died of the disease⁹². Lind lacked a formal education in science, but he was a keen observer and had the ability to critically analyze a clinical problem. He noted the difference in the incidence and prevalence of scurvy among officers and sailors on the same ships and hypothesized that the disease resulted from dietary deficiencies on long sea voyages, in particular the lack of citrus fruit.

On May 20, 1747, while serving as the senior surgeon on the HMS Salisbury, a fourth-rate man-of-war with a crew of 350, Lind initiated the first prospective, controlled clinical experiment^23,69,70. He selected twelve sailors suffering from advanced scurvy, choosing them so that "their cases were as similar as I could have them. They all in general had putrid gums, the spots and lassitude, with weakness of their knees."^69,70 He divided the twelve men into six groups of two but made sure that all twelve stayed in the same quarters and ate the same food. Five of the groups received five different control treatments: a quart of cider per day; twenty-five drops of oil of vitriol three times per day; two spoonfuls of vinegar three times per day; a teaspoon of an electuary (medicinal paste) containing garlic, mustard seed, radish root, and other ingredients once a day; and half a pint of sea water per day. The experimental group of two sailors received one lemon and two oranges per day. Six days later, none of the sailors in the first five groups had improved, but the two given oranges and lemons were fit for duty and caring for the others.

Lind left the navy in 1748 and received a medical degree from the University of Edinburgh in the same year. Five years later, he published a report of his study on the HMS Salisbury, A Treatise on the Scurvy^23,33,69,70, and concluded that "the result of all my experiments was that oranges and lemons were the most effectual remedies for this distemper at sea [scurvy]."²³ Lind's delay in publishing his report, and his modest statement of his conclusion, suggest that he did not fully appreciate the magnitude of his accomplishment or the implications of his results for saving lives. His experimental design and small number of subjects would not meet standards for controlled clinical trials, and he could not explain the antiscorbutic effect of citrus fruits. Albert Szent-Györgyi (1893-1986) isolated and synthesized vitamin C in the late 1920s and early 1930s⁹², and others showed how it prevented scurvy, but Lind demonstrated for the first time the value of a prospective clinical experiment and eventually the results of his work saved thousands of lives in the eighteenth and nineteenth centuries. Lind's contributions earned him recognition as the "father of naval surgery" and an appointment as the chief physician at the Royal Naval Hospital in 1758.

John Snow (1813-1858)^29,77,91,92, an English surgeon and a leader in the development of inhalation anesthesia^106,110,113, began his medical career as an apprentice surgeon at Newcastle upon Tyne during the cholera epidemics of 1831 and 1832. Stunned by the sudden, widespread onset of violent vomiting and diarrhea that killed previously healthy people within hours and by the inability of physicians to prevent or treat the disease, Snow began studying the pattern of the appearance of the cholera during previous Asian and European epidemics in an effort to understand its causes^111,112. In 1836 he moved to London's Soho to establish his medical practice, and in 1847 he began to spend an increasing amount of his time providing ether and chloroform inhalation anesthesia¹¹⁵.

During the 1849 English cholera epidemic that caused over 50,000 deaths, Snow turned away patients from his surgery and anesthesia practice to give him time to care for victims of the epidemic and to study the natural history of the disease¹¹². He observed that cholera "invariably commences with the affection of the alimentary canal,"^107,111,112 not with involvement of the lungs, and that deaths from cholera occurred in clusters but not necessarily in the most crowded areas. These observations led him to question the prevailing idea that cholera resulted from a "miasma," a vaporous airborne poison that escaped from decaying bodies or vegetable matter, fetid water, sewage, or clefts in the ground^53,92. Instead, he suggested that a poison that "has the property of increasing and multiplying in the systems of the persons it attacks"^107,111 caused the disease and that this poison spread through water "polluted" by evacuations, feces, and vomitus from patients suffering from cholera^12,92,107. Snow reasoned that, since the "morbid matter of cholera" could reproduce itself, it "necessarily must have some sort of structure, most likely that of a cell"^107,111 and that this "morbid matter" must be swallowed to cause the disease. Unlike Lind, Snow appreciated what he had discovered and the implications of his results. At his own expense, in the summer of 1849, he published his hypothesis concerning the cause of cholera and his recommendations for preventing the spread of the disease, in a thirty-nine-page pamphlet, On the Mode of Communication of Cholera^107,112. In November 1849, he published a more extensive, two-part article, "On the pathology and mode of communication of cholera,"^107-109 in the London Medical Gazette, but his ideas attracted little attention and no action, perhaps because the 1849 epidemic ended nearly as abruptly as it had started.

Following the 1849 epidemic, Snow returned to his anesthesia practice and developed a method of intermittent chloroform anesthesia that proved to be effective and safe for women in labor. On April 7, 1853, at the request of Queen Victoria and the Prince Consort, Snow was called to Buckingham Palace to anesthetize the Queen for the delivery of her fourth son¹¹⁵. Fifty-three minutes after Snow first administered chloroform, Prince Leopold was born without complication and without any complaint of pain by the Queen. The resulting publicity made Snow the most sought-after anesthetist in London.

In late August 1854, five years after the publication of Snow's pamphlet and articles, cholera suddenly appeared again in Soho. The number of deaths increased rapidly after August 31, 1854. Determined to discover whether his hypothesis was correct, Snow limited his anesthesia practice to investigate deaths that occurred in Soho during the week ending September 2, 1854^92,111. He found that eighty-three people had died during the last three days of the week and that seventy-seven of the victims had probably used water from the Broad Street pump, whereas in a crowded nearby workhouse few people had died. The workhouse had its own well. After considering these data, Snow knew how cholera spread. On September 7, 1854, Snow, a quiet, unassuming man but a man with the confidence that comes to the fortunate few who know they have found a new way to save lives, presented his evidence to the skeptical Board of Guardians of St. James Parish¹¹². He convinced them to remove the Broad Street pump handle; shortly afterward, deaths from cholera in Soho stopped. They may have stopped because the most susceptible people were already dead and most others had fled the area, but the apparent effect of removing the pump handle was taken as evidence that Snow's hypothesis was correct and, equally important, that applying the results of clinical research could save lives. Today, the John Snow Pub at the corner of Broadwick Street (formerly Broad Street) and Lexington Street in Soho honors Snow and marks the site of the Broad Street pump.

In 1855, Snow published the second edition of On the Mode of Communication of Cholera¹¹¹. In the same year, he presented his recommendations for preventing the spread of the disease, based on a series of investigations extending back to his experience in Newcastle upon Tyne^107,112, to a House of Commons Select Committee. His presentation stimulated improvements in the water-supply and sewage-disposal systems in London and other cities. Although Snow explained how to prevent the spread of cholera, he could not identify the cause of the disease. Nearly thirty years after Snow first correctly described the mode of communication of cholera, Louis Pasteur (1822-1895) presented his germ theory of infection before the French Academy of Medicine⁸⁹ and started experiments on chicken cholera⁹². Thirteen years later, in 1893, working with patients suffering from cholera, Robert Koch (1843-1910) proved that Snow was right about the morbid poison of cholera^65,92. Koch isolated and identified Vibrio cholerae, the organism responsible for human cholera, and showed that it reproduced itself in human intestines and spread primarily through contaminated water⁹².

Joseph Lister (1827-1912), during four decades of research, teaching, and clinical practice in Glasgow, Edinburgh, and London, helped to establish science as the basis for effective medical practice, developed a technology that prevented wound infections and death from septicemia, and did more to advance orthopaedics as a surgical specialty than any other individual^{39,72,77,91,92,114}. He is the model surgeon-scientist-teacher, and his work helped to bring on the age of science and technology.

In 1855, Lister started his career-long series of basic and clinical investigations by studying the inflammatory response in the skin of frogs' feet and his own forearm^39,47. He made progress in defining the sequence of cellular and vascular events in inflammation but found himself frustrated by his inability to prevent suppuration and gangrene in wounds (inflammation, pus formation, and tissue necrosis), which frequently ruined the results of his technically successful operations and often was followed by the death of his patients. Like his contemporaries, Lister assumed that poisonous matter absorbed from inflamed wounds caused death, a phenomenon then commonly called blood poisoning³⁹. He knew that fractures healed without suppuration if the skin was not broken but open fractures often resulted in death from blood poisoning^30,115. Since gangrene and blood poisoning commonly developed within three days or less following an open fracture, most surgeons recommended amputation proximal to the fracture without delay¹¹⁵. Yet even after early amputation, between 25 and 50 percent of the patients died³⁹. The results of deep lacerations and elective operations were comparable: one of Lister's colleagues observed that a man lying on the operating table had more chance of dying than an English soldier fighting at the Battle of Waterloo³⁹.

Although Lister performed a variety of operations, including mastectomies and dilation of urethral strictures, the operative treatment of limb diseases, deformities, and injuries made up most of his practice^39,47. His interest in improving surgery of the limbs led him to develop what he referred to as "bloodless" surgery⁴⁷. In 1863, ten years before the introduction of the Esmarch bandage in Germany, he started elevating limbs for several minutes to decrease their blood volume and then applying a tourniquet before beginning an operation. This innovation allowed him to operate with greater precision and to decrease blood loss.

In 1864, Lister learned of Louis Pasteur's observations that organisms invisible to the naked eye caused fermentation of milk, beer, and wine and that "pasteurization," or killing these invisible organisms or germs by heating the fluid, prevented fermentation^28,39,47,88. He was especially intrigued by Pasteur's evidence that airborne germs landed in exposed milk, beer, and wine; reproduced themselves; and caused fermentation. Pasteur's work may have caught Lister's attention because Lister was considering the possibility that putrefaction (suppuration and necrosis of tissues) and souring of milk and wine were similar processes. Another reason that Lister may have been interested in fermentation is that his grandfather's and father's success as beer and wine merchants had made the Lister family fortune³⁹, and pasteurization made it possible to export French wine and British beer⁸⁸. During the early years of Lister's practice, physicians believed that suppuration occurred when exposure to air caused chemicals present in wounds to organize into pus and thought that the best way to prevent wound infections was to apply an occlusive dressing^39,115. Lister had another idea. From his basic investigations of inflammation, his clinical observations of suppuration, and his studies of Pasteur's work, he became convinced that invisible airborne organisms invaded open wounds and then proliferated, causing suppuration of the wound and blood poisoning^39,71,115.

Based on this conviction, he developed his approach to antisepsis: destroying germs in wounds and surgical incisions with carbolic acid (phenol). Phenol, a coal-tar derivative discovered in 1834, was first used in its raw form, creosote, to keep railroad ties and ships' timbers from rotting; subsequently, undertakers used a more refined preparation to preserve corpses³⁹. Lister knew that carbolic-acid treatment of sewage eliminated the foul smell and hypothesized that this occurred because it killed germs. In March 1865, Lister tried carbolic-acid wound irrigation in two patients: the first had a painful swollen wrist, probably due to tuberculosis, that he treated by excision of the joint, and the second had an open fracture of the leg that he treated by dè¡²idement. Both patients developed suppuration of their wound³⁹. Following these failures, Lister refined his method of antisepsis. On August 12, 1865, he had an opportunity to test his modified technique when James Greenlees, an eleven-year-old boy, suffered a comminuted open tibial fracture^13,34,39. Lister irrigated the wound with carbolized water and used dressings soaked in carbolic acid. He was thrilled when the fracture healed without suppuration. He subsequently treated eleven consecutive patients with open fractures in the same fashion. One patient died of hemorrhage. Lister reported the previously unheard of mortality rate of 9 percent (one of eleven) for patients with open fractures in the March 1867 issue of Lancet^39,92.

Success with treatment of open fractures led Lister to expand the use of carbolic acid and to extend his surgical practice to elective procedures. In addition to bathing wounds and dressings in carbolic acid, he started soaking surgical instruments and his hands in carbolic-acid solutions and spraying the air in the operating theaters in an attempt to kill airborne germs. He performed an osteotomy for a malunited tibia in 1867, and the patient did not develop suppuration. A year later, he started performing arthrotomies of the knee and elbow to remove loose cartilage fragments⁴⁷. He recognized that, even when he treated wounds with carbolic acid, the silk sutures he used to ligate blood vessels might carry germs that could cause wound infections. In 1869, with the help of his wife, Agnes (1834-1893), the daughter of the prominent English surgeon James Syme (1799-1870), he developed and started using absorbable sutures made from carbolic-acid-treated catgut^39,98. Lister then turned his attention toward analyzing his own clinical results, making him one of the first surgeons to critically review the outcomes of his operations⁹². He found that the mortality rate for amputations that he had performed between 1864 and 1866 without antisepsis was nearly 46 percent (sixteen of thirty-five). His use of carbolic-acid antisepsis for amputations performed between 1867 and 1870 cut the mortality rate to 15 percent (six of forty).

Because of the great risk of fatal blood poisoning, only a few surgeons had opened closed fractures to reduce and stabilize them, especially fractures involving joints⁸. After refining his antiseptic technique and demonstrating its effectiveness in preventing suppuration and blood poisoning in patients with open fractures and in patients treated with osteotomies and arthrotomies, Lister believed that he could safely treat closed fractures with open reduction. In 1868, he performed what may have been his most daring operation: the open reduction of an ununited femoral neck fracture in a forty-five-year-old man. Four months later, the patient was walking on the limb without difficulty and the wound was healed⁴⁷. In 1873, Lister performed an open reduction and internal fixation of a closed olecranon fracture, using a silver wire to stabilize the fracture⁴⁷. The patient did not develop an infection and returned to work in a shipyard, using a hammer with the injured arm. Lister then began routinely treating olecranon and patellar fractures by open reduction and internal fixation⁴⁷. His successes with surgical treatment of bone and joint diseases and injuries led him to begin repairing lacerated tendons and peripheral nerves with catgut sutures in 1881³⁹.

When Lister first presented his clinical results, prominent scientists and surgeons publicly ridiculed his "germ theory" of wound suppuration and blood poisoning¹¹⁵. John Hughes Bennett, professor of physiology in Edinburgh, questioned the existence of microorganisms in wounds and commented, "Where are these little beasts . . . Show them to us, and we shall believe in them."⁹² Pierre Pochet, professor of physiology at Toulouse, called the germ theory of wound infection "a ridiculous fiction."²⁴ Dr. J. R. Wolf, in a letter to Lancet in 1867, questioned what he called the panspermatism hypothesis of Pasteur and attributed the effects of carbolic acid to preventing chemicals in wounds from organizing into a putrescent condition, and James Morton correctly pointed out that Lister had not shown that airborne germs were injurious³⁹. Others accused Lister of performing "unjustified procedures,"⁹² especially osteotomies, arthrotomies, and open reduction and internal fixation of closed fractures³⁹.

In an effort to bring the germ theory and antisepsis to the United States, Lister gave an enthusiastic two-and-one-half-hour address to the International Medical Conference in Philadelphia in 1876, a meeting attended by 480 of the world's most prominent physicians³⁹. Samuel Gross (1805-1884), a leading senior American surgeon with an interest in diseases of bones and joints^51,52, commented, in 1876: "Little, if any faith, is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called carbolic acid treatment of Professor Lister," and in 1882 he added that "demonstration of living, disease-producing germs is wanting."⁹⁸ Younger American surgeons also rejected antiseptic practices⁹⁸, and at the 1883 meeting of the American Surgical Association, two prominent American surgeons who were Lister's age, Tobias Richardson (1827-1892) and Claudius Mastin (1826-1898), proudly declared that not a surgeon in Louisiana or Alabama used the Lister method⁹⁸.

Others found Lister's ideas easier to accept, and his clinical research on antisepsis stimulated further advances in the understanding and prevention of wound infections. On April 7, 1873, in a lecture to the Royal Society of Edinburgh, Lister stressed the role of microorganisms in causing both putrefaction and fermentation⁷¹. On February 19, 1878, about five years after Lister's presentation to the Royal Society and thirteen years after Lister first used carbolic acid as an antiseptic, Pasteur presented his germ theory of disease to the French Academy of Medicine and discussed the applications of this theory to medicine and surgery^89,92. He stressed the importance of antisepsis and sterilization (asepsis) to decrease the risk of infections⁸⁹. In the same year, Robert Koch reported his experiments showing that bacteria causes wound infections⁶³. In the next decade, Koch and his followers identified the organisms responsible for tetanus, tuberculosis, diphtheria, typhoid, gonorrhea, meningitis, and streptococcal and staphylococcal infections^64,65,92, the "little beasts" that Professor Bennett wanted to see before he could believe in them.

Resistance to Lister's work stemmed partly from the difficulty that physicians have with learning that what they have believed and practiced is wrong, but another factor was Lister's unwavering dedication, for more than thirty years, to refining carbolic-acid-antisepsis technologies. Although he experimented with other antiseptics, he never ceased advocating the use of various forms of carbolic acid⁴⁷. If he had stressed practices based on the advancing scientific knowledge of infections, including using other substances as antiseptics and minimizing contamination of wounds by irrigating and debriding open fractures, sterilizing wound dressings, sutures, and surgical instruments, and washing surgeon's hands, acceptance of the germ theory of wound infections among surgeons might have come more quickly. Instead, many, if not most, physicians associated Lister's germ theory of wound infections and blood poisoning with use of carbolic acid. Aerosols and solutions of this substance had a number of adverse effects, and the dense clouds of carbolic-acid spray that soaked the patient, the surgeon, and the assistants caused coughing and headaches. Carbolic-acid solutions caused skin excoriations and other tissue damage, delayed healing, and poisoned some patients. A few of Lister's critics pointed out that carbolic acid caused superficial necrosis and thereby impaired the ability of the tissues to resist infection⁴⁷. Some of Lister's most enthusiastic pupils questioned the value of spraying the air with phenol, and the German surgeon Ernst von Bergman (1836-1907) and his colleagues provided evidence that carbolic-acid aerosols probably did little to prevent wound infections¹¹⁵. Using Koch's methods of culturing bacteria, they showed that air contained few germs that could cause suppuration. They argued that unclean hands and instruments were more likely sources of germs.

Repeated washing with carbolic acid during an operation macerated Lister's hands and those of his assistants³⁹. Others could not tolerate repeated exposure to carbolic acid and developed progressive cracking and intense inflammation of the skin. Although this effect may have delayed acceptance of antisepsis, it had unintended beneficial consequences. Eduard Albert (1841-1900), the head of surgery at the University of Vienna, focused his clinical research on disorders of bones and joints and developed a number of new operations for the treatment of musculoskeletal deformities. Adolph Lorenz (1854-1946), Albert's favorite pupil, was eagerly assisting in these developments, but Lorenz developed such severe eczema of his hands following exposure to carbolic acid that he abandoned his goal of becoming a great surgeon. Instead, he devoted himself to what he called bloodless surgery and earned an international reputation and a nomination for the Nobel Prize by developing his concept of molding reduction (modellierendes redressement), the use of gentle application of force over time to remodel living growing tissues. Based on this concept, he devised nonoperative treatments of clubfoot deformity and developmental dysplasia of the hip in the 1870s⁶⁸. Orthopaedists currently use modifications of this approach to treat these deformities^26,82. In the spring of 1889, William Halsted (1852-1922), an innovative surgeon, a champion of antisepsis, and the first professor of surgery at Johns Hopkins, developed a strong personal interest in a newly arrived young nurse working at the hospital, Miss Caroline Hampton. He promoted Miss Hampton to the position of chief nurse in the operating room and his personal assistant in late 1889. Her hands soon became rough and raw from repeated exposure to carbolic-acid solutions, and by early 1890 she was considering leaving her work in the operating room. To solve this problem, Halsted worked with the Goodyear company to develop thin rubber surgical gloves that could be sterilized with steam, an innovation that was rapidly accepted and that further reduced the incidence of wound infections^92,115.

Pasteur, Koch, and their coworkers, seeking better ways to kill bacteria, learned that some germs, especially bacterial spores, survive prolonged exposure to carbolic acid and high temperatures on dry surfaces but that moist heat kills even the spores that cause anthrax and tetanus. This led them to develop autoclaves in the early 1880s^28,121, and in 1884 Pasteur commented, "If I had the honor of being a surgeon, I would never introduce into the human body instruments that had not been passed through boiling water."¹²¹ Within a decade of Pasteur's comment, surgeons were abandoning Lister's carbolic-acid antiseptic techniques and adopting aseptic practices, including use of autoclaves, detergents, and sterile wound dressings, gloves, and operating gowns. Lister continued to refine his applications of carbolic acid and fought against aseptic surgery; he argued that it did not provide adequate protection against infection³⁹. His resistance to asepsis illustrates how commitment to a technology, in this case carbolic-acid antisepsis, can compromise the ability of a talented individual to appreciate that scientific advances will make that technology obsolete.

The work of Pasteur and Lister did not go unappreciated. Every nation in Europe, and innumerable universities throughout the world, honored Pasteur with proclamations, medals, honorary degrees, and memberships in their most prestigious scientific societies. In November 1888, the President of France, Sadi Carnot, opened the Pasteur Institute in Paris, and Pasteur and his wife moved into an apartment in the Institute, where he worked until his death on September 28, 1895. Since the establishment of the Pasteur Institute, its scientists have been leaders in improving the treatment of infectious diseases, and, since 1908, eight of them have been awarded the Nobel Prize for medicine and physiology. In recognition of Lister's contributions to medicine, he was knighted in 1882, and Queen Victoria made him First Baron Lister of Lyme Regis in 1887. The British Institute of Preventive Medicine, established in 1891, was renamed the Lister Institute of Preventive Medicine in 1903 to recognize Lister's contributions to the prevention of disease. Currently, the Lister Institute supports biomedical research in the United Kingdom.

Lister's life spanned the development and widespread clinical application of three major technical advances in the late 1800s and early 1900s: asepsis, inhalation anesthesia, and roentgenograms. The rapid and dramatic improvements in the diagnosis and treatment of diseases and injuries resulting from these three new technologies marked the beginning of the fourth age of medicine, the age of science and technology, and made possible the emergence of orthopaedics as a major surgical specialty. The acceptance of aseptic practices in the late 1800s meant that orthopaedic surgery no longer had a 40 percent mortality rate. Inhalation anesthesia meant that surgeons could operate without patients being held by strong men or strapped to the operating table, and roentgenograms allowed orthopaedists to see fractures and the bone abnormalities caused by diseases of the bones and joints.

The United States can legitimately claim the credit for one of the most important advances in the history of medicine, the development of inhalation anesthesia, but an English poet and scientist, Humphry Davy (1778-1829), was the first to discover that breathing a gas could relieve pain^31,85,92. Although Davy was knighted and awarded a baronetcy for his contributions to chemistry, he began his scientific career studying the effects of inhaling gases⁹². At age seventeen, experimenting on himself and probably some of his friends, he found that inhaling nitrous oxide caused intoxication⁸⁵. In subsequent investigations, he demonstrated that inhaling the gas produced reversible loss of consciousness and relieved pain⁹², and, in 1815, working with Michael Faraday (1791-1867), he found that inhaling ether produced similar effects^31,92. Davy recognized that these gases might be useful in producing temporary analgesia for operations^85,92, but instead of pursuing this possibility he directed his efforts toward the study of electrochemistry and the isolation of chemical elements, including sodium, potassium, barium, boron, calcium, and magnesium⁹.

In the early 1800s, itinerant salesmen and self-appointed professors of chemistry offered the American public opportunities to experience the intoxicating effects of inhaling nitrous oxide and ether. Laughing-gas (nitrous-oxide) parties and ether frolics became popular forms of entertainment, but the medical applications of these gases went undeveloped until American dentists and surgeons started using them as anesthetics in the early 1840s^31,92,98. In 1845, Horace Wells (1815-1848), a dentist from Hartford, Connecticut, who had used ether anesthesia to extract teeth, attempted to demonstrate the effects of inhalation anesthesia in front of a Harvard Medical School class and a group of distinguished Boston physicians. The patient jerked and cried out when his tooth was extracted. The kindest observers called the demonstration a humbug affair and labeled Wells a fraud^85,115, but an operation performed about a year later at the Massachusetts General Hospital proved that inhalation anesthesia deserved another look. On October 17, 1846, senior surgeon John Collins Warren (1778-1856) resected a neck tumor in a patient receiving ether anesthesia administered by William Thomas Green Morton (1819-1868)^{84,115,117,122}, a Boston dentist and former student and partner of Horace Wells⁸⁵. The patient lost consciousness after Morton clipped the patient's nose shut and applied his ether-inhalation apparatus to the patient's mouth for about three minutes. At that point, Morton turned to Warren and said, "Sir, your patient is ready."¹¹⁵ During the twenty-five-minute operation, while Warren dissected the nerves and blood vessels of the neck and removed the tumor, the patient occasionally appeared to be agitated, but afterward he stated that he did not have any pain even though he knew that the operation was taking place¹²². Following the procedure, Warren announced, "Gentlemen, this is no humbug."^92,115

Before the development of inhalation anesthesia, no patient could tolerate the meticulous dissection necessary to perform complex operations. Speed was the measure of a surgeon's skill - shorter operations meant less pain. Robert Liston (1794-1847), professor of clinical surgery at London's University College, earned a well deserved reputation as one of England's greatest surgeons for his masterful knowledge of anatomy, his willingness to attempt the most difficult and dangerous procedures, and his displays of dexterity, physical strength, speed, and dramatic talent in the operating theater. His operations and lectures attracted students and physicians from throughout the United Kingdom, Europe, and America, and his papers on surgical procedures were widely read and quoted^73-75. Liston routinely performed amputations in less than three minutes and as a result attracted large numbers of patients^49,92,115. He designed a long, narrow (thirty-six-by-two-centimeter) single-edged knife that allowed him to cut muscles, tendons, nerves, blood vessels, and skin with a single dramatic stroke. In his efforts to perform above-the-knee amputations and hip disarticulations with great speed and flare, Liston occasionally injured observers who stood too close to the operating table and amputated more than he had originally planned. On at least one occasion, he performed an accidental orchiectomy along with amputation of the patient's leg. Another of his leg amputations led to a 300 percent mortality; a distinguished spectator died after he was slashed during the operation, the patient died of sepsis several days later, and Liston's assistant died of sepsis as a result of losing several of his fingers during the operation⁴⁹. In London, on December 21, 1846, Liston performed an above-the-knee amputation with the patient under ether anesthesia^92,115 and thereby helped to make the exceptional speed that had earned him a fortune less valuable. Before the operation, Liston, along with others, expressed skepticism about the reports from America regarding the efficacy of inhalation anesthesia and announced to the assembled crowd, "We are going to try a Yankee dodge, today, gentlemen, for making men insensible."¹¹⁵ Along with other spectators, nineteen-year-old Joseph Lister attended the operation and was present when Liston declared, "This Yankee dodge, gentlemen, beats mesmerism hollow."^39,92

Clinical use of roentgenograms spread more rapidly than use of antisepsis, asepsis, and inhalation anesthesia. On November 8, 1895, Conrad Wilhelm Roentgen (1845-1923), a German physicist, asked his wife to hold her hand on a photographic plate while he directed a cathode-ray tube at her hand⁹². Development of the plate showed the bones of her hand. Since Roentgen did not know the nature of the rays responsible for producing the image, he named them x-rays. Two months later, German physicians used roentgenograms to study fractures, and, within a year, European hospitals had installed x-ray machines. At the 1896 meeting of the American Orthopaedic Association, De Forest Willard (1846-1910), an orthopaedic surgeon who served as President of the Association in 1890, presented a paper on the use of roentgenograms in orthopaedics⁹⁸. During the Spanish-American War, in 1898, a little more than two years after Roentgen published his initial report, the United States Army placed seventeen x-ray units in military hospitals and three on hospital ships¹¹. Surgeons quickly learned that the ability to see the skeleton in patients made it possible to diagnose fractures, classify skeletal diseases and injuries, and plan treatment.

In the last half of the twentieth century, the rate of technological progress in medicine increased dramatically and produced corresponding advances in orthopaedic surgery. Beginning with the discovery and production of penicillin, the development of antibiotics improved the ability of surgeons to treat bacterial infections beyond any methods devised by Lister and his contemporaries^40,41. In 1946, Alexander Fleming (1881-1955), the discoverer of penicillin, showed that some of Lister's more thoughtful critics were right: carbolic acid could impair the ability of tissues to resist infection⁴¹. Fleming infected defibrinated human blood with mixtures of bacteria and showed that the leukocytes killed about 95 percent of the bacteria, but the addition of certain dilutions of phenol killed the leukocytes and allowed the bacteria to grow. He noted that penicillin was the first substance ever encountered that destroyed bacteria without affecting leukocytes. Surgeons immediately used the new drug to prevent and treat bone, joint, and soft-tissue infections^1,22,35. New instruments, implants, and techniques made it possible to surgically treat deformities, including scoliosis and developmental dysplasia of the hip; to replace painful degenerated joints; to stabilize open and closed fractures with internal and external fixation devices; to perform free vascularized tissue transfers to save limbs that would have previously been amputated; to replant traumatically amputated limbs and digits; and to perform minimally invasive joint surgery using arthroscopy. Advances in imaging, including computerized tomography, magnetic resonance imaging, and positron-emission tomography, made it possible to precisely identify structural abnormalities, disease processes, and injuries of the musculoskeletal system and to devise new treatments.

The best is yet to come. In the first decades of the twenty-first century, biotechnology will make it possible to regenerate and to improve the healing of bone, tendon, ligament, and cartilage with use of artificial matrices, cytokines, and cell transplants and to stimulate selected cell functions with use of ultrasound, electromagnetic fields, and controlled mechanical stimuli. Some of us will also witness the beginning of the fifth age of medicine, an age based on an understanding of the human genome^94,95,128. We may learn how to use genes to treat injuries and diseases by delivering growth factors or other biologically active agents. Understanding of a patient's genetic information may make it possible to select the optimal treatment for musculoskeletal injuries and diseases for that individual and to prevent or slow the progression of genetic, developmental, and degenerative diseases.

After more than 5000 years, we find ourselves in the age of science and technology and looking forward to an even more exciting age; the practice of medicine has been transformed from an art based on belief in supernatural forces to an art based on science. The art of medicine - the ability of physicians to understand and care for patients, to make and act on critical decisions without definitive information, and to inspire confidence and trust - is learned only by observation of experienced, talented physicians and by practice. As has been true since the beginning of medicine in antiquity, skillful use of the art of medicine comforts patients, and surely this art is among the greatest contributions of the human heart and mind to the welfare of mankind. The science of medicine, the body of knowledge based on original research, and the ability of physicians to apply that knowledge and critical reasoning to medical practice is learned only by intense study and experience in testing hypotheses. The events of the last 250 years, beginning with Lind's controlled clinical experiment on the HMS Salisbury, show that it is the science of medicine that cures and that the science of medicine is the greatest contribution of the human intellect to the welfare of mankind.

The future looks bright for medicine and for orthopaedics in particular, yet worrisome trends have emerged. The great benefits of technology and procedures are clear and compelling; the threats they pose to science and the art of medicine are more subtle. Clinically experienced physicians and, in particular, those practicing specialties that depend heavily on technology, are devoting increasing attention to modifying and refining instruments, implants, and procedures and less attention to seeking new scientific advances that will make current technology obsolete. The practice of medicine is changing. Physicians increasingly accept and apply new technologies and techniques without critical review of their value, minimize time spent with patients, and decrease the emphasis on taking a history and performing an examination in favor of ever-better imaging techniques. They focus more on identifying and correcting structural abnormalities demonstrated by imaging studies and less on comprehensive evaluation and treatment and on patient expectations, concerns, and function^78,79.

At the same time, the information age has affected medicine as it has every aspect of society. In the last two decades, the number of medical journals, including those focused on the musculoskeletal system, has progressively increased. Anyone, anywhere, with a computer, a modem, and access to a telephone, can read the abstracts of articles published in any medical journal at any time. The abstracts of presentations at professional and scientific meetings, and, for a number of meetings, live presentations, are available through the Internet. A quick search of the Internet will yield an unstructured mass of information about any subject related to medicine, from a variety of sources, including medical centers, federal institutes and agencies, journals, news services, individual physicians, patients and patient-advocacy groups, and companies promoting their products.

Increases in the volume and availability of information have made it possible for physicians and scientists to learn of new advances more quickly and for patients to become better informed, but these changes also have promoted widespread dissemination of unsubstantiated observations and use of unproven treatments. Physicians find that they rarely have time to read journals and other publications critically and that they increasingly rely on summaries, abstracts, and presentations. However, many abstracts and presentations from scientific meetings are preliminary reports that are extensively revised before publication as peer-reviewed articles or that are never published²¹, and abstracts necessarily lack the detailed descriptions of methods and results necessary to determine the validity of the conclusions²⁰. Abstracts and presentations at scientific and professional meetings undergo at least some form of review, but much of the increased volume of information available to physicians and patients is not subjected to even this level of critical evaluation, a phenomenon that Robert Leach called "the misinformation boom"⁶⁷ and that Henry Cowell called "the millennium enigma - more information but less factual knowledge."²⁷ Examples include descriptions of new treatments with little or no information about their indications, scientific basis, and long-term results; selected series of patients treated with a specific technique, device, or drug without control or comparison groups; and testimonials from patients, physicians, and advertisements that have the appearance of scientific reports. In their eagerness to use the newest treatment, patients and physicians often do not evaluate the quality of the information that supports the use of that treatment. They may not distinguish between reports that have met the standards of critical expert reviewers and those that have not passed this test. Peer review is expensive and time-consuming, but it remains the best method for evaluating and improving the quality of information^19,21,27,67.

In addition to these general trends that affect all medical specialties, orthopaedics faces specific challenges, partially because of the great importance of implants, instruments, and operations in orthopaedic practice. Over the last twenty-five years, orthopaedic resident, fellowship, and graduate-medical-education programs have been placing increasing emphasis on techniques and technology and decreasing emphasis on the science and art of orthopaedics^56,60. Presentations at professional meetings and instructional courses tend to focus on explaining how to perform a procedure or on describing the use of an implant or instrument and the short-term results in selected patients. They devote little time to the pathophysiology and natural history of the injury or disease being treated, indications for the procedure, or objective comparisons of the short and long-term results, complications, and costs associated with other treatments. These educational programs prepare orthopaedists to fix structural and functional abnormalities of the musculoskeletal system; they do not prepare them to provide comprehensive care for patients with diseases and injuries that cause the structural and functional abnormalities.

A comprehensive approach to care is particularly important for patients with chronic diseases, and the aging of a population increases the proportion of patients with lifelong musculoskeletal disorders^16,17,48. As the proportion of the American population over the age of forty-five increases, the pattern of musculoskeletal diseases and injuries requiring orthopaedic treatment is changing, and the rate of this change will continue to increase in the next decades^16-18,48,93. Pain, stiffness, and weakness due to musculoskeletal soft-tissue injuries, muscle weakness, osteoarthritis, and degenerative disease of the spine are among the most common complaints of middle-aged and older people. Development of musculoskeletal complications of diabetes and metastatic disease of the skeleton are closely correlated with aging, and the incidence of hip, vertebral, and some long-bone fractures in patients with decreased bone density is increasing directly with the number of people over the age of fifty. Finding better methods of preventing and treating these disorders that cause pain and loss of mobility for middle-aged and older people is perhaps the greatest clinical and scientific challenge to orthopaedics at the beginning of the twenty-first century.

Orthopaedics is not well prepared to meet this challenge or to contribute to progress in cell and molecular biology and genetics that will improve the care of patients with musculoskeletal diseases and injuries. Orthopaedic basic research has not kept pace with the expansion of the clinical specialty or the development of new technology, nor has the specialty kept pace with other surgical disciplines in developing clinician-scientists and in supporting education in basic and clinical research^15,79,105. Since 1970, there has been a progressive decline in the number of orthopaedic surgeons who are principal investigators for major research projects or who have sustained productive research programs over more than a decade^15,60,79. Since 1980, the number of orthopaedic surgery residents who pursue education in basic research has declined from more than 10 percent to 3 percent^2,3,79, a trend that will further decrease the number of orthopaedic surgeon-scientists. Few orthopaedists have training or experience in rigorous clinical research, and fewer still have served as principal investigators for federally funded clinical investigations¹⁵. Clement Sledge recently commented that orthopaedic clinical research "has been characterized by largely anecdotal reports, often of one surgeon's experience with a procedure" and that these procedure-oriented articles "rely on data collected by the surgeon."¹⁰⁵ Reasons advanced for the current state of orthopaedic clinical research are that it is not possible to perform double-blind, crossover studies of patients treated with operations and that prospective, randomized, clinical trials of operative treatments would be inordinately time-consuming, prohibitively expensive, and, in some instances, unethical. These arguments have merit, yet well designed observational studies with appropriate comparison or control groups that use validated measures to evaluate results can provide information comparable with randomized, controlled trials^5,25,105.

Partially as a result of the limited number of orthopaedic clinician-scientists, the specialty has failed to gain levels of financial support for research from federal agencies and national foundations comparable with the levels achieved by other similar specialties. In the past, much of the funding for orthopaedic research has come from the clinical revenues of orthopaedists and from companies with an interest in developing products with orthopaedic clinical applications¹⁵. Neither of these sources can provide funding comparable with that available from federal institutes and agencies, and, given the current financial pressures on both of these sources, it is unlikely that they will be able to continue to support research at the current levels.

As technology and techniques have grown more important for orthopaedic practice, relationships have developed between the orthopaedic medical community and the industry that produces instruments and implants. Some of these relationships have advanced the specialty; others have had less salutary effects. Augusto Sarmiento recently expressed the opinion that industry has adversely affected the role of orthopaedic surgeons in advancing the science and art of orthopaedics^100-102. He noted that "we have lost control of the destiny of the discipline" and "for a number of years, and in increasing degrees, industry has dictated our practice priorities as well as our educational and research needs to a degree unimaginable a few decades ago."¹⁰¹

Should we be concerned about these trends in orthopaedic practice, research, and education? The lessons from history suggest that we should.

First, progress in medicine results primarily from rigorous original basic and clinical research. Basic research gives us a new and deeper understanding of health, disease, and healing; clinical research shows us how to improve diagnosis and treatment and leads to new directions in basic research. Development and evaluation of new technologies and techniques ultimately depends on basic and clinical research. Claude Bernard (1813-1878)³³, an exceptional experimental physiologist and physician, made a compelling argument for a scientific approach to medical practice in his book An Introduction to the Study of Experimental Medicine (1865)^6,7. He emphasized that, while caring for patients and "empirical medicine" (medical treatments based on experience) are critical components of medical practice, it is new knowledge generated by scientific investigation that conserves health and cures disease⁷.

Second, widely accepted theories and practices, even those advanced by experienced and skilled physicians, may not have a scientific basis. When an articulate, assertive physician promotes a theory or practice, considerable time may elapse before others dare to subject the theory or practice to critical review and independent scientific test. As study of Galen, Rush, and similar physicians shows, talented, well intentioned, influential physicians, who have great faith in themselves and who interpret what they observe to confirm what they believe, can do considerable harm. Good intentions, confidence, and talent cannot compensate for lack of understanding of science.

Third, basic scientific advances may not in themselves immediately or directly improve medical practice. The slow realization of the importance of the observations of Vesalius, Harvey, and Morgagni, and the vocal resistance to the germ theory of wound infections and septicemia, illustrate how new ideas that challenge existing concepts may be ignored or dismissed, even when they are based on sound scientific work. Yet recognition of the potential for new observations to improve medical practice has increased to the extent that some physicians and patients eagerly accept new treatments, even when these treatments have not been proven to be effective or even safe. Integration of scientific advances into practice, and knowing which directions scientific investigation should take, requires understanding of medical practice as well as science.

For this reason, orthopaedics needs to attend to another lesson from history: that is, clinician-scientists have critical roles in improving practice and stimulating advances in basic research. Like Lind, Snow, and Lister, clinically experienced physicians who apply a scientific approach to the diagnosis and treatment of their patients understand the complex relationship between medical practice and science. Because these individuals have the opportunity and the ability to make critical observations, develop hypotheses, and evaluate the clinical value of new scientific results and technologies, they can have a direct and rapid impact on medical practice⁶⁰. Lind's insights and use of a prospective clinical trial led to the effective treatment and prevention of scurvy nearly 200 years before advances in basic science made it possible to explain the cause of the disease and the reason Lind's treatment was effective. Snow's investigations provided effective methods of preventing cholera more than a quarter of a century before Pasteur argued for the germ theory of infectious diseases and more than forty years before Koch and his coworkers isolated the bacterium that causes human cholera. Lister discovered how to prevent infection in open fractures and fatal septicemia more than a decade before Koch identified the organisms responsible for wound infections. In each of these examples, the insights and hypotheses developed and tested by clinician-scientists stimulated basic scientific studies that confirmed the validity of these insights and hypotheses.

Currently, some of those involved in biomedical research promote the view that improvements in medical practice occur only as a result of basic research. The examples of Lind, Snow, and Lister, as well as the advances in orthopaedic practice that have resulted directly from the introduction of new technology and procedures in the nineteenth and twentieth centuries, show that the reverse is also true: clinical observations and improvements in clinical practice, including new technologies, stimulate basic scientific investigations that explain these observations and improvements. Basic scientific investigations, stimulated by clinical observations and improvements, lead to further advances.

At present, clinical research receives little attention compared with basic research, and American federal agencies direct almost all of their biomedical research funding to basic investigations¹⁴. In the United States, federal and foundation funding for observational and long-term clinical investigations, which are the only way to study the natural history and outcomes of treatment for many human developmental and chronic musculoskeletal disorders, is nonexistent. Orthopaedics, and most other medical disciplines, would advance more quickly if the value of clinician-scientists and clinical investigations was more widely recognized and if they received sustained support.

When our successors look back at the first part of the twenty-first century, they will identify new lessons from history. First, new technologies and procedures have the potential to do harm as well as good. What is new is not always better, and, without exception, new technologies and procedures should be carefully evaluated and refined before they are accepted as common practices. Second, skill in applying technology and performing procedures cannot substitute for skill in the art of medicine; patients will always want and need physicians who give them comfort as well as cures. Third, information is not knowledge. A greater volume of information that has not been critically evaluated does not improve understanding. They will also see that the greatest challenge for our discipline - maintaining a commitment to advancing the science and art of orthopaedics - did not come from outside of the specialty but from within.

In the early twenty-first century, the American Orthopaedic Association finds itself facing different social, economic, and political environments and different challenges than it did in the late nineteenth century, yet some things are the same. In the twenty-first century, the American Orthopaedic Association commands great intellectual resources and has exciting opportunities to further develop the specialty. We must make sure that another factor stays the same: our commitment to advancing the specialty. The role of a national Association committed to the enduring purpose of advancing the science and art of orthopaedics is as important now as it was 113 years ago. To accomplish this purpose, we must sharply focus our attention and the resources of this Association on specific goals. We must dedicate ourselves to improving our efforts to recognize, develop, and engage leaders who will advance the science and art of the specialty. Just as the social, political, and economic environments have changed since 1887, the individuals who will lead orthopaedics have changed. They are not only orthopaedists in prominent institutions who practice, teach, and conduct research but individuals who direct clinical teaching programs and the delivery of health-care services; devote themselves to basic, clinical, and health-policy research or technology development; participate in activities that shape local and national health-care economics; and lead local, state, regional, and national professional associations. In the past, the American Orthopaedic Association honored the established leaders of our specialty; it has been less successful in identifying those with the potential to become leaders, helping them to develop their skills, and engaging them in efforts to advance the specialty. We must make this a priority. More than ever, the Association must commit itself to identifying and defining the rapidly changing challenges that confront the profession and to devising strategies to meet them. I have mentioned a few of the challenges that face us, including the effects of new technology and techniques on the science and art of orthopaedics, the quality of information available to physicians and patients, the aging of our population, and trends in orthopaedic education and research. This Association has a long and distinguished history of improving the specialty: examples include its contributions to the development of The Journal of Bone and Joint Surgery, the American Academy of Orthopaedic Surgeons, the American Board of Orthopaedic Surgery, the Residency Review Committee for Orthopaedic Surgery, the Orthopaedic Research and Education Foundation, the American-British-Canadian Traveling Fellowship, and the International Center for Orthopaedic Education^14,123. The pace of change is accelerating, and we must match that pace. Over the last three years, we have been revising the structure and function of our annual meeting to identify and define challenges facing our specialty. We must now take this to the next step of reorganizing this Association to increase our flexibility and to improve our ability to devise strategies to meet these challenges.

Few physicians have abilities comparable with those of Galen and Rush, but we have the advantage of being able to learn from them. It is naive to think that the most important scientific advances in medicine have already occurred and that there is little room for improvement in medical practice. Most of the theories, and more than a few of the facts, that we currently accept will be proven wrong or incomplete; most of our current practices will be regarded as amusing if not barbaric by future generations. The implants, instruments, and techniques that we depend on to achieve our current success in treating musculoskeletal injuries and diseases will become historical curiosities. We do not have the foresight to know how soon, or even how, these changes will unfold, but if we understand the lessons of history and value the heritage of our Association, and if we commit ourselves to continuing to advance the science and art of orthopaedics, those who follow us will have every reason to recognize our wisdom as we recognize this rare and valuable quality in the founders of the American Orthopaedic Association.

Note: Much of the information in this Address came from rare opportunities, over the last twenty-five years, to use the collection of many of the most important works in medicine housed in the John Martin Rare Book Room of the Hardin Library for the Health Sciences at the University of Iowa. Richard Eimas, curator of the John Martin Rare Book Room, cheerfully and enthusiastically makes these priceless works available to those who wish to learn from them. Heirs of Hippocrates: The Development of Medicine in a Catalogue of Historic Books (1990)³³, an annotated list of more than 2300 of these books compiled and edited by Mr. Eimas, is an invaluable resource for those who have an interest in the history of medicine.

References

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