Robert William Smith: his life and his contributions to medicine

Robert William Smith is best known for the eponymous Smith's fracture. He also made other important contributions to medicine and medical education, publishing on topics ranging from arthritis to neuroma. He had a great interest in pathology and helped found the Pathological Society of Dublin. At the time of his death, he was the vice president of the Royal College of Surgeons in Ireland. His contributions to the understanding of various pathologic conditions make him an important figure in medicine and in hand surgery.     

The contributions of infection control to a century of surgical progress.

Although many surgical procedures were well-developed in principle before 1867, their application for the treatment of human disease was limited because of a mortality rate from postoperative infection alone of about 50%. It was the eventual acceptance of Lister's work and the development of the aseptic-antiseptic ritual that allowed operative therapy to be successful and made modern surgery possible. The background leading to the development of aseptic-antiseptic rituals is discussed.     

Dynamic contributions to superior shoulder stability.

It has been suggested that superior decentralization of the humeral head is a mechanical factor in the etiology of degenerative rotator cuff tears. This superior decentralization may be caused by muscular imbalance. The objective of this study was to investigate the contribution of individual shoulder muscles to superior stability of the glenohumeral joint. In 10 fresh frozen cadaver shoulders the tendons of the rotator cuff, teres major, latissimus, pectoralis major, deltoid and biceps were prepared. The shoulders were tested in a shoulder-loading device in 0 degrees, 30degrees, 60 degrees and 90 degrees of glenohumeral abduction. A constant superior force of 20 N was applied to the humerus. Tensile loads were applied sequentially to the tendons in proportion to their cross-sectional areas and translations of the humeral head relative to the glenoid were recorded with a 3Space Fastrak system. Depression of the humeral head was most effectively achieved by the latissimus (5.6 +/- 2.2 mm) and the teres major (5.1 +/- 2.0 mm). Further studies should elucidate their possible in vivo role in the frontal plane force couple to counter balance the deltoid. The infraspinatus (4.6 +/- 2.0 mm) and subscapularis (4.7 +/- 1.9 mm) showed similar effects while the supraspinatus (2.0 +/- 1.4 mm) was less effective in depression. Therefore, the infraspinatus and subscapularis should be surgically repaired whenever possible. The supraspinatus may be of less importance for superior stability than previously assumed.     

The contributions of microvascular surgery to emergency hand surgery

Microvascular surgery has revolutionized the field of emergency hand surgery in the areas of replantation and microvascular transplantation. Amputated parts from as small as a distal phalanx to the entire extremity can now be successfully replanted and unreplanted, or missing parts can be restored and reconstructed with immediate microvascular transplants (MVTs). MVTs can be used to cover exposed vital structures and replace missing complex parts. Part or whole digits can be reconstructed, with up to 4 toe transplants. Joints, bones, and muscles can be replaced with osteocutaneous and neuromyovascular transplants. Using the same approach for multiple replants, teams of 4 to 6 surgeons operating simultaneously and sequentially around the clock can accomplish multiple microvascular transplants in the acute setting. The classical principle of hand surgery, preserve length and function, can now be modified to restore length and function.

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Resumen La cirugí'a microvascular ha revolucionado el campo de la cirugía de la mano en las áreas de la reimplantación y del trasplante microvascular. Partes amputadas tan pequeñas como la falange distal o tan grandes como la totalidad de la extremidad pueden ser exitosamente reimplantadas, y aquellas partes no reimplantadas o perdidas pueden ser restauradas y reconstruidas con trasplantes microvasculares inmediatos (TMI). Los TMI pueden ser utilizados para cubrir estructuras vitales y para reemplazar partes complejas. La totalidad o parte de los dedos de la mano pueden ser reconstruidas con trasplantes de artejos, hasta cuatro de ellos. Se pueden reemplazar articulaciones, huesos y músculos con trasplantes osteocutáneos y neuromiovasculares. Utilizando el mismo aproche para las reimplantaciones múltiples, equipos de cuatro a seis cirujanos operando en forma simultánea y secuencial durante las 24 horas, pueden lograr la realización de múltiples trasplantes microvasculares en situaciones de emergencia. El principio clásico en cirugía de la mano de conservar longitud y función puede ahora ser modificado a restaurar longitud y función.

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Résumé La microchirurgie a radicalement transformé le domaine de la chirurgie de la main en urgence en raison des progrès de réimplantation et de transplantation par les procédés microchir-urgicaux, Des structures amputées aussi petites que la phalange distale d'un doigt à l'extrémité entière peuvent être réimplantées ou prélevées avec succès et des structures absentes ou détruites peuvent être restaurées ou reconstruites par des transplatations microvasculaires immédiates (TMI). Les TMI peuvent être utilisées pour recouvrir des structures vitales exposées ou pour remplacer des parties anatomiques complexes détruites par traumatisme ou processus pathologique. On peut reconstruire un doigt, en partie ou en totalité, à partir de transferts d'orteil, et ce, jusqu'à quatre doigts. Les articulations, de l'os, et des muscles peuvent être remplacés par des transplants ostéocutanés ou neuromyovasculaires. Par la même technique, pour des réimplantations multiples, des équipes de quatre à six chirurgiens, opérant de façon séquentielle mais simultanément, sont capables de réaliser plusieurs transplantations microvasculaires en urgence, 24 heures sur 24 heures. Le principe classique de chirurgie de la main conserver un maximum de longueur et la fonction devient de nos jours, restaurer la longueur et la fonction.

     

Christiaan Barnard and his contributions to heart transplantation.

Christiaan (Chris) Barnard was born in South Africa in 1922 and qualified in medicine at the University of Cape Town in 1946. Following surgical training in Cape Town and Minneapolis, Barnard established a successful open heart surgery program at Groote Schuur Hospital. In 1967, he led the team that performed the world's first human-to-human heart transplant. Although his first patient survived only 18 days, 4 of his first 10 patients survived for more than 1 year, 2 living for 13 and 23 years, respectively. With his junior colleague, Jaques Losman, Barnard then developed the operation of heterotopic heart transplantation. In 1981, his group was the first to successfully transport donor hearts using a hypothermic perfusion storage device. Several studies on the hemodynamic and metabolic sequelae of brain death were carried out in his department. Barnard retired from the University of Cape Town in 1983 at the age of 61. Now in his 79th year, he continues to pursue his interest in writing for the public. In the words of one of his former colleagues, he is a "surgical visionary and simply the most unforgettable character of the second generation of cardiac surgeons."