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Graft Fixation The femoral end of the graft is fixed with the appropriate sized Bio- Screw discount dramamine 50 mg overnight delivery treatment 4 stomach virus, usually the same size as the tunnel buy dramamine american express treatment by lanshin. This is inserted through the low anteromedial portal with the knee flexed at 110° (Fig buy 50mg dramamine with amex symptoms rsv. The low anteromedial portal gives a straight shot at the femoral tunnel with the knee flexed to 110° (Fig. To avoid screw diver- gence, it is important to insert the screw in the same angle that the tunnel was drilled. If the screw is divergent more than 15° from the tunnel, there is a significant loss of pullout strength. Insertion of the Tibial Screw The BioScrew guide wire is inserted into the anterior aspect of the tibial tunnel, on top of the graft (Fig. The screw (one size larger than the tunnel) is inserted up the tibial tunnel to the internal aperture of the tunnel. The low anteromedial portal gives a straight shot at the femoral tunnel with the knee flexed to 110°. The screw tip can just be visualized at the internal tibial tunnel opening. This prevents pushing the graft up in front of the screw, thereby resulting in a loose graft. The knee flexion angle should be 15° when the graft is tensioned and the screw inserted. The tibial screw compresses the graft against the tunnel wall, but does not push the graft up the tunnel (Fig. The leader sutures from the ends of the tendons are tied over a periosteal button to augment the tibial screw fixation (Fig. Graft Inspection: Look and Hook The graft is inspected as the knee is moved through a range of motion, looking for anterior impingement and lateral wall abrasion (Fig. KT-S Measurements Before the sutures are cut, the KT-S is used to pull a manual maximum number. Generally the manual maximum a-p translation will be equal or 1 to 2mm less than the opposite side (Fig. One common problem is when the tibial screw pushes the graft up the tunnel. The surgeon must maintain firm distal traction on the leader sutures to prevent the screw from grafting up. The sutures are cut off when the surgeon is satisfied that the knee is stable and the fixation is secure. Postoperative Regimen: Extension Splint, Cryo-Cuff, and Continuous Passive Motion Machine After the wounds are closed, the author applies a Tegaderm (Sklar Instruments, West Chester, PA) dressing, a compressive stocking and the Cryo-Cuff (Aircast, Summit, NJ) (Fig. This is a sleeve that contains cool water and lowers the temperature of the knee, thereby reducing the pain. The patient is transferred to a continuous passive motion (CPM) machine and to the recovery room (Fig. When the patient gets up, he/she use the extension splint and crutches (Fig. The patient goes home several hours postoperatively with the CPM, the Cryo-Cuff, the extension splint, and crutches. The Tegaderm dressing is removed, and the Cryo-Cuff applied directly to the skin. The wounds are cleansed for the next few days with 3% hydrogen peroxide. The author has a proto- col that can be mailed to remote physiotherapy locations to ensure that the early extension routine is started. The physician should try to get KT- 1000 measurements at 6 weeks and at 3, 6, and 12 months. If there is any loss of extension, this is addressed early by vigorous aggressive reha- bilitation. If there is still loss at three months, surgical debridement is suggested. Crutches and an extension splint are used for the first few days postoperative when ambulating. Some of the prepration for the procedures described in this chapter is the same as for the procedures discussed in Chapter 6. EUA, KT-1000 Measurements, Joint Injection, and Femoral Nerve Block First confirm which is the correct side. The low profile leg holder is high on the thigh to allow the graft passing wire to penetrate the anterolat- eral thigh. Preemptive Pain Management In a recently published paper, we documented the benefit of the pre- emptive use of the femoral nerve block, intravenous injections, and local knee injections. The knee joint and the incisions are injected with 20cc of bupivacaine 0. The patient has taken 50mg of Vioxx orally one hour before, and the anesthetist gives 1gm Ancef intravenously. The author uses a Linvatec (Largo, FL) fluid pump that works in coordination with the Apex driver system for the shaver and burrs to coordinate the flow level. Diagnostic, Operative Arthroscopy The diagnostic arthroscopy should be done before the graft harvest if there is any doubt about the diagnosis of partial versus complete ACL tear. The video on the CD illustrates this process, as well as the inside view of the “W,” as dis- cussed in Chapter 2. Diagnostic, Operative Arthroscopy 123 The ACL must be carefully examined. The conventional wisdom is that a tear more than 50% should be reconstructed. But a partial tear, one of less than 50%, may have to be reconstructed with a patellar tendon. If the tear is minimal, with a negative pivot shift, this patient should be treated conservatively. A complete diagnostic arthroscopy should be performed before any meniscal work is done. This ensures that the physician will not forget the lateral compartment if a lot of time is required to perform menis- cal repair on the medial side. In young patients, every attempt should be made to repair the meniscus rather than resect it. The long-term results of reconstruc- tion are more related to the state of the meniscus than to the stability. A flap tear of the meniscus will cause pain, swelling, catching and giving way (Fig. The flap is easily resected with a basket forceps and a motorized shaver. In young patients, the surgeon should make every attempt to repair the meniscus rather than resect it. The long-term results of reconstruction are more related to the state of the meniscus than to the stability.

The greater the height of this energy barrier purchase dramamine online pills treatment 4 hiv, the slower the rate of reaction purchase discount dramamine online symptoms shingles. Enzymes (like other catalysts) reduce the energy required to pass over this barrier buy dramamine online medicine misuse definition, thereby increasing reaction rate. The structure of the reactant at the top of the barrier is energetically unstable, and is known as the ‘transition state’. The energy required to pass over the barrier is the so-called ‘activation energy’ – the barrier is surmounted by thermal excitation of the substrate. This classical over-the-barrier treat- ment – known as transition state theory – has been used to picture enzyme- catalysed reactions over the past 50 years. However, recent developments indicate that this ‘textbook’ illustration is fundamentally flawed (at least in some circumstances). The transition state theory considers only the particle-like properties of matter. However, matter (especially those particles with smaller mass) can also be considered as having wave-like properties – this is known as the wave–particle duality of matter. For enzyme-catalysed reactions, an alternative picture to transition state theory has emerged from considering the wave–particle duality of matter. Large ‘pieces’ of matter, like tennis balls, exhibit pre- dominantly particle-like properties. Very small ‘pieces’ of matter, like photons (of which light is composed), whilst showing some particle-like properties exhibit mainly wave-like properties. One important feature of the wave-like properties of matter is that it can pass through regions that would be inaccessible if it were treated as a particle, i. This can be visualised, for example, by considering the Enzymology takes a quantum leap forward 23 Figure 2. A popular approach to modelling catalysis has been to visualise an energy barrier that must be surmounted to proceed from reactants to products. For the reaction to proceed, reactants (A–H B) must pass over the potential energy barrier to the product (A H–B) side via the so-called transition state (denoted by [A. The greater the height of this energy barrier, the slower the rate of reaction. Enzymes (like other catalysts) reduce the energy required to pass over this barrier, thereby increasing reaction rate. This classical over-the-barrier treatment – known as ‘transition state theory’ – has been used to picture enzyme-catalysed reactions over the past 50 years. However, recent developments indicate that this representation is, at least in some circumstances, fundamentally flawed and should instead be considered in terms of quantum tunnelling through the barrier. Thus, the pathway from reactants to products in an enzyme-catalysed reac- tion may not need to pass over the barrier, as in transition state theory with particle-like behaviour, but could pass through the barrier. As the analogy suggests, this can lower significantly the energy required to proceed from reactants to 24 M. Illustration of the wave-like property of matter by analogy with the vibrations on a violin string. Although there is a node (a position where the string is stationary) in the centre of the string, the vibration is transmitted through this node – this is analogous to passing through a region of zero probability as in quantum tunnelling. Thus, quantum tunnelling may play an important role in driving enzyme-catalysed reactions, especially for the transfer of small nuclei such as hydrogen. Indeed, quantum tunnelling is the established mechanism for enzyme- mediated transfer of the much smaller electron. Proteins are electrical insulators; nevertheless, electrons can travel large distances on the atomic scale (up to around 3 10 9 m) through them. This apparent paradox – of an electron passing through an electrical insulator – can be understood in terms of the wave-like properties of the electron. Thus, the electron can pass via quantum tunnelling through regions from which it would be excluded by its particle-like nature. In contrast to electron transfer via quantum tunnelling, evidence for hydrogen tunnelling in enzyme molecules is extremely limited. This arises conceptually because the mass of the hydrogen is approximately 1840 times greater than that of the electron. The probability of tunnelling decreases with increasing mass, which reduces significantly the probabil- ity of hydrogen versus electron tunnelling. Nevertheless, for those enzyme-catalysed reactions with a large activation energy – requiring a Enzymology takes a quantum leap forward 25 Figure 2. Tunnelling of a wave with kinetic energy E through a rectangular potential energy barrier, height V. The narrower the barrier, the smaller the mass of the particle and the smaller the difference between V and E, the greater the tunnelling probability. If the amplitude of the wave has not reached zero at the far side of the barrier, it will stop decaying and resume the oscillation it had on entering the barrier (but with smaller amplitude). Until recently, quantum tunnelling was thought to be significant only at very low (so-called ‘cryogenic’) temperatures. However, deviations from classical transition state theory behaviour have been seen recently, implying that hydrogen tunnelling may be significant at physiological temperatures. These results have, in the main, been modelled as hybrid ‘over’ (transition state theory) and ‘through’ (quantum tunnelling) barrier transfer reactions, i. Our own studies have revealed for the first time that quantum tunnel- ling can be the sole means by which an enzyme catalyses hydrogen trans- fer during C–H (carbon–hydrogen) bond breakage. The reaction pathway does not pass up the energy barrier prior to tunnelling – as with the quantum correction models of transition state theory – but tunnels through the barrier from the starting (or so-called ‘ground’) state. SCRUTTON Paradoxically, reaction rates (as with transition state theory) are still highly dependent on temperature. This observation is inconsistent with a pure ‘ground state’ tunnelling reaction, since the probability of tunnelling (and thus rate of reaction) is a function of barrier width, but is independent of temperature. This apparent paradox is resolved by taking into account the temperature-dependent natural breathing of enzyme molecules which dis- torts the structure of the protein to produce the geometry required for nuclear tunnelling (achieved by reducing the width of the barrier between reactants and products, thus increasing the probability of tunnelling). In this dynamic view of enzyme catalysis, it is thus the width – and not the height (as with transition state theory) – of the energy barrier that controls the reaction rate. The important criterion thus becomes the ability of the enzyme to distort and thereby reduce barrier width, and not stabilisation of the tran- sition state with concomitant reduction in barrier height (activation energy). We now describe theoretical approaches to enzymatic catalysis that have led to the development of dynamic barrier (width) tunnelling the- ories for hydrogen transfer. Indeed, enzymatic hydrogen tunnelling can be treated conceptually in a similar way to the well-established quantum the- ories for electron transfer in proteins. The basic premise of transition state theory is that the reaction converting reactants (e. A B–H) is treated as a two-step reaction over a static potential energy barrier (Figure 2. B]‡ is the transi- tion state, which can interconvert reversibly with the reactants (A–H B).

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To do this buy genuine dramamine medicine x ed, scientists attach luciferase to Bioaugmentation involves the deliberate addition of strains antibodies—molecules produced by the immune system that or species of microorganisms that are effective at treating bind to specific molecules called antigens order dramamine overnight symptoms hepatitis c. The antibody- particular toxic chemicals buy genuine dramamine on line treatment breast cancer, but are not indigenous to or abun- luciferase complex is added to a sample where it binds to the dant in the treatment area. Following washing to remove ditions may be altered in order to enhance the actions of such unbound antibodies, the molecule of interest can be quantified organisms that are already present in the environment. Methods used to quantify particular compounds in biological process is known as biostimulation and usually involves fer- samples such as the ones described here are called assays. Biostimulation focuses on In recent studies, luciferase has been used to study viral rapidly increasing the abundance of naturally occurring and bacterial infections in living animals and to detect bacte- microorganisms capable of dealing with certain types of rial contaminants in food. Once Luciferase is often used as a “reporter gene” to study spilled, petroleum and its various refined products can be per- how individual genes are activated to produce protein or sistent environmental contaminants. Most genes are turned on chemicals can also be metabolized by certain microorganisms, and off by DNA located in front of the part of the gene that whose processes transform the toxins into more simple com- codes for protein. A pounds, such as carbon dioxide, water, and other inorganic specific gene promoter can be attached to the DNA that codes chemicals. In the past, concentrates of bacteria that are highly for firefly luciferase and introduced into an organism. The efficient at metabolizing hydrocarbons have been “seeded” activity of the gene promoter can then be studied by measur- into spill areas in an attempt to increase the rate of degradation ing the bioluminescence produced in the luciferase reaction. Although this technique has occasionally Thus, the luciferase gene can be used to “report” the activity been effective, it commonly fails because the large concentra- of a promoter for another gene. Consequently, seeding of microorgan- 73 Biotechnology WORLD OF MICROBIOLOGY AND IMMUNOLOGY An oil spill. Most commonly the rate is limited by the availabil- offer a cheaper, less environmentally damaging alternative to ity of oxygen or of certain nutrients such as nitrate and traditional clean-up technologies. Therefore the microbial breakdown of spilled hydrocarbons on land can be greatly enhanced by aeration and See also Economic uses and benefits of microorganisms; fertilization of the soil. Microbial genetics; Waste water treatment; Water purification; Metals are common pollutants of water and land Water quality because they are emitted by many industrial, agricultural, and domestic sources. In some situations organisms can be utilized to concentrate metals that are dispersed in the environment. BIOTECHNOLOGY Biotechnology For example, metal-polluted waste waters can be treated by encouraging the vigorous growth of certain types of vascular The word biotechnology was coined in 1919 by Karl Ereky to plants. This bioremediation system, also known as phytore- apply to the interaction of biology with human technology. Accurately, biotechnol- then be harvested to remove the metals from the system. Decreasing the aqueous concentrations of toxic change in the last half century. Modern biotechnology is 74 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Bioterrorism greatly based on recent developments in molecular biology, attempt at producing live animals by embryo cloning was especially those in genetic engineering. Organisms from bac- reported by a research group in Scotland on March 6, 1997. Also, new methods of disease gene ponent of biotechnology, it is not alone. Biotechnology has isolation, analysis, and detection, as well as gene therapy, been used by humans for thousands of years. First, scientists decide the changes to be occur because of the process of fermentation. It is desirable in some seventeenth century, bacteria were used to remove copper cases to alter a human DNA molecule to correct errors that from its ores. Around 1910, scientists found that bacteria result in a disease such as diabetes. In other cases, researchers could be used to decompose organic matter in sewage. A might add instructions to a DNA molecule that it does not method that uses microorganisms to produce glycerol synthet- normally carry: instructions for the manufacture of a chemi- ically proved very important in the World War I since glycerol cal such as insulin, for example, in the DNA of bacteria that is essential to the manufacture of explosives. Scientists also mod- See also Fermentation; Immune complex test; Immunoelec- ify existing DNA to correct errors or add new information. Finally, scientists nologic therapies; Immunological analysis techniques; look for a way to put the recombinant DNA molecule into the Immunosuppressant drugs; In vitro and in vivo research organisms in which it is to function. Once inside the organ- ism, the new DNA molecule give correct instructions to cells in humans to correct genetic disorders, in bacteria (resulting in the production of new chemicals), or in other types of cells BBioterrorismIOTERRORISM for other purposes. Bioterrorism is the use of a biological weapon against a civil- Genetic engineering has resulted in a number of impres- ian population. Dozens of products that were once include the undermining of morale, creating chaos, or achiev- available only from natural sources and in limited amounts are ing political goals. Biological weapons use microorganisms now manufactured in abundance by genetically engineered and toxins to produce disease and death in humans, livestock, microorganisms at relatively low cost. In addition, the first trials with the alteration of used to achieve similar destructive goals, but unlike chemical human DNA to cure a genetic disorder began in 1991. They are easy to trans- on a daily basis to replicate various genetic materials such as port and resist detection by standard security systems. The process of molecular cloning general, chemical weapons act acutely, causing illness in min- involves isolating a DNA sequence of interest and obtaining utes to hours at the scene of release. For example, the release multiple copies of it in an organism that is capable of growth of sarin gas by the religious sect Aum Shinrikyo in the Tokyo over extended periods. Large quantities of the DNA molecule subway in 1995 killed 12 and hospitalized 5,000 people. In can then be isolated in pure form for detailed molecular analy- contrast, the damage from biological weapons may not sis. The ability to generate virtually endless copies (clones) of become evident until weeks after an attack. If the pathogenic a particular sequence is the basis of recombinant DNA tech- (disease-causing) agent is transmissible, a bioterrorist attack nology and its application to human and medical genetics. Positional cloning is a rela- Bioterrorism can also be enigmatic, destructive, and tively new approach to finding genes. A particular DNA costly even when targeted at a relatively few number of indi- marker is linked to the disease if, in general, family members viduals. Starting in September 2001, bioterrorist attacks with with certain nucleotides at the marker always have the disease, anthrax-causing bacteria distributed through the mail targeted and family members with other nucleotides at the marker do only a few U. Once a suspected linkage result is con- and seemingly random private citizens. As of June 2002, firmed, researchers can then test other markers known to map these attacks remain unsolved.

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Following this period he began his career in orthopedic surgery and was associated for several years with the late H dramamine 50mg otc medicinenetcom medications. Later dramamine 50mg for sale 7 medications emts can give, as Associate Professor of Surgery purchase dramamine online pills medications not to take before surgery, he was responsi- ble for orthopedic teaching in the University of Manitoba. His remarkable lectures on applied anatomy made a distinct contribution in bridging the gap between the basic sciences and the clini- cal field. His hospital appointments included: Orthope- dic Surgeon, Winnipeg General Hospital; Direc- tor of the Department of Orthopedic Surgery, Deer Lodge Hospital, Department of Veterans’ Affairs; and Consultant to the Sanatorium Board of Manitoba. During World War I, Gibson was active as a surgeon in the Royal Army Medical Corps in India and Egypt, and World War II found him again in service as orthopedic surgeon in charge of Hermeirs Red Cross Hospital in Scotland. During the war years, from 1942 to 1945, he was Surgeon-in-Chief of the Alfred I. Bruce Gill was always interested in the care of the crippled child; he held state clinics in central Pennsylvania during the whole of his active pro- fessional career. He was Chairman of a Joint Committee on Crippled Children of the American Academy of Orthopedic Surgeons, the American Orthopedic Association, and the American Medi- cal Association from 1942 until 1952. From 1942 to 1950 this committee was called the Com- mittee for the Study of the Public Care of the Arthur Bruce GILL Indigent Orthopedic Cripple and then, from 1951 to 1952, the Committee on the Public Care of 1876–1965 Crippled Children. He was a member of the Advi- sory Committee on Crippled Children to the Arthur Bruce Gill was born of Scotch ancestry on Federal Children’s Bureau for many years. He December 12, 1876, in western Pennsylvania, was at one time Chairman of the Committee on at Greensburg. He received his BA degree in Legislation and Medical Economics of the Amer- 1896 at Muskingum College in Ohio, from which ican Academy of Orthopedic Surgeons and of the college, 42 years later, he received an honorary Committee on the Treatment of Infantile Paraly- Doctor of Science degree. Bruce was always interested in education and He interned at the Presbyterian hospital in research: he was Chairman of the American Philadelphia, with which institution he was asso- Orthopedic Association’s Committee on Under- ciated for 47 years, for many years as Chief of the graduate Education for many years. Ashurst, of the Episcopal Hospital in posium on undergraduate education was held at Philadelphia, first talked to Bruce about going the Joint Meeting of the British, Canadian, and into orthopedics, but it was Dr. Davis as the third Professor of honorary member of the Ambrose Paré Society of Orthopedic Surgery at the University of Pennsyl- France, of the Pennsylvania Orthopedic Society, vania, which position he held until 1942. He was and of the Orange County (Florida) Orthopedic on the staff of the Philadelphia Orthopedic Hos- Society. He was a member of the Philadelphia pital from 1908 until it merged with the Univer- Academy of Surgery, the oldest surgical society sity of Pennsylvania in 1941. In 1911, he became in the United States, the Philadelphia Orthopedic an assistant surgeon at the Widener Memorial Club, of which he was a president, an active Industrial School for Crippled Children in fellow of the College of Physicians of Philadel- Philadelphia, which had been founded by Dr. Sixteen of these publi- 114 Who’s Who in Orthopedics cations are related to congenital dislocation of the spirit of unrest in the specialty and a tendency for hip; six to coxa plana and other conditions of the the rapid adoption of newer methods that prom- hip; six to the hand; four to cerebral palsy; four ised much but had not yet stood the test of time. He results of Stoeffel neurectomies for spastic paral- proposed several significant questions, such as ysis (1918). One of his best publications, “The whether extension of government control would Kenny Concepts and Treatment of Infantile Paral- improve medical services, whether this improve- ysis,” written in 1944, was an answer to many ment could be accomplished by other agencies, of Sister Kenny’s misleading statements and whether it is consistent with our form of govern- unwarranted conclusions on the treatment of ment, and whether this is conducive or detrimen- poliomyelitis. Bruce was always an enthusiastic golfer and Bruce was extremely well known for his work bridge player. He was a charter member and pres- on congenital dislocation of the hip, and was con- ident of the Doctors’ Golf Club of Philadelphia sidered by many to be one of the foremost author- and also a charter member and president of the ities on this subject in the United States. Bruce was one of the believed firmly that every dislocated hip that had organizers of the Golfing Players of the American a shallow acetabulum after reduction should have Orthopedic Association, which for many years a shelf operation—not only to give stability was responsible for the Association’s golf tourna- during the growing period, but also to decrease ments. In addition to golf and bridge, his hobbies the possibility of osteoarthritis in later life. He were swimming, chess, classical music (which he also advocated a shelf procedure for the large often played on the piano), the writing of poetry, femoral head, not well seated in the acetabulum, and in his later years, lawn bowling. For the par- In 1936, Bruce married Mabel Halsey alytic hip dislocation, he frequently advocated Woodrow, a wonderful and talented person, who fusion. In 1953, he tributions to surgical procedures in orthopedics, retired from active practice in Philadelphia, and he fully appreciated the nonoperative aspects of in 1955 went to Mt. He wrote that our “specialty was in a small but most comfortable and attractive founded in the spirit of conservatism. After he Orthopedic Surgeons in 1938, he spoke of using went to Florida, most of his summers were spent a knife only as a last resort and asked the ques- in the North Carolina Mountains outside of tion, “Are too many operations performed in the Asheville. A great orthopedic surgeon had talent and criterion of the great surgeon, he said passed on. He spoke of there being a 115 Who’s Who in Orthopedics regional orthopedics with its central orthopedic hospital, satellite clinics and unified staff. During the First World War he was prevented from serving overseas by the effects of a serious chest injury, the result of a motor cycle accident. However, he was placed in charge of the ortho- pedic division of a military hospital in Oxford, which rapidly developed until there were some 400 beds under his care. At this time, the Wing- field Convalescent Home was an old-fashioned institution in the neighboring village of Heading- ton; thanks to Robert Jones, Girdlestone was later able to take charge of some army huts, which were erected in the grounds of this convalescent home. In 1919 the Wingfield Hospital, to give it its new name, came under the Ministry of Pensions, but provision was made for crippled children to be treated in one of its wards. In 1922, the whole hospital was transferred by the Ministry Gathorne Robert to the Wingfield Committee and Girdlestone was GIRDLESTONE thus provided with the instrument which, until the end of his life, he wielded with such astonishing 1881–1950 success. Immediately after the war, Robert Jones and his Gathorne Robert Girdlestone was the son of staunch disciple launched their campaign for the the Rev. Girdlestone, Honorary Canon of establishment of regional orthopedic services, and Christ Church, Oxford. He was born in 1881 and in 1920 they organized the Central Council for the was educated at Charterhouse, at New College, Care of Cripples, of which Girdlestone was for Oxford, and at St. Thomas’ he settled in own experience in the three counties of Oxford- Shropshire at Oswestry and there came under the shire, Berkshire and Buckinghamshire was such influence of Sir Robert Jones, an influence that that he was able to write with authority on how a was destined to shape the whole of his career. The orthopedic hospital was to be not found it expedient to lay hands on the few remain- merely a place to which patients came to seek ing copies of Girlestone’s monograph and send relief, but rather a center from which workers them overseas with the advice that no better went out into neighboring towns, villages and guidance was obtainable anywhere. Girdlestone’s hamlets to discover those who were too far away, appointment to the staff of most of the general poor, ignorant or apathetic, to seak treatment for hospitals in the region—the Radcliffe Infirmary themselves or for their afflicted children. Diag- being the most important—and his establishment nosis and treatment of established complaints was of clinics in smaller centers, enabled him to build the first objective, but the ultimate aim was the up so complete a service that the benefits of ortho- detection and arrest of crippling conditions before pedic surgery were available to almost every- deformity or other serious disability had had time body in the region. It was some years before Girdlestone Wingfield staff, and permanent copies of all case was able to apply what he had learned from these notes were filed at the hospital. It was the two great pioneers; but he had a profound con- Oswestry scheme all over again but with every- viction of his mission, and when the time came one concerned working full time and under one he rose rapidly to a unique position in British head. Scott and a number 116 Who’s Who in Orthopedics of other able men who worked with him for the new National Health Service; and in 1949 he longer or shorter periods. In addition to this strong achieved the integration of all the activities central administration, there was also a very clear coming under the heading of orthopedics in the direction of therapeutic policy, and the team Oxford region in what was called the Nuffield worked on well-defined lines, which became Orthopedic Centre, which was endowed by Lord more widely known as a result of the many papers Nuffield with a sum of £50,000. This was the cor- that Girdlestone contributed to the literature of nerstone of the edifice to which he had dedicated orthopedics.