William Darrach, MD: His Life and His Contribution to Hand Surgery

William Darrach, MD: His Life and His Contribution to Hand Surgery

HISTORY OF HAND SURGERY William Darrach, MD: His Life and His Contribution to Hand Surgery Frank H. Lau, BS, Kevin C. Chung, MD From the University of...

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HISTORY OF HAND SURGERY William Darrach, MD: His Life and His Contribution to Hand Surgery Frank H. Lau, BS, Kevin C. Chung, MD From the University of Michigan Medical School, Ann Arbor, MI; and the Section of Plastic Surgery, Department of Surgery, the University of Michigan Health System, Ann Arbor, MI.

William Darrach popularized subperiosteal resection of the distal ulna for distal radioulnar joint dysfunction, a procedure also known as the Darrach procedure. He was also a major contributor to academic surgery and medical education, publishing at least 70 articles, most on the treatment of fractures. He was influential in organized medicine and served as Dean of the Columbia College of Physicians and Surgeons, Governor and Regent of the American College of Surgeons, President of the American Surgical Association, and President of the Association of the American Medical Colleges. His contributions to education, hand surgery, and fracture treatment methodology make him an important figure in medicine. (J Hand Surg 2006;31A:1056.e1–1056.e7. Copyright © 2006 by the American Society for Surgery of the Hand.) Key words: William Darrach, history, Darrach procedure, radioulnar joint dysfunction.

ubperiosteal resection of the distal ulna, or the Darrach procedure, is often used to treat distal radioulnar joint (DRUJ) diseases. Popularized by Dr. William Darrach in 1912,1 this procedure remains accepted and widely used. A PubMed search for the term “Darrach procedure” returned 53 results. In contrast little has been written about Darrach himself: a PubMed search for the terms “William Darrach” and “Darrach W” returned 1 result and the Library of Congress lists no pertinent biographies. This paucity of information is surprising because Darrach was a distinguished surgeon who contributed to academic medicine in many ways. He served as Dean of the Columbia College of Physicians and Surgeons (P&S), Governor and Regent of the American College of Surgeons, President of the American Surgical Association, and President of the Association of the American Medical Colleges. This article examines the history of Darrach’s most prominent contribution to hand surgery, the Darrach procedure, and sheds light on this notable physician’s life.

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The Darrach Procedure In the early 1900s the basic concept for the treatment of fractures still was under development. While surgeons debated the risks and benefits of open versus 1056.e1

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closed reduction the broader medical community often failed to reduce fractures in the acute setting, preferring instead to wait until the fractured limb was less edematous.3,4 These late attempts to reduce radius fractures often failed and it was these cases that led Darrach to perform subperiosteal distal ulna resection. The first such patient whom Darrach presented to the surgical community was a 20-year-old man who sustained a distal radius fracture as a result of an automobile crank-handle “back kick.”5 The patient was initially seen by a physician who unsuccessfully attempted closed reduction of the fracture. The unreduced state was confirmed by x-ray but nevertheless the arm was splinted for 5 weeks. At the end of 5 weeks the wrist and finger ranges of motion were minimal and did not improve with 3 weeks of massage treatment. Eight weeks after the injury the patient was referred to Darrach. Darrach’s physical examination was as follows: “When the patient was seen by Dr. Darrach there was a firm, hard swelling beneath the flexor tendons, just above the palmar crease, apparently the head of the ulna. The forearm was held in the position of 45 degrees of supination; there was not more than 10 degrees of flexion and extension at the wrist, and motion at the fingers was practically nil.”5

Lau and Chung / William Darrach

X-rays showed a radius fracture 6.4 cm from the distal articular surface and a volar displacement of the head of the ulna. Darrach first attempted closed reduction of the fracture– dislocation but was unsuccessful. He then succeeded in surgically reducing the fracture– dislocation: “. . . an incision was made over the anterior aspect of the head of the ulna. It was found firmly embedded in new tissue, and the old opening into the joint was freed with some difficulty. By firm pronation, with pressure over the ulnar head, the latter was finally made to enter the joint cavity and the remains of the anterior ligament were sewn in place with chromic catgut. The skin was then closed with silk and a dry dressing and plaster bandage applied.”5

No osteotomy was performed in this case. Two and a half months after the surgery Darrach’s examination of the patient showed the following: “. . . the fingers had almost completely regained their normal range; flexion at the wrist was ten degrees short of normal; extension 155 to 180 degrees; very little supination. The grip and finger motions were normal.”5

The patient’s primary complaint after reduction was an inability to supinate the forearm. For this reason Darrach began to consider distal ulna resection as a treatment for DRUJ dysfunction. Soon thereafter Darrach was given the opportunity to test this procedure. In “Anterior Dislocation of the Head of the Ulna” Darrach described a 34-year-old man whom he saw 6.5 weeks after a hyperpronation injury of the left hand.1 The patient had been unable to work because of pain and range-of-motion limitations. Physical examination showed that the “head of the ulna could be felt 1.3 cm above the palmar crease in the mid-line.”1 After an unsuccessful attempt at closed reduction Darrach subperiosteally resected the distal 2.5 cm of the ulna on July 27, 1911. The ulnar styloid process, which had broken off the ulna during the initial injury, was left in place. Five weeks after surgery the patient recovered full forearm pronation/ supination and was able to return to work, a marked improvement over the preceding case. Darrach did not describe the surgical procedure when he presented this case in 1912. The following year, however, Darrach provided details when describing his second distal ulna resection: “Through a small posterior incision the lower end of the ulna was exposed, its periosteum carefully reflected and about half an inch of the shaft removed. The bone was cut through with cutting forceps, resulting in a good

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deal of splintering, an effort thus being made to obtain a more rapid regeneration. The hand and forearm were put up in a starch bandage in strong adduction and left in that position for five weeks, the first dressing being done at the end of two weeks.”2

The outcome after 7 weeks was satisfactory. Before surgery Darrach’s examination of the patient had shown the following: “. . . both pronation and supination were limited to one-half; there was flexion to 135 degrees, extension to 200 degrees, normal abduction and no adduction. Attempts at supination and adduction caused pain.”2

After the surgery the patient no longer experienced pain with supination and complained only of slight pain with extreme pronation. Pronation and supination “were limited to one-fifth.”2 A comprehensive review of Darrach’s scientific publications yielded no further case reports of this procedure, nor did Darrach publish a case series regarding this procedure. Many of his subsequent articles, however, described the patient groups that Darrach believed would benefit most from this procedure. These groups were patients experiencing (1) DRUJ dysfunction caused by radius shortening,6 (2) recurrent dislocations of the DRUJ secondary to Colles’ fracture,7 (3) patients with late disability of the DRUJ as characterized by pain and (4) limited pronation and supination8 and late unreduced anterior dislocations of the ulna head.3 Today, nearly 100 years later, Darrach’s indications still are followed. In providing careful descriptions of his patients’ histories, physical examinations, radiographic studies, and postoperative examinations and outcomes, Darrach provided his peers with the data they needed to evaluate the merits of his procedure. The surgical community responded by readily adopting the procedure. In 1913 Douglas9 performed the Darrach procedure on a patient who suffered from persistent volar displacement of the right ulna head after fracture of the radius. The physical examination 3 months after the injury was described by Douglas as “. . . a slight silver-fork deformity, with the head of the ulna displaced anteriorly. . . . The hand was in the position of supination, and there was almost complete loss of pronation. Flexion was limited to 160 degrees; extension was slightly limited.”9 Radiographs showed the ulna head impinging on the carpus. After the surgery the patient regained full pronation and supination and had only a slight limitation of flexion. By 1941 the surgery had earned the eponym “Darrach procedure” as evidenced by Hucherson’s10 ar-

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ticle entitled “The Darrach Operation for Lower Radio-ulnar Derangement.” The context of the article shows the wide dissemination of this procedure. Hucherson10 was an orthopedic surgeon in Oklahoma. The primary source of information he used for the Darrach procedure was a copy of Darrach’s11 1915 article, “Derangements of the Inferior Radio-ulnar Articulation.” In his article Hucherson10 described 2 patients in whom he performed the Darrach procedure. The first was a 14-year-old girl with Madelung’s deformity. The second was a 27-year-old man who had open reduction of a radius fracture that was complicated by nonunion and recurrent ulna dislocation. Both patients had good postoperative outcomes. In 1952 Dingman12 published the first article to examine the effectiveness of the Darrach procedure. Dingman evaluated a series of 24 cases that used 4 variations of the Darrach procedure: subperiosteal resection with or without excision of the ulnar styloid process and extraperiosteal resection with or without excision of the ulnar styloid process. These variations reflect the 2 primary controversies at the time. The first was that excision of the ulnar styloid process disrupted the ulnar collateral ligament, thereby predisposing the patient to wrist instability and weakness. Darrach had left the ulnar styloid process in place for this reason. Dingman12 arrived at the same conclusion. The second controversy was whether the resection should be performed subperiosteally or extraperiosteally. Darrach performed subperiosteal osteotomies because he believed ulna regeneration would be beneficial to the patient. In his second case report he described intentionally splintering the bone as a means of inducing “more rapid regeneration.”2 In both the 1912 and 1913 articles Darrach discussed using follow-up radiographs to show regeneration of the resected bone.1,2 Four decades later it was recognized that distal ulna regeneration could cause DRUJ arthritis. Some surgeons thus advocated extraperiosteal resection as a means of preventing bone regeneration. In his article Dingman12 wrote, “At follow-up roentgenographic examination, it was noted that almost all of the patients with good or excellent results had had either very little bone removed or the process of regeneration had been very active with little final discrepancy between the lengths of the radius and ulna. As was mentioned earlier, several demonstrated an apparently functional distal radio-ulnar joint postoperatively. Inasmuch as the strength and the stability of such wrists were unimpaired, one is led to believe that physiological regeneration is an asset rather than a detriment to the end result.”

Dingman12 also concluded, however, that the most important variable in optimizing outcomes was minimizing the amount of bone resected. This observation still holds true today. Darrach was not the first to advocate distal ulna resection as a treatment for unreduced distal ulna dislocations. In 1897 Van Lennep13 described resecting the distal ulna to treat recurrent dislocation of the head of the ulna after a hypersupination injury. This case is notable because the resection was performed 2 months after the initial injury, thereby bearing the same clinical indications as Darrach’s first cases. An even earlier description of distal ulna resection for treatment of volar displacement of the distal ulna can be found in an 1880 article by Moore.14 The clinical indication differs in that Moore14 resected the ulna head because it had broken through the skin of the volar wrist and was not reducible. Compared with Darrach’s articles these publications provided less detail and did not address the controversies regarding subperiosteal versus extraperiosteal resection or removal of the ulnar styloid process.

Darrach’s Career Darrach was born in Germantown, Pennsylvania. He attended private schools until he entered Yale University, from which he graduated in 1897. After obtaining his MD from the Columbia College of Physicians and Surgeons in 1901 he served his internship at Presbyterian Hospital in New York. He then joined the surgical staff of Roosevelt Hospital in New York and began to contribute to his field of interest—the treatment of fractures.15 In 1913 Darrach was appointed Associate Attending Surgeon at Presbyterian Hospital in New York. He remained affiliated with Presbyterian Hospital for the remainder of his life. When the United States entered World War I Darrach volunteered his services to the United States Army. His initial role was as surgical director of the US Base Hospital No. 2 in Normandy, but he was promoted to commanding officer of the hospital within a year. During his time there Darrach pushed for the inclusion of a nurse anesthetist on his surgical team, a move that helped convince the British to train nurse anesthetists.16 Darrach served in the Army until 1919 when he was discharged honorably with the rank of colonel. He returned to Presbyterian Hospital and began rebuilding his private practice. That same year Darrach was nominated to become the Dean of the Faculty of Medicine of Columbia University.17 He was reluc-

Lau and Chung / William Darrach

tant to accept this administrative post in large part because it would limit the time he could dedicate to surgery.18 His fellow faculty members insisted and from 1919 until 1930 Darrach served as Dean of the Faculty of Medicine. During his 11-year tenure Darrach’s crowning achievement was the successful completion of the Columbia-Presbyterian Medical Center in New York City.19 This project was difficult not only because of its size, which required Darrach to mediate negotiations between numerous parties, but also because it was the culmination of major changes in medical education. Until 1891, when the College of Physicians and Surgeons merged with Columbia University, the College of Physicians and Surgeons as a medical school was not affiliated with a university.20 It was only in 1904 that medical students at Columbia were required to serve daily on hospital wards. This requirement was initiated by Darrach’s predecessor, Samuel W. Lambert.21 Fulltime clinical faculty in academic medical institutions did not exist until 1914 when such posts first were created at Johns Hopkins University.22 In this climate of change Columbia University and Presbyterian Hospital in 1911 formalized their first Agreement of Alliance.20 This marked the medical school’s most important attempt at permanently affiliating with a hospital. The challenges in enacting such a merger were enormous and by 1918 the merger had stalled, largely because of disagreements over the new medical center’s site and unsuccessful fundraising drives by Columbia University.22 Darrach was chosen to become the new Dean of the Columbia College of Physicians and Surgeons in 1919 primarily to solve these challenging issues.18,22 On assuming the deanship Darrach immediately began working to revive this project. He held discussions with all parties involved and in December 1919 prepared a “Memorandum on the School of Medicine.”23 This memorandum was remarkable because it adequately addressed the concerns of all the major parties involved in the merger.24 It broke the deadlock between Columbia and Presbyterian and in 1921 a second Agreement of Alliance was formed.20 Groundbreaking for the new center took place in 1925. In 1928 the new facilities opened. After completion of the medical center Darrach resigned his deanship in 1930 and refocused on his primary interest, the surgical treatment of fractures. He established the fracture service at Presbyterian Hospital and continued to teach as a senior attending. He retired in 1945 but continued to work full time as an advisor to the Bronx Veterans Hospital.25

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Darrach died on May 24, 1948. He had contributed to academic medicine, publishing at least 70 articles (Appendix A can be viewed at the Journal’s web site, www.jhandsurg.org) and serving in numerous academic organizations. To the nascent field of hand surgery he provided a procedure that continues to be an accepted treatment. Despite his many accomplishments all accounts relate that he remained a humble, approachable, and caring man. On his death editorial obituaries were published not only in medical journals but also in lay news sources including The New York Times26 and The New York Herald-Tribune.27 Received for publication January 6, 2006; accepted in revised form February 7, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Kevin C. Chung, MD, Section of Plastic Surgery, the University of Michigan Health System, 1500 E Medical Center Dr, 2130 Taubman Center, Ann Arbor, MI 48109-0340; e-mail: kecchung@ med.umich.edu. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A07-0002$32.00/0 doi:10.1016/j.jhsa.2006.02.010

References 1. Darrach W. Anterior dislocation of the head of the ulna. Ann Surg 1912;56:802– 803. 2. Darrach W. Partial excision of the lower shaft of the ulna for deformity following Colles’ fracture. Ann Surg 1913;57: 764 –765. 3. Darrach W. The operative treatment of fractures and dislocations. JAMA 1912;59:350 –352. 4. Darrach W. A plea for the immediate reduction of fractures. Ann Surg 1916;63:593–595. 5. Darrach W. Forward dislocation at the inferior radio-ulnar joint, with fracture of the lower third of the shaft of the radius. Ann Surg 1912;56:801– 802. 6. Darrach W. Colles’s fracture. N Engl J Med 1942;15:594 – 595. 7. Darrach W. Open treatment of fractures. Surg Clin North Am 1931;11:577–581. 8. Darrach W. Fractures of the lower extremity of the radius. JAMA 1927;89:1683–1685. 9. Douglas. Resection of the head of the ulna for anterior displacement accompanying unreduced Colles’s fracture. Ann Surg 1914;55:388 –389. 10. Hucherson DC. The Darrach operation for lower radio-ulnar derangement. Am J Surg 1941;53:237–241. 11. Darrach W. Derangements of the inferior radio-ulnar articulation. Med Rec 1915;87:708. 12. Dingman PVC. Resection of the distal end of the ulna (Darrach operation). J Bone Joint Surg 1952;34A:893–900. 13. Van Lennep GA. Dislocation forward of the head of the ulna at the wrist-joint—fracture of the styloid process of the ulna. Hahnemannian Monthly 1897;32:350 –354.

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14. Moore EM. Three cases illustrating luxation of the ulna in connection with Colles’ fracture. Med Rec 1880;17:305–308. 15. St. John FB. William Darrach 1876 –1948. Trans Meet Am Surg Assoc 1948;66:569 –571. 16. Dougherty M. Nurses who went to war. In Vivo 2003;2:1–3. 17. Editors. William Darrach. Alumni Mag Columbia Univ Presbyt Hosp Sch Nurs Alumni Assoc 1948;39:24. 18. VanBeuren FT. A great Yale surgeon. Yale Alumni Weekly 1931:657– 658. 19. Editors. William Darrach 1876 –1948. J Bone Joint Surg 1948;30A:791–792. 20. Columbia Health Sciences Library. The health sciences at Columbia University: a timeline. Available at: http://library. cpmc.columbia.edu/hsl/archives/HSTimeline.html. Accessed: January 4, 2006. 21. Enochs BE. The College of Physicians & Surgeons: already rooted in tradition, P&S renews itself at CPMC. Coll Phys

22.

23. 24. 25. 26. 27.

Surg Columbia Univ 2003;23. Available at: http://cumc. columbia.edu/news/journal/journal-o/fall-2003/cps.html. Accessed: November 30, 2005. Lamb AR. The Presbyterian Hospital and the ColumbiaPresbyterian Medical Center, 1868 –1943; a history of a great medical adventure. New York: Columbia Univ Pr; 1955:89 –166. Darrach W. Memorandum on the School of Medicine. New York: Columbia University; 1919:1–11. Rappleye WC. Dean Darrach. Columbia Phys Surg J 1968; 13:8 –11. Whipple AO. William Darrach 1876 –1948. Bull Am Coll Surg 1948;33:162. Editors. Dr. Darrach dead; Columbia ex-dean. NY Times 1948;May 25:27. Editors. Dr. William Darrach, 72, dies; Columbia Medical Faculty Dean. NY Herald Tribune 1948;May 25:20.

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Appendix A: Darrach’s Publications Compiled from Index Medicus, Index to Current Medical Literature, Index Catalogue, and Web of Science.

1907 Variations in the post cava and its tributaries as observed in 605 examples of the domestic cat [abstr]. Anat Rec 1907;1:30 –33.

1910 Epithelioma of the scalp. Ann Surg 1910;51:726.

1911 Tumors of the hand and fingers. Ann Surg 1911;53: 290 –291. Hypertrophic arthritis of the hip treated by Albee’s operation (arthrodesis). Ann Surg 1911;54:265–267.

1912 The operative treatment of fractures and dislocations. JAMA 1912;54:350 –354. Acute diffuse peritonitis from ruptured abscess of Riedel’s lobe of the liver. Ann Surg 1912;56:803. Forward dislocation at the inferior radio-ulnar joint, with fracture of the lower third of the shaft of the radius. Ann Surg 1912;54:801– 802. Anterior dislocation of the head of the ulna. Ann Surg 1912;54:802. Acute suppurative tenosynovitis of the flexor longus policis. Ann Surg 1912;56:799 – 801.

1913 Carcinoma of the stomach: partial gastrectomy: pulmonary thrombosis: abscess of the lung. Ann Surg 1913;57:762–763. Partial excision of the lower shaft of ulna for deformity following Colles’ fracture. Ann Surg 1913; 57:764 –765. Ureterolithotomy. Ann Surg 1913;57:761–762. Habitual forward dislocation of the head of the ulna. Ann Surg 1913;57:928 –930. Fracture-dislocation of the shoulder. Ann Surg 1913; 58:666 – 668. Fracture of the radius, lower shaft. Ann Surg 1913; 58:668 – 669. Open operation for fracture of the clavicle; middle third. Ann Surg 1913;58:669 – 670.

1914 Fracture of the head of the radius. Ann Surg 1914; 54:631– 634. Anterior dislocation of the head of the radius with

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fracture of the ulnar shaft; open reduction. Ann Surg 1913;59:799 – 800. Fracture of the astralagus, with dislocation backward of the posterior fragment; removal of the fragment. Ann Surg 1914;59:800 – 802. Complicated fracture of the head of the radius. Ann Surg 1914;59:514 –516.

1915 Non-reducing operations for fracture and dislocation. Am J Surg 1915;29:85– 86. Derangements of the inferior radio-ulnar articulation. Med Rec 1915;87:708. Excision of breast for carcinoma in a woman 84 years of age. Ann Surg 1915;62:98 –101.

1916 Carcinoma of the rectum. Ann Surg 1916;63:501– 502. Open reduction of fractured external condyle of humerus. Ann Surg 1916;63:486. Open reduction of fracture of the capitellum. Ann Surg 1916;63:487– 488. A plea for the immediate reduction of fractures. Ann Surg 1916;63:593–595. Late changes following open reduction of fractures. Ann Surg 1916;63:746 –749. The importance of the early reduction of fractures with displacement. Ann Surg 1916;63:437. Reduction of fractures. Boston Med Surg J 1916; 175:437– 438.

1917 Fracture of the lower articular surface of the humerus. Ann Surg 1916;64:724 –725. Post-operative bursting of sutured abdominal wounds. Ann Surg 1917;64:243–245.

1921 Full time teachers in clinical departments. Am Med Bull 1920 –1921;14:36 –38.

1925 Massage and movements in treatment of fractures. J Iowa Med Soc 1925;15:582–585.

1926 Fractures in the aged. Am J Surg 1926;1:37–39. Massage and movements in treatment of fractures. Ill Med J 1926;49:199 –202. Inter-relations of physicians and hospital. Boston Med Surg J 1926;194:1105–1110.

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1927 Fracture of the lower extremity of the radius; diagnosis and treatment. JAMA 1927;89:1683–1685.

1928 Le traitement précoce des fractures. Paris Chir 1928; 20:111. Le traitment précoce des fractures. Bull Mem Soc Chir Paris 1928;20:416 – 418. Relation entre les écoles de medicine et les hôpitaux. Bull Mem Soc Chir Paris 1928;20:419.

Darrach W, Stimson BB. Displacements in fractures of neck and femur. Ann Surg 1934;100:833– 842.

1935 Prevention of secondary trauma in treatment of automobile fractures. N Y State J Med 1935;35:568 –571. Darrach W. Internal derangements of the knee. Ann Surg 1935;102:129 –137.

1936 Lee WE, Darrach W, Astley Paston Cooper Ashhurst. Surg Gynecol Obstet 1936;62:645– 648.

1929

1937

Forum on practice of medicine by organizations; profession and medical center. N Y State J Med 1929;29: 579 –580. Internship as requirement for medical degree. Proc Ann Cong Med Ed 1929;64. Disasters following operative treatment of fractures. Ann Surg 1929;90:595– 602. Old bad results on difficult fractures. Proceedings of the International Assembly of the Inter-State PostGraduate Medical Association of North America 1929;5:162–166. Treatment of fractures. Proceedings of the International Assembly of the Inter-State Post-Graduate Medical Association of North America 1929;5:196–199.

Patterson RL, Darrach W. Treatment of acute bursitis by needle irrigation. J Bone Joint Surg 1937;19:993– 1002.

1931

1942

Open treatment of fractures. Surg Clin North Am 1931;11:577–581. Report on work of Committee on Grading of Nursing Schools. Trans Am Surg Assoc 1931;33:732– 744.

1932 Some old truths about fractures. Surg Gynecol Obstet 1932;54:290 –293.

1933

1939 Chondritis of knee. Ann Surg 1939;16:948 –950.

1940 George Emerson Brewer, July 28, 1861–December 24, 1939. Bull Am Coll Surg 1940;25:110 –111. George Emerson Brewer, 1861–1939. Ann Surg 1940;112:795–797. Fractures of shaft of femur; open reduction and internal fixation. Am J Surg 1940;49:177–180. The care of the lightly wounded. Surg Gynecol Obstet 1942;74:402– 405. Fractures around ankle joint. N Engl J Med 1942; 226:333–335. Colles’ fracture. N Engl J Med 1942;226:594 –596. Fractures sustained in war. Am J Surg 1942;56: 341–342.

1943 Treatment of minor casualties. Am J Surg 1943;59: 349 –353.

Causes of trouble in healing of fractures. Penn Med J 1933;36:565–570. Complications of fractures in the aged. Ann Surg 1933;98:147–149. Darrach W, Lee WE, Astley Paston Cooper Ashhurst, 1876 –1932. Trans Meet Am Surg Assoc 1933; 51:512–516.

1945

1934

1947

Traction and suspension in treatment of fractures. Int J Med Surg 1934;47:292–295.

Ellsworth Eliot Jr., 1864 –1945. Trans Meet Am Surg Assoc 1946;64:1187–1188.

Surgical approaches for surgery of extremities. Am J Surg 1945;67:237–262.

1946 Presidential address; treatment of fractures. Ann Surg 1946;124:607– 616.