History Of Orthopaedics
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HISTORY OF ORTHOPAEDICS
Prof. Nirbhay Shrivastava Dean , HOD Orthopaedics Gandhi Medical College Bhopal
The past is our foundation for future developments, we must build upon it so that we too can act as a stable foundation for future generations.
One must be aware of the way surgeons in the past have contributed to Orthopaedics.
www.esnips.com/web/gohiya
Pr imi ti ve Ma n
Evidence of fractured bones has been found, in some of which union has occurred in very fair alignment. Primitive man created a very crude splint, and that from that stage on, its advantages were recognised. Primitive man was probably also the first to perform crude amputations of limbs.
www.esnips.com/web/gohiya
Anc ient E gypt
Splints have been found on mummies and they were made of bamboo, reeds, wood or bark, padded with linen. There is also evidence of the use of crutches, with the earliest known record of the use of a crutch coming from a carving made in 2830 BC on the entrance of a portal on Hirkouf's tomb. www.esnips.com/web/gohiya
Anc ient E gypt
In the papyrus (a book), the examination of peripheral was described. In this papyrus, injuries were classified according to their prognosis into three categories: • • •
an ailment which they would treat, an ailment that they would contend and an ailment which they would not treat.
The papyrus also mentioned many cases and the treatment involved. www.esnips.com/web/gohiya
Anc ient Gree ce
Many principles behind conditions and their treatment have been attributed to the Ancient Greeks. They could be regarded as the first to use a scientific approach. They were also the first to document in detail their history and developments. www.esnips.com/web/gohiya
Hegetor also of Alexandria, but of 100 BC, described in detail the anatomical relations of the hip joint, and was the first to record a description of the ligamentum teres. Corpus Hippocrates. It is named after Hippocrates who is known as the father of Medicine dislocation of the shoulder was described together with the various methods used in reduction and correction of club foot. www.esnips.com/web/gohiya
Hippocrates had a thorough understanding of fractures. He knew of the principles of traction and countertraction. He developed special splints for fractures of the tibia, similar to external fixation
www.esnips.com/web/gohiya
Roma n Er a
Another respected Greek figure by the name of Galen (129-199 BC). "the father of sports medicine". He gave a good account of the skeleton and the muscles that move it. He first recorded a case of cervical ribs. He described bone destruction, sequestration and regeneration in osteomyelitis and sometimes performed resection in such cases.
www.esnips.com/web/gohiya
During this Graeco-Roman period, there were also attempts to provide artificial prostheses. It is said that both linen and catgut sutures were used for the procedures. Various drills, saws and chisels were also developed during this period.
www.esnips.com/web/gohiya
Ar ab Er a
Although the Arab practices were regarded as an extension of those of the Greeks, the use of plaster-of Paris in the l0th century was significant. With the addition of water to a powder of anhydrous calcium sulphate a hard crystalline material was produced.
www.esnips.com/web/gohiya
It was not until the l2th century that Europe began to awake gradually from its Dark Ages until the l6th century, all developments remained within the shadow cast by Hippocrates.
www.esnips.com/web/gohiya
AMB ROI SE P ARE (1510159 0)
most famous surgical figure of the l6th century and the father of French Surgery
use of ligature for large vessels in amputations.
used a tourniquet in his amputations,
Pare did design a scoliosis corset and a clubfoot boot
www.esnips.com/web/gohiya
NI CH OL AS AND RY (165 8175 9)
Father of orthopaedics He gave the term orthopaedics He published a famous book called Orthopaedia: or the Art of Correcting and Preventing Deformities in Children
www.esnips.com/web/gohiya
PE RC IVAL PO TT ( 171 4178 8)
He is best known for the fracture that bears his name Pott's fracture, as he was the first to give a good description of this ankle fracture.
Pott's most famous work is on the paraplegia of spinal tuberculosis, where he stressed that the condition was not related to spinal cord compression, but associated with strumous disorders in the lungs. This is known as Pott's paraplegia.
www.esnips.com/web/gohiya
JO HN HU NTER (1 7281793) His saying Don't Think, try the
His saying Don't Think, try the experiment has inspired generations of modern surgeons He described how to assess muscle power in a weak muscle. He believed that healing depended on the body's innate power, and that the surgeon's task was to aid this. He studied loose bodies in joints, pseudoarthroses and fracture healing.
www.esnips.com/web/gohiya
WILLIAM HE Y (1 7361819 )
Subacute Osteomyelitis of the tibia was described by him and he advocated deroofing of the lesion. In 1773, Hey banged his knee getting out of the bath, and many attribute his subsequent interest in the knee to this. He coined the phrase internal derangement of the knee, and described meniscal injuries. Hey described loose bodies and introduced tarso-metatarsal amputation.
www.esnips.com/web/gohiya
ABR AHAM COL LES (17731843 )
He was the first to tie the subclavian artery best known for his description of Colles' fracture, in 1814
www.esnips.com/web/gohiya
ANTONI US MATH YSEN (1805- 1878)
Mathysen was a Dutch military surgeon who in 1851, invented the plaster of Paris (POP) bandage which was to become so important to orthopaedic practice.
www.esnips.com/web/gohiya
JO SEPH LI STER ( 18271912)
Lister is known for the introduction of antisepsis. He first applied carbolic acid to a compound fracture in 1965. It was soon clear that the practices had had a dramatic effect in reducing in particular abscesses. have trialed the application of the Penicillium mould directly to wounds. www.esnips.com/web/gohiya
HUGH TH OMAS ( 1834 1891) Father of British Orthopaedics.
Hugh Owen Thomas was the eldest of five sons born to a well-known bonesetter at that time. Hugh Owen Thomas could not even work with his father and never held a hospital appointment. He treated all his patients at his home. His practice was so busy that he started his rounds at five or six in the morning and never left his home for other than professional purposes. Thomas would designate Sunday as his free day and hundreds of patients from the country would surround his house in order to be treated. www.esnips.com/web/gohiya
The people of Liverpool knew Thomas as a short and quick man. A man who always wore a black coat buttoned up to the neck and a sailors cap pulled over a damaged eye. A cigarette was also seen constantly in his mouth Thomas developed a great number of splints the cervical collar, metatarsal bar, heel wedge and knee splint. Many of these are still in use, such as the Thomas splint. He was the first to demonstrate concealed flexion of the hip joint and a way of unmasking this by performing the Thomas Test.
www.esnips.com/web/gohiya
SI R WI LLIAM ARB UT HNOT LANE (1856- 1938)
Lane is known for his attempts at improving alignment of fractures by using internal fixation. He started off using silver wire, then he used steel screws and this was followed by the use of plates and screws.
www.esnips.com/web/gohiya
WILHE LM CONRA D RONT GEN (18 45-19 23)
Rontgen was a professor of Physics at Wurzburg, his discovery of X-rays (Rontgen rays) and their use has provided an enormous contribution to Orthopaedics The first radiography that Rontgen took was of his wife's hand on the 22nd of December 1895. This was allegedly her Christmas present. Rontgen received the Nobel Prize for his discovery in 1901.
www.esnips.com/web/gohiya
THE MODER N ER A (2OTH CENT UR Y ORT HOPAE DI CS)
The discovery of the X-ray almost marked 1900 and Orthopaedics itself was only now being seen as a true specialty of its own.
www.esnips.com/web/gohiya
Si r Robe rt Jone s (1 8551933) Jones was a nephew of the great Hugh Owen
Thomas and became one of his apprentices in Liverpool.
In 1896, Jones published the first report of the clinical use of an X-ray to locate a bullet in a wrist.
His textbook Orthopaedic Surgery is said to be the first to have dealt systematically with the diagnosis and treatment of fresh fractures.
In World War I, Jones headed the orthopaedic section of the British Forces. Jones was an advocate of tendon transplantation, bone grafting, and other conservative, restorative procedures.
www.esnips.com/web/gohiya
Worl d Wa r I
It must be noted that war has played an important part in Orthopaedic history. Many of our greatest contributors were military surgeons. It is interesting to note that many of the achievements during and after World War I were not related directly to traumatic injuries received at war. Orthopaedics was definitely seen as a separate specialty after World War I and that this was the first major war where aseptic techniques were saving many more lives than in the past wars. www.esnips.com/web/gohiya
In the chain of great surgeons that followed Hugh Owen Thomas, came Thomas Porter McMurray (1888-1949), who worked for Robert Jones. His operative dexterity was renowned, for he could remove an entire meniscus in five minutes and disarticulate a hip in ten minutes! He introduced his sign for a torn meniscus, McMurray's sign. An operation was also named after him as McMurray was the first to perform a displacement osteotomy for un-united fractures of the femoral neck and arthrosis of the hip. www.esnips.com/web/gohiya
Worl d Wa r II
The knowledge learnt in fighting World War I helped in treating the casualties of World War II. In the Second World War, there were less amputations performed, there was less gangrene, better measures for fixation of fractures. we must not forget the importance of penicillin (whose effects were discovered by Sir Alexander Fleming in 1928). The Germans needed quick measures to restore their fighters to optimal fighting potential and developed a number of nailing procedures during this period. Together with this the Americans were now making more contributions than ever before. www.esnips.com/web/gohiya
Wi ll is Campbe ll (1 8801941)
Main advocate of interpositional arthroplasty at that time. Campbell used a free autogenous transplant of fascia lata. Campbell was also a key figure in bone grafting and performed inlay full thickness grafts for non-union fixed with screws of beef bone.
www.esnips.com/web/gohiya
Gerha rd Kun tsch er (19001972 )
He served in the German army during the Second World War and published his revolutionary procedure in the opening months of the war. His work was concerned with the intramedullary nailing of fractures of the shafts of long bones and his name is associated with the nail.
www.esnips.com/web/gohiya
Ma rt in K ir sc hner ( 1879 1942 )
Known for his methods of fixation, in particular for the Kirschner or K-wire. He also performed the first successful pulmonary embolectomy.
www.esnips.com/web/gohiya
Sir Re gin ald Watso n-J one s (1 902-1 972)
During World War II, he was among the leading teacher in fracture therapy. Watson-Jones published Fractures and Joint Injuries in 1940, which remained a standard reference for several decades and was translated into many languages.
www.esnips.com/web/gohiya
Au sti n T. M oor e (1 8991963)
Performed the first metallic hip replacement. He had replaced, for the first time, the entire upper portion of the femur with a vitallium prosthesis Over the years, the design of the prosthesis and the procedure improved. Consequently, there is one type of prosthesis called the Austin-Moore, which is still used today
www.esnips.com/web/gohiya
Aft er the Wars
In the years following the war, orthopaedic surgeons sought to perfect their treatment of fractures, in particular with the use of metallic pins and wires for fixation. With the introduction of alloys that could be used effectively, there was also a new wave of prostheses, which are developing for treatment of arthritis as well as problematic fractures. Antibiotics have greatly improved and so have our diagnostic devices. www.esnips.com/web/gohiya
1948, Knu t Lindb lom
Technique of direct injection of the lumbar intervertebral discs with radioopaque dye to reproduce the symptoms.
H. Lowry Rush (1879-1965)
used pins made of especially hardened stainless steel for treating long bone fractures www.esnips.com/web/gohiya
Sir J ohn Cha rn le y (1911 1982 )
Wrote a classic book on the nonoperative approach to fractures, The “Closed Treatment of Common Fractures”. Charnley is however renowned as the effective innovator of the total hip replacement. Development of a self-curing acrylic Bone cement Many of the total hip replacements that he performed in the 1960's are still sound and serving their patients effectively. www.esnips.com/web/gohiya
Min imal Invasiv e Surg ery (MI S) End os copy w as fi rst descr ibed
by Hi pp ocr ate s in Gr ee ce (4 60 – 375 B C) He ma de refer en ce to a rect al sp eculum Pi one er ing work in t he fi eld of ar thros copy b eg an as ea rly as the 192 0s with the work of Eug en Birche r . Jap anese sur ge on Masak i Wat anabe , MD r ecei ve s pr imar y cr ed it for usi ng ar th rosco py fo r in ter ven tio nal sur ger y. Wat anab e was insp ired by t he wor k an d teachi ng of Dr Richar d www.esnips.com/web/gohiya
Ar th rop la sty
www.esnips.com/web/gohiya
Ar th ropl ast y
www.esnips.com/web/gohiya
In some ways, Orthopaedics has lost its way by producing surgical technicians (surgeons merely content to operate) with not enough commitment to fundamental biomedical research and the protection of their craft.
www.esnips.com/web/gohiya
Imagine what these great figures were able to achieve 200 years ago without a formal education or the Internet. Read widely to catch a glimpse of the excitement of Science and remain true to your patients, family and profession
www.esnips.com/web/gohiya
www.esnips.com/web/gohiya
Prof. Nirbhay Shrivastava Dean , HOD Orthopaedics Gandhi Medical College Bhopal
The past is our foundation for future developments, we must build upon it so that we too can act as a stable foundation for future generations.
One must be aware of the way surgeons in the past have contributed to Orthopaedics.
www.esnips.com/web/gohiya
Pr imi ti ve Ma n
Evidence of fractured bones has been found, in some of which union has occurred in very fair alignment. Primitive man created a very crude splint, and that from that stage on, its advantages were recognised. Primitive man was probably also the first to perform crude amputations of limbs.
www.esnips.com/web/gohiya
Anc ient E gypt
Splints have been found on mummies and they were made of bamboo, reeds, wood or bark, padded with linen. There is also evidence of the use of crutches, with the earliest known record of the use of a crutch coming from a carving made in 2830 BC on the entrance of a portal on Hirkouf's tomb. www.esnips.com/web/gohiya
Anc ient E gypt
In the papyrus (a book), the examination of peripheral was described. In this papyrus, injuries were classified according to their prognosis into three categories: • • •
an ailment which they would treat, an ailment that they would contend and an ailment which they would not treat.
The papyrus also mentioned many cases and the treatment involved. www.esnips.com/web/gohiya
Anc ient Gree ce
Many principles behind conditions and their treatment have been attributed to the Ancient Greeks. They could be regarded as the first to use a scientific approach. They were also the first to document in detail their history and developments. www.esnips.com/web/gohiya
Hegetor also of Alexandria, but of 100 BC, described in detail the anatomical relations of the hip joint, and was the first to record a description of the ligamentum teres. Corpus Hippocrates. It is named after Hippocrates who is known as the father of Medicine dislocation of the shoulder was described together with the various methods used in reduction and correction of club foot. www.esnips.com/web/gohiya
Hippocrates had a thorough understanding of fractures. He knew of the principles of traction and countertraction. He developed special splints for fractures of the tibia, similar to external fixation
www.esnips.com/web/gohiya
Roma n Er a
Another respected Greek figure by the name of Galen (129-199 BC). "the father of sports medicine". He gave a good account of the skeleton and the muscles that move it. He first recorded a case of cervical ribs. He described bone destruction, sequestration and regeneration in osteomyelitis and sometimes performed resection in such cases.
www.esnips.com/web/gohiya
During this Graeco-Roman period, there were also attempts to provide artificial prostheses. It is said that both linen and catgut sutures were used for the procedures. Various drills, saws and chisels were also developed during this period.
www.esnips.com/web/gohiya
Ar ab Er a
Although the Arab practices were regarded as an extension of those of the Greeks, the use of plaster-of Paris in the l0th century was significant. With the addition of water to a powder of anhydrous calcium sulphate a hard crystalline material was produced.
www.esnips.com/web/gohiya
It was not until the l2th century that Europe began to awake gradually from its Dark Ages until the l6th century, all developments remained within the shadow cast by Hippocrates.
www.esnips.com/web/gohiya
AMB ROI SE P ARE (1510159 0)
most famous surgical figure of the l6th century and the father of French Surgery
use of ligature for large vessels in amputations.
used a tourniquet in his amputations,
Pare did design a scoliosis corset and a clubfoot boot
www.esnips.com/web/gohiya
NI CH OL AS AND RY (165 8175 9)
Father of orthopaedics He gave the term orthopaedics He published a famous book called Orthopaedia: or the Art of Correcting and Preventing Deformities in Children
www.esnips.com/web/gohiya
PE RC IVAL PO TT ( 171 4178 8)
He is best known for the fracture that bears his name Pott's fracture, as he was the first to give a good description of this ankle fracture.
Pott's most famous work is on the paraplegia of spinal tuberculosis, where he stressed that the condition was not related to spinal cord compression, but associated with strumous disorders in the lungs. This is known as Pott's paraplegia.
www.esnips.com/web/gohiya
JO HN HU NTER (1 7281793) His saying Don't Think, try the
His saying Don't Think, try the experiment has inspired generations of modern surgeons He described how to assess muscle power in a weak muscle. He believed that healing depended on the body's innate power, and that the surgeon's task was to aid this. He studied loose bodies in joints, pseudoarthroses and fracture healing.
www.esnips.com/web/gohiya
WILLIAM HE Y (1 7361819 )
Subacute Osteomyelitis of the tibia was described by him and he advocated deroofing of the lesion. In 1773, Hey banged his knee getting out of the bath, and many attribute his subsequent interest in the knee to this. He coined the phrase internal derangement of the knee, and described meniscal injuries. Hey described loose bodies and introduced tarso-metatarsal amputation.
www.esnips.com/web/gohiya
ABR AHAM COL LES (17731843 )
He was the first to tie the subclavian artery best known for his description of Colles' fracture, in 1814
www.esnips.com/web/gohiya
ANTONI US MATH YSEN (1805- 1878)
Mathysen was a Dutch military surgeon who in 1851, invented the plaster of Paris (POP) bandage which was to become so important to orthopaedic practice.
www.esnips.com/web/gohiya
JO SEPH LI STER ( 18271912)
Lister is known for the introduction of antisepsis. He first applied carbolic acid to a compound fracture in 1965. It was soon clear that the practices had had a dramatic effect in reducing in particular abscesses. have trialed the application of the Penicillium mould directly to wounds. www.esnips.com/web/gohiya
HUGH TH OMAS ( 1834 1891) Father of British Orthopaedics.
Hugh Owen Thomas was the eldest of five sons born to a well-known bonesetter at that time. Hugh Owen Thomas could not even work with his father and never held a hospital appointment. He treated all his patients at his home. His practice was so busy that he started his rounds at five or six in the morning and never left his home for other than professional purposes. Thomas would designate Sunday as his free day and hundreds of patients from the country would surround his house in order to be treated. www.esnips.com/web/gohiya
The people of Liverpool knew Thomas as a short and quick man. A man who always wore a black coat buttoned up to the neck and a sailors cap pulled over a damaged eye. A cigarette was also seen constantly in his mouth Thomas developed a great number of splints the cervical collar, metatarsal bar, heel wedge and knee splint. Many of these are still in use, such as the Thomas splint. He was the first to demonstrate concealed flexion of the hip joint and a way of unmasking this by performing the Thomas Test.
www.esnips.com/web/gohiya
SI R WI LLIAM ARB UT HNOT LANE (1856- 1938)
Lane is known for his attempts at improving alignment of fractures by using internal fixation. He started off using silver wire, then he used steel screws and this was followed by the use of plates and screws.
www.esnips.com/web/gohiya
WILHE LM CONRA D RONT GEN (18 45-19 23)
Rontgen was a professor of Physics at Wurzburg, his discovery of X-rays (Rontgen rays) and their use has provided an enormous contribution to Orthopaedics The first radiography that Rontgen took was of his wife's hand on the 22nd of December 1895. This was allegedly her Christmas present. Rontgen received the Nobel Prize for his discovery in 1901.
www.esnips.com/web/gohiya
THE MODER N ER A (2OTH CENT UR Y ORT HOPAE DI CS)
The discovery of the X-ray almost marked 1900 and Orthopaedics itself was only now being seen as a true specialty of its own.
www.esnips.com/web/gohiya
Si r Robe rt Jone s (1 8551933) Jones was a nephew of the great Hugh Owen
Thomas and became one of his apprentices in Liverpool.
In 1896, Jones published the first report of the clinical use of an X-ray to locate a bullet in a wrist.
His textbook Orthopaedic Surgery is said to be the first to have dealt systematically with the diagnosis and treatment of fresh fractures.
In World War I, Jones headed the orthopaedic section of the British Forces. Jones was an advocate of tendon transplantation, bone grafting, and other conservative, restorative procedures.
www.esnips.com/web/gohiya
Worl d Wa r I
It must be noted that war has played an important part in Orthopaedic history. Many of our greatest contributors were military surgeons. It is interesting to note that many of the achievements during and after World War I were not related directly to traumatic injuries received at war. Orthopaedics was definitely seen as a separate specialty after World War I and that this was the first major war where aseptic techniques were saving many more lives than in the past wars. www.esnips.com/web/gohiya
In the chain of great surgeons that followed Hugh Owen Thomas, came Thomas Porter McMurray (1888-1949), who worked for Robert Jones. His operative dexterity was renowned, for he could remove an entire meniscus in five minutes and disarticulate a hip in ten minutes! He introduced his sign for a torn meniscus, McMurray's sign. An operation was also named after him as McMurray was the first to perform a displacement osteotomy for un-united fractures of the femoral neck and arthrosis of the hip. www.esnips.com/web/gohiya
Worl d Wa r II
The knowledge learnt in fighting World War I helped in treating the casualties of World War II. In the Second World War, there were less amputations performed, there was less gangrene, better measures for fixation of fractures. we must not forget the importance of penicillin (whose effects were discovered by Sir Alexander Fleming in 1928). The Germans needed quick measures to restore their fighters to optimal fighting potential and developed a number of nailing procedures during this period. Together with this the Americans were now making more contributions than ever before. www.esnips.com/web/gohiya
Wi ll is Campbe ll (1 8801941)
Main advocate of interpositional arthroplasty at that time. Campbell used a free autogenous transplant of fascia lata. Campbell was also a key figure in bone grafting and performed inlay full thickness grafts for non-union fixed with screws of beef bone.
www.esnips.com/web/gohiya
Gerha rd Kun tsch er (19001972 )
He served in the German army during the Second World War and published his revolutionary procedure in the opening months of the war. His work was concerned with the intramedullary nailing of fractures of the shafts of long bones and his name is associated with the nail.
www.esnips.com/web/gohiya
Ma rt in K ir sc hner ( 1879 1942 )
Known for his methods of fixation, in particular for the Kirschner or K-wire. He also performed the first successful pulmonary embolectomy.
www.esnips.com/web/gohiya
Sir Re gin ald Watso n-J one s (1 902-1 972)
During World War II, he was among the leading teacher in fracture therapy. Watson-Jones published Fractures and Joint Injuries in 1940, which remained a standard reference for several decades and was translated into many languages.
www.esnips.com/web/gohiya
Au sti n T. M oor e (1 8991963)
Performed the first metallic hip replacement. He had replaced, for the first time, the entire upper portion of the femur with a vitallium prosthesis Over the years, the design of the prosthesis and the procedure improved. Consequently, there is one type of prosthesis called the Austin-Moore, which is still used today
www.esnips.com/web/gohiya
Aft er the Wars
In the years following the war, orthopaedic surgeons sought to perfect their treatment of fractures, in particular with the use of metallic pins and wires for fixation. With the introduction of alloys that could be used effectively, there was also a new wave of prostheses, which are developing for treatment of arthritis as well as problematic fractures. Antibiotics have greatly improved and so have our diagnostic devices. www.esnips.com/web/gohiya
1948, Knu t Lindb lom
Technique of direct injection of the lumbar intervertebral discs with radioopaque dye to reproduce the symptoms.
H. Lowry Rush (1879-1965)
used pins made of especially hardened stainless steel for treating long bone fractures www.esnips.com/web/gohiya
Sir J ohn Cha rn le y (1911 1982 )
Wrote a classic book on the nonoperative approach to fractures, The “Closed Treatment of Common Fractures”. Charnley is however renowned as the effective innovator of the total hip replacement. Development of a self-curing acrylic Bone cement Many of the total hip replacements that he performed in the 1960's are still sound and serving their patients effectively. www.esnips.com/web/gohiya
Min imal Invasiv e Surg ery (MI S) End os copy w as fi rst descr ibed
by Hi pp ocr ate s in Gr ee ce (4 60 – 375 B C) He ma de refer en ce to a rect al sp eculum Pi one er ing work in t he fi eld of ar thros copy b eg an as ea rly as the 192 0s with the work of Eug en Birche r . Jap anese sur ge on Masak i Wat anabe , MD r ecei ve s pr imar y cr ed it for usi ng ar th rosco py fo r in ter ven tio nal sur ger y. Wat anab e was insp ired by t he wor k an d teachi ng of Dr Richar d www.esnips.com/web/gohiya
Ar th rop la sty
www.esnips.com/web/gohiya
Ar th ropl ast y
www.esnips.com/web/gohiya
In some ways, Orthopaedics has lost its way by producing surgical technicians (surgeons merely content to operate) with not enough commitment to fundamental biomedical research and the protection of their craft.
www.esnips.com/web/gohiya
Imagine what these great figures were able to achieve 200 years ago without a formal education or the Internet. Read widely to catch a glimpse of the excitement of Science and remain true to your patients, family and profession
www.esnips.com/web/gohiya
www.esnips.com/web/gohiya
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