Splints are among the most ancient medical devices, and the oldest surviving examples date back to early Egypt, around 3,000 B.C. These were made of wood, and wood would remain the material of choice for millennia, although virtually any material strong enough to support an injured limb would work. Because of their flat and relatively smooth surfaces, wooden barrel staves became very popular and were still being used in the U.S. in the late nineteenth century. But this was to change, primarily because of one man.
Revra DePuy
Revra DePuy was born in 1860 in Grand Rapids, Michigan. Although his family briefly moved to Canada when he was still a boy, young Revra’s mother brought the family back to the Midwest after her husband died, settling in Marseilles, Illinois, about eighty miles southwest of Chicago. When he was old enough, DePuy took on a variety of jobs, and one of them made a lasting impression. Working as a clerk in a local drug store, he became interested in medicine and chemicals, and he pursued this interest when he enrolled in the University of Toronto. There he received a degree in chemistry and upon graduation became a traveling pharmaceutical salesman, work that took him to Warsaw, Indiana, a small town in the north-central part of the state. The locale apparently appealed to him: when he later decided to open his own business, he chose Warsaw as his base. He already knew what he wanted to do.
DePuy was convinced that carefully designed splints would work far better than the wooden, often improvised ones routinely used by doctors of the time, and in 1895 DePuy Manufacturing became the first commercial orthopedic company in the United States. Its initial products were indeed fiber splints, and the Unites States Army became the company’s best customer. The product line would soon include “slings, neck collars, and braces.”
For a while, the business was headquartered in a Warsaw hotel, but in 1901 DePuy relocated to Niles, Michigan, just across the state line, enticed by incentives offered by leading citizens of that town. This move turned out to be temporary, however, because DePuy’s products did not sell well in Michigan, and after only three years he moved the plant back to Warsaw.
A year after his return DePuy made an employment decision that would have significant consequences not only within the field of fracture appliances, but in an industry that did not yet even exist—the manufacturing of orthopedic implants. That decision was to hire twenty-year-old Justin O. Zimmer as his first sales representative.
The young man had been born on the family farm south of Warsaw, and he had later attended school to become a Western Union telegraph operator. He must not have enjoyed the work, however, because the same day he finished his telegraphy training he went to work as a DePuy splint salesman instead. Zimmer would stay with DePuy’s company more than twenty years, the last five as sales manager, and when he did leave, he would quickly demonstrate that he had learned the business well.
DePuy Manufacturing grew rapidly and by 1919 had sixteen full-time employees, including six salesmen who traveled the country as DePuy himself once had. When Revra DePuy died in 1921, his widow Winifred took over company operations. At that time, women heading any businesses, let alone a manufacturing business, were rare, but she did very well, managing the business and her marriage to Herschel Leiter in 1924.
Justin Zimmer
When Justin Zimmer finally left DePuy in 1926, he was not just changing jobs. He left to set up his own splint-making business, and he persuaded some key DePuy employees to join him. One story has Zimmer, in the months before his departure, making copies of all of DePuy’s products. This kind of move—learning the company business and then striking out on one’s own in a similar enterprise—would be repeated many times in the industry over the next four decades, and the circumstances of his departure would become part of industry lore.
According to Zimmer, he had approached Winifred a year earlier with two proposals. He suggested adding aluminum splints to the company’s product line, and he asked to buy an interest in the company. This was not the first time Zimmer had raised the partnership issue with her—he wanted to be more than an employee—but she dismissed both ideas out of hand. The Zimmer company history records his reaction: “I have had it,” Mr. Zimmer told his wife and daughter that evening. “She said to me: ‘You know, Justin, you are just small potatoes!’”
Rebuffed and certainly angry at being so casually dismissed, he was able to find two investors, William Felkner and William Rogers, willing to back him, and a year after Zimmer left DePuy the Zimmer Manufacturing Company set up shop in the basement of Zimmer’s home in Warsaw. Assisting Zimmer were two former DePuy employees, J.J. Ettinger and Dr. C.F. Lytle, who helped create and market Zimmer’s new aluminum splints and other orthopedic devices. Ettinger was the factory manager, while Lytle, a physician who had worked as a salesman at DePuy, worked alongside Zimmer. Zimmer also hired his former secretary at DePuy as office manager. Ettinger would later recall that local “experts” were convinced that there simply was not enough business for two splint manufacturing companies.
By the following May, Zimmer Manufacturing had fabricated enough products to be able to display samples of its new aluminum splints at that year’s American Medical Association [AMA] conference in Washington, D.C. The response was enthusiastic. Zimmer’s product line was so popular that the company soon had to employ a nine-man sales network, and its catalog began advertising a total of fifty aluminum splints. In just seven months of operation, company sales surpassed those of DePuy, Justin Zimmer’s former employer, for the entire previous year.
With demand for its products surging, the new firm soon outgrew its basement facilities and moved its operations to a building on North Detroit Street in Warsaw. It also developed additional product lines, including what it called “the fracture bed,” a device that enabled hospital staff to change the bed sheeting without disturbing the patient. Profits were routinely plowed back into the business to purchase new equipment and further expand the size of the plant. In 1929, the same year the stock market collapsed, the company sold its first splints overseas, to a Scottish surgeon. This was no fluke: it was the beginning of a trend. Even during the harshest days of the Great Depression, Zimmer’s sales continued to increase.
Not that DePuy suffered any revenue loss. Despite the predictions of “experts,” the demand for orthopedic products was more than enough to sustain not only two manufacturing companies in Warsaw, but new competitors as well. In fact, one was about to start up in the South.
Memphis: Where AAOS and Modern Orthopedics Take Root
Years before Memphis’ first manufacturer of orthopedic products opened its doors, the practice of orthopedic medicine in the city was already well established and gaining national attention. Again, it was one man, a visionary, who was primarily responsible.
By the early 1900s, Memphis had fully recovered from the ravages of yellow fever epidemics that had nearly destroyed the city in the 1870s, and the area’s economy was on an upswing. For decades the city had been the world’s largest inland cotton exporting center, and its prosperity had been enhanced before the close of the nineteenth century by an increasing demand for another local resource—the vast stands of timber that grew in the river valley. As the new century dawned, Memphis was undeniably the hardwood lumber capital of the nation, and business was booming for both hardwoods and cotton.
The city had also become an important railroad hub—the only railroad bridge over the Mississippi River between St. Louis and New Orleans was at Memphis—and it remained a busy river port. In short, it was the kind of place a talented young southern doctor might find inviting.
Dr. Willis Cohoon Campbell – The First President of AAOS
Dr. Willis Cohoon Campbell arrived in the city in 1906 just two years after receiving his medical degree from the University of Virginia, and it is probable that he had already decided that this was where he would open his own practice. Memphis was the largest city within a 200-mile radius, it was prosperous, and the young doctor would not be far from his hometown of Jackson, Mississippi.
However, Campbell did take a while to settle on a career. He first tried general practice and, briefly, pediatrics, but after a few years he began to think seriously about orthopedics. At that time, there were few orthopedic surgeons in the South, and Memphis was no exception. A new technology may also have influenced his decision—the discovery and use of X-rays.
Wilhelm Roentgen had discovered the potential of X-rays in 1895 when he made an X-ray photograph of the bones in his wife’s hand, and by May of the following year Italian doctors were using the technology to find bullets in wounded soldiers. Bone structures were clearly visible in the X-ray films, and this meant that doctors no longer had to diagnose bone injuries and joint problems by touch alone.
Once Campbell chose to pursue a career in orthopedic surgery, he acted decisively. In 1909 he suspended his practice and traveled to Vienna to study under Adolph Lorenz, a leading orthopedic physician renowned for his methods of treating congenital hip dislocations, especially in children.
Lorenz had been a guest at the AMA’s 1903 annual meeting and made regular visits to the United States, conducting lectures on his work. After working with Lorenz, Campbell did further training with specialists in London, New York, and Boston before returning to Memphis in 1910 to begin a new medical practice, this time in orthopedics.
It turned out to be an auspicious time, as American medicine was about to undergo profound changes. Although Campbell had received his medical degree from a university, many doctors in his day entered practice with little formal education: some learned about medicine as apprentices to local physicians, while others enrolled in proprietary schools, institutions in which the school owners, usually local doctors, would lecture on various medical topics. Against this backdrop, it was not surprising that the quality of medical practice in the country varied greatly, and this inconsistency became a concern of the American Medical Association.
Many AMA members believed the fault lay with the training doctors received, and the logical first step was to find out how good, or how bad, medical education actually was. This would not be an easy task, however, and they decided to look for help outside the organization.
At the urging of the AMA’s Council on Medical Education, the new Carnegie Foundation for the Advancement of Teaching agreed to fund a survey of American and Canadian medical schools, and Abraham Flexner was selected to lead the project. Flexner was a progressive Kentucky educator and essayist who had recently published a controversial book highly critical of teaching methods at Harvard, where he had done postgraduate work. Although Flexner was not part of the medical fraternity, the director of the Foundation apparently liked what the educator had written. Flexner’s findings would certainly be unvarnished. The results of the study were published in 1910 in Medical Education in the United States and Canada, later known simply as “The Flexner Report.”
As part of his research, Flexner visited and evaluated about 155 medical schools of all sorts, and many of these were found to be so wanting in the basics of medical education that they were forced to close. The report’s description of a Knoxville school was typical: “The catalogue of this school is a tissue of misrepresentations from cover to cover.” Other schools fared better, and in 1911 two proprietary schools in Memphis merged to form the University of Tennessee Medical School in Memphis.
That same year, Campbell applied for a position with the new school. He was not only accepted—he was asked to organize its Department of Orthopaedic Surgery. Campbell quickly agreed and became the school’s first Professor of Orthopaedic Surgery, holding that position until his death in 1941. He also continued to practice surgery and became “one of the pioneers in the development of arthroplasties,” especially knee surgery.
Perhaps because of his early pediatric experience, Campbell was deeply concerned with the plight of children who had been crippled by orthopedic disease or injury, and in 1919 he helped found the Memphis’ Crippled Children’s Hospital, one of the first of its kind. This was followed four years later by the Hospital for Crippled Adults, established by Campbell and some of his friends and colleagues.
Always a strong supporter of advancing the profession of medicine, Campbell was one of the founders of the American Academy of Orthopaedic Surgeons [AAOS] and became its first president in 1933. He also found time to share his knowledge and experience with a wider audience, authoring numerous journal articles, a popular monograph, Orthopaedics of Childhood, and Orthopaedic Surgery, a 1930 textbook. In 1939, near the end of his career, he also published Operative Orthopaedics, which became the preeminent book in its field. Periodically updated and revised, the book would remain a classic: in 2007, the four-volume eleventh edition of Operative Orthopaedics became available.
But it was for the clinic that bears his name that Campbell became most widely known. The Willis C. Campbell Clinic opened in December 1920 to offer specialized orthopedic care and to provide training in orthopedic surgery for doctors just out of medical school. It was so successful that four years later the clinic was able to establish postgraduate fellowships that guaranteed a level of expertise equal to what would soon be mandated by the American Board of Medical Specialties.
Determined to have only the best physicians in his new clinic, Campbell recruited the best medical school graduates. Three early enlistees were James Spencer Speed, Joseph Hamilton, and Joseph I. Mitchell, a Memphis native and graduate of the new medical school.
Speed had received his degree from the Johns Hopkins Medical School, but because he had no orthopedic training, he was initially reluctant to join the staff. Campbell convinced him that after a year of working under Campbell’s personal supervision that he would be able to perform orthopedic surgeries on his own.
Hamilton’s training was as an internist (an expertise that helped the clinic deal with various postoperative problems), and Mitchell’s residency had been at the prestigious Mayo Clinic. Mitchell would later prepare many of Campbell Clinic’s publications as well as author his own journal articles. By the beginning of the 1930s Campbell Clinic was widely recognized as one of the top orthopedic clinics in the country.
It was also an important asset to the region. There were few hospitals and little specialized medical care in the sparsely developed hinterlands, and this made Memphis the obvious choice for patients with any non-routine medical problems, including those that required orthopedic surgery. Moreover, a large percentage of local physicians were graduates of the University of Tennessee Medical School, where Campbell was still department head.
Orthopedic Manufacturing Comes to Memphis
As a market for orthopedic goods, the South was not unlike the rest of the nation. Manual labor, which was the rule, guaranteed occasional broken bones, and quality splints meant quicker and better healing. Congenital skeletal problems could now also be treated by medical devices. Physicians understood this, and so did DePuy Manufacturing in Warsaw. Wherever there were broken bones and malformations, and physicians to treat them, there was also a market for orthopedic products. And to reach the greatest number of markets throughout the nation, DePuy divided its sales force into different geographical regions, and Mississippi and Tennessee were assigned to one of its salesmen, J. Don Richards.
J. Don Richards
Don Richards was born on a farm near Warsaw, Indiana, and he had close family ties to DePuy’s only business competitor, Zimmer Manufacturing. Richards’ mother was the sister of J.O. Zimmer, and it was from him that Richards had first learned about the orthopedic business. With such connections, no doubt the young man could have done very well had he stayed in Warsaw, but it did not work out that way.
Richards’ sales route took him through Brookhaven, Mississippi, a town due east of Natchez, in the heart of the Mississippi Delta. It was there that he met, fell in love with, and soon married, a young woman named Euna Brister.
Richards would later tell how he had explained to Euna, before they married, that because he was planning to go into business for himself they would have to move “up north.” She was fine with that, she said, and was willing to move as far north…as Memphis. This was certainly not what Richards had in mind, but her notion of “north” apparently prevailed because in 1934 the couple moved to Memphis, where he opened the nation’s third orthopedic manufacturing facility.
Richards Manufacturing Company started out in a rented building at 756 Madison Avenue, a few blocks east of downtown, next to a dry cleaners. It was not a large enterprise, but the choice of location made sense: Campbell Clinic and John Gaston Hospital were just down the street. Predictably, the company’s first products were splints, cast materials, and soft goods such as rib belts and arm slings, and its first buyers included the local hospitals, Campbell Clinic, and, after it opened, the orthopedic section of Kennedy Hospital.
An early speciality product was the Campbell-Boyd pneumatic tourniquet, a device which worked along the same lines as the inflatable cuffs used to take blood pressure measurements. The tourniquet was specifically designed for use by the Campbell Clinic and was sold only to the clinic.
Memphis’ newest business got off to a good if modest start, relying on a handful of employees. Lelia Jones was hired as company seamstress (she personally sewed each belt and sling), and other initial employees were Jimmy Brower, who made the splints, and Pete Porch, who worked as a metal polisher. C.C. “Smitty” Smith became the company’s first salesman in 1938. Richards at this point was much smaller than either DePuy or Zimmer, but these three companies formed the foundation of the future orthopedic industry in the U.S.
Due to what can only be described as tragic reasons, the orthopedic business was about to boom. World War II brought an unprecedented demand for orthopedic products, and the U.S. government was soon buying large quantities of pins, plates, wires, slings, and other devices from Richards, as well as from DePuy and Zimmer.
Richards may have had a unique advantage, at least in terms of feedback from doctors and even patients. In 1943, the Army opened a new general hospital in Memphis, and within three years it would become the largest such facility in the United States, with some 6,000 patients by war’s end. Named in honor of a Spanish-American War surgeon, Kennedy Hospital would be taken over by the Veterans Administration in 1946.
Even after the war ended, Richards continued to enjoy dramatic growth as demand for new and better products continued to increase, and by 1950 Memphis would have its second orthopedic manufacturing company.
Among the new sales personnel that Richards hired during the war was Frank Wright, and in 1944 he became its Memphis area sales representative. A few years later, history—at least the piece of history that relates how orthopedic salesmen often have greater ambitions—was about to repeat itself.
Frank had learned from doctors that patients in leg casts frequently reported chronic back pain, which was attributed to the hard steel heel located at the foot of the cast, and Wright thought he saw a solution: replace the steel heel with a walking heel made of rubber.
He left Richards in 1950, patented his rubber heel device, and formed Wright Manufacturing Company to produce the heel. In later years, its product line would expand, making it a direct competitor with Richards and other manufacturers.
Another U.S. manufacturer, one which was not yet in the orthopedic business, but which would one day become the largest of them all, also experienced a surge in sales during the war. Its chief product was the Stryker Turning Frame, invented in the late 1930s by Dr. Homer Stryker while he was taking a course in surgery at the University of Michigan. The frame made it possible to safely move bed-ridden patients suffering from spinal injuries. Near the end of the war Stryker also invented an oscillating saw which could cut through body casts without damaging the skin below. He applied for a patent on this in 1945, and it was granted a year later.
Notwithstanding the ever-increasing interest in his products, Stryker considered his inventions as merely a part of his regular practice, and it was not until 1946 that he incorporated his “sideline” as the Orthopedic Frame Company. That same year he hired as general manager a man who would also leave his mark on the industry, albeit at another manufacturer.
Harry Treace
Harry Tillson Treace was a gifted designer as well as a manager, and he and Stryker would invent and patent numerous medical devices together. In fact, Treace soon made modifications to Stryker’s original cast saw design and in 1948 applied for a patent on his changes. The patent was granted, and he assigned it to Orthopedic Frame Company.
Treace also was allowed to buy stock in the firm. How many shares Treace purchased is not known, but the author of The Stryker Story believes it was “sizable.” As part of the deal, Stryker apparently reserved the right to have first refusal if Treace decided to sell his shares.
Although both men contributed to the growth of the company, they did not always agree on how the company should be run. For example—this according to Treace’s own handwritten notes—he was dismayed by Stryker’s handling of a dispute with J.O. Zimmer, whose company had come out with a cast saw similar to Orthopedic Frame Company’s device. Treace’s account of this episode differs from that reported years later by Marshal Morrison, a long-time Stryker employee. Treace wrote:
“This story also is incorrect. Zimmer came out with and offered for sale a poorly designed Lucks Bone Saw with oscillating attachment. Homer and I went to Warsaw for a pow wow with J.O. Zimmer. The idea was to bring legal action if they didn’t stop. J.O. sweet-talked Stryker into taking a small royalty [paid to him, not the company]. I wasn’t pleased with the sell-out.” (Brackets in original)
Partly because of such differences, the business relationship between Stryker and Treace was not to last, and again there are differing versions of exactly how the split came about. By 1954 it was obvious to Treace that Stryker was planning for his son Lee to take over the running of the company, and Treace began to look for other business opportunities that would let him use his talents. The timing turned out to be fortuitous because Don Richards happened to be actively looking for an investor in his company. The two men met, and it did not take long for them to reach an agreement. Treace sold his Orthopedic Frame Company shares back to Stryker, bought a 40 percent interest in Richards Manufacturing Company, became its vice president and sales manager, and moved to Memphis.
Treace’s impact at Richards was immediate and profound. In just his first two years with the company, he was responsible for the introduction of not one but two revolutionary medical devices.
The first of these was one he developed in 1956 with Dr. John Shea, a noted ear surgeon who had founded the Shea Ear Clinic three decades earlier. Shea had an idea, and he needed an engineer to make it work.
Inside the middle ear is a tiny stirrup-shaped bone, called a stapes, that is essential for converting sound waves into hearing. A frequent cause of hearing loss was otosclerosis, a calcification of the stapes that eventually renders the bone immobile. This results in deafness. The usual treatment was the removal of the calcium deposit from the stapes, but this would provide only temporary relief—within a few months the patient would again be deaf. Surgeons around the country experimented with different materials to replace the entire stapes, but each material that was tried was rejected by the body. Shea later recalled how he came up with his idea:
“I was reading Popular Science and read about a new material that was discovered by accident at DuPont. Nothing affected it. I already knew that if I was going to replace a bone, I needed something that the body wouldn’t react to.”
The material Shea wanted to try was Teflon. He had done initial research on the material and believed it was the solution, but he had no way to make the device. Which was why he came to Treace.
On a Friday afternoon in May, Shea met with Treace and explained his idea. He even brought along a stape to show what he was talking about. The engineer was interested, and the following Monday morning he was able to present Shea a Teflon version of the bone, hand-carved by Treace himself. Shea was now able to perform the world’s first successful stapedectomy, and Richards Manufacturing became the only company in the middle ear implant business. In the ensuing years, Shea and Treace would file dozens of patents together, but it was not merely a business arrangement—the two men would also become good friends.
Treace’s second early contribution was the design and development of the compression hip screw, a device that significantly improved the treatment of hip fractures in the elderly. Until then, the standard surgical procedure to repair a hip fracture was to nail the femur into the ball of the hip and secure it with screws fastened into a plate. Surgeons frequently used the Jewett nail, named for Dr. Eugene Jewett, who developed it in the 1940s. This procedure would work fine at first, but problems would arise as the healing hip naturally compressed. Treace’s device screwed into the ball of the hip and could move backward enough to let the bone compress naturally. Treace filed for the patent in 1956, and it was soon in heavy demand although the Jewett nail would remain popular as well.
Richards’ overall sales growth was also strong, and by 1960 its annual sales reached approximately $800,000. This was only about a fifth of the dollar volume recorded that year by Zimmer, which had become the industry leader, but both numbers would soon be dwarfed as a result of surgical advances by Charnley and others. The entire industry was about to be radically transformed. Of course, no one at Richards knew this in August 1960—not Don Richards, not Harry Treace, and certainly not a newly-hired 27-year-old shipping room clerk: L.D. Beard.
