COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64068773 RD721 Shi Brief essays on orth RECAP WSBb ESSAYS NEW: -^ Mi SHAFFER "W3T2J SV\| COLUMBIA UNIVERSITY EDWARD G. JANEWAY MEMORIAL LIBRARY Wztfi t7ze CcmxplimeThts of THE AUTHOR. BRIEF ESSAYS ON ORTHOPAEDIC SURGERY INCLUDING A CONSIDERATION OF ITS RELATION TO GENERAL SURGERY, ITS FUTURE DEMANDS, AND ITS OPERATIVE AS WELL AS ITS MECHAN- ICAL ASPECTS, WITH REMARKS ON SPECIALISM BY NEWTON M. SHAFFER, M. D. Surgeon-in-Chief to the New York Orthopaedic Dispensary and Hospital ; Clinical Professor of Orthopaedic Surgery, University of New York City (Medical Department) ; Consulting Orthopaedic Surgeon to St. Luke's and the Presbyterian Hospitals, New York ; Consulting Surgeon, New York Infirmary for Women and Children ; Member American Orthopaedic Association, New York Academy of Medicine, New York Neurological Society, etc. NEW YORK D. APPLETON AND COMPANY 1898 Copyright, 1898, By D. APPLETON AND COMPANY. PREFACE. At the request of a few friends, who have been kind enough to take considerable interest in my work, these essays, which have appeared at various periods during the past fourteen years, are now presented in their present form, and they are submitted to the medical profes- sion and the public with the hope that ortho- pedic surgery may be benefited by their pub- lication. __ __ _ N. M. S. 28 East Thirty-eighth Street, New York, January jo, i8g8. iii CONTENTS. PAGE The present status of orthopaedic surgery . i New York Medical Journal, January 26, 1884. What is orthopaedic surgery? . . . .12 Read before the Orthopaedic Section of the Tenth Inter- national Medical Congress, Berlin, August 5, 1890. Medical Record, September 27, 1890. On the definition and scope of orthopaedic surgery 33 New York Medical Journal, November 14, 1891. The relation of orthopaedic surgery to gen- eral SURGERY 46 Boston Medical and Surgical Journal, February 26, 1891. The present needs and future demands of orthopaedic surgery 56 New York Medical Journal, December 12, 1896. The operative side of orthopaedic surgery . 66 Medical Record, December 18, 1897. is orthopaedic surgery to become an obsolete specialty? — With remarks on specialism . 76 Medical Record, March 27, 1897. v BRIEF ESSAYS ON ORTHOPEDIC SURGERY. THE PRESENT STATUS OF ORTHOPAEDIC SURGERY* Tracing the history of orthopaedic surgery from the time of Andry to the present day, we notice that its more important progress has taken place within a very recent period. It will be further noted that America has made by far the most important contributions to, at least, the mechanical element in orthopsedic sur- gery, and that the impetus given to the study of diseased joints and spines by American sur- geons has influenced the treatment of these dis- eases and deformities throughout the entire world. * Reprinted from the New York Medical Journal, January 26, 1884. 2 ESSAYS ON ORTHOPEDIC SURGERY. Whether it was Brodie or Harris that first used or pointed out the value of traction in joint disease, or whether the possibility of successfully treating Pott's disease by the modern form of apparatus was first suggested by English or American surgeons, matters but little from a practical standpoint. It will probably not be disputed that Dr. H. G. Davis, formerly of New York, conferred a .e^reat benefit upon humanity when he gave his | 0^ perfected apparatus to the world, embodying the principles of traction as applied to joint dis- ease ; and, since his day, while various surgeons have from time to time modified and changed Davis's instruments, the Davis principle under- lies all of them. His plain and simple directions as to the mechanical principles involved in treat- ment are followed, more or less in detail, by al- most all who treat diseased spines and joints to- day. Twenty-one years ago, when the writer be- gan the study of orthopaedic surgery, there was little to be proud of in its status in the city of New York. At that time a certain prominent surgeon, in speaking to the writer, not only dis- couraged the adoption of orthopaedic surgery as a specialty but predicted that any one adopt- PRESENT STATUS OF ORTHOPEDIC SURGERY. 3 ing it would fail and be called a blacksmith for his pains. Forty years ago orthopaedic surgery did not include joint and spinal disease, but only such deformities as clubfoot, wryneck, knock-knee, etc. Strabismus was classed as an orthopaedic condition by Bigelow when he wrote his prize dissertation in 1845 — about ten years before Davis gave to the profession his treatment of joint and spinal diseases. After Davis's time, those making any pretense to the treatment of deformities classed joint and spinal diseases as orthopaedic ; or, at least, their reputations have been due to successes not so much in the field of operative work as to a mechanical aptitude in the treatment of the diseases and deformities of the joints and spine. It is, perhaps, in this latter field that Bauer, Sayre, and Taylor ap- pear to the greatest advantage, and the teach- ings of these gentlemen, all more or less in- spired by Davis, form the foundation of much of the orthopaedic surgery practiced in the United States to-day ; for, while all must con- cede the debt owed by orthopaedic surgery to Dr. W. J. Little, of London, that eminent writer, the father of orthopaedic surgery in England, does not include articular disease in his treat- 4 ESSAYS ON ORTHOPAEDIC SURGERY. ises, and, without a full discussion of the me- chanical and secondarily of the operative treat- ment of joint disease, no treatise on orthopaedic surgery can now be called complete. It is not intended, however, to make this short note an historical review of orthopaedic surgery ; it is neither profitable nor necessary to raise points which may involve questions of priority. It is rather the aim of the writer to give a short sketch of what orthopaedic surgery is to-day, and what it demands from those who enter upon its study and practice, for orthopae- dic surgery may now be ranked among the growing and necessary specialties — as a more useful one, indeed, than some which make greater pretensions. In my lectures at the University Medical Col- lege and at the New York Orthopaedic Dis- pensary and Hospital I have ventured to define orthopaedic surgery as follows : " That depart- ment of general surgery which includes the mechanical and operative treatment of chronic and progressive deformities, for the proper treatment of which specially devised apparatus is necessary." Whether, therefore, the condition be one of clubfoot, joint disease, lateral curvature, or PRESENT STATUS OF ORTHOPAEDIC SURGERY. 5 spinal caries, the indications are to be studied, and these indications are to be met from a pathological, anatomical, surgical, and mechan- ical standpoint. To do this the orthopaedic surgeon must be fully informed upon general medicine and surgery, and must be prepared to prescribe his apparatus precisely as a general practitioner prescribes a remedy for disease. In order to satisfactorily carry out the sys- tem of prescribing apparatus for deformities, the instrument-maker should be placed in the same category as the pharmacist, and should supply apparatus for deformities only upon a prescription — i. e., a carefully executed diagram of the apparatus needed. But how is an edu- cated orthopaedic surgeon to execute this plan? While orthopaedic surgery has advanced to the dignity of a well-recognized place in general surgery, the facilities for filling a mechanical prescription are in some respects no better than they were fifty years ago. As a rule, the instru- ment-maker who now fills the prescription of the orthopaedic or general surgeon is not un- willing to treat deformity himself, and it not infrequently occurs that he makes suggestions to the patients that are sent to him. There is, I regret to say, some excuse for this, for it has 6 ESSAYS ON ORTHOPEDIC SURGERY. sometimes happened that the instrument-maker has a better idea of what is needed than the sur- geon who sent the patient to him, for the reason that orthopaedic surgery is not, as a rule, taught in our medical schools, and the generally lax way in which chronic deformities are referred to leaves the newly fledged graduate utterly unprepared to treat them, especially in a me- chanical sense. Nor is it at all unusual for the instrument-maker to be called in a kind of a consultation by the surgeon, to devise some sort of apparatus to accomplish an ill-defined end in a given case of deformity or disease. Still further, there are scattered throughout the country various agents of the prominent in- strument-making firms — druggists, for example, who prescribe for the most serious cases in orthopaedic surgery and order an apparatus from a distance about which they know little or nothing, except that gained from the cata- logues. The amount of deformity — not to mention incidental suffering and expense en- tailed by this system of ignorance and charla- tanry — can not be estimated. The writer knows that in a certain city not far from New York an instrument-maker is called in by the surgeons of a certain hospital, and the patient is practically PRESENT STATUS OF ORTHOPAEDIC SURGERY. y turned over to the mechanic after a diagnosis is made, as if there were something degrading and unprofessional in attending in detail to the me- chanical department of orthopaedic work. But it requires education and a long system- atic training to make a competent orthopaedic surgeon ; and more : it requires a peculiar adapt- ability to successfully prosecute the mechanical detail in any case of orthopaedic surgery, even under the best auspices. The orthopaedic sur- geon should be able, as a matter of education, to make, if necessary, the apparatus which he needs. He should at least know how to make it; he should know more than his workman about the various grades of steel, the points where strength is necessary, where lightness may be tolerated without sacrifice to strength, etc. ; and, indeed, unless one is willing to master such details and to become a mechanician him- self, it is better that he should let orthopaedic surgery alone. No man can be a scientific or- thopaedist, competent to give to his patients the skill which they have a right to demand, who does not become responsible for everything not directly pertaining to the manufacture of the in- struments to be used. The day can not be very far distant when the truth of these statements 8 ESSAYS ON ORTHOPEDIC SURGERY. will be recognized ; and, while a more com- prehensive course of instruction in orthopaedic surgery will be demanded, the various public institutions will provide the means by which de- formities can be properly cared for. There seems to the writer to be no reason why the mechanical element of treatment should be ignored because it is so purely manual ; nor can he imagine that a disease or a deformity essentially painless in its nature, though insidi- ously progressive in character, should be rele- gated to an uneducated class simply because death is not imminent. The pathological con- ditions existing in many cases involving de- formity are very serious, and should not be placed in the hands of ignorant or designing men. They can not be successfully handled by even the general practitioner unless he has the time, the ability, the experience, and the pa- tience to follow a case in detail for perhaps two or three years. Success such as ought to characterize orthopaedic practice comes only through hard work, patient attention to detail, and a thorough mastery of mechanical surgery. These matters are, I think, more thoroughly appreciated in New York than elsewhere in this country. When the writer was appointed ortho- PRESENT STATUS OF ORTHOPEDIC SURGERY. g paedic surgeon to St. Luke's Hospital, eleven years ago, it was with the distinct understand- ing that these principles were to underlie the orthopaedic work, and the success of the move- ment there is greatly due to this provision. In the New York Orthopaedic Dispensary and Hospital there is, in direct connection with the institution, a fully equipped mechanical room in which four or five men are constantly employed making apparatus directly under the instructions of the surgeons. No apparatus is made without a drawing, and careful measure- ments accompanied by actual outlines, when necessary, are given with every order. No re- pairs are made except by personal instruction of the surgeons, accompanied by drawings if necessary. The consequence is that patients are there treated with great satisfaction, and the instrument-makers have there become skilled workmen, some of whom have gone to the aid of orthopaedic surgeons in other cities. It is a great pleasure to note in this connection that in another city steps have been taken to introduce the methods of the New York Orthopaedic Dis- pensary into one of the most prominent hospi- tals and medical schools of the country. The Orthopaedic Dispensary of the University Hos- IO ESSAYS ON ORTHOPEDIC SURGERY. pital in Philadelphia has, in connection with its service, a fully equipped shop, supplied with steam power, where the apparatus used is made after the diagrams, and under the direction of the attending surgeon. This change can not but result in good, for reasons that must be apparent to all. It relegates the instrument- maker to his proper sphere, bringing him wholly under control of the surgeon, upon whom it fixes the entire responsibility for the conduct of his cases. No delays are incurred either in making new apparatus or in repairing old ones, and the patients are supplied with ap- paratus at first cost — an important item when one considers the enormous prices charged by instrument-makers for their apparatus. The fact is, that all hospitals should be similarly equipped with a complete orthopaedic depart- ment. The expense is not great. Dr. A. Sid- ney Roberts, formerly an assistant surgeon to the New York Orthopaedic Dispensary and Hospital, and through whose personal exertions the orthopaedic shop of the University Hospital was organized, informs me that the entire cost of the same did not exceed $2,000, which in- cludes a building erected for the purpose, and that the shop is now nearly self-sustaining — PRESENT STATUS OF ORTHOPEDIC SURGERY, i r the actual cost of production only being charged to those patients who were able to pay it.* This is certainly a good exhibit, and confirms our experience at the New York Orthopaedic Dispensary. The great advantage it will confer upon the institution, the surgeons, and the pa- tients, leads to the hope that other colleges and hospitals throughout the country may be led to adopt the same plan, and thus, while extending to a large class of sufferers all the benefits of a thorough, systematic, and scientific treatment, aid in placing orthopaedic surgery in its proper status before the profession at large. * Since the resignation and death of Dr. Roberts this work has been most successfully carried on by Dr. De Forest Willard and Dr. J. K. Young, of the University College and Hospital staff. WHAT IS ORTHOPAEDIC SURGERY?* The recent action of the Orthopaedic Sec- tion of the New York Academy of Medicine in appointing a committee to secure for ortho- paedic surgery an official recognition by the Tenth International Medical Congress has been successful. Orthopaedic surgery is placed, by this act, upon the same plane with the other special branches of medicine and surgery, and an important duty is imposed upon those who will assemble in Berlin to participate in the proceedings of this newly created section. It would seem, from the many replies which have been received by the committee in response to the circular letter which was sent to those inter- ested in orthopaedic surgery, that there exists a very general desire to aid this important de- * Read before the Orthopaedic Section of the Tenth Interna- tional Medical Congress, Berlin, August 5, 1890. Reprinted from the Medical Record, September 27, 1890. 12 WHAT IS ORTHOPEDIC SURGERY? x * partment of surgery. Over one hundred re- plies have been received from English, Conti- nental, and American surgeons. With a few exceptions the replies have been favorable to the views and wishes of the committee. Of those who have expressed doubts as to the advisability of creating a special section of orthopaedic surgery at the congress, some have plainly said that this special section was not necessary; others have stated that in certain localities the treatment of deformities was influ- enced by a class of men who were not regular- ly educated surgeons ; while others, again, see difficulty in drawing the line between general and orthopaedic surgery. These facts raise some important questions which, it seems to the writer, should be dis- cussed by the members of the orthopaedic sec- tion at its first meeting in Berlin; and the re- marks that I have the honor to present have been suggested by the evident differences of opinion that exist regarding the status of ortho- paedic surgery. And the writer desires to state that the opinions here expressed are his per- sonal views only, and that the committee ap- pointed by the Orthopaedic Section of the New York Academy of Medicine (of which the writer H ESSAYS ON ORTHOPEDIC SURGERY. has the honor to be a member) is in no way re- sponsible for them. It seems unnecessary on this occasion to consider orthopaedic surgery from a, strictly speaking, historical standpoint. A few histori- cal facts may be mentioned, however, which bear upon the rise and progress of the treat- ment of deformities. From the time of Andry the word " ortho- paedic " has been identified with the treatment of deformities, and an " orthopaedist " has been one who treated deformity. But it was not until Stromeyer, in 1830, demonstrated the feasi- bility and the value of subcutaneous tenotomy that " orthopaedics " obtained its first firm foot- hold in the profession. Both before and after Stromeyer's time, however, mechanico-therapy was the fundamental part of the treatment of deformities. The introduction of subcutaneous tenotomy and of subcutaneous myotomy sup- plemented the treatment of deformity by me- chanical means. Subcutaneous surgery did not dispense with the mechanical element of treat- ment ; it rather emphasized its value and neces- sity. And it is fitting that we should note that the first great advance in orthopaedic surgery occurred in Germany, under the influence of WHAT IS ORTHOPAEDIC SURGERY? jr Stromeyer's teachings, and that his methods soon became recognized and practiced in all parts of the world. The status of orthopaedic surgery in 1844, about fourteen years after Stromeyer's methods were introduced, is very clearly shown by the essay* of Dr. Henry J. Bigelow upon ortho- paedic surgery. In this work Dr. Bigelow quotes largely from Stromeyer, Guerin, Bonnet, Velpeau, Phillips, Duval, Dieffenbach, and Little. The subjects treated by Bigelow, in addition to clubfoot, lateral curvature of the spine, torticol- lis, etc., include both stammering and strabis- mus. The operation for the last-named condi- tion has long since been recognized as belonging to the special department of ophthalmology, while the former was long ago abandoned. It seems clear, however, from Bigelow's essay, that, at the date he wrote, orthopaedic surgery, so far as operative treatment is concerned, was synony- mous with subcutaneous tenotomy and subcu- taneous myotomy, and that any condition re- quiring either of these operations was to be classed under orthopaedic surgery. A few years later, or about 1852, an Ameri- * Manual of Orthopaedic Surgery. The Boylston Prize Essay for 1844 ; published in 1845 in Boston. l6 ESSAYS ON ORTHOPEDIC SURGERY. can surgeon, Dr. Henry G. Davis, published his essay, in which he advised the use of elastic traction by means of a portative apparatus in the treatment of hip-joint disease. He also demonstrated the value of traction apparatus for overcoming- the deformities occasioned by chronic articular lesions. The treatment of Pott's disease by means of the antero-posterior spinal apparatus was also demonstrated by Dr. Davis and Dr. C. F. Taylor, and the subject of the mechanical treatment of chronic joint and spinal disease received a marked degree of at- tention from the surgeons of the United States especially. In this field Dr. Lewis A. Sayre and Dr. Charles Fayette Taylor became very conspicu- ous. They amplified Dr. Davis's apparatus, and devised many forms of apparatus for the treat- ment of chronic and progressive deformities, and under their leadership the treatment of chronic joint and spinal disease became a dis- tinctive feature of the American School of Orthopaedic Surgery, and another era in ortho- paedics, second only to that of Stromeyer, was inaugurated. Up to about 1870, or thereabouts, it would therefore appear that two important factors had WHAT IS ORTHOPEDIC SURGERY? 17 aided in placing orthopaedic surgery upon a satisfactory basis : First, the introduction of subcutaneous surgery by a German surgeon; and secondly, the introduction of the portative traction method of treatment of chronic joint disease by an American surgeon. Of the for- mer it may be said that subcutaneous surgery is rarely used in the treatment of chronic deformity without after-mechanical treatment, which after-mechanical treatment is oftentimes more important and essential than the cutting operation, and special skill and training are often required to apply it successfully. Of the latter we may safely say that it is not until the mechanical treatment has proved inefficient that cutting measures are, as a rule, thought of, and that when cutting measures are deemed neces- sary the after-treatment calls for little else than simple surgical dressings, which do not demand a special orthopaedic training to apply. The in- troduction of the traction splint in the treatment of chronic joint disease, as well as the introduc- tion of the antero-posterior splint for Pott's dis- ease, enlarged the field of practical orthopaedics very much. " Preventive " surgery, the highest aim of surgery, became an important factor in the treatment of this class of chronic deformi- 1 8 ESSAYS ON ORTHOPEDIC SURGERY. ties. By the judicious use of traction apparatus, portative or otherwise, deformity can be pre- vented, and in many cases the disease producing the deformity can be arrested. And even after the deformity of chronic articular disease has become pronounced, it can, in many cases, be overcome or greatly modified without any cut- ting operation. Indeed, the tendency of ortho- paedic surgery has always been toward conserv- atism. Its principal victories have been won in this field, and it would seem to be a great error to lose sight in any way of the principal factor which has contributed so largely to its present position. Up to this point, or about 1870, it will be seen that orthopaedic surgery had not invaded the field of general surgery. Availing itself of all that contributed to the relief of deformity from its conservative standpoint, it found many difficult problems which it did its best to mas- ter. It took hold of and cared for a much neg- lected class of humanity — a class that had long been neglected by the profession at large. Even at this day the general surgeon, as a rule, cares but little for orthopaedic work. He is fully occupied in a large field which is every day becoming more exacting — while the ortho- WHAT IS ORTHOPEDIC SURGERY? jg psedic surgeon is devoting himself to a depart- ment which has none of the brilliancy of opera- tive surgery ; which requires much patient attention to mechanical detail ; which demands special facilities for altering and modifying ap- paratus, and a special training and education which very few surgeons have received. It is not many years ago, however, that gen- eral surgery began to invade the domain of or- thopaedic surgery. This is especially true since the Lister method has become so universally accepted. The knife, the saw, the chisel, and the osteoclast have become potent factors in the reduction of obstinate osseous deformities. Knock-knee, bowlegs, old and obstinate cases of clubfoot, and other conditions are relieved by the direct surgical method, without special after-treatment except simple surgical dressings. This marks another era in the treatment of de- formities, and is a legitimate advance in general surgery. And it was about this time also that joint resections began to attract the marked at- tention of surgeons of the United States. To some orthopaedic surgeons these innova- tions of general surgery have proved a stum- bling-block. They diverted the attention from the hard and rugged paths of orthopaedic work 20 ESSAYS ON ORTHOPEDIC SURGERY. per se to the brilliant work of the general sur- geon. I know myself that the allurements of the operating table are very great, for about this time I had my own attack of " surgical fe- ver," which, I am happy to say, proved a self- limiting fever of comparatively short duration. But it raised the questions then, as it raises them now — Where shall the line be drawn ? What is orthopsedic surgery ? Shall orthopae- dic surgeons be general surgeons as well, and shall general surgeons be orthopaedists ? If these questions are answered in the affirmative, there is no room for a special orthopaedic sec- tion in the Berlin Congress. Reference has already been made to Bige- low's work, published in 1845. If we compare it with Sayre's work on Orthopaedic Surgery and Diseases of the Joints, published in 1876, or with Bradford and Lovett's work on Ortho- paedic Surgery, published in 1890, we will see that the tendency of modern orthopaedic sur- gery is to invade the field of general surgery. Bigelow's work teaches subcutaneous tenotomy and myotomy plus special mechanical treat- ment, and nothing more. It does not mention diseases of the joints or Pott's disease of the spine. It deals with the subject of the mechan- WHAT IS ORTHOPAEDIC SURGERY? 2 I ical treatment of chronic deformity in a meager way, a subject which is full of brilliant promise in the future. It suggests a field which has never been fully developed, and which rests with orthopaedic surgery to develop — viz., com- plete and scientific methods of mechanical treat- ment, which, when fully developed, will repre- sent as much of real value to the human race as general surgery itself. It already represents a great deal, especially in the mechanical treat- ment of chronic joint and spinal disease, for since orthopaedic surgeons have done so much to render plain the early diagnosis of joint and spinal diseases, mechanico-therapy can prevent the occurrence of deformity, and can frequently arrest the disease in its first or non-deforming stage. And still more : when the articular dis- ease has advanced and pain is present, or when deformity is progressive and abscess is about to form, or has already formed, mechanico-thera- py, properly understood and applied, can hold out to the sufferer more than the operative or general surgeon. In the field of chronic articu- lar disease alone there is enough to do, and enough for the orthopsedic surgeon to learn, without invading at all the field of general or operative work. 22 ESSAYS ON ORTHOPEDIC SURGERY. Let us see the position Say re takes in 1876. His work, already mentioned, covers, generally speaking, the conditions treated by Bigelow in 1844, and adds to the list " diseases of the joints." This is to be expected, for the author's greatest reputation is based upon his experi- ence in the treatment of joint and spinal dis- eases. He is especially strong in his description of joint and spinal conditions, ample attention being given to diagnosis and prognosis. He devotes much space to excision of the joints. The great strength of his work, however, lies in its orthopaedic part, or in the description of de- formities and their mechanical treatment. The work is one of the pioneers in an important field, Dr. Louis Bauer having covered some- what the same ground a few years before. The part of the work that is of the least value per se is the part which treats of joint excisions, for the reason that the subject is well considered and amply discussed in contemporary surgical literature. While the part which dwells upon orthopsedic surgery is novel, interesting, and, in its way, classical. Bradford and Lovett, in 1890, group all de- formities under one head of "orthopsedic sur- gery " and reject the qualifying title of " dis- WHAT IS ORTHOPEDIC SURGERY? 23 eases of the joints " adopted by Sayre. In addition to the conditions treated by Bigelow and Sayre, we find these authors include sev- eral new titles. Among them are the " cerebral paralyses of children," " pseudo-hypertrophic paralysis," " Dupuytren's contraction," " webbed fingers," and " functional affections of the joints." They extend the surgical aspect of the treatment of deformities and give a large por- tion of their work to resection of the joints, amputation at the hip joint, laminectomy, oste- otomy, osteoclasis, etc. It seems unnecessary to call attention to the excellent and thorough way in which the, strictly speaking, orthopaedic part of the work is executed. It is rather the object of the writer to call attention to the un- necessary invasion of the field of general sur- gery, in a special treatise on orthopaedic sur- gery, when the purely surgical aspect of the conditions named is amply covered in the cur- rent surgical literature of the day. None of the writers I have referred to de- fine orthopaedic surgery in their works, and the definitions given in the various dictionaries are familiar to us all. I have found none that seems sufficiently definite, or that covers the ground from the standpoint of modern orthopaedic sur- 24 ESSAYS ON ORTHOPEDIC SURGERY. gery. Under these circumstances, I found my- self, several years ago, called upon to define orthopaedic surgery, by the class at the Uni- versity Medical College, and I then ventured upon the following definition * : " Orthopaedic surgery is that department of general surgery which includes the mechanical and operative treatment of chronic and progressive deformi- ties, for the proper treatment of which spe- cially devised apparatus is necessary." I would modify this definition to-day so that it would read as follows : " Orthopaedic surgery is that department of surgery which includes the pre- vention, the mechanical treatment, and the operative treatment of chronic or progressive deformities, for the proper treatment of which special forms of apparatus or special mechanical dressings are necessary." No one doubts, myself least of all, that the orthopaedic surgeon should be, from the stand- point of education, a surgeon in every sense of the word ; that he should be a well-educated medical man, with ample clinical experience, before he enters the field of specialism. In short, it seems to the writer that the orthopae- * The Present Status of Orthopaedic Surgery, New York Medi- cal Journal, January 26, 1884. WHAT IS ORTHOPEDIC SURGERY? 25 die surgeon should take a step in advance of the general surgeon, and that his education should include all that is necessary to make a general surgeon, before his study of mechanico-therapy is commenced. As one thus equipped enters the field of orthopaedic surgery he will, if he is wise enough to resist the temptation to become an operative surgeon, find many valuable mines to be explored, and much to be learned that is as yet untouched by any writer. And he will find ample work without invading the field of the general surgeon, just as he will find in all parts of the civilized world very many surgeons who are amply qualified to perform all the oper- ations of surgery, and but very few who can intelligently devise and apply apparatus in the various and varying conditions of chronic de- formity. The needs of orthopaedic surgery are clearly shown when we appreciate how thoroughly general surgery is taught in all the universities and colleges, while on the other hand me- chanico-therapy — a very wide and important field — is too apt to be practically ignored. The result is that the work that should fall into the hands of the educated surgeon is relegated to the commercial instrument-maker. We have 2 6 ESSAYS ON ORTHOPEDIC SURGERY. only to look at the barber pole of to-day to recall the position of surgery in former years, and it is not impossible that in a few years the opprobrium that attaches to mechanico-therapy will become a thing of the past, and that we may have a class of surgeons interested in orthopaedic work who will be orthopaedic sur- geons in the strictest sense of the word. From the standpoint here taken, and as a matter of experience, it seems to the writer that the invasion of the field of general surgery by the modern orthopaedist is unnecessary and un- called for. It further seems to the writer that it can only bring discredit upon a new and im- portant field of work, which is even further removed from general surgery than ophthal- mology or laryngology. This invasion will di- rect the attention of the profession to the weak point in the armament of those who combine general surgery with orthopaedic work, and it will, if persisted in in the future, break down the lines between it and general surgery. The remark of a prominent general surgeon to the writer, after reading the latest work on ortho- paedic surgery, is not, perhaps, so much out of place. He said : " The next work on ortho- paedic surgery will likely tell us all about frac- WHAT IS ORTHOPEDIC SURGERY? 2 J tures and dislocations." The fact that the plan here proposed will necessarily limit the opera- tive work of the orthopaedist does not lessen either the importance or the honor of the work that lies before him. Operative surgery has its own place, and in orthopaedic work that place should be second ; and operative surgery should be used by orthopaedists only as it supplements mechanico-therapy. Orthopaedic surgery is as yet in its infancy, and needs men with strong heads and strong hearts, men who are willing to work and study and wait, and to those who do this there will be, I am sure, an ample reward. And looking at the subject from the stand- point of our meeting here in Berlin, we may learn another lesson. The only possible excuse for the foundation of a special section of ortho- paedic surgery at this congress is the rapid rise and development of mechanico-therapy, espe- cially in the United States. There would be no true orthopaedic surgery to-day if mechanico- therapeutics had not been studied long and patiently by a comparatively small body of intelligent surgeons. And if the committee who addressed their petition to the congress asking recognition, had relied upon the record of orthopaedic surgery in the field of joint re- 28 ESSAYS ON ORTHOPEDIC SURGERY. sections, amputation at the hip joint, laminecto- my, osteotomy, etc., I fancy that the committee would have been referred, and rightfully so, to the section of general surgery. In closing my remarks, I feel that I ought to state that the conclusions reached in this paper are based upon an experience of nearly thirty years in orthopaedic work. In 1873 I found myself in charge of the ortho- paedic service of St. Luke's Hospital, with no restrictions as to the operative work of my own department. I soon found that the purely sur- gical aspect of the work was very attractive, and that my interest in the patients under my care was gauged by their present or prospective operative value — and that the conservative or orthopaedic side of the work was becoming less interesting. After mature reflection, it became apparent that the operative field was well repre- sented in the eminent surgical staff of the hospi- tal, and that it was clearly my duty to develop and establish the principles of orthopaedic sur- gery. After reaching this conclusion I volun- tarily turned over to my colleagues all the purely operative work which required no ortho- paedic treatment after operation, and from that time up to the day of my resignation I operated WHAT IS ORTHOPAEDIC SURGERY? 2 9 only on those cases which would necessarily re- main under my care after operation. Soon after my appointment as surgeon in charge of the New York Orthopaedic Dispensary and Hospi- tal, an attempt was made to combine a general surgical staff with the orthopaedic work. At first it seemed to be just what was needed, and while questions of jurisdiction were sometimes raised, there was no conflict between the sur- gical and orthopaedic departments. The real difficulty appeared later, when it was found that the junior medical officers seemed to lose their interest in the orthopaedic work, while they were very active in the purely surgical work. The hospital was gradually becoming a surgical hos- pital rather than an orthopaedic one. It became apparent to the trustees after a while that the institution was drifting away from its avowed object. After a time the surgical staff retired, and since that time the institution has been a strictly speaking orthopaedic one. As the medical officer in charge of the New York Orthopaedic Dispensary and Hospital, and having absolute control of its surgical policy, I have for several years — and since the retirement of the actual surgical staff — -operated only on those patients who required special orthopaedic 30 ESSAYS ON ORTHOPEDIC SURGERY. care after operation. All other cases requiring surgical operation have been referred to some general hospital ; and I have pursued the same course in my private practice — that is, I have referred all patients requiring surgical opera- tion, who have not demanded special ortho- paedic care after operation, to a general surgeon. And this, I believe, is the proper position for the orthopaedic surgeon to take. During my service at St. Luke's Hospital it was made apparent very soon after my appointment that the resident house staff took little or no in- terest in the orthopaedic ward. Their interests, as young and recently graduated men, were in general surgery and general medicine. Aside from this, though they were all picked men, very few of them seemed to possess the mechan- ical ability which is an essential element of suc- cess in orthopaedic work. After a few years' effort to keep the house staff interested, an effort which failed, I was obliged to ask the hospital authorities for a special assistant. At the New York Orthopaedic Dispensary and Hospital it has sometimes been difficult to secure the attention of the junior staff during a period long enough to fit them for future ortho- paedic work. At the end of six months or a year WHAT IS ORTHOPEDIC SURGERY? 3! they may regard themselves as fully equipped orthopaedic surgeons. On the other hand, we have had able men as assistants whose college and competitive examination records were high, whose mechanical instincts were lacking. These men were clearly out of place in ortho- paedic work. My experience proves that it re- quires an exceptional man to succeed in or- thopaedic practice. If he possesses mechanical tastes and ability, and devotes himself to ortho- paedic work for a sufficient period, he will almost surely succeed in reaching a high place. But if he attempts at the same time to do the work that would naturally fall to the general surgeon, he will, sooner or later, become the latter in effect, if not in name. And if he does not pos- sess, in a high degree, an educated appreciation of the various and complex mechanical problems which will constantly confront him in daily prac- tice, he will very likely turn to operative meas- ures when there may be no need for such a step. Nor can any one expect to equip himself as an orthopaedic surgeon in a short time. After graduation, and a term of service as an interne in a hospital, a course of study covering at least five years (including a wide clinical experience in dispensary and hospital work) should be de- 32 ESSAYS ON ORTHOPAEDIC SURGERY. manded of those who expect to become orthopae- dic surgeons. Orthopaedic surgery lies wholly within the domain of " chronic " surgery. The junior medical officers in large general hospitals see but little of this class of surgery. On the other hand, they acquire during their hospital residence a wide experience in " acute " surgery. No one can acquire a safe clinical experience without a prolonged study of many cases ; and in the chronic joint department of orthopaedic surgery one may wait several years before see- ing the end of one's first case. A great deal will be expected of the ortho- paedic surgery of the future, and it seems to the writer that the sooner the followers of ortho- paedic surgery realize that it has enough in itself to sustain its well-earned reputation without en- croaching upon other grounds, the better it will be for orthopaedy. I feel a natural embarrass- ment in thus presenting my views, but I also feel that it is a duty, which the present occasion demands; and if my remarks are regarded as embodying the conclusions of one who desires to see orthopaedic surgery occupy the high place it deserves, I shall be wholly satisfied ; and if they aid at all in solving the question which heads this paper, I shall be content. ON THE DEFINITION AND THE SCOPE OF ORTHOPAEDIC SURGERY* REPLY TO A CRITICISM^ I HAD begun to think that my remarks on What is Orthopaedic Surgery ? read before the International Medical Congress held in Berlin, were to receive the most formidable and crush- ing of all criticisms — viz. : the silence and neglect of my colleagues. A whole year has passed since my paper was read, and no one has been kind enough to take any notice of my attempt to define modern orthopsedic surgery. I was therefore much pleased to know that another effort would be made to define ortho- paedic surgery by one well known in this work, * Delivered before the American Association at its fifth annual meeting. f Vide article entitled Orthopsedic Surgery ; its Definition and Scope, New York Medical Journal, November 7, 1891. Reprinted from the New York Medical Journal for November 14, 1891. 33 34 ESSAYS ON ORTHOPEDIC SURGERY. whose opinions and views we have all been glad to hear. While I can not but feel grateful to my friend for his kind attempt to clear up any mis- interpretation of my position, I feel, so far as our German friends are concerned, that his ex- planation is unnecessary. Just prior to the reading of my essay before the Orthopaedic Section of the Berlin Congress I distributed seventy-five copies of the essay translated into German ; and I noticed, as I read, that many of my hearers followed me line by line. There was doubtless considerable confusion on the first day, owing largely to the fact that I read in my native tongue. But whatever doubt there may have existed was set at rest by the appearance of my essay, kindly translated by my friend Dr. F. Beely, of Berlin, in the Ber- liner klinische Wochenschrift,* soon after the adjournment of the congress. I can not under- stand how any of my English-speaking col- leagues, who were present when I read my essay, misunderstood my plainly stated views. As to the quotation referring to my personal responsibility for the views expressed, I feel * Was ist orthopadische Chirurgie ? Berliner klinische Wochen- schrift, No. 43, 1890. THE SCOPE OF ORTHOPEDIC SURGERY. 35 that I ought to say that I had the honor of in- augurating the movement which resulted in the recognition of orthopsedic surgery by the Ber- lin Congress ; and that, as chairman of the com- mittee, I should have been false to my trust if I had permitted even an inference that the com- mittee as a whole was in any way responsible for the views expressed. We have all listened with pleasure to our friend's remarks. But he does not, I think, make it clear why orthopaedic surgeons should undertake to do the work that the general sur- geon is so well equipped to perform. He does not make it clear why orthopaedic surgeons should not confine themselves to, strictly speak- ing, orthopaedic work — which is as yet in its in- fancy of usefulness to humanity, and which has before it a career of great brilliancy. I think we are all agreed that specialties in medicine are the natural outgrowth of a true progress ; and that no specialty ought to suc- ceed which attempts to cover, or which even invades, the well-defined limits of general medi- cine or general surgery. In short, all special- ties in medicine should have a distinct and valid reason for their existence. If we stop to ask how orthopaedic surgery became a spe- 36 ESSAYS ON ORTHOPAEDIC SURGERY. cialty, we can readily answer that it was due to the undeserved neglect of mechanico-therapy by the entire medical profession. A few ear- nest and intelligent surgeons have rescued me- chanico-therapy from its unenviable position, and have made it what it is to-day. They did it, not by devising new operative procedures for the relief of deformity — the general surgeon did that ; but by investigating and studying the mechanical principles involved in the treatment of deformity, and by inventing apparatus to meet the required therapeutical ends. Without the work of these men, the present American Orthopaedic Association would have had no ex- istence, and orthopaedic surgery as a distinct specialty would scarcely be recognized to-day. It is universally admitted, I think, that all specialists in medicine should be thoroughly equipped both in medicine and surgery, and there is no reason why one thus equipped should not practice both general medicine and general surgery. It must, however, be appar- ent that the so-called specialist who does this weakens his own claim to specialism and apolo- gizes for his specialty. This will be true so long as medicine and surgery, generally speak- ing, are progressive and so long as there are THE SCOPE OF ORTHOPEDIC SURGERY. 37 unsolved truths awaiting the special investi- gator and the special student. This, it seems to me, is especially true of orthopaedic surgery. There is much to be done, much to be learned, in the mechanical treat- ment of deformities, while the surgical treat- ment of deformities will receive ample and well-prepared attention from the general sur- geon. A brilliant future awaits those who will steadfastly devote themselves to the develop- ment of the scarcely taught and the compara- tively unknown branch of mechanico-therapy. There are unexplored fields in sight with rich rewards awaiting the patient tiller ; and while there is so much to learn, so much to be devel- oped, and so much to be made available for the benefit of suffering humanity in these unex- plored fields of mechanico-therapy, some ortho- paedic surgeons are content to ignore the benefit they could bestow upon humanity by perfecting true orthopaedic surgery and are willing to follow more or less in the beaten paths of general surgery. And we will all ad- mit that the general surgeon is fully prepared to perform all the operations for the relief of certain chronic deformities and that he needs no help from the orthopaedic surgeon in apply- 38 ESSAYS ON ORTHOPAEDIC SURGERY. ing the conventional surgical dressings they require ; but we also know that the early train- ing of the general surgeon does not prepare him to apply properly devised apparatus in the more difficult cases of chronic or progressive deformity. It should be the aim of orthopaedic surgeons to excel in that which gives ortho- paedic surgery its existence and makes it, prop- erly interpreted, one of the most distinct and necessary of all the special branches of medi- cine. Orthopaedic surgery has had its first trials and has slowly reached a point from which it can look forward to ultimate success. Sooner or later it will, I think, reach a point where its followers will be true orthopaedic sur- geons. In the present status of orthopaedic surgery the invasion of the field of the general surgeon by the orthopaedist can only be justified on the plea of expediency ; but, as a matter of princi- ple, it can never be just or wise for orthopaedic surgeons to leave the undeveloped fields of true orthopaedic science for the well-trodden but perhaps more attractive paths of general sur- gery. To mingle the two is to endanger both, especially the orthopaedic part. There are very THE SCOPE OF ORTHOPEDIC SURGERY. 39 few of us who have not witnessed examples which prove this statement. We may go anywhere in the civilized world and we shall find general surgeons who have been amply educated to perform all the opera- tions of general surgery. The medical colleges and universities of the world are monuments to the brilliant success of general surgery. On the other hand, how many of the cities of the world contain men who have received a thor- ough training in orthopaedic work and meth- ods ? A liberal training in our colleges and hospitals does not make an orthopaedic surgeon any more than it makes an ophthalmologist or neurologist. Years of post-graduate study and work are necessary to make an accomplished specialist in orthopaedic surgery ; and when one has mastered the rudiments of the science — and the best of us have only done this — he will even then have to be on his guard or he will be di- verted from his plain line of duty by the attrac- tiveness and brilliancy of operative work. The true orthopaedic surgeon will desire to extend the benefits of a developed mechanico-therapy to relieve the sufferings and the deformities of the human race ; and he will find his time fully taken up in one of the most attractive fields of 40 ESSAYS ON ORTHOPEDIC SURGERY. study in the whole range of medicine. His re- ward will be ample, for the benefits which will accrue to humanity from a perfected ortho- paedic science will be second only to the grand results of operative surgery itself ; but he who would strive for this goal — of the greatest good to suffering humanity — must necessarily, in the present state of orthopaedic surgery, work in new fields. He must devote all his energies and time to his work, and he will scarcely have time — even if he has the inclination — to compete with the general surgeon in the field of operative work. The pleasure that attends the practice of or- thopaedic surgery needs only to be stated to be appreciated. As I have remarked elsewhere, orthopaedic surgery is an exact science. The orthopaedic surgeon is dealing with mathemati- cal and mechanical problems all the time, and the application of the principles of treatment is limited only by the vulnerability of the human tissues and his therapy is regulated by his own hands. If his patience equals his confidence, the orthopaedic surgeon can achieve many very brilliant results. So long as orthopaedic surgeons combine general operative surgery with their orthopae- dic practice, the medical profession will fail to THE SCOPE OF ORTHOPAEDIC SURGERY. 41 properly recognize their position. This will ac- crue to the advantage of an uneducated class of instrument-makers, whose efforts to serve the profession are laudable, but whose failures are only to be expected. So long as this unedu- cated class are relied upon by the profession, humanity will be the sufferer, and the general surgeon will be dissatisfied with his manage- ment of cases of chronic deformity requiring special mechanical treatment. The medical pro- fession need educated orthopaedic surgeons to whom they can refer patients with chronic de- formity requiring special mechanical treatment with confidence ; and the orthopaedic surgeons, * with equal confidence and with a merited self- respect, should refer their operative cases not requiring special orthopsedic care after opera- tion to the general surgeon. By and by a sufficient number of surgeons trained in orthopaedic work and methods will exist, and then the profession at large will rec- ognize their position and claims. Then the in- strument-maker will be relegated to the posi- tion which the pharmacist now occupies — viz. : that of " compounding " the " prescription " of the surgeon. There is too much false pride among some 42 ESSAYS ON ORTHOPAEDIC SURGERY. orthopaedic surgeons — and this false pride inter- feres very materially with the advance of true orthopaedic surgery. Some orthopaedic sur- geons seem to want to be recognized as opera- tive surgeons. They dislike, for example, to have it said : " Oh, yes, Dr. is good enough at applying a brace for deformity, but they say he is too timid to excise a joint." The conse- quence is that Dr. wants to prove his abil- ity to perform all the operations of surgery. I have heard remarks like this made of some of our best orthopaedic surgeons — I know it has been said of myself. But we must rise above such puerile criticism. The fact that we choose to send our, strictly speaking, operative cases # directly to some general hospital or to some general surgeon places the orthopaedic surgeon in a secure position ; for the difficult cases which he retains and which he is competent to treat are better cared for than they could be by the general surgeon — and we know that the general surgeon is fully equipped to care for the, strictly speaking, operative cases. If we candidly study the element of humanity and progress in our work, it would seem that this would be the best for those whose interests are committed to our care. THE SCOPE OF ORTHOPAEDIC SURGERY. 43 But I must not be misinterpreted. The ma- jor work of the orthopaedic surgeon lies in the mechanical field. On the other hand, he must be prepared and equipped to operate when his work demands it, and he must keep abreast with current medical thought and practice. He is not to be a mechanic alone. But, as a matter of principle, and a logical sequence of his chosen specialty, the orthopaedic surgeon should only operate upon those patients with chronic deformity who ought necessarily to remain under his care after operation. This is where, I think, the operative line should be drawn, for the function of the orthopaedic surgeon should be to fill a place not occupied by the general surgeon. This position is one which all ortho- paedic surgeons can occupy with credit to them- selves — and if it is maintained, it will result greatly to the credit of orthopaedic surgery and to the benefit of suffering humanity. I can not but feel flattered in thinking that our friend has adopted my definition of ortho- paedic surgery in every respect except the final and qualifying clause. He would have it read as follows : " Orthopaedic surgery is that de- partment of surgery which includes the pre- vention, the mechanical treatment, and the op- 44 ESSAYS ON ORTHOPEDIC SURGERY. erative treatment of chronic or- progressive deformities." Let us see where this would lead us. It would make the orthopaedic surgeon a general surgeon in effect. He would be called upon to trephine for cerebral paralysis, to perform lam- inectomy for spinal paralysis, to amputate for incurable deformity, to excise diseased joints which do not require mechanical treatment, and to operate for spina bifida, harelip, elephantia- sis arabica, etc., and in cases requiring plastic surgery, etc. I respectfully submit that these operations belong to that class which our friend calls " the operative procedures that legitimately belong to the general surgeon," to which, he says, " or- thopaedic surgery lays no claim." The above-mentioned modification of my definition would lead us far from the goal which all orthopaedic surgeons should strive to reach. On the other hand, it would appear that the definition submitted at the Berlin Congress draws a very distinct line, founded on the real traditions of modern orthopaedic surgery. It places orthopaedic surgery in a clearly defined position, which makes it incumbent upon its fol- THE SCOPE OF ORTHOPAEDIC SURGERY. 45 lowers to operate in those conditions only which clearly demand special orthopaedic care. In order to be explicit, I again submit my definition of orthopaedic surgery as read before the Berlin Congress. It is as follows : " Ortho- paedic surgery is that department of surgery which includes the prevention, the mechanical treatment, and the operative treatment of chronic or progressive deformities, for the proper treatment of which special forms of apparatus or special mechanical dressings are necessary." THE RELATION OF ORTHOPAEDIC SURGERY TO GENERAL SURGERY* Gentlemen: It has been for several years the special function of the New York Ortho- paedic Dispensary and Hospital to aid in the development of purely orthopaedic methods. Its work has been to develop and improve the much-neglected branch of mechanico-therapy. It has devoted much time and effort to the early recognition of the deforming diseases, especially of childhood, and it has aided in devising meth- ods not only for the prevention of deformity, but also for relieving or curing it after it has occurred. While the general surgeon has been occupied in bringing operative surgery to its present very high standard of efficiency, your * An address delivered before the Trustees of the New York Orthopaedic Dispensary and Hospital, upon the occasion of its twenty-third annual meeting. Reprinted from the Boston Medical and Surgical Journal of February 26, 1891. 46 THE RELATION TO GENERAL SURGERY. 47 institution has been working- in a field of almost equal importance — though far less brilliant and far less attractive to the rank and file of the medical profession. The operative side of general surgery has always been well taught in all the medical col- leges and universities. On the other hand, there has been in the same institutions an almost gen- eral neglect of orthopaedic surgery — a depart- ment of surgery almost as important as opera- tive surgery itself, and one which is of great value to the human race. Your institution has been content to work in those lines which would aid in removing the unjust opprobrium that at- taches to mechanico-therapy, and in demonstrat ing the usefulness and the wide range of prop- erly applied mechanical principles of treatment. In short, your institution has been steadily working upon conservative lines — neither ignor ing the great strides in general surgery, nor for- getting its own mission. Its efforts have been rewarded in more ways than one. The steady increase in the number of patients which have sought your services was mentioned in the last annual report ; and while orthopaedic institu- tions and orthopaedic departments of institu- tions and orthopaedic clinics at the colleges 48 ESSAYS ON ORTHOPAEDIC SURGERY. have multiplied in New York city and else- where since this institution was organized in 1866, it still remains a fact that a large percent- age of the patients which apply to your institu- tion for treatment have previously had no ortho- paedic treatment at all ; and while there are now quite a number of places to which the poor crip- ple may apply, so broad and so generous is the philanthropy of New York, the important ortho- paedic institutions of our city are overcrowded, and some of them, like our own, are asking for more room and increased facilities. • The subject of mechanico-therapy is so im- portant and its future usefulness is now so well assured that we, as an institution, may well feel proud that our efforts have been so steadfastly directed toward its development. The general surgeon, whose ample and easily obtained train- ing fits him to perform the cutting operations for the relief of deformity, finds himself fully occupied in keeping abreast with the current surgical thought and literature of the day. The dexterous operator finds his time fully taken up in his peculiar and special work. But there is another side to surgery. The joint, for exam- ple, that is excised in many instances may be saved; the limb condemned to amputation on THE RELATION TO GENERAL SURGERY. 49 account of its deformity may in many cases be straightened. Properly applied mechanico-ther- apy will save many of the deformities that fall into the hands of the operative surgeon. In- deed, many of the deformities that were for- merly almost habitually operated upon can be relieved or cured by orthopaedic measures with- out operation. But if a patient with deformity reaches a point where orthopaedic measures are contraindicated, or useless, or where a surgical operation, with ordinary surgical dressings only, is necessary to remove the deformity, he should at once be placed under the care of the general surgeon. Orthopaedic surgeons, in short, ought to limit their work to their own department — in which there is enough to do and enough to learn, without interfering in the slightest degree with the already overcrowded ranks of the general surgeon. Orthopaedic surgeons have until recently been placed at a great disadvantage. The early followers of true orthopaedic surgery — and some of them are alive to-day — were necessarily self- educated in orthopaedic methods and work. They had no school or college ; no hospital or dispensary to which they could go to receive instruction in orthopaedic surgery. Equipped 50 ESSAYS ON ORTHOPEDIC SURGERY. as regularly educated men, amply prepared to amputate a limb or excise a joint, etc., they were not taught even the simplest rudiments of mechanico-therapy. They might have been told that " Smith's clubfoot shoe is the best," or that "Jones's knock-knee instrument is su- perior to Brown's " ; but of the mechanical principles involved they were taught little or nothing. In addition to this, they had to meet and overcome the still existing opprobrium that attaches to the subject of mechanical treatment. They had also to meet the criticism that " Dr. X. could perhaps apply a clubfoot shoe pretty well, but he could not amputate a limb as well as Dr. Y." — as if any means that relieves human suffering is beneath the dignity of the most highly educated and accomplished surgeon that ever lived. This is becoming changed. There are sev- eral places where the seeker after ortho- paedic knowledge may find opportunities for study ; and while it is difficult to remove the old prejudice that exists, especially outside of New York city, it will not be long before orthopaedic surgery, per se, will occupy its legitimate place in the estimation of the entire medical profession. In the meantime, ortho- THE RELATION TO GENERAL SURGERY. 51 pasdic surgery needs men who will work and wait — men who will patiently investigate the many unsolved questions that confront it on all sides ; men who will devote themselves to a true specialism, and who will steadfastly refuse to compete with the general surgeon in the field of operative surgery. We have only to look about us to see how fully the field of general surgery is occupied. No one in the civilized world, requiring the services of the general surgeon, need go unre- lieved. The general hospitals of all countries are numerous and well-equipped, and this is especially true of our own great city. On the other hand, what are the special provisions made for the treatment of the deformed? There are comparatively few surgeons in the whole world whose early education and train- ing fit them to intelligently apply apparatus to the conditions of deformity. In some of the large cities, both here and abroad, there are orthopaedic dispensaries and hospitals, but the surgeons connected with them and controlling them are too frequently men with strong oper- ative instincts and training — surgeons who are accomplished in all that pertains to diagnosis, the conventional surgical dressings and the use 52 ESSAYS ON ORTHOPEDIC SURGERY. of the knife, but who are necessarily lacking in the special training- required to successfully apply the fundamental principles of mechanico- therapy to an average case of progressive de- formity. They are, by nature and education, operative surgeons who duly recognize the value of mechanico-therapy, but they are, I think, too often willing to relegate the mechanical detail of treatment, both before and after operation, to the uneducated instrument-maker, whose interest in the patient is merely a commercial one. It is largely so in England, France and Germany — it is only less so in America. At the same time, there are quite a number who are, strictly speaking, orthopaedic surgeons, whose educa- tion is based upon an early and prolonged train- ing in orthopaedic methods, and it is to these men that we must look, I think, for the advance- ment of true orthopaedic surgery. It must be apparent that it is only by spe- cial effort and prolonged study and work that any department of medicine can reach its maxi- mum of benefit to the human race. The his- tory of medicine proves that many of its great- est advances have been made by broadly edu- cated men who have devoted themselves to special branches of work. And so it is in ortho- THE RELATION TO GENERAL SURGERY. 53 paedy. It is not the surgeon who amputates a thigh, reduces a fracture or a dislocation, and applies a hip splint the same day, that is likely to advance orthopaedic science. It is more likely to be the surgeon who, with the wide and almost unexplored field of mechanico-therapy before him, devotes his life to demonstrating its great value in the various conditions of deform- ity and deforming diseases. The function of the orthopaedic surgeon should therefore be to fill a place not occupied by the general surgeon — to do a work that the general surgeon is either unwilling or unfitted to undertake, and to aid in developing an im- portant department of surgery which has been too long neglected or ignored. Those deform- ities which general surgery is competent to relieve, without the intervention or aid of the orthopaedist, should be placed at once under the care of the general surgeon ; while, on the other hand, chronic cases requiring special mechani- cal treatment, either in the prevention or cure of deformity, should be placed under the care of the orthopaedic surgeon. It is my experience that a longer training is necessary to fit one to be an orthopaedic surgeon than to fit one to be an operative surgeon. The 54 ESSAYS ON ORTHOPEDIC SURGERY. brilliancy of operative work attracts many of the best men in the profession, while the hard and rugged work of mechanico-therapy seems to repel many who are adapted to orthopaedics ; and yet the work of the orthopaedist may be called an exact science. He is dealing with mathematical and mechanical problems all the time. He has a definite object in view, and his therapy is controlled by his own hands. He is limited in the application of his principles of treatment only by the vulnerability of the hu- man tissues ; and while he may be in doubt as to the best " method " to be employed, he is never in doubt as to the ultimate principles of treatment. The field of othopaedic surgery is therefore a very wide one — so wide and so comprehensive that one engaged in its practice need not en- croach on the field of the general surgeon. Still, the orthopaedic surgeon should be an edu- cated operative surgeon — and he should be pre- pared to operate upon any patient who requires special mechcmical treatment after operation. But the operative treatment should be secondary to the mechanical, and the element of conservatism should necessarily enter largely into the work. The patient mechanical work — may be of years — necessary to save a limb or joint from deformity, THE RELATION TO GENERAL SURGERY. 55 may be less brilliant than the operative means that removes them, but the real merit lies in that method which saves the limb and restores the af- fected individual to society with a useful member. In an essay read before the International Medical Congress held in Berlin in August last the writer raised the question, " What is Ortho- paedic Surgery?" and he ventured to define it as follows : " Orthopaedic surgery is that de- partment of surgery which includes the preven- tion, the mechanical treatment and the opera- tive treatment of chronic or progressive de- formities, for the proper treatment of which special forms of apparatus or special mechanical dressings are necessary." The conclusion formulated in this definition is based upon nearly twenty-two years of work in your institution — seventeen years spent in the orthopaedic ward of St. Luke's Hospital, combined with an early training of five years in the New York Hospital for the Relief of the Ruptured and Crippled. It places your insti- tution on record as being the first to formulate a definite plan of work, which separates ortho- paedic from general surgery, and which aims to cover a definite field not included in that of the general hospitals and dispensaries. THE PRESENT NEEDS AND FUTURE DEMANDS OF ORTHOPAEDIC SURGERY.* Gentlemen : As I rise to address you this evening the new hospital building approaches completion. Recently remodeled and much en- larged, it is fully equipped in every important respect for modern orthopaedic work. A year ago we were deeply in debt. The ordinary dwelling house adjoining your prop- erty on the east, unfitted for hospital use, had been purchased. We were without means to erect a suitable hospital structure in its place. To-day, through the kindness of friends, a new fireproof hospital building, as yet not wholly * A portion of an address delivered before the trustees of the New York Orthopaedic Dispensary and Hospital upon the occasion of its twenty-ninth annual meeting, held November 16, 1896. Reprinted from the New York Medical Journal for December 12, 1896. 56 PRESENT NEEDS OF ORTHOPEDIC SURGERY. 57 paid for, stands in the place of the property which we purchased. Aided by this additional building, we find that our capacity for hospital patients has been increased one third ; we have made various changes in the Sloane pavilion and in the older hospital structure ; an elevator has been introduced ; we have a complete Rontgen-ray apparatus, a modern operating room has been added to our equipment, and the three original buildings comprising our now consolidated hospital represent all that the most earnest critic could demand in orthopedic work. It matters but little where the examination com- mences, whether in the shop, where the most in- tricate and delicate apparatus for the treatment of deformity can be made ; or in the domestic department, where all the modern improve- ments have been introduced, the progress up- ward from story to story develops a careful economy of space, with a liberal allotment of room for both the dispensary and hospital. The dispensary is especially adapted to the needs of the outdoor patients, who crowd the reception and treatment rooms daily. It is on this floor that the X-ray room has been placed, and it is here also that the interesting work of the neurological department has been located. 58 ESSAYS ON ORTHOPEDIC SURGERY. Nearly the whole first floor of the three build- ings comprising our remodeled hospital is given up to dispensary work. On the second floor are located the rooms for the administrative work of the hospital, the children's dining room, and the operating room — the two latter being rooms that would attract attention in any hospital. Six wards, accommodating seventy-five pa- tients, occupy the third and fourth floors, and everything has been done to make these wards bright, attractive, and aseptic, while the prob- lem of ventilation has received its full share of attention. The fifth story contains the children's play room, the roof garden, and rooms for nurses, while, at a remote point and unconnected with the rest of the house, and with an entrance from an open roof only, there is an isolated ward with suitable sanitary adjuncts, for sus- pected acute infectious and contagious dis- eases. This, in brief, is a description of your com- pleted building. The more one studies the ar- rangement of the various parts of the building and notices how completely the compact whole represents the needs of a modern and progress- PRESENT NEEDS OF ORTHOPEDIC SURGERY. 59 ive orthopaedic hospital, the more the friends of your work must be satisfied. Modern orthopaedic work demands all that you have given your medical staff. The theo- ries of a few years ago regarding the causation of tuberculosis have become demonstrated facts. The light which modern bacteriological investi- gation has thrown on the various morbid pro- cesses which enter into the question of the pro- duction of certain chronic deformities is no less important to the orthopaedic than to the general surgeon. In treating these deformities from the operative standpoint, the orthopaedic surgeon needs the same training as the general surgeon, and the same aseptic and general surgical care should be exercised, for example, in opening a simple abscess connected with a diseased joint as in operating for an acute appendicitis. But while the general surgeon covers a wide opera- tive field, the orthopaedic surgeon finds, in his work, a more limited operative field. The lat- ter, however, should be no less a surgeon be- cause he operates in those cases only which require special orthopaedic care after operation. To extend the operative field of orthopaedy be- yond this point is to break down the only bar- rier between it and general surgery, and the 6o ESSAYS ON ORTHOPEDIC SURGERY. effect is to belittle true orthopaedic surgery and to emphasize the impression, only too pro- nounced, that the tendency of the orthopaedic surgeons of to-day is to make orthopaedy a stepping stone to general surgery. The effect of this on legitimate orthopaedic surgery can be imagined. If it should so happen that the pres- ent views of some of those who are known as orthopsedic surgeons should prevail, there will be no orthopaedic surgery, except as it may exist as an adjunct to general surgical practice, and the real foundation of orthopaedy — that is, the study of mechanico-therapy — will be rele- gated to the instrument-makers from whom legitimate orthopaedic surgery rescued it not many years ago. Your institution stands as the exponent of legitimate orthopaedic practice. Until recently it has been hampered, by the lack of proper facilities, in the full performance of its work. During this time it has striven patiently and persistently to develop the much-neglected side of deformity surgery — namely, the unattractive mechanical side. But unattractive as is this part of the work to the average orthopaedic or general surgeon, it is the important side, and it is the side of the work upon which the success PRESENT NEEDS OF ORTHOPEDIC SURGERY. 6 1 of the treatment of a case of deformity depends. It seems almost useless for me to say that the same attention will be given to this part of the work in your institution in the future as long- as I have the honor of being its surgeon-in-chief, and I dare to hope that my successor, whoever he may be, will hold the same views. The addi- tion of an operating room simply enables us to treat our patients from both an operative and mechanical standpoint. It does not mean that the operative side will be developed at the ex- pense of the mechanical work. It does not mean that there is any danger of your hospital being known as a general hospital, where all. or even many, of the operations of surgery are to be performed. If it becomes necessary for us to operate to overcome a deformity, and the pa- tient requires special orthopaedic care after operation, we propose to operate, but all other patients requiring surgical care will be referred to some general hospital, where they belong. The future of orthopaedic surgery depends upon the deliberate study and development of the mechanical aspect of the work. There will always be operative surgeons who can perform the cutting operations which are sometimes necessary to relieve chronic deformity. On the 62 ESSAYS ON ORTHOPEDIC SURGERY. other hand, there is to-day a scarcity of surgeons who understand, or who have been taught to apply, the principles underlying the mechanical correction of deformity. The student of me- chanico-therapy needs encouragement, and the medical profession should understand more fully that it is only by a conscientious and prolonged study of both the operative and mechanical work that a fully equipped orthopsedic surgeon can be produced. It is taken for granted even in our best medical colleges that a student is a natural mechanician — born to devise and apply apparatus in the treatment of chronic deformity — and yet I venture to say that there is no more delicate or difficult problem in the whole field of surgery. Who will be the first one to endow a chair of mechanico-therapy, associated with a clinical professorship of orthopaedic surgery, in one of our medical schools ? To apply an apparatus, already made, to a patient, to give a description of Smith's hip splint, or Jones's spinal brace, or Robinson's clubfoot shoe, or to apply a plaster-of-Paris splint in presence of a class of students, is like giving a simple verbal description of the quad- riceps extensor femoris muscle to one who has PRESENT NEEDS OF ORTHOPAEDIC SURGERY. 63 never dissected a human body. Actual train- ing in mechanical work is as necessary to a suc- cessful student of orthopaedy as is dissection to an anatomist, or as clinical study and laboratory work are to the successful development of the well-trained medical man. As the old style of giving didactic lectures in medical schools has given way to more practical and scientific methods of instruction, so, in the future, the present methods of teaching orthopaedic sur- gery will be re-enforced by practical work in the mechanical room. The perfunctory applica- tion of an apparatus before a class will give way to a description of the fundamental principles underlying the mechanical, anatomical, and sur- gical problems involved. The student will then be obliged to apply these principles under the instruction of the professor — and the student will thus gain a real knowledge of the subject. When one sees, in the various instrument- makers' shops, the many crude and incorrectly constructed instruments for the treatment of chronic deformity which are, literally, like sugar or salt, in the market, one can realize the embar- rassment of the average medical man in his ef- fort to cope with the treatment of a patient with a chronic or progressive deformity. His guide 64 ESSAYS ON ORTHOPEDIC SURGERY. is the profusely illustrated catalogue of some enterprising instrument-maker. His knowledge — for there are no text-books on the mechanico- therapy of orthopaedic surgery — is limited and his failures are many. The existing works on orthopaedic surgery do not satisfactorily cover this field. Whose is the fault? It lies wholly with those who teach, and it will be thus until the subject of mechanico-therapy, as applied to the problems involved in orthopaedic surgery, is made an obligatory course in the medical col- leges. So far as is possible this work has been done in your institution in the annual course of lec- tures which have been given under your au- spices for the past twenty years. It has been further amplified by throwing open the doors of the institution to those who wish to study the mechanical principles involved in the treatment of deformity, and many have availed themselves of this privilege. There are at present three or four surgeons from various distant cities who are following the work of the dispensary and hospital. Our work in this direction might easily be increased if it were more generally known that we always welcome those who wish to study our work and methods. PRESENT NEEDS OF ORTHOPEDIC SURGERY. 65 From causes entirely beyond our control the Morgan operating room was not completed until early in the summer. We had used the room only once when orders came to remove all the hospital inmates to the country, in an- ticipation of the extensive changes in the building — which have since been made. On this account, and also on account of the flying mortar dust arising from the demolition of the old building, it was deemed best to keep the op- erating room closed all summer. The furniture, etc., which was removed, has been replaced and the room is now in order and operative work has already begun. It is due to the generosity of one of our trustees that we have a complete Rontgen-ray apparatus as a part of our regular dispensary and hospital work. Its use opens a large field for scientific work and study. It will serve to throw much light on that which has hitherto been obscure and difficult. In all the diseases and deformities of the major articulations and long bones, and also in other respects, its assist- ance in forming a picture of the conditions will be invaluable — and the entire medical staff of the Hospital desire to thank the gentleman who made this valuable present to the institution. THE OPERATIVE SIDE OF ORTHOPAEDIC SURGERY* Gentlemen : The founders of the New York Orthopaedic Dispensary and Hospital builded better than they knew when, thirty- one years ago, they met and organized the work which calls us together on this occasion. Thirty-one years ago orthopaedic surgery was scarcely more than a name in New York city. It may almost be said that few outside of the medical profession and the technically educated classes grasped the full meaning of the word "orthopaedic." A few surgeons, in- spired largely by the late Dr. Henry G. Davis, were devoting themselves to the treatment of deformities, especially those occasioned by dis- eases of the spine and hip joint. Modern ortho- * A portion of an address delivered before the trustees of the New York Orthopaedic Dispensary and Hospital on the occasion of its thirtieth annual meeting, held November 15, 1897. Reprinted from the Medical Record, December 18, 1897. 66 OPERATIVE SIDE OF ORTHOPEDIC SURGERY, ty pasdic surgery was in its infancy, and the work of these pioneers was attracting the attention of the lay as well as the professional public. It was during this embryonic period that the founders of your institution applied to the State Legislature for a charter, in the following lan- guage : " The purposes of the said corporation shall be to establish and maintain an institution for the treatment of physical deformities and to give instruction in such treatment — and more especially to afford surgical and mechanical treatment to the disabled and deformed among the poor." It was the mechanical genius of Davis which contributed greatly to this new era in the treat- ment of physical deformities. It was he and his colleagues who made American orthopaedic surgery famous. It was, however, the mechan- ical rather than the surgical side of orthopae- dy of those days which brought to the front the names of those who are to-day recognized as the fathers of orthopaedy in this country, and it was the mechanical treatment of hip-joint dis- ease and spinal disease, as taught by Taylor, which led to the foundation of your institution and which has had more or less effect upon the development of American orthopaedic surgery. 6% ESSAYS ON ORTHOPEDIC SURGERY. It was under these circumstances that your spe- cial charter was obtained from the New York State Legislature. It would have been a mat- ter of no surprise to me, knowing as I do the sentiment of the profession in those early days, and appreciating also the influences which origi- nated our great work, if the charter had sim- ply designated the mechanical treatment of deformity as the sole object of the corporation. But with a wise and almost prophetic fore- sight, the charter was framed in a' broad and liberal sense, and the portion quoted above might almost be called a definition of modern orthopaedic surgery. On previous occasions I have called your attention to the relation of orthopaedic surgery to general surgery — to the necessity of a thor- ough mechanical training as a preparation for orthopaedic work, and to the future demands of orthopaedic surgery from a mechanical stand- point. It would seem only proper on this oc- casion, therefore, that I should dwell somewhat upon the operative aspect of the treatment of deformities. The treatment of chronic deformities would be emasculated if mechanical treatment was omitted. Indeed, under those circumstances, OPERATIVE SIDE OF ORTHOPAEDIC SURGERY. 69 there would be only operative surgery left. On*the other hand, if operative surgery was omitted, mechanico-therapy would still find an important place in surgical science and the major part of orthopaedic work would still go on. To the legitimate orthopaedic surgeon, , therefore, operative work takes a secondary and minor position, just as the mechanical part takes by far the more important place ; and in true orthopaedic surgery operative work, per se, has no real status. In short, if orthopaedic sur- gery is to maintain its position among the spe- cialties in medicine, it must exist upon a me- chanical foundation and its disciples must be experts in the use of apparatus. At the same time the orthopaedic surgeon should be well prepared to operate upon those patients who require special mechanical treatment after oper- ation. Hence it is that I maintain that the sim- ple excision of joints is not within the field of orthopaedic work, because the general surgeons and the general hospitals are fully equipped to do this work and are glad to receive and care for this class of cases, the after-treatment of which ordinarily requires no special orthopaedic training. The same may be said in a general way of the operative treatment of knock-knee ;o ESSAYS ON ORTHOPAEDIC SURGERY. and bowlegs. The artificial fracture of a bone requires the same treatment as an accidental fracture, and this certainly comes within the scope of general surgery. Under these circum- stances there is no occasion to fill the wards of an orthopaedic hospital with patients of this class, as long, at least, as there is such a great demand upon it for strictly orthopaedic cases, which are not as a rule received by the general hospitals. For example, a patient with knee- joint disease or hip-joint disease needing exci- sion, or a patient with rhachitic leg deformity requiring osteotomy, applies for admission to your wards. Am I, as your surgeon-in-chief, justified in receiving the case when there are fifty or more cases of hip-joint disease, spinal disease, clubfoot, etc., which urgently demand your care and which are awaiting admission to your wards? My reply is, " No." We could fill our wards with operative cases in a month, the larger number of which do not require orthopaedic care after operation, and which can be cared for in every way in the general hos- pitals. I certainly feel it my duty to decline them, when the only objects I would have in admitting them would be to gratify a personal ambition to appear as an operative surgeon, and OPERATIVE SIDE OF ORTHOPEDIC SURGERY. j\ to submit for your consideration at the end of the year an ample table of " operations per- formed. " Some surgeons best known as ortho- paedic surgeons are wasting their time on work that is well done by general surgeons and well performed in general hospitals. These men are making a serious error, I think, and are retard- ing the normal growth of true orthopaedic sur- gery. Some day these facts will be appreci- ated. It may not be in my day, but sooner or later the truth will prevail, and both the medi- cal profession and humanity will be benefited. In the mean time I shall keep on in the course I marked out twenty-four years ago, when at an early age in my professional career I had the opportunity to gratify my surgical ambition in the orthopaedic wards of St. Luke's Hospital. Nor is that opportunity lacking now, with the great mass of clinical material which presents in the service of your institution. I am gratified to know that the seed sown near- ly a quarter of a century ago is bearing good fruit. The operative part of orthopaedic surgery therefore becomes the simple but necessary ad- junct of the mechanical work. One may be an operative surgeon and know but little or noth- 72 ESSAYS ON ORTHOPEDIC SURGERY. ing of real orthopaedic work, but the ortho- paedist must be the one and know the other. One may perform all the major operations of surgery, and yet not have the requisite techni- cal knowledge properly to adjust a hip splint or a spinal brace. The orthopaedic surgeon should be able, if the after-treatment demands it, to excise a joint or to perform any operation which supplements mechanico-therapy, but in all but very exceptional cases he should confine his cutting work to that field which supple- ments his mechanical operations. Nor does it follow, I think, because a de- formity exists, that the patient should neces- sarily come under the care of the orthopaedic surgeon, any more than that the general con- dition giving rise to the retinitis of Bright's disease, or to the tabetic atrophy of the optic nerve in locomotor ataxia, should come under the care of the ophthalmologist. All special- ties have their origin in general medicine or general surgery. The existence of a specialty depends upon several factors, the important one being the necessity for the development upon certain lines of a neglected branch of medicine or surgery involving patient study and careful research. It is along these lines OPERATIVE SIDE OF ORTHOPAEDIC SURGERY. 73 that a specialty succeeds, and the danger of specialism of the present day lies in the fact that those who follow it are prone to invade other fields. The fault with many of those who are known best as orthopaedic surgeons is that they do not confine themselves to orthopaedic work ; they often operate when there is no ne- cessity for cutting, and they are not familiar enough with the technique of mechanical work to get the best results from mechanico-therapy. They do the work of the general surgeon in- stead, neglecting or ignoring the plain path of duty which lies so patent before them. Why is this so ? A few extracts from a re- cent editorial in the New York Medical Record may help us in answering this question. The editorial referred to is entitled, " Is Gynaecology Destined to Become an Obsolete Specialty?" After a general consideration of the relation of gynaecology to general surgery, the writer says : " Not content with confining themselves to their proper region, they [the gynaecologists] have reasoned that their familiarity with abdominal surgery should render them the equals if not the superiors of general surgeons in the han- dling of cases which bear no relation to diseases of the pelvic organs." The writer then asks: 74 ESSAYS ON ORTHOPEDIC SURGERY. " How is it that this change has come about in America, when abroad the distinction between the gynaecologist and general surgeon is just as sharp as ever? It appears to be due to some extent to the fact that the commercial factor has become prominent to the exclusion of the scien- tific." Again: " If gynaecology is to remain a specialty, it must be because its followers con- tinue to demonstrate the fact that they can do the work better than the general surgeon. . . . It is along the line of conservatism that the battle must be fought, not radicalism." Still further : " Gynaecology is the natural outgrowth of general surgery, but the contrary is far from being true, and any attempt to reverse the condition must end in ultimate failure." And finally : " Let gynaecologists prove that their specialty is capable of development along other lines besides those of radical surgery, and there is no danger that it will ever come to be re- garded as unnecessary." Comment on these plain statements seems superfluous. But if the words " orthopaedic surgeon " or " orthopaedic surgery" be inserted in place of "gynaecologist" or " gynaecology," in the quotations given above, the truth will be apparent to the candid ob- server. It will be along the lines of conserva- OPERATIVE SIDE OF ORTHOPEDIC SURGERY. 75 tism that orthopaedic surgery will be developed — not on the lines of operative surgery — and it will be all the better for the men now engaged in preparing for future work in orthopaedic surgery if they bear these facts in mind. IS ORTHOPEDIC SURGERY TO BE- COME AN OBSOLETE SPECIALTY?— WITH REMARKS ON SPECIALISM. To the Editor of the Medical Record : Sir: No one interested in the advancement of true specialism in medicine can fail to thank you for your editorial, " Is Gynaecology Des- tined to Become an Obsolete Specialty?" which appeared in the Medical Record of Feb- ruary 27, 1897. Aside from the merits of the question raised by the discussion between the surgeons and the gynaecologists, the more important issue is, Is it the best policy, both from a scientific medical, and humanitarian standpoint, for any special department of medicine to " overlap " and in- vade other fields? All will admit that this is in many instances a necessity as a matter of study and education. But as a matter of practice it would seem to be an error. In a humble way I 76 IS IT AN OBSOLETE SPECIALTY? 77 have discussed this subject elsewhere when my essay, " What is Orthopaedic Surgery ? " was criticised in the New York Medical Journal of November 7, 1891. In my reply * I say : " It is universally admitted, I think, that all specialists in medicine should be thoroughly equipped both in medicine and surgery, and there is no reason why one thus equipped should not prac- tice both general medicine and surgery. It must, however, be apparent that the so-called specialist who does this weakens his own claim to specialism and apologizes for his specialty. This will be true so long as medicine and sur- gery, generally speaking, are progressive, and so long as there are unsolved truths await- ing the special investigator and the special student." Have the specialists solved all the truths in their special departments? How many have ceased to be special investigators as well as spe- cial practitioners ? Unless these questions can be satisfactorily answered it would seem that the reply made to my critic regarding orthopaedic surgery is also applicable to other specialties. * " On the Definition and Scope of Orthopaedic Surgery," New York Medical Journal, November 14, 1891. jS ESSAYS ON ORTHOPEDIC SURGERY. I do not stop to question the motives of those who " overlap." They may be honest but mistaken, or they may be selfish or " commer- cial." But it is a fact that the effect of the pres- ent state of affairs upon the entire medical pro- fession is bad, and I have noticed that the lay public is beginning to ask : " What sort of a specialist is he who, in his office, in his writ- ings, and in his college and hospital work is a specialist, but who is a family physician and a general practitioner among a selected clientele on other occasions?" The outlook for the general practitioner is indeed an uncertain one if the " specialist " is to invade the domain of the family physician. Why should he do so? Not long ago, for example, T had occasion to send a gentleman who consulted me to a well- known specialist. With my full approval this specialist took entire charge of the conduct of the case. He is now duly installed as the regu- lar medical attendant of not only the patient himself, but of his immediate family and some of his friends. I frankly told the "specialist" that I was surprised at his course, but he only smiled and said, " Others do it." This is no excuse. As I have often said to IS IT AN OBSOLETE SPECIALTY? 79 those who have honored me by asking my ad- vice regarding the adoption of a specialty: " One can make no better investment of one's time after a thorough training than gradually to adopt a specialty when opportunity or incli- nation favors. When, however, a certain point is passed, or a hospital or college position, pre- senting an opportunity for clinical study and investigation, enables one to assume a position as an authority, one should, if he adopts a spe- cialty, cease to be a general practitioner." The demoralization which has apparently in- vaded the gynaecological field has already left its marks on orthopaedic surgery, and the re- marks made in your editorial, with a slight change of words, are applicable to quite a num- ber of men who are best known as orthopaedic surgeons. Not content with a patient study in the wide and practically unexplored field before them, these " orthopaedic surgeons " " overlap " and, neglecting legitimate orthopaedic work, in- vade the field of the general surgeon. There are orthopaedic surgeons to whom even laparotomy is not a stranger. A consider- able portion of a chapter in a recent work on orthopaedic surgery is devoted to " amputation at the hip joint." A paper read before the 80 ESSAYS ON ORTHOPEDIC SURGERY. American Orthopaedic Association and pub- lished in its Transactions is entitled "Amputa- tion as an Orthopaedic Measure." One man, until quite recently a member of the Orthopae- dic Association, resigned because he felt that he could not afford to have it known that he was connected with the association. Other good and able men, starting out with the intent and desire of becoming orthopaedic surgeons, have failed to have the " courage of their convic- tions" at a critical moment and have become in effect general surgeons. And the profession smiles and the communities in which they live can not see any great difference between the general surgeon and his orthopaedic competitor. Orthopaedic surgery is bound to become a great specialty, but it will not succeed on gen- eral surgical lines. Before it can be a real spe- cialty it must cease to appear in the role of a competitor with general surgery. It must not " overlap." Its disciples must cease to antago- nize the best elements of the profession by pos- ing as orthopaedists, when they only lack op- portunity to become general surgeons. And until this change is brought about there will be no true orthopaedic surgery, except as here and there a man stands up for the right and defies IS IT AN OBSOLETE SPECIALTY? 8 1 criticism, for it is getting to be almost as rare to find a legitimate orthopaedic surgeon as it is to meet with an orthodox gynaecologist who does not " overlap " and compete with the gen- eral surgeon in operating for appendicitis, etc. Many do not, I think, appreciate how much there is in orthopaedic surgery, outside of its somewhat limited operative work, or how far it may be made useful to humanity. It certainly can not aid the orthopaedist to compete with the general surgeon, and indeed there is no neces- sity for it. If it were accepted and understood by the profession at large that the orthopaedic surgeon should confine his operative work to those cases which require special orthopaedic care after operation, the entire profession would be benefited ; orthopaedic surgery would find itself busy with congenial work, and it would occupy a well-defined and enviable position among the specialties. Newton M. Shaffer, M. D. 28 East Thirty-Eighth Street, New York, March 10, i8g^. RD721 Shaffer COLUMBIA UNIVERSITY LIBRARIES fhsl stxj RD721 Sh1 C.1 Brief essays on orthopaedic surgery 2002310988