AN ADDRESS 
DELIVERED BEFORE THE AMERICAN ORTHOPEDIC ASSOCIATION, 
Washington, D. C., in May, 1894, 
By the President 
A. M. PHELPS, M.D., 
NEW YORK- 
Gentlemen : Undoubtedly the subject of modern surgical bacter- 
iology and pathology has made, and will still further make, a most 
decided impression upon orthopedic surgery. 
The discovery of the bacillus of tuberculosis, pus germs, and other 
forms of microscopic life, and their influence upon human tissues in 
a state of disease and health, has revolutionized surgical pathology 
and the treatment of wounds and lesions. 
Among the older pathologists, inflammation was taught to be a 
diseased condition, and all of the various complications arising dur- 
ing the healing process were treated upon as a part of the inflamma- 
matory process. 
The definition of inflammation given by Palmer, of the University 
of Michigan, covers nearly two pages of his book. In this defini- 
tion he includes every process, normal and abnormal, which takes 
place in the healing of wounds, including suppuration and sloughing, 
which we now recognize as complications. 
Inflammation is recognized by the advanced pathologist to be a 
perfectly normal process of repair. For example, when an incised 
wound is made, the first process that takes place is an effusion of 
blood and its coagulation, then a rapid wandering of cells into this 
blood-clot occurs, together with rapid cell proliferation. These cells 
form themselves into lines between the cut ends of the tissues, for 2 
THE PRESIDENT’S ADDRESS. 
the purpose of repair. Very soon organization takes place, new 
tissue is built up. After this, contraction takes place, capillaries 
are destroyed, epithelium grows over the surface, and we say the 
wound is healed. 
This is now believed to be the normal process of repair. This is 
inflammation, and the process is as normal as the growth of the stag’s 
horn. This reparative inflammation is necessary in all cases where 
injury has been inflicted. If at any time during this process of 
repair or normal inflammation, germ life is inoculated, another con- 
dition is at once established, and that moment marks the beginning 
of disease. If these germs are pus germs, they at once seize upon 
this inflammatory material, and they, with their ptomaines, destroy 
the whole. The wound has become infected, and disease is the result. 
This disease is suppuration. 
If the germs of tuberculosis should be inoculated into this new 
inflammatory tissue, their growth immediately takes place. No pus 
is formed from the bacilli of tuberculosis, hut the germs grow and as 
surely destroy this new inflammatory material as did the germs of 
suppuration. 
Then we say that this normal inflammatory material has become 
diseased, a tubercular inoculation, producing a tubercular focus or 
disease, is the result. Then there is a vast difference between inflam- 
mation and disease. 
Should these germs be pyogenic and the inoculation take place in 
the bone, a very rapid osteomyelitis with abscess is almost sure to 
result. If, on the contrary, the germs of tuberculosis come in con- 
tact with this area of normal inflammation, then so sure will this 
condition be a tubercular one. The process is insidious, producing 
destruction by ulceration or caries. 
After a time, should inoculation be present, the new inflammatory 
material is destroyed, and its place taken by germs and the products 
of germ life; but just outside of this area of disease a new barrier 
of normal inflammatory material is thrown up by the tissues, similar 
to the first. This is normal embryonic material, into which germ 
life rapidly grows and destroys, and so the normal process of repair 
goes on just a little in advance of disease, or germ invasion, until 
after a time, as in the head of the femur, or in the body of a verte- 
bra, a large portion of bone is destroyed. A . M . PHELPS. 
To produce disease caused by germs, two conditions are essential: 
First, inflammatory material, which is made up of embryonic cells, 
and second, the presence of germ life. In the absence of either, 
such disease cannot occur. 
In a given case, an injury is received to the joint or spine. This 
injury may be very slight in character. From the fact that greater 
pressure occurs at the ends of bones, in the inter-vertebral cartilage, 
and spongy portions of the bodies of the vertebra, the lesion is more 
likely to take place at this point. 
Immediately following a slight injury, Nature attempts repair by 
means of normal inflammatory action, but should there be floating 
in the circulation germ life, either tubercular or pyogenic, inocula- 
tion of this area of inflammation is almost sure to take place. When 
it occurs, if the phagocytes, which are the wandering and the fixed 
tissue-cells, are weakened on account of the strumous condition of 
the child, they fail to destroy the germ. The germs then destroy 
the phagocytes and convert the area of normal inflammation into 
disease, with the symptoms of which we are all familiar. 
If, however, germ life is destroyed by the phagocytes, repair goes 
on uninterrupted as in any other wound, and, after a longer or shorter 
period, the parts are restored to their normal condition. 
During the period of active inflammation the symptoms are 
almost identical with those of disease. Understanding this, we can 
now account for the ephemeral forms of hip and Pott’s disease. 
Then the term osteitis, which is so frequently used, should not be 
applied to indicate a diseased condition, but rather a normal process 
of repair. The term struma should be used to indicate a condi- 
tion. Struma is a condition. The reason why one child is attacked 
by tuberculosis and another escapes under similar circumstances is 
because one is strumous and the other not. 
The difference between these two children is similar to that of the 
celery which is grown in the trench, kept away from the light of the 
sun, making the succulent plant fit for the table, and the other, 
which is grown in the sun, building up strong woody fibre. The 
tender celery, which has but little woody fibre, cannot resist the 
sting of the insect which deposits its larvse, while the other with its 
woody fibre can. One is strumous, and the other not. The differ- 
ence between them is only in degree and quality. So it is with the 4 
THE PRESIDENT’S ADDRESS. 
strumous child. He has either inherited an enfeebled condition, or 
has acquired it through bad nourishment and bad surroundings. The 
protoplasm which makes up the phagocytes of his body is enfeebled, 
and differs from that of the strong, well-nourished child with a good 
ancestry. The phagocytes of his body, consisting of enfeebled pro- 
toplasm, do not resist the attack of germ life—the result is inocula- 
tion, destruction, and death; whereas, in the strong non-strumous 
child, phagocytes destroy the germ. 
Then we must conclude that struma is located in the protoplasm 
of the ultimate cell of the body, and measures the resistance of the 
individual to the attack of germ life. This is struma ! 
The process which takes place after the inoculation of the bacilli 
of tuberculosis produces tubercular disease unattended with pus. 
Pyogenic germs produce rapid purulent destruction and the forma- 
tion of abscesses. 
Tubercular cavities or foci of disease may become inoculated writh 
pyogenic germs, Avhich result in the rapid formation of abscess. 
The growth of the bacilli of tuberculosis is slow, while that of the 
pyogenic cocci is rapid. 
This explains why a child may carry around a fluctuating tumor 
filled with tubercular material that remains quiescent or possibly 
diminishes in size, when in a single day it increases, becomes hot 
and possibly painful, and very soon ruptures, with the escape of a 
large quantity of pus and cheesy material. 
In such cases an inoculation of pus germs has taken place into 
the area of tubercular disease. The powder magazine of tubercular 
disease finally, after months, received the fatal spark which precipi- 
tated the abscess. Both tubercular material and pus possess the 
poAver of destroying tissue with Avhich they come in contact. This 
explains the extensive destruction of joints Avhen allowed to macerate 
for Aveeks or months in these materials. Understanding all this 
(and these facts are established beyond a question), we should not 
hesitate to decide Avhat should be done in a given case, and the 
knife and drainage should be freely used. The term scrofula has 
become obsolete—tuberculosis has taken its place. The term scrofula 
Avas a makeshift Avord; it was the quacks’ stock in trade. The 
term scrofula, alteratives, and many other terms in medicine are the 
breastAvorks behind which ignorance skulks. A. M. PHELPS. 
5 
It is to be hoped that we will never again see in print the terms 
strumous or scrofulous joints. The term scrofula means nothing, 
and struma is a condition. Infection may take place from within 
the body or from without. From within by germs floating in the 
circulation, which have been carried there by the lymphatics of the 
mucous membrane; from without by the direct entrance of germ 
life through the denuded skin. Of late it has been discovered that 
one of the most frequent sources of infection is from the milk of 
tuberculous cows. The inoculation of Koch’s lymph detects animals 
infected. Whole herds of cattle have been killed recently after the 
demonstration with Koch’s lymph, and in every instance the animals 
were found suffering from general or local tuberculosis. This being the 
fact, we should look to the feeding of our orthopedic cases. Undoubt- 
edly relapses are frequently produced by inoculation from milk. A 
case is nearly cured; the bacilli of tuberculosis have been entirely 
destroyed in the healing process or become encysted; the normal 
process of repair is still going on, with its myriad of embryonic cells 
at work to complete a cure. At this stage, if a child drinks a glass 
of milk contaminated with the bacilli of tuberculosis, inoculation is 
almost sure to take place, and a relapse follows. To prevent this, 
animals supplying milk for patients or institutions should be exam- 
ined. The milk should be sterilized; but this does not destroy the 
products of germ life, and this deleterious material does harm. 
THE PAST, PRESENT, AND FUTURE OF ORTHOPEDIC SURGERY. 
The history of orthopedy and orthopedic surgery, like that of 
general surgery, is humiliating. For many centuries general 
surgery struggled with the people and the priest for the high posi- 
tion which it now occupies. 
It is only within a few years that surgery was divorced from the 
barber shop, and even to this day throughout Europe are seen in front 
of these shops the three small brass basins—the sign of the barber 
—used by his predecessors to catch the blood that flowed from his 
suffering patients. 
’Tis true that all along through the dark ages of the past, when 
manacles were put upon the brains of man, occasionally a great 
light shown through the rifted clouds. The wonderful original 
work of men of the character of Galen, Ambrose Par6 and others 6 
THE PRESIDENT’S ADDRESS. 
was a particular bright star in the dark-domed firmament of ignorance 
and religious superstition. The influence of the labors of such men 
upon modern surgery can hardly be estimated. And so we can 
trace the history of orthopedy through the slough-holes of bigotry 
and jealousy almost from the time of earliest man. Their work 
was confined to the application of appliances to overcome deformity 
when it was not considered a sacrilege to do so. 
In looking over the literature upon the subject one becomes bewil- 
dered. The armamentarium of the ancient orthopedist was, at least, 
the equal of our present appliances in point of ingenuity and intricacy. 
And the braces used at the present time bearing the names of modern 
men, supposed to be modern inventions, are nothing more or less, 
with but few exceptions, than the revival of the old ideas of the past. 
The orthopedist was always at war with the general surgeon. 
There never was a time when they could lie peacefully together in 
the same bed, excepting like the lion and the lamb—one inside 
the other, and the poor orthopede was always inside. The ortho- 
pedist was a mere bandagist, adjusting his appliances to the lame and 
the halt, regardless of pathology or etiology, and the surgeon of his 
day was but little better. 
But the science of surgery did progress, and it gradually made 
inroads upon the field of the orthopedist, and he soon saw many of 
his pet deformities, which had been to him through long years a 
source of pleasure and remuneration, filched by the skilful and 
investigating surgeon. 
His failures in the treatment of club-foot and in many other 
deformities were well known to the surgical world, notwithstanding 
the boasted statements and the praise of patients cured. 
The first tenotomies of Stromeyer began the beginning of the end 
of senseless mechanical work in certain forms of severe club-foot. 
The work of McEwen, in more recent days, in bone deformities 
marks another era, and has taken from the orthopedist a large and 
important slice of his practice. 
The work of Volkman, Koenig and others in joint diseases has 
made it extremely uncomfortable for the gentlemen who see nothing 
but a brace and strap for the treatment of such diseases. And so I 
might go on ad infinitum to show where general surgery has grad- 
ually made inroads upon the work of the orthopedist, until to-day A. M. PHELPS. 
7 
they have but little left; and this consists in the adjustment of braces 
to a very limited number of deformities, and frequently at the sug- 
gestion of the general surgeon, who condescends to operate for them 
when called upon. 
These facts have stimulated to action another very important class 
of men who are known as orthopedic surgeons, and who claim that 
these deformities and many other diseases heretofore not included, 
and now treated by the general surgeon in a general way, come 
justly in their field. 
These orthopedic surgeons believe in orthopedic surgery—they 
believe in mechanical work, whether by the adjustment of a brace or 
the use of the knife. They believe also that a thorough knowledge 
of pathology, surgical bacteriology and etiology is the only safe guide 
to treatment. They believe that a perfect knowledge of surgery and 
surgical laws is all important. 
The combination of mechanical with surgical work constitutes 
orthopedic surgery. One divorced from the other makes general 
surgery and orthopedy. To illustrate : 
Only a few decades ago the world was blessed or cursed with a 
specialist known as the oculist. He fitted glasses and did some other 
unimportant work about the eye. The general surgeon operated 
upon cataract, squint, removed the eyeball, and treated trachoma and 
other diseases of the eye. His field of work was so large that he had 
but little time to devote to the study of diseases of the eye. 
A few of these oculists began the work, and, as a result, the world 
is now blessed with a most important special department of surgery 
knowrn as ophthalmology. These men do all of the work of the older 
oculists. They adjust glasses. They have made grand discoveries 
in the ophthalmological world. They are in fact surgeon and oculist 
combined. 
Less than half a century ago gynecology was limited to a few 
diseases of women, and the works of the older authors led us to 
believe that about all a woman was ever afflicted with was ulceration 
of the cervix. The gentleman who made his local applications and 
treated his patients with pills, pukes, purgatives, and pessaries, was 
known as a woman doctor. He was a general practitioner, and paid 
special attention to diseases of women; but his patients did not 
recover, and the general surgeon began to investigate his work. 8 
THE PRESIDENT’S ADDRESS. 
Others also who had been women doctors began investigation, 
and the result is the grand specialty known as gynecology, and 
to-day the woman doctor is the gynecological surgeon, and he in- 
cludes in his field not only ulceration of the cervix, but all of the 
diseases connected with the generative organs of the female, including 
the capital operation of coeliotomy. 
The reason why these specialists took from general surgery the 
subjects which they now treat, is because, by special study and prac- 
tice, they advanced and did better work and got grander results. 
These published results completely routed the general surgeon, whose 
time was too much taken to give special study to the subject. They 
won the battle in a fair fight upon the field of thought, and the 
profession of medicine awarded them the victory. 
What, in your opinion, Avould have been the effect upon the spe- 
cialty of ophthalmology if the gentleman away hack there who fitted 
spectacles and was contented to be called an oculist had said: It is 
wrong for us to remove a lens, men who are educated as surgeons 
can do that? Suppose he, in his infinite stupidity, had said the 
adjustment of these glasses will cure the lens and return the sight, 
hence the knife is not to be used; it is wrong. Many of them did 
say just that. But investigators said we can improve upon the 
operation for cataract, and the cry was, give us more and better work. 
They discovered the cause, and their results wron for them the confi- 
dence of the profession, and this specialty came to stay. 
Where would gynecology be at the present moment if the general 
practitioner had continued his work. His practice would to-day be 
limited to his field of vision when applied through a speculum. But, 
thanks to McDowell, Battey, Emmet, Sims, Polk, Tait, Keith, 
Wells, Martin, Hanks, Dudley, and a host of others the field was 
widened, and their work won for gynecology the proud distinction it 
now enjoys in spite of the general surgeon. I might go on to 
illustrate with other important special departments of surgery and 
medicine, but time will not allow. 
So we see that we are gradually drifting to that high standard of 
excellence attained by other departments of medicine, if we may be 
allowed to judge from the work of many of our most eminent ortho- 
pedic surgeons. We are forging ahead. We are rapidly becoming 
independent of the general surgeon and accepting his established A. M. PHELPS. 
9 
scientific facts. We are attaining a perfect knowledge of his opera- 
tive methods and applying this knowledge, together with our mechan- 
ical methods, to the successful prevention and cure of deformities. 
The question of what diseases or deformities are to be included in 
our specialty will depend entirely upon our results, and the general 
profession will be the umpire. Mr. Edmund Owen, of London; 
Kirmisson and R6dard, of Paris; Schede, Hoffe, and Beeley, of 
Germany ; Lorenz, of Vienna, and Kaptein, of Holland, are among 
the orthopedic surgeons of Europe who believe in orthopedic sur- 
gery in all that word implies. In our own country, I am pleased to 
say, are many who believe the same. 
One of the best definitions which has been offered for orthopedic 
surgery is that of Dr. Gibney, printed in the New York Medical 
Journal, November 7, 1891. It is: “that department of general 
surgery which includes the prevention, mechanical treatment, and 
the operative treatment of chronic and progressive deformities.” 
But I can see no reason why acute joint disease attended Avith 
a deformity should not be treated by the orthopedist; then by adding 
the word “acute,” it seems to make the definition a very good one. 
The able text-book on Orthopedic Surgery by Prof. Iloffa does 
not include in its pages the subject of chronic joint disease. He 
does not include Pott’s disease of the spine. Why include Pott’s 
disease of the spine and not joint disease? In America the ortho- 
pedist and the orthopedic surgeon include in their list of orthopedic 
subjects both joint disease and Pott’s disease of the spine. I cannot 
see why both should not belong exclusively to our specialty. Brad- 
ford and Lovett also include certain forms of paralysis in their recent 
text-book, with which I agree. And then, again, many members of 
this Association include in their wrork the treatment of fractures of 
the neck of the femur, and with them I fully agree. But why frac- 
tures of the neck of the femur and not all fractures ? If all fractures 
are to be treated, why not dislocation ? It is my earnest conviction 
that within a very few years fractures and dislocations will be treated 
by the orthopedic surgeon. These are conditions requiring the 
highest degree of mechanical knowledge and skill. Excisions of 
joints for chronic diseases, operations upon the spine for paralysis 
following Pott’s disease, belong decidedly to the orthopedic surgeon, 
for the following reason : 10 
THE PRESIDENT’S ADDRESS. 
Such cases are more frequently treated to-day, prior to excisions, 
by the orthopedic surgeon. And then, after excisions have been 
performed, mechanical treatment is necessary, covering over periods 
of months, and even years. Unquestionably, if all joint diseases of 
an acute or chronic nature were handed over to the skilful ortho- 
pedic surgeon, much better work would be done, and many a child 
would be saved from a cripple’s life. 
Working and teaching as I have for years in general surgery, I 
think I can speak, without prejudice to the general surgeon, upon 
this subject. I know that the general surgeon is too much occupied 
in his general work to carry out a prolonged treatment after his 
excisions; and then to hasten recoveries he is apt to resort to the 
knife when mechanical means would be better. These are the 
reasons why this class of joint diseases, either acute or chronic, 
should be forever claimed by the orthopedic surgeon. 
All kinds of bone deformities requiring osteotomies or osteoclasis 
should be classified with orthopedic work. We readily see, then, that 
the orthopedic surgery of the future contemplates a wider field and 
the application more frequently of operative interference. If any 
orthopedic surgeon feels that he is not competent to do his work, let 
him call in the general surgeon. Let him do that for a few years, 
and he and his work will be seriously impaired. 
Hernia unquestionably should be classified as an orthopedic sub- 
ject. It is as important and as difficult to adjust a support to 
remedy a hernia as a splint to hip-joint disease, and frequently, by 
mechanical means, herniae are cured. 
In the Hospital for Crippled and Ruptured, New York, hernia is one 
of the diseases there treated, and it is recognized as an important part 
of their orthopedic work, and justly it should be. In the early history 
of that institution, cutting operations were, as I understand it, entirely 
dispensed with, not only for hernia, but all other deformities. 
But under the present management the institution has been 
gradually raised to a higher plane, and to-day it ranks with our best 
institutions. I find now, when mechanical treatment fails in hernia, 
that an operation is performed to relieve the sufferer, and the same 
is true of joint diseases and deformities. 
I visit Boston and its well-equiped Children’s Hospital; there I 
witness similar work to that I now see in our best orthopedic A. M. PHELPS. 
11 
hospitals for the crippled and ruptured—operative work combined 
with mechanical, making indeed an orthopedic hospital, cared for 
by orthopedic surgeons and not orthopedists', and the work done by 
these institutions and the statistics which they will publish will go 
far toward divorcing many of the diseases which we now claim 
should be given to us from general surgery. 
I visit other institutions in England, France, in this country, and 
especially in New York City, where surgical work is entirely dis- 
pensed with; where abscesses are alloAved to burrow and sequestra 
in joints, to macerate in corroding pus, eventually either to kill the 
patient by infection or, fortunate for the patient, to be discharged as 
debris; where bow-legs and genu valgum in children of maturer age 
are still treated with braces, and patients suffering from suppur- 
ation regarded as hopeless or of doubtful recovery are transferred 
to other institutions to linger, and if recover, hopelessly crippled 
or more frequently die. 
Fortunately for the profession, reports are published from all of 
these institutions which are an open book, and they who are not 
blind can read and judge of the comparative work performed. So 
enthusiastic was one of the advocates against non-surgical interfer- 
ence of joint disease that he made the statement upon the floor ol 
the New York Academy of Medicine that “ in his report for the 
past year he was happy to say that of the large number of cases 
suffering from, abscesses which had been treated in the institution 
where he had charge not one had been opened.” 
Publishing broadcast to the profession of medicine statements of 
this kind, printing statistics which are bristling all over with failures 
and unusually bad results, the large mortality in institutions where 
these cases are sent to die has done more to degrade orthopedic 
surgery to the low level which it found only a short time ago than 
all the ignorance of the dark ages of the past. 
No member of this profession, be he orthopedist, oculist, or woman 
doctor of the past, has the right to violate well-established surgical 
laws, based upon scientific and clinical experimentation and labora- 
tory truths, and he who does that will no longer drag these special- 
ties down from the high pinnacle where a few men in this and other 
countries have placed them; but he will find himself floundering in 12 
THE PRESIDENT’S ADDRESS. 
the mud and mire of condemnation so deep that his presence and 
work in our professional world will be ignored. 
In the New York Post-Graduate School and Hospital the faculty 
a few years ago thought proper to establish an Orthopedic Depart- 
ment and in my opinion it is one of the wisest steps taken by that 
institution. A large portion of that beautiful building, which cost 
us nearly half a million of money, has been set aside for this 
work. Wards especially built, large dispensary rooms properly 
arranged, and convenient machine shops for the making of free 
braces for the unfortunate cripples, combine to make it a well- 
equipped orthopedic institution. The work in that department will 
give to it its character. Not only will mechanical appliances be ad- 
justed there, but also, when necessary, operations performed. The 
staff of surgeons will strive to make that a department of orthopedic 
surgery, and shall hope to give from time to time to the profession 
of medicine data which may help to establish or disprove many 
theories. 
The orthopedic surgeon of the future will be a man who has been 
thoroughly schooled in all the departments of medicine, who will 
have a perfect knowledge of pathology, surgical bacteriology, and 
anatomy. He will have added to this knowledge a general practice 
of at least twelve years. With all of these acquirements, and by his 
superior work, he will secure for our specialty the subjects which are 
rightfully ours. He will be fully competent to do orthopedic surgery 
as it should be done. He will be able to draw the line sharply and 
elevate his department as high as that of any other specialty, not 
excepting general surgery. 
Orthopedic surgery when thus contemplated is a grand specialty. 
It is as important as that of general surgery. When this stand has 
been taken colleges will want professors of orthopedic surgery. We 
will no longer be called a society of buckle-and-strap men. We will 
include in our membership the best pathologists, general surgeons 
and anatomists that this broad Republic can furnish. The orthope- 
dist will take the position that he chooses. The orthopedic surgeon 
will move on that high plane of scientific work which will not be the 
execration but the admiration of the entire profession of medicine.