riodern Orthopedic Surgery, What it is, and What it Should be, as the Members op the American Orthopedic Associaton by a Vast Majority Proclaim. An Answer to an Attack Made Upon Me Person- ally and Upon Orthopedic Surgeons. A. M. PHELPS, 1*1. D., NEW YORK. rioilern Orthopedic Surgery, What it is, and What it Should be. as the Members op the American Orthopedic Associaton by a Vast Majority Proclaim. An Answer to an Attack Made Upon Me Person- ally and Upon Orthopedic Surgeons. By A. M. PHELPS, fl. D., NEW YORK. Professor of Orthopaedic Surgery in the University of the City of New York and the New York Post- Graduate Medical School and Hospital; Professor of Surgery in the University of Vermont; Sur- geon to the City Hospital; President of the Amer- ican Orthopaedic Association. Danbury, Conu. THE DANDURY MEDICAL PRINTING COMPANY. ins, Modern Orthopedic Surgery, What it is, and What it Should be, as • the Members of the Ameri- can Orthopedic Associa- tion by a Vast Major- ity Proclaim. An Answer to an Attack Made Upon Me Personally and Upon Orthopedic Surgeons. As the president of the American Orthopedic Association for 1894, and its representative to the next Ameri- can Congress of Physicians and Sur- geons, I feel that it is my duty to reply to the attack made upon the position which has been taken by a very large majority of its members: The per- sonal attack made by Dr. Shaffer upon me in the American Medico- Surgical Bulletin, for Jan. 15th is of. but very little moment. The ques- tion is one of principle and is of im- portance to the future stand of the orthopedic surgeons of this and other countries. For this reason I feel that his unwarranted “misstatements”" should receive consideration. Dr. Shaffer has arrogated to him- self the privilege of speaking, or of attempting to speak, for orthopedic surgery. This he did in Berlin at the Tenth International Congress, when he gave a definition which vir- tually tied the orthopedic surgeons of the world to the shrine of the buckle, bar, and strap, notwithstand- ing his subsequent disclaimer and attempted explanation when he found that the orthopedic surgeons of the world were almost unanimously against him. His work in practice explains what was intended in his definition, as we will soon see. This definition has already been printed by him in his address, and in the article to which I am now replying. It is not worth quoting, as it has been repudiated by a majority of the members of the American Ortho- pedic Association, and has been buried so deep that nothing but a miracle will ever resurrect it. The definition of Dr. Gibney, with the addition of the word “acute,” makes one that the American Ortho- pedic Association is prepared to •accept and the majority of its mem- bers have accepted, and will continue to teach and live by, in spite of the ■“dictum ” of Dr. Shaffer. It is a 4 source of satisfaction to this majority of American orthopedic surgeons to know that nearly every country in Europe has taken almost precisely the same stand. Dr. Gibney’s defini- tion is, “ that department of general surgery which includes the preven- tion, mechanical treatment, and oper- ative treatment of chronic and pro- gressive deformities.” Add to this, as I suggested, the word “acute,” and the definition is complete—and that isthe rule by which we practice. The subject has been so thoroughly discussed that I shall not enter into a further discussion of it at this time, but shall confine myself to answering a few incorrect statements made in the article by Dr. Shaffer. Dr. Shaffer says: “Dr. Phelps is nothing if he is not intense.” This is an unintended compliment. I care not for the statement of any man; I want to know what he does. Dr. Shaffer would have the profession believe that about all he does is to revel with the knife and that he be- guiles away his weary and tiresome hours by fearlessly operating. He tells us, in his attack, of the large percentage of operations that he does in the Orthopedic Dispensary and Hospital amounting to “15 or 20 per cent.,” and he further says: “ It is ap- parent that Dr. Phelps does not know this.” His report for the last year positively contradicts this percentage statement. In a series of 2440 cases treated'in that institution last year we can readily see that his amphitheatre would be running most of the time with the blood of his patients, were the percentage so large. Let us ex- amine the Twenty-Seventh Annual Report of the New York Orthopedic Dispensary and Hospital; there we will find that among the cases treated were the following: 114 cases of club-foot over three years of age. 72 cases of genu valgum over three years of age, of which 20 were over five years. 2 were over ten years. 2 were over fifteen years, and 1 was over twenty years. 83 cases of bow-legs over three years of age, and 5 cases of bow-legs over five years, and 333 cases of hip- joint disease. I turn over a page, and I find unde the head of operations that all of th 6 operations that have been performed in that institution during the year are summed up to the statement that “tenotomies for the relief of club-foot were performed twelve times in the hospital.” Does Dr. Shaffer “mis- represent,” in his report, or in the article to which I am now replying, when he states that he operates upon 15 or 20 per cent, of these cases; in other words, does he sing one song to the benevolent and kind-hearted patrons of the Fifty-ninth street dis- pensary and another to the profes- sion? We are curious to know. Twenty per cent, would be 488 opera- tions. I compare this report with that of the Hospital for Ruptured and Crip- pled, of this city, under the direction of Dr. Gibney—an institution which has been resurrected from the night- mare of the “orthopedist,” and I find in the same class of cases that 347 operations were performed during the year. I examine the work of the Children’s Hospital, in Boston, the work performed by Branford and Lovett, the work of De Forest, Wil- liard, and Wilson, of Philadelphia; Griffith, of Kansas City; Sherman, of San Francisco; Park, of Buffalo; Poore and Sayre, of New York; Schede, of Hamburg; Hoff a, of Wurz- burg; Lorenz, of Vienna; Kirmeson and Redard, of Paris; Edmund Owen, of London; Grattan, of Dublin; Mac- ewen, of Glasgow; Levy, of Copen- hagen; Kaptyn, of Holland; Moore and Gillett, of Minneapolis; Kerr, of Washington; Weigel, of Rochester— in fact, of nearly every member of the American Orthopedic Associa- tion—and I find the percentage of operations in this class of cases is as great as, or even greater than, that found in the report of the Hospital for Ruptured and Crippled, in this city. Are all of these eminent or- thopedic surgeons—men who have helped to shape the ideas of the scien- tific world—wrong, or is Dr. Shaffer right? I leave this to the opinion of the reader. In the passage where Dr Shaffer exclaims, “Conservatism still lives,” and then flaunts in our faces the twelve operations performed last year as an illustration, I would sub- stitute the term “donothingism.” He makes no allusion to the countless departed whose lives have been sacri- 8 ficed at the shrine of this so-called “conservatism,” or “donothingism.” He conveys the idea in this same paragraph that we recommend opera- tion as the great cure-all for ortho- pedic cases, and that it is he who made the grand discovery that it was necessary, for cases requiring opera- tion, to have orthopedic treatment to complete the cure. Nothing is fur- ther from the fact. This self-admira- tion, to the orthopedic surgeon, must, to say the least, seem ludicrous. Dr. Shaffer’s whole line of reason- ing is illogical; he seizes upon his conclusions namely, mechanics and then endeavors to patch it up with musty theories and arguments to fit the conclusions—anything to escape the knife, is his motto; and yet he cannot help saying that the orthopedic surgeon should hold him- self in readiness to operate when it is necessary. The constant nightmare of the so- called “brutality of operative work” will make a sensitive and kind-hearted woman revolt at the thought of the word operation, when educated to the idea that it is comparatively unneces- sary, and she will decide in favor of the strap and buckle, brace and bar, when an operation should be per- formed. Can any argument justify the course of unlimited mechanics in certain cases, when failure must be the result with all its pain and loss •of time, when an operation can, in a brief period, accomplish much more? We can conceive how lack of skill in operating would make a man hesi- tate; but we can hardly understand the assurance of any one who would attempt to excuse himself by saying that mechanics comprise such a vast ■domain that, in order to fathom it, he has no time for operative proced- ure; and then to characterize those whose experience and progressive- ness have taught them that opera- tions, when necessary, should be per- formed to acquire results, as hybrids,” seems to me to be the acme or ego- tism. Orthopedic surgery without operations is like the play of “Hamlet” with the part of Hamlet left out. Dr. Shaffer says that the time for the “hurrah of operations,” has gone by. I will say that there has never been any time of “hurrah operations,” and that operative work in orthopedic surgery began long years ago. Its pioneers were a Post, a Volkman, Koenig, an Owen, a Stromeyer, a Schede, a Sayre, a Mott, and count- less others, who believed m scientific work; and the real dawn of operative work in orthopedic surgery has at last come. If Dr. Shaffer had said that the hurrah of senseless mechanical work in orthopedic surgery in a large class of cases was passed, or was pass- ing; that senseless, interrupted trac- tion upon the remunerative plantar fascia and tendo Achillis, in certain cases —covering over years and yearsv of torture, not only to the patient,, but to the feelings of the mother, de- priving the child of many of the pleasures of the playground, and causing deformity and non develop-- ment of the limbs—had now been' condemned by the vast majority of the members of the American Ortho- pedic Association, and by orthopedic surgeons the world over, he would have stated a fact. Any mechanical work which runs counter to etiology surgical bacteriology, and modern, pathology is unbecoming the posi- tion of any man who pretends to- speak for a considerable portion of: the orthopedic surgeons of America. The day is not far distant when an orthopedic surgeon will be ashamed to say that he treated a case of club- foot with interrupted traction upon the remunerative plantar fascia and tendo Achillis for as long as twelve years. Still, this is the work that Dr. Shaffer says we must do. He will be careful about his statements in regard to the treatment of ab- scesses, when scientific data have de- monstrated such treatment to be an error; he will know that the ortho- pedic surgeon knows that the remu- nerative fibrous plantar fascia and tendo Achillis are better cut than stretched. He will know that the reparative process is interfered with or destroyed by the trauma caused by stretching after a tenotomy, or fasciotomy is performed; that de- formity should be immediately super- corrected thereby securing quicker and better results. He will also know that the orthopedic surgeon knows that pus allowed to lie in contact 'with living tissue will destroy it; that it will invade the epiphyseal lines, .and perforate into the pelvis, going no one knows where; that the hor- rible results of pus destruction can 12 usually be avoided by early and timely evacuation and drainage. After the abscesses are opened we wash them out with a solution of bichloride of mercury, i to 2000, and finally with hydrozone until foaming ceases. Notwithstanding all this, in the re- port already quoted, I find the state- ment: ‘‘No abscesses were opened during the year.” Let us glance once more at the re- port. I find 2440 cases were treated, and that among them were: 333 cases of hip-joint disease. 174 cases of club-foot. 117 cases of genu valgum. 163 cases of bow-legs. 138 cases of other diseases; and 10 cases of non-deforming club- foot, so called. In all 935 cases, to say nothing of Pott’s disease. In this list of cases would be found, we think, a large number suitable for operative work, and they would have been operated upon had they fallen into the hands of the distinguished orthopedic sur- geons already quoted, thereby reduc- ing the number of “continued cases,” and saving thousands of dollars to the institution. Abscesses occur in from 15 to 60 per cent, of all cases of hip-joint disease, and the same rule holds good in the other cases of joint- disease quoted. Still we find, accord- ing to this report that “no abscesses were opened during the year.” The bow-legs and genu valgum, cases of maturer age, are loaded down with steel braces for years, according to the statement found in the “instru- ment report,” on page 30. The mortality from suppuratinghip- joint disease, the profession knows, ranges from 10 to 15 per cent., and I have been informed that in the Hospital for Ruptured and Crippled during the time of the late Dr. Knight 60 per cent, of the hip cases sup- purated, and the mortality was even greater than 12 per cent, counting the cases that died after they had left the hospital. I quote from my address, to which Dr. Shaffer has taken such excep- tions: “I visit other institutions in Eng- land, France, in this country, and es- pecially in New York city, where surgical work is entirely dispensed with; where abscesses are allowed 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 suppuration, regarded as hopeless or of doubtful recovery, are trans- ferred to other institutions to linger, and, if they recover, to be hopelessly crippled, or, more frequently to die.” These statements in my address before the American Orthopedic As- sociation seem to be proved by the “Report of the Fifty-ninth Street Dispensary.” I want to ask Dr. Shaffer, inasmuch as he knows, and as every orthopedic surgeon knows, that ioper cent., or more, of all cases of suppurating hip-joint disease die —where did his cases die? But we find that Dr. Shaffer publishes in the report quoted that “no death occur- red in the hospital during the year,” and none was reported in the dis- pensary work. He holds up his hands in indignation when a gentleman said to him, while walking through the hospital. “What do you want of 16 an operating-room? You never oper- ate!” And then he further says: “I might duplicate other instances like this, but this one will suffice. I have taken this occasion to answer them, one and all, and refer them to my published views and my work.” This is printed to prove that he does ex- tensive operative work. We have referred to Dr. Shaffer’s work in the report for 1895, and notwithstanding all of his efforts to convey a different impression, we find that in 2440 cases treated in the Orthopedic Hospital and Dispensary, he performed tenot- omy twelve times and no other opera- tions. He speaks enthusiastically of a four-thousand dollar operating- room. We all say: “What do you want of a four-thousand dollar oper- ating-room, in which to perform twelve tenotomies?” It is immaterial to us whether he operates or not; whether he has a four-thousand dollar operating-room, or operates as most of us have to do, without an operat- ing-room. What we do wish is that he will state to the profession in his writings what he states to his pa- trons; that he will take the stand as an orthopedist and stand by it so long- as he does only mechanical work; and that the profession of this country, as well as foreign countries, will not be deceived by articles which are disproved by his annual reports, but will understand that American or- thopedic surgeons do not tie them- selves exclusively to the buckle and bar and strap, but do follow rational scientific methods. One word in regard to the word “conservatism” or donothingism, as used and followed in practice by Dr. Shaffer. I hate the word and have defined it. The word “conservatism.” (donothingism), “alteratives,” “re- lapsing club-foot,” and “scrofula” are the breastworks behind which ignor- ance and empiricism skulk. The dis- covery of the action of a drug takes it at once from the list of “altera- tives;” ignorance of its action leaves it in the list; the discovery of the cause of the vast number of surgical diseases has taken them out of the column of “conservatism,” and placed them in the list of rational, scientific surgery. Appendicitis is no longer treated “conservatively,” because we know what it is; it is now treated scientifically. Conservative surgery does the right thing at the wrong time: scientific surgery does the right thing at the right time. And so it is in “orthopedic surgery”—and I use this term as it is understood by most -of the members of the American Orthopedic Association. We are es- caping from the ideas of the past; we are applying our braces and mechan- ical appliances in a class of cases suitable for such work, but we are not losing sight of the advances which have been made in surgical bacteriology and modern pathology, and we are now applying that knowl- edge to our speciality. We are not stretching fibrous tissues in the sole of the foot or palm of the hand so much as we did; we are not allowing joints to macerate for months in pus, with all the disastrous results of which we know. We are not bracing bow-legs and genu valgum in chil- dren of maturer years- we are not dallying for ten re- munerative plantar or palmar fascia. We believe that the loading down of the child of maturer years with braces for genu valgum and bow-legs after the bones have become hard and consolidated is not the best plan, but that osteotomy or osteoclasis should be performed. This seems to be the trend of the mind of the ma- jority of the members of the Ameri- can Orthopedic Association. I quote from my address: “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; who will have added to this knowledge a general practice of at least twelve years before en- gaging in the speciality. With all of these requirements and by his su- perior work, he will secure for our specialty the subjects which are right- fully ours. He will be fully com- petent 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 speciality,not excepting general surgery. Orthopedic surgery, when thus contemplated, is a grand spe- cialty. 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 in- clude in our membership the best pathologists, general surgeons, and anatomists that our broad republic can furnish. The ‘orthopedist’ 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 profes- sion of medicine.” Now in regard to the personal at- tack which Dr. Shaffer feels called upon to make upon me. He says in his article: “It is probably my desire to have the mechanical take precedence of operative teaching which leads Dr. Phelps to reach the acme of his misrepresentations, when he speaks of an institution (meaning the New York Orthopedic Dispensary and Hospital) where ‘buckle and strap- men degrade orthopedic surgery.’” Dr. Shaffer knows that nowhere in my address did I allude to him per- sonally or to the Fifty-ninth Street Dispensary, and nowhere did I say that “buckle and strap men degraded orthopedic surgery”—only orthopedy could be disgraced; but I will say,, now, however, that when the “ortho- 20 pedist” presumes to speak for ortho- pedic surgery and shackle its limbs with nothing but buckles, bars and straps, as Dr. Shaffer attempts to do and as his report proves, any or thopedic surgeon would be justified in resenting the attempt and de- nouncing it with indignation. This is the height of “misrepresentation” and misquotation. My address was a general one, and if there is any- thing in it that seems to fit the case of Dr. Shaffer and his institution, I have not the slightest objections to his applying it. Dr. Shaffer accuses me of “misrepresentations.” I ask him to state specifically in these col- umns where I have “misrepresented.” and I may be able to make any cor- rection and offer to him and the pro- fession a suitable apology. He further says: “Dr. Phelps re- fers to the ‘oculist’ and the ‘woman- doctor’ as being examples for the or- thopedic surgeon to follow. Does Dr. Phelps represent them correctly?” This is another “misquotation” and willful “misrepresentation.” If Dr. Shaffer will read my address he will find that I allude to them as being the primitive source whence came 21 the grand specialties of gynecology and ophthalmology. I said: “Less than a half 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, etc., etc.” He was known as a woman-doctor. I also said: • “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 dis- eases of the eye. A few of these oc- ulists began the work, and, as a re- sult, the world is now blessed with a most important special department of surgery known as ophthalmology.” So it is with the orthopedist and his work. From him and his antiquated and absolete work has evolved the grand specialty of orthopedic sur- gery, and among those in this coun- try who raise their voices in defense of a practice that extends back through the absolete schools of Eu- rope, and whose antiquity we can 22 trace almost to the traditions of medi- cine, is my friend, Dr. Shaffer. Furthermore, Dr. Shaffer asks: “And how about the gynecologist; would he operate upon an aneurism of the abdominal aorta, because it interferred with the functions of the uterus?” No; neither would he ex- cise the left ventricle of the heart. He refers to my address in this way: “Notwithstanding all this, Dr. A. M. Phelps, of New York, rushes into print, and with an undue impetuosity adds to the misrepresentations of my work. His remarks are embodied in an article, ‘The Influence of Surgical Bacteriology and Modern Pathology Upon Orthopedic Surgery, and the Past, Present, and Future of that Speciality.’ The first part of the ad- dress reads like an extract from a lecture to a class of first-course stu- dents. It would seem wholly un- necessary to present it in a presiden- tial address before a body of scien- tific men. To publish it as such is a reflection upon the intelligence of the American Orthopedic Associa- tion.” I will inform Dr. Shaffer that there are facts stated in that part of the ad- 24 dress that he, nor any other man— so far as I know—ever read before. I will add that any man who will print in a report of an institution that receives 881 cases of diseases, a considerable percentage of which are attended with abscesses, the state- ment that “No abscesses were opened during the year,” and who stretches the remunerative plantar fascia and tendo Achillis for twelve years--might read even a lecture for first-course students on surgical bacteriology and modern pathology with profit to him- self and benefit to his patients. The letters of congratulation which I have received from many members of the American Orthopedic Association indicate, to my mind, that the Asso- ciation does not take the same view of that part of my address as the dis- tinguished orthopedist. It may be owing to the fact that they have not attained to the same sublime degree of scientific excellence in the subjects as Dr. Shaffer. About the only severe strain upon the intelligence of the Association that we have been compelled to lis- ten to is that original name fora cer- tain deformity of the foot, evolved by Dr. Shaffer. I allude to “non-de- forming club-foot.” All the club- feet which the members of the Ameri- can Orthopedic Association have ever seen were deformed. The term con- veys the same scientific idea to the mind that the statement made by Munchausen did when he said “that his eyes were dazzled by the brilliant rays of the sun as it shown upon Bat- tery Park at mid-night.” Then, again, Dr. Shaffer says: “To those who know the real state of af- fairs, Dr. Phelps’ statements may not carry conviction with them, but as there may be somewhere in the wide range of the “A. M. S. Bulletin’s” cir- culation a few persons or places where Dr. Phelps is not known, I venture to make a brief reply, not so much for myself or in reply to his obvious attack upon me, as for ortho- pedic surgery. As I have already said, nowhere in my address will Dr. Shaffer find any personal attack upon him or the institution where he works. There are other institutions in this city where surgical work is almost entirely dispensed with, and the buckle, bar, strap, and brace is the same shrine at which they worship as 2 6 that erected at the Fifty-ninth Street Dispensary and Hospital by my friend Dr. Shaffer. His report verifies every statement that I have, in a general way, made regarding the orthopedist and his work, in my address. Judging from the report of the Fifty-ninth Street Dispensary and Hospital, and the large number of cases of club-foot, knock-knees, bow-legs, and suppurat- ing joints, which drift into my clinics at the Post-Graduate School and Hospital and the University Dis- pensary, that have been treated with braces for years with disastrous re- sults, lead me to think that we have both the “orthopedist” and the “ortho- pedic surgeon,” and that the Fifty- ninth Street Dispensary and Hos- pital is an institution controlled by an “orthopedist.” Replying to Dr. Shaffer’s personal attack upon me, where he casts reflec- tions upon my veracity and charges me with “misrepresentation,” ard expresses the fear that “a few per- sons in places where Dr. Phelps is not known might believe them,” T will say that those who know me best would know that any such unwar- ranted and unethical statement would not be believed. Dr. Shaffer says: “Why should orthopedic surgeons care to excise a joint simply because a deformity happens to be connected with the dis- ease or condition producing it ?” I ask him why he did not send for a surgeon to perform his twelve tenot- omies ? The surgeon is ready to do that work. He might ask, “Why does not the ophthalmologist, a Roosa, Knapp, Bull, Pooley, Noyes, Volk, and a Moore, and scores of others in this city, send for the surgeon to per- form their cataract operations for them ? ” Why don’t the gynaecolo- gist, in his grand specialty, send for the surgeon to remove the tubes and ovaries for him, in cases which he is treating for septic endometritis ? It is hardly necessary for me to answer such questions. The oculist, woman- doctor, and orthopedist would. But in the light of the dawn of this scien- tific era, in which men, working in special lines, have made themselves more expert, possibly, in their line of work, the orthopedic surgeon, gyne- cologost, ophthalmologist propose to do their own work, which only sup- 28 plements the subsequent treatment. He further says that “Dr. Phelps would probably insist that the gyne- cologist would operate for cataract if the patient happened to be a woman.” It would take the same amount of mental gymnastics to conceive of such a question that it would for an “orthopedist” to find a reason for stretching the“remunerative” plantar fascia and tendo Achillis for twelve or fourteen years, with all its failures; to brace bow-legs and knock-knees for years after the bones have become consolidated, or to treat hundreds of abscesses, and then arrogantly print that “no abscesses were opened dur- ing the year.” He further says: “Why should the unsolved be neg- lected for the prefunctory work of ordinary cutting operations ? ” It is not. I would like to ask Dr. Shaffer, why should the solved be neglected by the orthopedist ? Why should he not drain abscesses in joints; remove the head of the femur, which has been separated from the neck by disease, and now is a sequestrian and foreign body, keeping up the irritation and disease, and resulting often in the loss of limb and life by neglect, in- stead of watching them for years with steel splints ? Why does not the orthopedist perform osteoclasis or osteotomy in children after the bones have become consolidated ? These are questions solved; and still, Dr. Shaffer prefers to run counter to the demonstrated and accepted clinical fact, well established by every sur- geon and orthopedic surgeon of this world. It has been “solved” that the plantar fascia and tendo Achillis, when lengthened by an operation,give better results in a very short time in a certain class of cases, than all the machine work known to the “ortho- pedist. Relapsing club-foot is wholly unknown to the orthopedic surgeon, when cared for subsequently. By instrumental work in this class of in- veterate club-foot, relapses and fail- ures occur too frequently. I am speak- ing now, not of the young child, where treatment begins during the first year of life (ninety-five per cent, of such cases can be cured without operation), but of neglected cases after the first, second, or third year of childhood. Certainly the opening of abscesses, osteoclasis, tenotomies, fasciotomies, and myoto- mies do not require an elaborate operating-room for their successful performance. The cry in Dr. Shaf- fer’s “attack,” that he has declined to perform “open operations in the gen- eral ward, the only available place in the hospital,” in this class of casses, amounting to several hundred, will impress the reader as being very ludicrous. Osteoclasis for knock- knee and bow-legs is not a cutting operation. Then he further says: “And this fact, strong and inconsist- ent as it may seem, has been used by my critics to place me in an unfavor- able light.” If he would substitute for “unfavorable” the word “unfor- tunate,” it would more accurately describe the position in which Dr. Shaffer has placed himself before the profession. He further says: “I feel like say- ing to my critics, and in response to their unkind and ungenerous re- marks, I feel more and more each day that no one can properly judge of the value of conservative versus operative work in orthopedic surgery until one has had an ample experi- ence in both fields.” If conserva- tive work means the performing of twelve tenotomies in a series of 2440 cases; that no abscesses were opened no joints drained, and no sequestra removed from suppurating joints, if it means that bow-legs, genu valgum, knock-knee, and wry-neck, in a series of many hundred cases, are operated upon, but treated for years by me- chanical means, with all the failures which must necessarily result—we all say, give us a little more scientific operative work and less unscientific donothingism under the cloak of “conservatism.” He further says: “If I have demon- strated to my own satisfaction that more than one-half of the operative work that is being performed to-day tor chronic deformities is unneces- sary, I ought to be satisfied with the result.” Undoubtedly many opera- tions are performed for chronic de- formities that could be dispensed with by employing years of mechan- ical work; but it is a serious question whether it is better among the poor laboring classes to spend years in mechanical work, with all its pain, inconvenience, and failures, even though after many years success might reward the effort, and whether it is not better to operate and get a speedier and grander result in a few weeks’ time. If Dr. Shaffer had said that three-fourths or one-half of the misapplied mechanical efforts could and should be dispensed with in a certain class of cases, and, instead of doing twelve tenotomies in a long series of many scores of cases, opera- tive work took its place, after a few months of mechanics had, perhaps, failed, he would have come nearer to the fact. Then he further says: “Anyway, I think I know more than I did, and, perhaps, can better esti- mate when to operate and when not to operate in cases demanding ortho- pedic care.” The reports of the Fifty-ninth Street Dispensary and Hospital do not seem to verify this statement. The Hospital for Crip- pled and Ruptured, in this city, and the orthopedic hospitals of this and other countries, controlled by “ortho- pedic surgeons,” have from year to year extended their field of operation until their operative cases are num- bered by the hundreds; but I find by consulting the report of the Fifty- ninth Street Dispensary and Hos- pital that Dr. Shaffer has diminished the number of operations from year to year, until this year we find only twelve operations were performed in the institution—and these simple tenotomies—and that no abscesses were opened in the score of cases treated. Last year seventeen tenoto- mies were performed. At this ratio in two years more no operations will be performed, unless Dr. Shaffer meets with a change of heart. I have written this article in a spirit of fairness, I hope, to Dr. Shaf- fer and in justice to orthopedic sur- geons who believe that orthopedic sur- gery is a combination of mechanical and operative work. New York city; 40 W. 34th Street —A. M. Phelps, The Bulletin. 33