TENTH INTERNATIONAL MEDICAL CONGRESS WHAT IS ORTHOPAEDIC SURGERY? READ BEFORE THE ORTHOPAEDIC SECTION OF THE TENTH INTER- NATIONAL MEDICAL CONGRESS, BERLIN, AUGUST 5, 1890 BY NEWTON M. SHAFFER, M.D. ATTENDING SURGEON IN CHARGE OF THE NEW YORK ORTHOPAEDIC DISPENSARY AND HOSPITAL, CONSULTING ORTHOPAEDIC SURGEON to st. luke’s hospital, new york G. P. PUTNAM’S SONS NEW YORK LONDON *7 WEST TWENTY-THIRD ST. 27 KING WILLIAM ST., STRAND ®jje Ihticluxbcckrr press 1890 Compliments of the A uthor. TENTH INTERNATIONAL MEDICAL CONGRESS WHAT IS ORTHOPAEDIC SURGERY? READ BEFORE THE ORTHOPAEDIC SECTION OF THE TENTH INTER- NATIONAL MEDICAL CONGRESS, BERLIN, AUGUST 5, 1890 BY NEWTON M. SHAFFER, M.D. ATTENDING SURGEON IN CHARGE OF THE NEW YORK ORT*HOPEDIC DISPENSARY AND HOSPITAL, CONSULTING ORTHOPEDIC SURGEON to st. luke’s hospital, new York G. P. PUTNAM’S SONS NEW YORK LONDON *7 WEST TWENTY-THIRD ST. 27 KING WILLIAM ST,. STRAND <£{j£ JJrcss 1890 WHAT IS ORTHOPEDIC SURGERY?* THE recent action of the Orthopaedic Section of the New York Academy of Medicine in ap- pointing a committee to secure for orthopaedic surgery an official recognition by the Tenth Inter- national Medical Congress has been successful. Orthopaedic surgery is placed, by this act, upon the same plane with the other special branches of medi- cine 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 circu- lar-letter which was sent to those interested in orthopaedic surgery, that there exists a very general desire to aid this important department of surgery. Over one hundred replies have been received from English, Continental, 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 ortho- * Read before the Orthopaedic Section of the Tenth International Medical Congress, Berlin, August 5, 1890. 3 4 paedic surgery at the Congress, some have plainly said that this special section was not necessary ; others have stated that in certain localities the treat- ment of deformities was influenced by a class of men who were not regularly educated surgeons, while others again see difficulty in drawing the line be- tween general and orthopaedic surgery. These facts raise some important questions which, it seems to the writer, should be discussed by the members of the orthopaedic section at its first meet- ing in Berlin ; and the remarks that I have the honor to present have been suggested by the evident differ- ences of opinion that exist regarding the status of orthopaedic surgery. And the writer desires to state that the opinions here expressed are his personal views only, and that the committee appointed by the Orthopaedic Section of the New York Academy of Medicine (of which the writer has the honor to be a member) is in no way responsible for them. It seems unnecessary on this occasion to consider orthopaedic surgery from a, strictly speaking, histori- cal standpoint. A few historical facts may be men- tioned, however, which bear upon the rise and progress of the treatment of deformities. From the time of Andry, the word “ orthopaedic ” has been identified with the treatment of deformi- ties, and an “orthopaedist” has been one who treated deformity. But it was not until Stromeyer, in 1830, demonstrated the feasibility and the value of subcu- taneous tenotomy, that “orthopaedics” obtained its first firm foothold in the profession. Both before and after Stromeyer’s time, however, mechanico-therapy 5 was the fundamental part of the treatment of defor- mities. The introduction of subcutaneous tenotomy and of subcutaneous myotomy supplemented the treatment of deformity by mechanical means. Sub- cutaneous surgery did not dispense with the mechani- cal element of treatment; it rather emphasized its value and necessity. And it is fitting that we should note that the first great advance in orthopsedic sur- gery occurred in Germany, under the influence of Stromeyer’s teachings, and that his methods soon became recognized and practised in all parts of the world. The status of orthopsedic surgery in 1844, about fourteen years after Stromeyer’s methods were in- troduced, is very clearly shown by the essay1 of Dr. Henry J. Bigelow upon orthopaedic surgery. In this work Dr. Bigelow quotes largely from Stro- meyer, Guerin, Bonnet, Velpau, Phillips, Duval, Deiflenbach, and Little. The subjects treated by Bigelow, in addition to club-foot, lateral curvature of the spine, torticollis, etc., include both stammer- ing and strabismus. The operation for the last- named condition has long since been recognized as belonging to the special department of ophthalmol- ogy, while the former was long ago abandoned. It seems clear, however, from Bigelow’s essay that, at the date he wrote, orthopsedic surgery, so far as operative treatment is concerned, was synonymous with subcutaneous tenotomy and subcutaneous my- otomy, and that any condition requiring either of 1 “ Manual of Orthopaedic Surgery.” The Boylston Prize Essay for 1844 ; published, in 1845, in Boston. 6 these operations was to be classed under orthopaedic surgery. A few years later, or about 1852, an American 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 de- formities occasioned by chronic articular lesions. The treatment of Pott’s disease by means of the antero-posterior spinal apparatus was also demon- strated 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 conspicuous. They amplified Dr. Davis’ apparatus, and devised many forms of apparatus for the treatment of chronic and progressive deformities, and under their leadership the treatment of chronic joint and spinal disease be- came a distinctive feature of the American School of Orthopaedic Surgery, and another era in orthopaedics, second only to that of Stromeyer, was inaugurated. Up to about 1870, or thereabouts, it would there- fore appear that two important factors had 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- 7 mer it may be said that subcutaneous surgery is rarely used in the treatment of chronic deformity without after mechanical treatment, which after me- chanical treatment is oftentimes more important and essential than the cutting operation, and special skill and training are often required to apply it success- fully. 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 necessary the after treatment calls for little else than simple surgical dressings, which do not demand a special orthopaedic training to apply. The introduction of the traction splint in the treatment of chronic joint disease, as well as the introduction of the antero- posterior splint for Pott’s disease, enlarged the field of practical orthopaedics very much. “ Preventive ” surgery, the highest aim of surgery, became an im- portant factor in the treatment of this class of chronic deformities. By the judicious use of traction appar- atus, 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 pro- nounced, it can, in many cases, be overcome or greatly modified without any cutting operation. Indeed, the tendency of orthopaedic surgery has always been toward conservatism. 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 8 orthopaedic surgery had not invaded the field of gen- eral surgery. Availing itself of all that contributed to the relief of deformity from its conservative stand- point, it found many difficult problems which it did its best to master. It took hold of and cared for a much neglected 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 exact- ing—while the orthopaedic surgeon is devoting him- self to a department which has none of the brilliancy of operative surgery ; which requires much patient attention to mechanical detail; which demands special facilities for altering and modifying apparatus, and a special training and education which very few sur- geons have received. It is not many years ago, however, that general surgery began to invade the domain of orthopaedic surgery. This is especially true since the Lister method has become so universally accepted. The knife, the saw, the chisel, and the osteoclast have be- come potent factors in the reduction of obstinate osseous conformities. Knock-knee, bow-legs, old and obstinate cases of club-foot, 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 deformities, and is a legitimate advance in general surgery. And it was about this time also that joint resections began to attract the marked attention of surgeons of the United States. 9 To some orthopaedic surgeons these innovations of general surgery have proved a stumbling-block. They diverted the attention from the hard and rugged paths of orthopaedic work per se, to the brilliant work of the general surgeon. I know myself that the allure- ments of the operating table are very great, for about this time I had my own attack of “ surgical fever,” 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 orthopaedic surgery ? Shall orthopaedic 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 section in the Berlin Congress. Reference has already been made to Bigelow’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 “ Orthopaedic Surgery,” pub- lished in 1890, we will see that the tendency of modern orthopaedic surgery is to invade the field of general surgery. Bigelow’s work teaches subcutane- ous tenotomy and myotomy plus special mechanical treatment, 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 mechanical treatment of chronic deformity in a meagre 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, 10 viz., complete and scientific methods of mechanical treatment, which, when fully developed, will represent as much of real value to the human race as general surgery itself. It already represents a great deal, especially in the mechanical treatment of chronic joint and spinal disease, for since orthopaedic sur- geons 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 disease has advanced and pain is present, or when deformity is progressive and abscess is about to form, or has already formed, mechanico-therapy, properly understood and applied, can hold out to the sufferer more than the operative or general surgeon. In the field of chronic articular disease alone there is enough to do, and enough for the orthopaedic surgeon to learn, without invading at all the field of general or operative work. Let us see the position Sayre 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 experience in the treatment of joint and spinal diseases. 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 deformities 11 and their mechanical treatment. The work is one of the pioneers in an important field, Dr. Louis Bauer having covered somewhat 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 orthopaedic surgery is novel, interesting, and, in its way, classical. Bradford and Lovett, in 1890, group all deformi- ties under one head of “ orthopaedic surgery ” and reject the qualifying title of “ diseases of the joints ” adopted by Sayre. In addition to the conditions treated by Bigelow and Sayre, we find these authors include several new titles. Among them are the “cerebral paralyses of children,” pseudo-hypertrophic paralysis,” “ Dupuytren’s contraction,” “webbed fin- gers,” and “functional affections of the joints.” They extend the surgical aspect of the treatment of de- formities and give a large portion of their work to resection of the joints, amputation at the hip joint, laminectomy, osteotomy, osteoclasis, etc. It seems unnecessary to call attention to the excellent and thorough way in which the, strictly speaking, ortho- paedic part of the work is executed. It is rather the object of the writer to call attention to the unneces- sary invasion of the field of general surgery, in a special treatise on orthopaedic surgery, when the purely surgical aspect of the conditions named is amply covered in the current surgical literature of the day. None of the writers I have referred to define orthopaedic surgery in their works, and the definitions 12 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 surgery. Under these circumstances, I found myself, several years ago, called upon to define orthopaedic surgery, by the class at the University Medical College, at a time when I was connected with the College, and I then ventured upon the fol- lowing definition1: “ Orthopaedic surgery is that department 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.” I would modify this definition to-day so that it would read as follows : “ Orthopaedic surgery is that de- partment of surgery which includes the prevention, the mechanical treatment, and the operative treat- ment, 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 ortho- paedic surgeon should be, from the standpoint 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 orthopaedic 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 sur- geon, before his study of mechanico-therapy is com- 1 “ The Present Status of Orthopaedic Surgery,” New York Medical Jour- nal, January 26, 1884. menced. 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 sur- geon, 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 in- vading 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 operations of surgery, and but very few who can intelligently devise and apply apparatus in the various and varying conditions of chronic deformity. 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 mechanico-therapy—a very wide and important field—is too apt to be totally 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 only to look at the barber-pole of to-day to recall the position of surgery in former years, and it is not im- possible 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 ortho- paedic surgeons 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 or- thopaedist is unnecessary and uncalled for. It further seems to the writer that it can only bring discredit 14 upon a new and important field of work—which is even further removed from general surgery than ophthalmology or laryngology. This invasion will direct 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 orthopaedic surgery, is not, perhaps, so much out of place. He said : “ The next work on orthopaedic surgery will likely tell us all about fractures and dis- locations.” The fact that the plan here proposed will necessarily limit the operative work of the orthopae- dist 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 supple- ments 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 standpoint of our meeting here in Berlin, we may learn another les- son. The only possible excuse for the foundation of a special section of orthopaedic surgery at this Con- gress is the rapid rise and development of Mechanico- therapy, especially in the United States. There would be no true orthopaedic surgery to-day, if me- chanico-therapeutics had not been studied long and 15 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 resections, amputation at the hip joint, laminectomy, osteotomy, etc., I fancy that the com- mittee 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 ortho- paedic work. In 1873, I found myself in charge of the orthopae- dic service of St. Luke’s Hospital, with no restric- tions as to the operative work of my own department. I soon found that the purely surgical 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 conser- vative or orthopaedic side of the work was becoming less interesting. After mature reflection, it became apparent that the operative field was well represented in the eminent surgical staff of the hospital, and that it was clearly my duty to develop and establish the principles of orthopaedic surgery. After reaching this conclusion I voluntarily turned over to my col- leagues all the purely operative work which required no orthopaedic treatment after operation, and from that time up to the day of my resignation I operated only on those cases which would necessarily remain under my care after operation. Soon after my appointment as surgeon in charge of the New York 16 Orthopaedic Dispensary and Hospital, 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 surgical and orthopaedic departments. The real diffi- culty 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 hospital rather than an orthopae- dic 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 re- tired, 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 ab- solute control of its surgical policy, I have for several years—and since the retirement of the active surgical staff—operated only on those patients who required special orthopaedic 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 operation, who have not demanded special orthopaedic 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 interest 17 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 mechanical ability which is an essential element of success 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 orthopaedic work. At the end of six months or a year they may regard themselves as fully equipped orthopaedic surgeons. On the other hand we have had able men as assist- ants whose college and competitive examination records were high, whose mechanical instincts were lacking. These men were clearly out of place in orthopaedic work. My experience proves that it re- quires an exceptional man to succeed in orthopaedic practice. If he possesses mechanical tastes and ability, and devotes himself to orthopaedic 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, be- come the latter in effect, if not in name. And if he does not possess, in a high degree, an educated appreciation of the various and complex mechani- cal problems which will constantly confront him in daily practice, he will very likely turn to operative 18 measures when there may be no need for such a step. Nor can any one expect to equip himself as an or- thopaedic 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 demanded of those who expect to be- come orthopaedic 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 pro- longed study of many cases; and in the chronic joint department of orthopaedic surgery, one may wait sev- eral years before seeing the end of one’s first case. A great deal will be expected of the orthopaedic surgery of the future, and it seems to the writer that the sooner the followers of orthopaedic surgery realize that it has enough in itself to sustain its well-earned reputation without encroaching upon other grounds, the better it will be for orthopaedy. I feel a natural embarrassment 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 em- bodying 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.