THE HISTORY OF ORTHOPAEDICS

Orthopaedics, like many specialties, has developed through a necessity. A necessity to correct deformity, restore function and alleviate pain. Orthopaedic surgeons have developed an ability to prevent major losses of bodily function and indeed they can prevent otherwise inevitable death. They seek perfection of their art, by ensuring that the patient reaches optimal condition in the shortest period of time by the safest possible method.

History is very important to any surgeon, particularly the Orthopaedic surgeon. The Orthopaedic surgeon has once again been presented with advancing technology. This technology must be applied to the surgeon's practice, but it is best applied only when the surgeon has an underlying knowledge of the history of his art. He must be aware of the way surgeons in the past have contributed to Orthopaedics and more importantly, of the mistakes but they have made in the process. The surgeon who makes a mistake that was made by someone before him, is surely humbled and seen as poorly educated. So is he who states that he has developed a technique that no one has thought of before, because chances are that it has been thought of in the past.

In order for Orthopaedics to advance in an optimal manner, it is clear that attention must be paid to a history of Orthopaedics. The past is our foundation for future developments, we must build upon it so that we too can act as a stable foundation for future generations.

ANCIENT ORTHOPAEDICS

PRIMITIVE MAN

Although we have no written historical accounts, primitive man provides us his fossils. These show that the same pathology affecting bone existed in primitive times, hence an environmental cause for many of our common ailments seems unlikely. Evidence of fractured bones has been found, in some of which union has occurred in very fair alignment. This is interesting to note, as it gives us an ethical manner in which we can see the effects of no treatment at all, i.e. applying rest by instinct and early motion. It is inevitable that, at some stage, primitive man created a very crude splint, and that from that stage on, its advantages were recognised. Primitive man was probably also the first to perform crude amputations of limbs and fingers, and to trephine the skull.

ANCIENT EGYPT.

Mummified bodies, wall paintings and hieroglyphics, have shown us that the people of the Egyptian age suffered from the same problems that we suffer today. They also show us some of the orthopaedic practices of that time. Splints have been found on mummies and they were made of bamboo, reeds, wood or bark, padded with linen. There is also evidence of the use of crutches, with the earliest known record of the use of a crutch coming from a carving made in 2830 BC on the entrance of a portal on Hirkouf's tomb.

Perhaps the most important source describing the practices of the Ancient Egyptians comes from a papyrus, which was stolen from a tomb in 1862. The papyrus was then sold to an American Egyptologist by the name of Edwin Smith and so is sometimes known as the Edwin Smith papyrus. The author is not known, but believed to be Imhotep. Imhotep was seen as a genius of his time. He was a physician, an architect, an astrologer, and a chief minister and there is no knowing in Egypt and Greece, with some evidence that he received this status only 100 years after his death.

In the papyrus, the examination of peripheral was described together with an understanding that pulses reflected the action of the heart from which vessels went to the limbs. In this papyrus, injuries were classified according to their prognosis into three categories: an ailment which they would treat, an ailment that they would contend and an ailment which they would not treat. The papyrus also mentioned many cases and the treatment involved. These include, reducing a dislocated mandible, the signs of spinal injuries, and the signs of torticollis, the treatment of a fractured clavicle as well as signs and treatment of other fractures. Discharge was referred to as "ryt", this is presumably the pus of osteomyelitis.

ANCIENT GREECE

Many principles behind conditions and their treatment have been attributed to the Ancient Greeks. They could be regarded as the first to use a scientific approach, however they were also the first to document in detail their history and developments. Homer alone, in his account of the Trojan war, has provided us with an adequate insight to the understanding of injuries at that time and the treatment used for those injuries. The Iliad also contains references to various deformities. The Greek anatomists of Alexandria, during the 3rd century BC were also great contributors. Herophilus, who is believed to have practised human dissection, is regarded as the first to divide nerves into sensory and motor components and also the first to distinguish arteries from veins. Hegetor also of Alexandria, but of 100 BC, described in detail the anatomical relations of the hip joint, and was the first to record a description of the ligamentum teres.

In the period between 430 and 330 BC a very important Greek text was collated and is known as the Corpus Hippocrates. It is named after Hippocrates who is known as the father of Medicine. Hippocrates was born on the island of Cos in 460 BC and died at an old age in 370 BC. He is known as having brought a systematic and scientific approach to Medicine and as having defined for the first time the position and the role of a doctor in society. Although centuries have passed, the Hippocratic oath will always remain central to our practices.

Various volumes in the Corpus Hippocrates had relevance to Orthopaedics. One such volume is the one on joints. Here dislocation of the shoulder was described together with the various methods used in reduction. There were also sections describing the reduction of acromioclavicular, temporomandibular, knee, and hip and elbow joint dislocations. The correction of club foot was described. The problem of infection after compound fractures was described and treated with pitch cerate and wine compresses without forcible bandaging. Probing into any compound fracture was avoided.

Hippocrates had a thorough understanding of fractures. He knew of the principles of traction and counter-traction. He developed special splints for fractures of the tibia, similar to external fixation. Hippocrates also developed the Hippocratic bench or "scamnum". Of all the developments that Hippocrates has given to us, his careful clinical observation and rationale thinking must be particularly commended.

THE ROMAN ERA

Although the teachings of Hippocrates were to dominate thinking for many centuries after his death, there are several contributors to Orthopaedics worthy of mention. During the Roman era, there was another respected Greek figure by the name of Galen (129-199 BC). He was originally from Pergamon and became a gladiatorial surgeon there before travelling to Rome. Galen is often referred to as "the father of sports medicine". He gave a good account of the skeleton and the muscles that move it. In particular, the way that signals are given from the brain through the nerves and to the muscles. He first recorded a case of cervical ribs. He described bone destruction, sequestration and regeneration in osteomyelitis and sometimes performed resection in such cases. Galen is believed to be the first to have used the Greek words, kyphosis, lordosis and scoliosis for the deformities described in the Hippocratic texts. He also devised several methods for correcting these deformities.

During this Graeco-Roman period, there were also attempts to provide artificial prostheses. There are accounts of wooden legs, iron hands and artificial feet. Soranus of Ephesus is said to have first described rickets. Ruphus of Ephesus described tendon ganglia and their treatment by compression. Antyllus of the 3rd century is said to have practised subcutaneous tenotomy to relieve contractions around a joint. It is said that he used both linen and catgut sutures for thee procedures. Various drills, saws and chisels were also developed during this period.

THE ARAB ERA.

Another Greek named Paul of Aegina (625-690 A.D.) worked in Alexandria and wrote "The Epitome of Medicine" which consisted of seven books based on the Hippocratic texts. The sixth book dealt with fractures and dislocations. With the invasion of Alexandria by the Moslems, many great books such as these were taken and translated into the Arab language. The great library of Alexandria was burnt. Although the Arab practices were regarded as an extension of those of the Greeks, the use of plaster-of Paris in the l0th century was significant. With the addition of water to a powder of anhydrous calcium sulphate a hard crystalline material was produced. A Persian by the name of Abu Mansur Muwaffak described the coating of plaster for fractures and other bony injuries of the limb.

THE FOUNDATIONS OF MODERN ORTHOPAEDICS.

It was not until the l2th century that Europe began to awake gradually from its Dark Ages. Universities and hospitals were beginning to be established, human dissection resumed and the great Greek texts were being translated from Arabic to Latin. However, until the l6th century, all developments remained within the shadow cast by Hippocrates.

AMBROISE PARE (1510-1590)

Ambroise Pare is regarded as the most famous surgical figure of the l6th century and the father of French Surgery. He was born in Bourg Herent in France. In 1532 he became an apprentice to a Parisian barber-surgeon, then worked for four years at Hotel Dieu in Paris. In 1541, he became a master barber-surgeon and did some work as an army surgeon. In 1564, he published a monumental work on Surgery, the Dix Livres de la Chirurgie. The first part contained Anatomy and Physiology and the second, Surgery. In this, many surgical techniques were described, one of the most significant being the use of ligature for large vessels in amputations. He also used a tourniquet in his amputations, to hold the muscles retracted with the skin, prohibit the flux of blood and to dull the senses. He designed a wide variety of forceps, instruments and braces of all kinds. With the help of armourers, he made a variety of artificial limbs from iron. The majority were cosmetic, although Pare did design a scoliosis corset and a clubfoot boot.

NICHOLAS ANDRY (1658-1759)

Andry was the professor of Medicine at the University of Paris and Dean of the faculty of Physick. In 1741, at the age of 81, he published a famous book called Orthopaedia: or the Art of Correcting and Preventing Deformities in Children. By such means that may easily be put into Correcting and Preventing Deformities in Children. By such means that may easily be put into practice by parents themselves and all such as are employed in Educating Children. In This book, Andry presents the word Orthopaedic, which derives from the Greek words straight and child. Andry was interested in postural defects and this has been reflected by his famous illustration, which is known The tree of Andry. Andry believed that skeletal deformities were due to faults of posture and shortness of muscles. Some regard Andry as the Father of Orthopaedics, by many strongly disagree, believing that his work was un-scientific and that his only contribution was the use of the word Orthopaedics.

THOMAS SYDENHAM (1624-1689)

Sydenham is likened to Hippocrates because his writings cover a large field and are characterised by good observation. Likewise, he is also known as the father of English medicine. He was born at Winford Eagle, and studied at Oxford and Montpellier. He himself suffered from gout and wrote an excellent description of the disease, detailing the attack, the changes in urine and the link with renal stones. He described acute rheumatism, chorea, and the articular manifestations of scurvy and dysentery.

PERCIVAL POTT (1714-1788)

Pott was from London and worked in St. Bartholomew's Hospital, were he received the diploma of the Barber-Surgeons' Company in 1763. He is best known for the fracture that bears his name Pott's fracture, as he was the first to give a good description of this ankle fracture. In 1756, he received a fracture of his own. This was an oblique compound fracture of the lower third of the tibia, which was acquired after falling from his horse. He refused to be moved until he had purchased a door to be carried on, as he believed that the jolting of a carriage would have exacerbated the injury. Immediate amputation was usually conducted on such injuries, but at the last moment amputation was stopped and the limb was saved. Pott's most famous work is on the paraplegia of spinal tuberculosis, where he stressed that the condition was not related to spinal cord compression, but associated with strumous disorders in the lungs. This is known as Pott's paraplegia.

WILLIAM HEBERDEN (1710-1801)

Heberden was born in London were he also built up a busy practice. He is known for initiating the Medical Transactions in 1766, but even more so for his description of Heberden's nodes.

JOHN HUNTER (1728-1793)

Hunter worked on a Lowland farm until he was 20 years of age. Until he was 32, he was a pupil and house surgeon at St. George's Hospital in London and also worked in his brother's dissecting room in Covent Garden. In the Seven Years' War, he served as a military surgeon. He set up a research centre in London's Golden Square and taught and lectured at Leicester Square until angina eventually led to his death. Hunter's contribution was immense and even stemmed through the pupils he taught (e.g. Abernethy, Chessher, Jenner and Philip Syng Physick). Hunter himself was a pupil of Percival Pott. Although he received little formal education (unlike his brother William, an obstetrician in London) Hunter put the practice of surgery on a scientific foundation and laid the framework for the twentieth century developments. His saying Don't Think, try the experiment has inspired generations of modern surgeons.

Much of Hunter's knowledge may be attributed to his military experience and his experiments on animals. He described how to assess muscle power in a weak muscle. With joint injury and disease, he states that voluntary movement should not be permitted until inflammation has settled, otherwise contracture is promoted. He believed that healing depended on the body's innate power, and that the surgeon's task was to aid this. Hunter believed that bone disease often required mechanical assistance. He studied loose bodies in joints, pseudoarthroses and fracture healing, where he described the transformation from fracture haematoma to fibrocartilagenous callus to the deposition of new bone, trabeculation, reestablishment of the medullary canal and the resorption of excess bony tissue. Hunter wrote A Treatise on the Blood, Inflammation and Gunshot Wounds in 1794, and also made attempts at tissue grafting.

His collection of specimens (initially over 14,000 POT's; half destroyed in the bombing of London) is in the College of Surgeons, London. They describe the development of the various systems from the simplest (insects) to the most complex. It is a humbling and inspiring experience to visit the museum and see one mans monumental contribution to surgery.

JEAN-ANDRE VENEL (1740-1791)

Jean-Andre Venel was a Genevese physician who studied dissection at Montpellier at the age of 39, and in 1780, established the first orthopaedic institute in the world at Orbe, in Canton Waadt.

This was the first true hospital that dealt specifically with the treatment for crippled children's skeletal deformities. Venel recorded and published all his methods and for this was known as the first true orthopaedist. He is also regarded as the father of orthopaedics, as his institute acted as a model for hospitals throughout Europe. Venel stressed the importance of sunlight and made various braces and appliances at the workshops within the institute.

WILLIAM HEY (1736-1819)

William Hey was born in Pudsey near Leeds. At the age of 14 he was apprenticed to a surgeon and apothecary and nearly died of an overdose of opium whilst studying its effects. He was the founder of Surgery at Leeds and trained at St. George's Hospital. Hey wrote a book on Surgery which contained several chapters on Orthopaedics. Subacute Osteomyelitis of the tibia was described and he advocated deroofing of the lesion. In 1773, Hey banged his knee getting out of the bath, and many attribute his subsequent interest in the knee to this. He coined the phrase internal derangement of the knee, and described meniscal injuries. Hey described loose bodies and introduced tarso-metatarsal amputation.

GIOVANNI BATTISTA MONTEGGIA (1762-1815)

Monteggia was born at Lake Maggiore and was a Milanese pathologist who acquired syphilis by cutting himself at autopsy and became a surgeon and professor at Milan. He is particularly remembered for his description in 1814 of the fracture that bears his name, Monteggia's fracture.