HISTORIC BACKGROUNDS OF ORTHOPEDIC SURGERY* By WALTER G. STUCK, M.D. SAN ANTONIO, TEXAS AS the developments and at- paleolithic age (25,000 years ago) as / vk tainments of modern sur- evidenced by primitive drawings on /\k gery are studied, and its the walls of paleolithic caverns in **“* divisions and specializations Spain.7 considered, it is easy to overlook the A striking parallelism continues distant past of each of these branches further in the knowledge of the his­ and to forget their collateral ancestry. toric backgrounds of these two major The legacy from primitive surgery is specialties. Except for the primitive not great and the debt to the surgeons circumcision knives discovered in before Lister’s time may be easily Egypt, the earliest surgical appliances paid; yet even so, there is still intense known are the splints found by the fascination in tracing and discovering members of the Hearst Expedition on the poignant contributions of all our two mummies in the same tomb at progenitors. Naga-ed-der. Smith examined these bodies, which were judged to be Ancient Surgery 5000 years old, and in one body, that The neurosurgeon of today beholds of a girl, aged about fourteen years, his earliest predecessors in those un­ there was a fracture in the middle known prehistoric medicine men who third of the femur (Fig. 1), and in trephined the skulls of men of the another, fracture of both bones of the neolithic age 10,000 years ago. Plastic forearm. These members were splinted surgery saw its birth in the early by wooden strips wrapped in linen rhinoplastic operations performed by with padding of coarse grass and the the ancient Hindus, and the ophthal­ whole bound by linen sheets. Ap­ mologists are the heirs to the skilful parently the early orthopedists made Greek, Antyllus, who mentioned re­ no effort toward extension; however, moval of cataract by extraction and criticism is unjustified when one con­ suction. siders the efficacy of such splints for But more ancient than any of immobilization and the singular thor­ these are the earliest evidences of oughness with which they are applied. techniques which began the evolution Nevertheless, in an extensive study toward two great modern branches of of paleopathology in Egypt, Sir Arm­ surgery, genitourinary and orthopedic. and Ruffer concluded that the final Lost in the mists of antiquity is the results of treatment of fractures in story of the origin of the operation of ancient times was bad, and that the circumcision, the first distinctly spe­ frequency of malunitcd and ununited cialized urological surgical procedure, breaks was high. and likewise, another rite, amputation Again the earliest portrayal extant of the fingers, a distinct orthopedic of surgeons at work combines the problem, goes back at least to the late backgrounds of these two specialties. *Read before the Salerno Medical History Club of The Mayo Clinic, Rochester, Minn., April 5, 1932. Max Muller,4 in IQ04, explored a tomb tained an important position in their at Lb ret, near ancient Memphis, and traditions. Likewise, in Ezekiel 30:20, there found a sculptured panel be­ is a casual consideration of the current lieved to date not later than 2500 b.c. (4500 years ago). Here in the upper panels (Fig. 2) were pictured the surgeons at work on the hand, foot, and knee of their several patients, and in the lower rows of illustrations, the treatment of fractured extremities for genitourinary surgeons of a bygone it is stated: “Son of man, I have age were apparently cutting for broken the arm of Pharaoh, King of chordee or performing circumcision Egypt, and lo it shall not be bound up on two adults. In the accompanying to be healed, to put a roller to bind it, hieroglyphics are manifested intimate to make it strong to hold the sword.” sidelights of the problems of primitive Henceforth the subsequent story of practice. How familiar to us all is the genitourinary surgery passes to those cry of the patient, “Do this and let chapters describing the charlatanism me go!” or “Do not hurt me thus!” of the uroscopists (water doctors) and equally characteristic in its calm and the adroit maneuvers of the and respect for authority, is the sur­ prc-Listerian Iithotomists on its path geon’s reply, “I’ll do as bids me the to the final story of the complete king.” specialty today. Likewise the narra­ Furthermore, in the King James tive of the progress of orthopedics version of the Bible, only two surgical engrosses in passing the indispensable procedures are mentioned which at services of the early army surgeons the same time depict the beginnings and the unquestioned adeptness of the of our modern orthopedics and urol­ bone setters and brace makers who ogy. Circumcision, of course, is fre­ contributed to the composite back­ quently referred to; for as a sacerdotal ground of the present-day orthopedic rite among the Hebrews, it main­ surgeon. In the surgical thinking of primitive by fisticuffs and her subjects com­ man, orthopedics indubitably played monly wielding heavy clubs, we must an important part. Human life was reiterate that life among the ancients was unquestionably violent! The war wounds in ancient times, however, were not so important ortho- pcdically for, until the introduction of gunpowder in the thirteenth cen­ tury, injury to bones was much less common. Wounds from lance, spear, and arrow engendered much infection and loss of life, but it is significant that of the 250 wounds mentioned in Homer8 with a mortality of 75 per cent, there was not a single case of loss of limb. Hippocratic Era From the time of Hippocrates on­ ward, surgical writings were not essentially violent and disordered so complete without a considerable por­ that in the pursuit of food, the defense tion being devoted to the subject of of homes, and the conquest of ene­ fractures, dislocations, and other mies, our ancestors frequently must problems encompassed in modern or­ have experienced fractures, disloca­ thopedics. In the Hippocratic writings tions, and other injuries of the ex­ preserved for us today, the four tremities. Smith has pointed out that treatises (“On the surgery,” “On since time immemorial the Egyptian fractures,” “On the articulations,” native has habitually carried a and “The mochlicus”) relating to “naboot,” a thick heavy staff about these subjects comprise more than a 5 feet long, which he utilized for third of the total. Adams, the trans­ sport or for more serious acts of lator, summarized: “When we reflect defense.29 This weapon, by its very on the admirable manner in which antiquity and usefulness, was no the whole subject is handled, and the doubt a most prolific source of cracked many important truths which are heads and fractured forearms. Those evolved in the course of it, we cannot of you who heard Lord Moynihan’s surely but regard with veneration the historic address in August, 1930, recall labors of our forefathers.” that he determined the shrewish iras­ Hippocrates, after a casual review cibility of the mother of King Tutank­ of the structure and function of the hamen by discovering a poorly-united skeletal system, proceeded directly fracture of one of her metacarpal to consider the care of injuries and bones. This injury, he explained, is disease sustained by it. His considera­ produced almost always by striking tion of dislocated shoulder is superb with the closed fist and is a common and was matchless until modern times: sequel to domestic brawls. What with “When, then, a dislocation to the the queen-mother settling altercations armpit takes place, seeing it is of frequent occurrence, many persons extended, the physician should apply know how to reduce it, for it is an the palms of his hands and adjust easy thing to teach all the methods the fractured parts, and then having by which physicians effect the reduc­ tions, and the best manner of applying them.” Follows then a detailed de­ scription of four successful maneuvers including the use of the heel in the axilla (a familiar technique to us all) and the “method with a ladder.” In the latter method he explained that “some round thing should be tied upon the step of the ladder which may be fitted to the armpit, whereby the head of the bone may be forced into its natural place” and then, with the wrist secured to it, the ladder is forced downward to the vertical posi­ tion. However, caution was advised in any methods of treatment since “it should be known that one con­ rubbed the parts with cerate ... it stitution differs much from another is to be bound up in this state.” as to the facility with which disloca­ This cerate dressing (Fig. 3), ante­ tions in them may be reduced.” dating the plaster-of-Paris cast by Hippocrates,1 in this connection, 2000 years, was a very tangible devised and described minutely his contribution to surgery and, if it was scamnum, an effective mechanical generally utilized, a source of much contrivance for extending limbs and benefit for centuries. bodies. He said: “By means of such Spinal deformities, with “subluxa­ machines and of such powers it ap­ tions” or “gibbosities,” called also for pears to me that we need never fail extension and correction by these, as in reducing any dislocation at a joint.” we see them today, enormous forces. Not altogether unjustified optimism Traction in the scamnum (Fig. 4), is this, however, when we study the accompanied by levering directly over mechanical powers enlisted. He coun­ the bony prominence, was an accepted sels that “there are many methods standard and may even have been of of making extension.