Orthopedics in the Graeco - Roman era

Abstract

In this study the evolutionary development of orthopedics (management of diseases of bones and joints), which commenced in early Mesopotamia and Egypt, is followed through Classical times.The Greek infl  uence probably commenced in the 6thcentury BC with Democedes of Croton who cured the Persian king’s dislocated ankle. The Corpus Hippocraticum laid the foundation of orthopedic practice in antiquity. Although knowledge of anatomy was limited, its four books on orthopedics (The Nature of Bones, Mochlicon, On Fractures, On Joints) count amongst the outstanding contributions of Hippocratic writers. In systematic manner the general recognition and management of fractures and dislocations are covered, followed by the handling of individual lesions. Hippocrates differentiated between closed and open fractures (with overlaying skin wounds). Closed fractures were reduced to as normal a position as possible – manually where possible, but with large bones and in the presence of formidable muscle mass, mechanical traction was often employed (e.g. the Hippocratic bench and the bizarre succusion ladder for spinal deformities). There is no mention of the use of analgetic drugs. After application of cerate (mixture of olive oil, soda and pitch) to the skin, the fracture was immobilized by a combination of plasters and compresses (often fi  rmed up with gum-mixtures) – but never very fi  rmly. On the 3rd, 6/7th, 9thand 12th days the bandaging was removed, the lesion inspected and if considered necessary, re-aligned, A variety of splints were then applied. Strict bed rest was enforced, as well as a light diet (no wine or meat for 10 days). It was believed that fractures of the feet, clavicle, ribs and jaw healed after 20 days, of the forearm after 30 days, and fractures of the upper arm and leg after 40 days. Open fractures were considered very serious injuries, and reduced very carefully. Protruding bone fragments were removed (sawn off if necessary) and the wound was covered with black cerate, compresses and light bandages. Pressure and heavy splints were thought to induce infection and gangrene and thus avoided. Dislocations were reduced as soon and as effectively as possible, before muscle spasm set in. As with fractures manual reduction was, where necessary, complemented by mechanical traction. After extensive washing of the joint area with warm water, cerate was applied to the wound and specialised bandaging (even splints) ensured immobilization. Open dislocations like open fractures were considered very serious and reduction was not attempted. Again all pressure bandaging was avoided. A non-functional joint was commonly the end result. The management of 18 specifi  c fractures is described in detail. Jaw fractures were fi  xed by the binding of contiguous teeth. Fractures of the spinal column clearly presented a major problem. Although knowledge of spinal anatomy was surprisingly good, the diagnosis of fractures was very difficult and its association with spinal curvatures presented almost insurmountable problems of management. It was recognized that rib fractures could cause serious damage to the lung and pleura. Complex problems caused by arm fractures involving the elbow or shoulder joints, and combined radius and ulna fractures, are addressed. Femur fractures presented major problems and permanent leg deformity was very common. Open femur fractures were extremely serious and Hippocrates even stated that a physician who could ethically avoid becoming involved in treating such an injury, should do so. Fractures of femur necks were not recognised. The Hippocratic work, Wounds of the head, dealing with fractures of the skull, is not covered in this study.Management of the major joints are individually described. Seven different techniques of reducing a dislocated shoulder joint are mentioned The original description of the management of the dislocation of the wrist and hand is lost. Proper reduction of hip-dislocation was essential to avoid muscle atrophy and life-long limping, and was achieved by intricate mechanical suspension. Strangely enough, lateral dislocation of the knee was a common occurrence and not seen as a serious problem. Congenital club feet were effectively treated by prolonged fi  xation in the correct position by way of tight bandaging with compresses stiffened in glue-mixtures.There is abundant skeletal evidence of osteo-arthritis in Neolithic man, but no clear description of it in the Corpus Hippocraticum. Gout is repeatedly mentioned in the Corpus but without detailed descriptions of the disease. In the Roman era authors like Heliodorus, Antyllus and Celsus in particular, wrote authoritatively on orthopedic subjects, Osteo-archaeological evidence is that fractures were treated expertly in the Roman army. Conditions consistent with degenerative osteoarthritis and true gout (as podagra and chiragra) were described by Celsus and Aretaeus of Cappadocia. Soranus, Rufus of Ephesus and Galen also wrote on orthopedic subjects. We will today differ from many statements made in the Corpus Hippocraticum, but it is clear that the orthopedic basis laid by those documents was not seriously challenged for 1 000 years.