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Relief depicting surgical tools from the Temple of Kom Ombo in Egypt Photo credit: Michael Bohl [/caption]
In 1741, Nicholas Andry coined the term orthopædics from the Greek words orthos, meaning “correct” or “straight”, and paideia, meaning “children”. At the time, the field of orthopædics was exclusively focused on correcting skeletal deformities in children and limited its practice to splinting, manipulation, and promoting exercise as a way of strengthening muscle groups. This was effective in treating conditions such as foot deformities and spinal curvature but the vast majority of conditions that we now associate with orthopædics weren’t addressed at all. In time, innovation grew orthopædics into the field it is today. The development of implantable material, the invention of medical imaging, a better understanding of how to treat infections, advanced techniques for managing fractures and tendon damage, the rise of arthroscopy, and many other advances all helped to transform orthopædics from a limited discipline solely devoted to correcting childhood malformations to a major surgical field for people of all ages with all sorts of problems.
But 1741 is fairly recent in human history. We might not have had a word for orthopædics, but certainly people still had orthopædic problems prior to that time. How did they address these problems? What treatments were available? At what point in history can we look back and say, “This was truly the beginning of orthopædics”?
With their society coalescing around 3150 BCE, ancient Egypt is our best answer for when the practice of orthopædics began. The ancient Egyptians are often lauded as having been scientifically, architecturally, and medically more advanced than any contemporaneous civilization. A relief at the Temple of Kom Ombo speaks to these advances in medicine and is believed to be the first representation of surgical instruments in existence. In the relief, one can see scalpels, curettes, forceps, a dilator, scissors, and medicine bottles. Other reliefs have also been found in Egypt depicting aspects of orthopædics. Hirkouf’s tomb illustrates the first known usage of crutches, the tomb of Ipwy shows the reduction of a shoulder dislocation alongside two other medical accidents (a man who has dropped a hammer on his foot and a man with a foreign body in his eye), and a carving at Medinet Habu shows piles of hands that have been amputated (however these were most likely done posthumously for punitive purposes rather than for therapeutic ones).
The best sources of information we have referring to medicine in ancient Egyptian society are written papyri. While there are a handful of medical papyri – the most famous of which is the Ebers Papyrus – the Edwin Smith Papyrus is unique in being the only one that talks about orthopædics (in fact, it was most likely used as a guide for treating trauma sustained in battle). The papyrus is approximately 5 meters in length that was found in a tomb in 1862. Its authorship is debated but it is frequently attributed to the physician, architect, engineer, and priest known as Imhotep. If he indeed wrote the papyrus that would mean it dates to the Old Kingdom, approximately 3000-2500 BCE. The papyrus details 48 case presentations and divides each condition into one of three categories: a condition to treat, a condition to contend, or a condition not to treat. Working from head to toe the papyrus includes how to reduce a dislocated mandible, how to identify torticollis, the signs of certain spinal injuries, how to treat a dislocated clavicle, and how to use stiff rolls of linen as splints to treat a variety of other fractures. The papyrus often suggests application of grease, honey, and lint as treatment and refers to pus/discharge (possibly from osteomyelitis) as ryt. Unfortunately, the text abruptly ends mid-sentence and does not detail any cases of the pelvis or lower extremities, so it is often considered to be incomplete. An interactive version of the papyrus with notes that summarize each of the cases is available for viewing online here.
Lastly, what we know of ancient Egyptian orthopædics comes from what we can actually find on mummies. Mummies have been found wearing splints made out of bamboo, reeds, wood, and bark padded with linen. And there are a handful of mummies that have been discovered with well-healed amputations of the arms, legs, or toes, indicating that perhaps therapeutic amputations did take place in Egypt (and not just posthumous amputations, as the Medinet Habu relief depicts).
All in all, it appears the Egyptians were at least somewhat aware of orthopædic conditions and made an attempt to distinguish between conditions they could treat and conditions they could not. Splinting appears to have been fairly common and the Egyptians had the tools to perform surgery even though their understanding of human anatomy was fairly limited. It wasn’t until the Greeks and Romans came along in the 3rd and 2nd centuries BCE that orthopædics really started moving forward. Greek anatomists in Alexandria were the first to distinguish between arteries and veins as well as between motor and sensory nerves. And the Romans began using artificial prostheses (including wooden legs and iron hands), attempted tenotomies to relieve contractures, and developed catgut sutures to use during these procedures.
Following the Graeco-Roman period, orthopædics entered the Dark Ages and any advances were few and far between. Splints continued to be used and techniques were honed for successfully completing therapeutic amputations, but no other major advances occurred during this time. Eventually we get back to 1741, which is where this story began. The beginnings of orthopædics may seem simple, but it was a humble beginning to a field that has a lot to offer. Seeing how much things have changed over the years only make it more exciting to anticipate what is yet to come!
References:
1. Blomstedt, Patric. “Orthopedic surgery in ancient Egypt”. Acta Orthop. 2014 December; 85(6): 670–676.
2. Ponseti, M.D., Ignacio V. “History of Orthopaedic Surgery”. Iowa Orthop J. 1991; 11: 59–64.
3. World Ortho. http://www.worldortho.com/dev/history-of-orthopaedics
Michael Bohl is a guest blogger. He is currently a fourth year Brown Medical Student.
