Hippocrates: A Pioneer in Orthopaedics and Traumatology

Abstract

Purpose

Hippocrates, the ancient Greek physician, is considered the father of Medicine; however, his contributions to Orthopaedics and Traumatology have not been highlighted enough. The present historical review represents an effort to present and categorize his work, in this field, per clinical disorder and anatomical region.

Methods

The “Hippocratic Corpus” original text was thoroughly studied to identify all Hippocrates’ contributions in Orthopaedics and Traumatology. Volume III of his works, especially “On Fractures”, “On Joints”, and “Mochlicon” includes a plethora of information regarding the management of traumas, as well as other disorders and clinical entities of the musculoskeletal system.

Results

In particular, Hippocrates describes reduction techniques for fractures, as well as joint dislocations, elaborates on the biology of the fractures’ healing process and the basic principles of fracture management and fixation, presents the signs and symptoms of gangrene, teaches the treatment of osseous infections and offers valuable insight on the biomechanics and treatment of spinal diseases.

Conclusions

Hippocrates’ contributions in Orthopaedics and Traumatology are unprecedented, making him a true pioneer in this field, while the basic principles that he presented were further studied and confirmed in the 19^th and 20^th centuries.

Introduction

The initial steps of Medicine in the Western civilization find their origin in ancient Greece, early during the Archaic era (c. 800 to 480 BC) and later during the Classical period (c. 480 to 223 BC).^1,2 Medical, surgical and anatomical information are widely mentioned already throughout the Homeric poems (Iliad and Odyssey) from c. 800 BC. War and battles dictated management of trauma and a plethora of such interventions is reported in ancient Greek mythology.^1,3

Hippocrates was an ancient Greek physician (born c. 460 BC and died c. 375 BC) who lived during the Classical period. He has been the first who did not consider the divine intervention as major component of the healing process, that was a strong believe until his time.^2,4 He has been revered for the Hippocratic Oath and his ethical standards in medical practice. He is considered the father of medicine. ⁵

The “Hippocratic collection” or “Hippocratic Corpus” represents the work of Hippocrates covering many aspects of medicine. “On Fractures”, “On Joints”, and “Mochlicon” are the 3 chapters presenting information about orthopaedic disorders and clinical entities, as well as their treatment.^6-10

The purpose of the present review is to document and to evaluate Hippocrates’ contribution to Orthopaedics and Traumatology by thoroughly reviewing and studying the “Hippocratic Corpus”, as well as relevant literature.

Materials and Methods

The original text of the “Hippocratic Corpus” was meticulously studied for identification of every reference to an Orthopaedic clinical entity and its management. All these references were recorded and evaluated. Additional relevant literature was also studied. Hippocrates work in Orthopaedics and Traumatology was categorized and is presented in sections, in a narrative way, in accordance with clinical entity and anatomical site.

Results

Open Fractures

Hippocrates classified open fractures according to the mechanism of injury into 3 categories: (1) direct trauma, (2) lacerations from bone fragments and (3) abrasion and irritation that eventually leads to open wound. He described “continuous traction” as the main method of these fractures’ reduction and fixation by applying the principles of external fixation. He used leather hooks firmly fixed to the ends of the long bones and flexible or rigid wooden rods. He performed open reduction in cases that external fixation did not achieve the desired alignment.

Hippocrates had commented that complications occur in trauma patients on the third or fourth post-injury day, mainly leading to inflammation and pyrexia. He treated infected traumas with wound dressing with herb ointments and bandages soaked in wine, while he mentioned that wound-dressing should be renewed every 3 days. Furthermore, excision of bony fragments preventing reduction was described as necessity.

Osseous Infections

Wound suppuration was attributed to the injury itself or to some endogenous or environmental factors. Suppuration was reported as common complication in injured patients, while it was considered manifestation of the human body’s defense mechanism. Swelling, pain, redness and high local temperature, as well as tissue necrosis and pus discharge are thoroughly described by Hippocrates as the main symptoms of inflammation. Treatment of infected wounds consisted of frequent wound changes, washings with wine and rest. The danger of gangrene has been emphasized, while the clinical signs and symptoms of this severe infection, including tissue necrosis, were described in detail. Amputation was indicated as the sole radical treatment.

Additionally, he referred to hematogenous osteomyelitis, usually occurring in the bone’s epiphysis, as result of septic arthritis, in children during the developmental stage, leading to limb shortening.

Close Fractures

Hippocrates reported that fracture reduction was achieved through manipulations and traction, while splints must be applied along the entire length of the affected limb, including the adjacent joints for safer stabilization. He also referred to the functional immobilization of the limbs, stating that the elbow should be immobilized at 90° flexion and the forearm in neutral position, while the knee in extension. Furthermore, it was documented that the affected limb should be at rest and in elevated position, while the accuracy of the bone reduction was established by evaluating the healthy contralateral side. Splints were made of light wood, they were thin, placed in the diaphysis and remained until the fracture would be totally healed. The concern of the affected limb swelling was also taken into account and discussed. The role of kinesiotherapy and rehabilitation after fracture healing was also reported.

Clavicle Fractures

Hippocrates reported that the clavicle fracture did not cause permanent disability, while he suggested the application of a bandage as treatment. Healing would be completed in a short-time-period.

Humerus Fractures

Hippocrates reported that the healing time-period for a humerus fracture was 40 days, while the reduction method, including bandages around the humerus and the use of a stick under the armpit and traction with a rope, was thoroughly described.

Forearm Fractures

For forearm fractures, Hippocrates suggested bandages (solidified with wax ointment), change every 3 days for swelling evaluation and re-reduction in cases that the initial alignment had been lost, while after the 10th day, he suggested the application of a wooden splint. He considered the intermediate neutral position of the forearm with the elbow at 90° as the most appropriate immobilization position. He defined the normal healing progress of the fracture in 30 days, without considering potential side effects, which he attributed to non-obvious causes, related to patient characteristics and patient’s age. He also referred to fracture of one of the two forearm bones and emphasized that the intact bone may act as internal splinting, while in case of both bones fracture, instability is present.

Femoral Fractures

Hippocrates emphasized the importance of sufficient traction for reduction and healing of the femoral fracture. He also commented on the disabilities that shortening causes due to malunion. He also described immobilization techniques with bandages and splints that included both iliac bones, as well as the hip until the end of the foot. He attributed the delayed healing to the unnatural position and micro-movements at the fracture site.

Tibia and Fibula Fractures

Reduction with traction, splint immobilization in straight extension of the limb and frequent monitoring of the edema was the method followed by Hippocrates for the fractures of the tibia-fibula.

Talus Fractures

The talus fracture was described by Hippocrates as a usual result of vertical fall from height, while he reported on the possible tissue necrosis during the healing period. Treatment included rest, bandages and wax ointments, while the healing period was 60 days.

Dislocations

Dislocation was described as a disorder where a bone which was normally functioning within a cavity, after excessive force, lies out of the cavity, in an abnormal position. The dislocated bone must be reduced with traction to relieve pain and restore function. Reduction had to be performed immediately, since after swelling re-alignment is becoming difficult and more painful.

Shoulder Dislocation

The clinical signs of shoulder dislocation were described in Hippocrates’ work. In particular, he compared the dislocated limb with the healthy one and described the deformity of the shoulder girdle as head protuberance and protrusion of the acromion, accompanied by severe pain and loss of functionality. He also documented that the affected limb’s elbow lies far from the chest cavity. He mentioned many methods of shoulder reduction: (1) with the operator´s heel in the patient´s axilla, (2) with the operator´s hand, (3) by hanging from the shoulder, (4) with pestle, (5) with ladder, (6) with wood. Following reduction, bandage dressing was applied and the arm was immobilized on the chest, while gentle massages and movements should be performed. Furthermore, he stated that recurrent dislocation was due to articular ligament loosening, requiring avoidance of physical activities or even cauterization which, according to Hippocrates, limited the gap of the joint cavity.

Elbow Dislocation

Hippocrates distinguished the medial, lateral and posterior elbow dislocations. He mentioned that the posterior one was associated with neurological deficits, while he suggested reduction by traction and pronation or supination with concomitant manipulation of the proximal ulna and radius. Splinting in 90° flexion should be then applied. Additionally, he expressed concern for the stiffness of this particular joint due to immobilization.

Hip Dislocation

Hip dislocation was also mentioned in the Hippocratic works, with distinction between the anterior and posterior dislocation. The treatment was based on traction, the use of lever and pressure. Neglected cases and those in which reduction was not successful were leading to major disability.

Knee Dislocation

Knee joint stiffness and instability were the main complications after successful reduction with traction and manipulation. He referred also to patellar dislocation, as an easily reduced injury.

Wrist Dislocation

Four directions of wrist dislocation were described: anterior, posterior, medial and lateral. Treatment consisted of reduction by traction and wooden splint which should cover the whole forearm and reach the fingers. The contralateral arm should be used for evaluation of the reduction.

Finger Dislocations

Finger dislocations were described as an easy to recognize injury. Treatment consisted of traction and manipulation with pressure upon the protruding bone.

Varus Forefoot Deformity

Hippocrates stated that prompt diagnosis and initiation of treatment for varus forefoot deformity in children are of outmost importance for successful outcomes. Management of this disorder included correction of the varus deformity with gentle manipulations, progressive immobilization with soft tapes and use of special footwear.

Spinal Fractures and Dislocations

Spine was described as kind of a chain. Neurological deficits were mentioned as severe complications of injuries affecting this region that may not be worth treating. Hippocrates reported that spinal ligaments extend anteriorly and posteriorly. He reported that posterior dislocation of a vertebra could not be common, unless excessive force had been applied that would have led to major abdominal organ damage. Furthermore, he stated that in fracture cases without complications, conservative management led to rapid recovery.

Kyphosis and Scoliosis

From the anatomical point of view, Hippocrates described the spinal curvatures, while he reported also scoliosis and kyphosis cases. He observed that different curves may develop in spine due to aging or degenerative diseases. As management, stretching was proposed.

Discussion

Hippocrates is traditionally considered the father of medicine. ⁸ Nevertheless, his contributions in Orthopaedics and Traumatology have not been highlighted enough. The present review categorized and presented his contributions in Orthopaedics and Traumatology after thoroughly studying the “Hippocratic Corpus” in its original text.

He followed and taught realistic medical practices, in contrast to divine and religious prejudices of previous time.^2,4,11 It is of note that Hippocrates introduced the basic principles of external fixation that even today are followed in clinical practice.^10,12 Furthermore, the concept of antisepsis was introduced, since he used wine to clean the wounds of open fractures, obviously considering the antiseptic activity of alcohol. Similar ideas had been presented in Homer’s Iliad where surgical instruments were cleaned in seawater, which was considered naturally clean, before small interventions taking, also, into account the disinfecting activity of salt.^1,3

Moreover, Hippocrates especially emphasized the dangerous gangrene infection and described the clinical signs and symptoms, including tissue necrosis as an extremely poor prognostic sign, requiring amputation.^10,13 No safer therapeutics have been found until today, than those formulated by Hippocrates, for this severe, life-threatening and irreversible infection.

Regarding fracture management, immobilization as a practice began to be applied already in prehistoric times. ¹⁴ Splinting with tree bark at first and straight wooden splints later on were the first methods of conservative immobilization. Hippocrates established the basic principles for the treatment of close fractures. ¹⁰ He described extremely radical, for that time, theories, such as his reference to the unnatural position of the fractured bones and micro-movements at the fracture site, as reasons for non-or-mal-union. ¹⁵ Such in-depth knowledge of the fractures’ biomechanics and biology and their consequences were examined and studied again in the 19^th and 20^th centuries. Furthermore, he investigated and presented in-depth the spinal biomechanics and treatment of fractures, dislocations and degenerative diseases.^16,17

In conclusion, Hippocrates was a true pioneer in the field of Orthopaedics and Traumatology. He examined and presented the pathophysiology and biomechanics of fractures based on thorough observation. He described in detail the principles of orthopaedic disorders’ management, achieving an initial breakthrough in the history of medicine. His works represent the transition from the medical treatments related to religious and divine interventions to realistic practical medical solutions, representing the first step of Western medicine.