Doctor's Review: Medicine on the Move

October 20, 2017
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Bad to the bone

It wasn't until the 18th century that the field of orthopedics was able to stand on its own

Fossils of primitive men show bone and limb deformities similar to ones we see today. Millennia later, from the ancient caves and desert tunnels of early Egypt, the first crutches were among the treasures excavated from Hirkouf’s tomb, dating back to about 2830 BCE. Hieroglyphics found nearby describe a boy Pharaoh with bent and crooked limbs. Several mummies have also been discovered wearing splints made of reeds, bark and wood.

 

From the influential ancient papyri of Egypt to the annals of Greek, Arab, Roman, Western, Hindu and Chinese medical history, physicians have documented their attempts to correct broken bones and congenital skeletal defects with a variety of techniques. Battlefield doctors, barber-surgeons, phlebotomists and physicians of all kinds tried their best to cure and correct, whether by hacking, splinting or bleeding, but bad bones remained notoriously hard to treat.

Among the many pioneers who tried to fix skeletal abnormalities, a handful of stars stand out from the crowd. Hippocrates waged war on fractures and clubfeet, and he also identified osteomyelitis. There was also the nameless ninth-century Arabian physician who created the precursor of modern plaster casts with his hardening mixtures of lime and egg whites. Of course, much of the groundwork in the field was laid by the French surgeon and able amputator Ambroise Paré (1510-1590), who was regarded by many as one of the most important figures in orthopedic and even medical history, since he devised so many groundbreaking surgical and battlefield-injury techniques. But it was another Frenchman who first framed the entire field of orthopedics as a discipline worthy of standing on its own, a man by the name of Nicolas Andry de Boisregard.


 

FROM FATHER TO DOCTOR

Nicolas Andry was born in 1658 in Lyon, France. His father was a poor merchant, and young Nicolas was not eager to follow in his footsteps. At first, he was drawn to religion rather than medicine, entering a seminary in 1685 to study theology. Presumably drawn to the workings of the natural world rather than the spiritual one, he left in 1690 to teach humanities at a local college — inexplicably adopting the surname de Boisregard at the same time, perhaps to add an air of authority or to distance himself from his working-class roots. Still searching, he entered medicine at the University of Reims and then Paris, graduating in 1697. He retained a unique approach to the study of science, often looking at things in an unexpected way — something that would both serve him well as a scientist and yet also lead him to encounter great opposition along the way. The topic of his thesis revealed his humanistic, modern approach: “The relationship in the management of diseases between the happiness of the doctor and the obedience of the patient.”

Andry soon became a physician of diverse interests, as was often the case back in the days before formal sub-specialization. His medical practice led him to the field of parasitology first, presumably since so many of his patients suffered from worms. He believed something very radical about parasites at the time, something that rendered him a laughing stock among many of his contemporaries. His idea was that worms were not spontaneously generated within the body, but rather they were ingested by infected food sources. In 1701, he shared with the world his preferred methods of expelling them in the first book ever written on parasitology: An account of the breeding of worms in human bodies: their nature and several sorts; their effects, symptoms and prognostics; with the true means to avoid them and med’cines to cure them.

As one might expect, he prescribed various violent purgatives and emetics to rid sufferers of intestinal parasites, but he also suggested the therapeutic use of tobacco in expelling the troublesome critters from one’s colon. Incidentally, Andry was also arguably the first physician to go on the record against tobacco, for while he advocated it as a treatment, he also stated that smoking the weed regularly could lead to a “withering of one’s noble parts.” Eventually, years later, the rest of the medical community came around to his way of thinking about parasites, but until then, Andry’s preoccupation earned him the dubious nickname of The Worm Doctor.

Eventually, Andry gained a prestigious professorship in the Faculty of Medicine at the University of Paris and also became Dean of the Faculty of Physick. One of the first things he did with his newfound power was to restrict the role of barber-surgeons, whom he saw as unskilled and dangerous quacks. He made many enemies in so doing, and some say he caused further strife between the fields of surgery and medicine.


 

BOOK WORM

Though he led a rich and involved academic life, Andry continued to treat patients and soon became interested in matters of the bones. In his practice, he encountered many children with bone and limb deformities since they were common childhood conditions at the time, in part because of a staggering array of public-health crises ranging from congenital syphilis to rickets. This inspired him to spend years working to correct and prevent these problems in kids, because he recognized that the malleable nature of children’s skeletal systems offered physicians a unique opportunity to do some good early on.

Andry published the work for which he would become most well-known in 1741, at the ripe old age of 83: Orthopaedia, or in its longer form, L’orthopedie, ou l’art de prevenir et de corriger dans les enfants, les difformités du corps, le tout par des moyens a la porte des pères et des mères, et de toutes les personnes qui ont des enfants a élever. While the title may not roll off the tongue, the work was groundbreaking in that it contained the first-ever use of the word orthopedics, an act through which an entire medical discipline was born:

“As to the Title, I have formed it of two Greek Words, Orthos, which signifies straight, free from Deformity, and Paedis, a Child. Out of these two Words, I have compounded that of Orthopaedia, to express in one Term the Design I propose, which is to teach the different Methods of preventing and correcting the Deformities of children.”

The book was actually less of a medical textbook than it was a parenting guide, designed to teach mothers and fathers how to prevent common playground injuries and bone disorders but also how to raise post-Renaissance rugrats in general. He advised on the treatment of broken bones, poor posture and even devoted an entire volume to craniofacial conditions and diseases.

Orthopaedia is also the source of one of the most famous and recognizable symbols within medicine, drawn by Andry’s collaborator and illustrator, Antoine Humblot: The so-called Tree of Andry. The picture shows a crooked trunk of a tree tied to a stake, allowing it to resume normal growth once again. Indeed, it is a perfect visual metaphor for the treatment of skeletal injuries and deformities.


 

STRAIGHT SHOOTER

Of course, Andry wasn’t the first to use braces and splints to correct problems of the limbs and spine; Ambroise Paré had created scoliosis corsets and designed other corrective and immobilizing devices more than a century earlier. Andry, however, was intent on using them in a preventative manner in childhood, which was a significant signal in the development of the discipline of orthopedics. Indeed, he was a huge proponent of prevention rather than correction, and he was very focused on good posture as a way to avoid later orthopedic problems.

Andry believed that poor posture and even scoliosis were caused by assymetrical tightness of the muscles — bones curved in response to short muscles, he wrote, “just in the same manner as a bow is made more crooked by tying its cord tighter.” He also felt that this could be compensated for in childhood by rigorously applying his suggested techniques. Mostly, he advocated comfortable clothes, rest and regular exercise (specifically gymnastics), plus braces early on to correct any deformities as they arose. For patients with scoliosis, he created a series of whalebone corsets with customized padded protuberances designed to offset the offending curvatures and push them back into submission.

Andry died in Paris in 1742. He certainly would have cherished the dramatic discoveries that came so long after his death, from antisepsis to X-rays, which transformed the fields of parasitology and orthopedics. Anthelmintics, of course, have revolutionized the treatment of parasites and worms without harming the patient, while the two most common forms of pediatric bone malformations have been neatly put to rest with the vaccine for polio and the identification of rickets as a vitamin-D deficiency.


 

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