A history of the management of wounds in open fractures and joint infections

By Val Stockdale (presented February 26, 2004)

In 4,500 years of recorded history, before the discovery of antibiotics, the management of bone and joint infections was nasty.

The very oldest medical text was the Edwin Smith Papyrus, written around 300 BC in Egypt by a man named Imhotep. He was the first man to stand out clearly from the mists of antiquity, as a physician. In this text, we see the first description of open fractures and wound infection.

The general treatment and management of open fractures consisted of splinting and the application of poultices.

Here is a description of an open fracture of the humerus. "If thou examinest a man having a break in his upper arm over which a wound has been inflicted, and thou findest that the break crepitates under the fingers, thou shall make him two splints, thou shouldst bind it with YmRw and thou shouldst treat it afterward with grease and honey and lint every day until thou knowest that he has reached a decisive point."

Hippocrates was born in 460 BC on the Island of Cos off the coast of Greece. He was born into a family of Asclepiads, who were followers of the god Asclepiads. They were healers who practised their trade near temples. Their methods of healing were limited to prayer and induction and interpretation of dreams. However, they kept records that were handed down from generation to generation and became the basis of knowledge on which to build.

Hippocrates recommended cleansing of the wounds with one hand and using the other hand to do cauterization, which resulted in large amounts of residual contaminants and necrotic tissue. If you can imagine pouring hot oil into a wound, it would cook the tissue and kill it, hence necrotic tissue.

The theory back then hypothesized that bone and joint infections were due to air being let into the body, probably based on the observation of open fractures. It wasn't until much later that scientists like Monroe and Hunter came to the conclusion that microbes caused infections.

Hippocrates made three major contributions to medicine. First and most importantly, he dissociated the practice of medicine from religious mysticism. Second, he combined existing knowledge with his own observations and, thus, moved the practice of medicine towards what we consider science. Third, he demanded that physicians have high moral standards, that they not perform abortions or euthanasia, and that they maintain confidentiality of their patients.

Hippocrates also described cases to relate his knowledge, not just to report his successes. Such as when a captain of a ship squashed his finger with an anchor. In seven days, it had a foul discharge and he had problems with his speech and tongue. The presence of tetanus was diagnosed and this disease was always fatal.

The typical way to treat open fractures was amputation, because they always became infected. Following amputation, cauterization was done painfully, by hot oil or heated metal. This was practised for 2,000 years.

Later, a couple of nice fellows, Alexandria and Herophilus, dissected corpses and performed trial operations on criminals.