Words and our business

17.5.21

  Curiosity, one of the driving forces behind the Great Discoveries, will allow us, more modestly, to better understand today by going to meet yesterday, aware that what comes to us from the past tends towards the future. Let there be no misunderstanding between us: I do not claim to be a historian, philosopher, epistemologist or linguist. My objective is, quite simply, to share with you the fruit of a questioning. As some people have gone to meet other continents, let us go to meet words.

  In France, the history of what we still call orthopaedic surgery remains to be written. Especially as it has not always been called "orthopaedic". We will come back to this essential idea a little later.

  It is true that one can find, here and there, an event-based history of discoveries and technical advances, a history crossed by eminent names, some of which are even known to the general public. But one will look in vain for the existence of a conceptual historical work. By conceptual history of orthopaedic surgery we mean, beyond anecdotal accounts, beyond hesitant and uncertain progress, step by step, most often linked to necessity, a highlighting, in the course of the history of our surgical practice, of major stages, of moments of important breaks in the very conception of a procedure or an objective to be achieved. Like any human activity, the evolution of our profession is intimately linked to the global evolution of fundamental research, techniques, industry, to the options and choices of schools, to the expectations of the social body as a whole and from which we are not independent, but our art has never been the only confluence, the strict resultant, of influences outside it. It has had, and still has, its own objectives and approach. 

  We can sketch out this highlighting of a few decisive stages, notably through the terminological evolutions of our discipline. More simply put, the words to say it could faithfully relate some essential stages revealing the thinking of the time. As we will try to show, words are never used by chance, but they reflect the state of mind of a given moment.  

  We could take as an image the training of a surgeon who is still called an orthopaedic surgeon, by tracing the Ariadne's thread of words that he will encounter during his training.

To begin with, the apprentice will have to learn anatomy, and we will see where these words come from, etymologically related to Greek and Latin but perhaps not historically.

Then we will entrust him with a rugin, a word that reveals the operative origins of our profession  

Finally, he will have become an "orthopaedic surgeon", a term eminently representative of pre-revolutionary France 

Then perhaps he will be able to enlighten us on the current terminology 

  In fact, long before Hippocrates, Homer in the Iliad and the Odyssey gives some quite astonishing anatomical descriptions of the hip, such as "Diomedes had thrown a stone at Aeneas, where the thigh turns on the hip and which is called the acetabulum". The acetabulum refers to a container for liquids, a bowl for the Athenians, called kotulê. For the Romans, the acetabulum was a "small beaker for measuring vinegar" (which gave the names of acetate: acetic acid). This is a good reference to the hemispherical, well-congruent joint cavity, the receptacle of the femoral head. Historically, the acetabulum was also a game of bishop which consisted of a cup with a string attached to the bottom and a ball. The ball had to be retrieved by throwing it into the air, into the cup. This set-up clearly shows the femoral head and its ligament connecting it to the bottom of the acetabulum. This game is similar to bilboquet. Let us now mention the vagaries of the so-called new nomenclature of anatomical terms. Sometimes a too quick translation can be a source of confusion. For example, to speak of coronal sections could make one think that they are sections made in the same plane as the crown of the sovereign. This is correct, but we must refer to Caesar's crown. The authors of this nomenclature wanted there to be no possible similarity between two terms. To avoid any confusion between decubitus (lying down, a fetish of the Romans) and ulna (the elbow, the cubitus), the latter has been replaced by ulna (forearm). The loss seems insignificant, but it is symbolically strong since the cubitus was part of the three units of measurement with the thumb and the foot, which were used as references for architectural constructions such as temples (areostyle). Let's take a few more examples: we have all already made a "coracoid stop". "Butée" is a word derived from "but", as in "stop", "rebute" and seems to come from the Frankish word "bût" which meant a tree stump or a wooden log. Anyone who has ever stubbed their toe against a stump will understand the meaning. The word "coracoid" is found not far from the tree, since it is the animal comparison with a bird, this time the "raven". Indeed, the coracoid process of the scapula, because of its curved shape, resembles a crow's beak

  Almost all the terms in anatomy have a Greek or Latin origin. I therefore believed for a long time that they were given at that time. Nevertheless, one must legitimately ask the question "Did Hippocrates dissect? Nothing is less certain, in his writings there is never any mention of the ulna, the humerus or the femur. The only bones described are the clavicle (key shape) and the vertebrae called ossicles. 

It is not impossible to think that all these words were proposed later, especially in the Arab world, as we shall see, and re-translated into Latin and Greek for the purpose. Indeed, our country will then experience a period of important regressions linked to the theologians' prohibitions. The transmitters of medical thought were to be found in the Arab world, at its peak in the year 1000, particularly in the south of Spain, which had been occupied since 714. It was in Cordoba, the capital of the western Muslim world, with its 1 million inhabitants, 80 schools, 50 hospices and a library of 600,000 books, that ABUL CASSIS (Abdul Al Qasim Khalaf Ibn Abbas Al-Zahrawi) was born in 936. Abulcassis quickly distinguished himself in the field of surgery, traumatology, emergency and orthopaedics. 


   For Abulcassis, operations must be performed according to a pre-established plan. He practises the treatment of fistulas, amputations and trepanations. He is familiar with goitre surgery and the resection of limb aneurysms. He ensured haemostasis by digital compression and cauterisation with hot iron. He also knew the method of reducing shoulder dislocations, which today is called the Kocher manoeuvre. On the patella he performed patellectomies, almost a thousand years before RalphBrooke's description.
- He was the first to use the classic Trendelenburg position in operations on the small pelvis, later attributed to the German surgeon. Abulcassis left us an encyclopaedia of 1500 pages in 30 books. His contribution is immense. He is the main transmitter of knowledge and know-how from Ancient Greece and his contributions are considerable. We find them again 2 centuries later in Italy with Roger of Parma who deals with the traumatology of the body, with the Dominican Guillaume Salicet, who teaches Physics in Verona and who writes his cyrurgia which, in part, deals with "algebra and the restoration that is appropriate for fractures". The word algebra is very characteristic of the Arab influence on the medical and surgical terminology of the Middle Ages, in fact, it is the adaptation in French of "Al djaber el mogabelah" i.e. "art des restaurations osseuses" which is appropriate to the place of the fracture and dissolution. This term, from the Latin dissolutio, separation of parts, was widely used in the Middle Ages to designate a state of discontinuity, such as a fracture or dislocation.

 

  At the same time, however, in the kingdom of France, the Church had recently prohibited monks from practising surgery, while dissection was also prohibited. Medicine became a whole that included various disciplines such as botany, chemistry, physics, pharmacy, beauty care, hygiene of life, physiology and surgery. This whole is not part of the Seven Liberal Arts, but since surgery uses some of them, it is classified in the second philosophy. What bothered the theologians of the time was the technical and practical side. Priests were therefore forbidden to practice. This ban facilitated the emergence of a new elite: the Physicists. Moreover, the Anglo-Saxons still use the term physicist to designate the doctor. Thus these new doctors acquired a scientific status by being assimilated to natural philosophers, but at the same time they disdained surgery, which lost the status it had had for a thousand years. However, the need for surgical repair is no less real. These surgical gestures, leaving the ranks of medicine, were practised by manual workers: the barbers.


  The surgeons, reduced to the rank of barbers, created their own schools, of which the Confraternity of the Surgeons of Saint Como is a famous example. Teaching was in French. Degrees appeared, such as that of Master Surgeon. New words were borrowed from the vocabulary of the trades. Rugine comes from rouanne, a word derived from the popular Latin of Gaul and coming from rucina (to weed) and rhukane (to plane). This word was used to designate a kind of compass used by carpenters. 

From 1550 onwards, the number of surgical texts in French increased considerably. Paris retained a Latin tradition, but surgical centres such as Lyon developed a publishing policy that combined Latin with the vernacular language of French in an educational perspective in a literary tradition where the humanist heritage was present. Jacques Daléchamps, a doctor, published a considerable work, Chirurgie Françoise, intended for Compagnons and Maîtres Chirurgiens organised and structured as a Corporation of Trades. It is difficult not to mention the example of Ambroise Paré, son of a barber from Laval, who despite the immensity of his talent had to wait for a decree from the King to be appointed surgeon as he did not speak Latin. Surgeons were therefore men of the field, efficient and pragmatic. Because of the services they rendered, they enjoyed a great reputation at the Royal Court. This reputation allowed them to be reintegrated into the medical and scientific world. And the return of surgeons to the faculty marked the exclusion of women, who until then had frequently practised our art.

      Now that our student knows anatomy and how to handle a rugin he deserves his title of orthopaedic surgeon.

As we have seen, our apprentice was able to progress thanks to the work of his illustrious predecessors. However, it was not one of them who created the current name of our discipline. Here we are in the Age of Enlightenment. Under the influence of the philosophers, notably Jean Jacques Rousseau, social awareness and the role of the social body, conceived as a collective representing a whole, whose parts are managed by a contract, whose strict observance through the virtues of education and learning guarantees the harmony of the whole, appear. In this context, it was Nicolas Andry, a doctor, dean of the Faculty of Medicine in Paris and professor of medicine at the Royal College, who in 1741 coined the term "Orthopaedics" in his publication "Orthopaedics or the art of preventing or correcting deformities in children, all within the reach of fathers and mothers and all those with children to bring up". He explains himself on the choice of his title by writing: "As for the title in question, I formed it from two Greek words, namely, Orthos which means right, and Paidion, which means child. From these two words I have composed the word orthopaedics, to express in a single term the purpose I have in mind... »

  Andry is totally in tune with the times, with neologisms that translate a new perspective of social transformation by acting on Nature, especially human Nature. As a symbol, on the first page of Nicolas Andry's treatise we find the image of the fragile shrub whose growth is guided by a tutor. Andry can thus be credited with the creation of the word orthopaedics and a dynamic conception of the body by stating the basic principles of orthopaedic treatment which is based on education, in this case, re-education. This vision completes what Galen already called "tortuous" by creating the descriptive word scoliosis, while Amboise Paré in 1575 recommended a "corselet" to straighten a twisted body. But why has the entire history of our profession taken refuge behind a word that represents us so little?

Etymologically, the term orthopaedic surgeon no longer has any meaning. Our activity, as we have seen, cannot be reduced to the work of the hand, as the word surgeon means (from the Latin cirurgia, from the Greek kheirourgia, from kheir: the hand and ergon: work). So are we still "orthopaedic surgeons" in the sense that Andry would have us believe? 

   Today's bone and joint surgery is dominated by the search for comfort, the fight against pain and ageing, in a context of limiting costs and immobilisation times. So-called new techniques such as minimally invasive surgery are emerging. The term is very representative of our time, it reflects the external constraints and the internal evolution of our profession. But by minimising the act, is there not a risk of minimising the actor?



Acknowledgements :

Frédérick Béguin , Gérard Bligny , Michel Dufour , Michel Le Bourg , Robert Mouchet

References :

Alain Rey : Historical dictionary of the French language , Le Robert Paris

Dominique Lecourt: Dictionary of medical thought, Presse Universitaire Française 

Malgaigne J F : Etude sur l'anatomie et la physiologie d'Homère , bulletin de l'académie royale de médecine Tome N°VII 

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