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< Al-Zahrawi's contribution in the Management of Fractures>
CONTRIBUTION
OF ABUL QASIM AL-ZAHRAWI Dr.
Quazi Mohd. Iqbal It is often difficult to procure evidence upon which a definite answer to the numerous facets of progress of human advancement can be based. However, it is in general acceptance that advancement in knowledge is achieved through a process of continuous occurring of data from all available sources at different times. What is termed Islamic Medicine may be considered to be essentially an amalgam of philosophical theorems and numerous materia medica that had prevailed or were available in areas around the Mediterranean and the adjoining countries of Asia. With the unparalled progress that accompanied Islam, the Arabs chose to develop their medical heritage based largely. upon the accumulated data available within the Greek system of medicine. Islamic medicine did not grow wholly upon Arab soil nor were all great Islamic physicians Arabs. Islamic medicine is better considered as a cultural force which absorbed many different currents within itself and having integrated developed them. The cultural Islamic respect for the dead is said to have dissuaded the Islamic physicians from undertaking dissection of the human body. Hence, it has been alleged that the anatomical knowledge, so essential to the art of surgical practice, was neither considerable nor original. Enmity, rivalries and prejudices have distorted the truth. The study of osteology by Abdel Latif el-Baghdadi (1161-1231) on a remarkably large number of human skeleton led him to write his book on 'Improved Anatomy'. Unfortunately, this is no longer available. By providing factual observations he concluded that Galen was wrong in many ,important aspects 5 . The object of this presentation is to give, in as concise a form as is compatible with clarity and accuracy, (and to summarise) the contributions of Abul Qasim al-Zahrawi in the management of fractures. His contributions to medicine in general must not be constrained by a too narrow interpretation of thf title of this essay. Most physicians of the time occupied themselves with the science of medicine, of internal medicine as it is known today. There were also those who even considered the surgical art to be inferior and a separate branch of medicine. And orthopaedic was not yet separated from surgery 2 . Hence, with personal interest in orthopaedic and the sustained increase in fracture incidences it seems pertinent to recapitulate the contributions of Abul Qasim, a doyen among the Islamic physicians in fractures; and attempt to evaluate its relevence in the light of contemporary medicinal practice. Abul Qasim Khalaf Ibn al-Abbas al-Zahrawi, known as Albucasis in Latin Europe, was a practicing physician in Cordova at the time of Caliph Abd-ar-Rahman III. He was born in al-Zahra in 936 and died in 1013 .His great work, the Kitab-al- Tasrif in thirty parts dealing with surgery and medicine has become especially well known. A plethora of information is available in this well illustrated medico-surgical encyclopedia. The information presented in this article is acquired from this book taken from the chapter on Surgery and Instruments, Book 3 on Bone setting. He defined
a fracture as a separation or fragmentation of a bone. This may be a clean
break without splintering, or along the bone, or with splinters or may
involve a wound. Hence, among its clinical features he included, distortion,
protrusion and palpable crepitus. In its absence, however, and if pain
is not elicited on attempted movement of the affected bone he advised
to suspect a crack in the bone, the greenstick fracture in current terminology.
He mentioned that there were various types of fractures and well described
the two most common clinical types namely the closed and the open fractures. In his recommendations on the managements of fractures he advocated manipulative reduction with external immobilisation. If the bones were parted, he said, reduction was to be effected by traction, and counter-traction, using diligent manipulation in order to secure exact reposition of the bones and avoiding violent compression. His classical method of resetting a fractured coccy was by exerting corrective pressure by a finger introduced through the rectum, a practice not un-commonly used today. In green- stick fractures he practiced immobilisation without manipulation. As to the method of immobilisation Abul Qasim suggested the use of either bandages, plasters or splints. Bandages were cut in different sizes to suit the size of the fractured part. It was used as slabs or applied circumfrentially exerting gentle and even pressure, often in two or three layers and extending beyond the level of the fracture site. Between the layers of the bandage enough soft tow or rags were inserted to help correct any curves of the fracture and mellow the pressure. The current Robert Jones bandage seem to simulate this very closely. In order to make a plaster, when a stiffenning effect was required on the bandage the recommendation was to treat with mill dust, fine flour and egg albumen. Identical plasters were used in England and in the Napoleonic compaigns. It was to be replaced only by introduction of plaster of paris in 1877. As an alternative method combination of pulse, gum mastic, accacia, powdered clay with water and egg white was also being used. And, in his management of lower jaw fracture with binding of teeth using gold or silver wire or silk ligature in conjunction with external gum mastic plaster is a reminder to the modern management with interdental wiring and the Gunning splint. Splints were made out of broad halves of cane, branches of palm, or pine wood. They were cut and shaped and made of a size that suited the fractured part. In practice, splints were helped by bandages with the greatest pressure over the fracture site and lessened pressure only from it. They were well padded with soft tow or carded wool to alleviate the pressure points. Other than the construction material there appears to be no substantial differences with the splints of today. Being aware
of the potential dangers of splinting a fractured extremity, he cautioned
against: - In all such cases he advocated immediate removal of bandage and resting the limb until the signs and symptoms abated. Re-application was done only when the safety of the limb was assured. A remarkable feature in his immobilisation technique, was to defer it in fresh fractures complicated with gross swelling and adopt the practice of "DELAYED SPLINTAGE" only when the swelling had disappeared usually after a period of 5-7 days. In accordance with the contemporary accepted surgical principles, he advocated that immobilisation was to be continued until healing had taken place. In his experience, bones of the extremities healed as follows: - Scapula in 20 to 25 days, lower jaw in 21, the collar bone in 28 and humerus in 50 to 60 days. In the case of forearm bones, the average time for healing was 30 to 32 days, but in cases with isolated fracture of the ulna the healing tended to be a bit delayed. Almost 900 years later, Sarmiento-et-al in 1976 concluded "Solitary fracture of the ulna shaft has a reputation of non union".3 London in 1967 stated "it is uniformly agreed that the ulna, although it is called the stationary bone of the forearm, is most likely to fail to heal following a fracture. Even an 'innocent looking' crack across the bone may end in non-union". These reflect the brilliance of the observations of Abul Qasim. In the lower extremity, the femur took 50, the leg bones 30 and the pelvis 7 days to heal. He further clarified that such healing was influenced by the general constitution of the patient and the local conditions at the fracture site implying thereby the presence or absence of a compound wound. For compound fractures seen early, he advocated prompt reduction of the protruding bone using moderate extension failing which it was his practice to effect instrumental reduction using his BARRIMA commonly known as bone levers. In the event, the extruded bone could not be levered back into its place, cutting of the excess bone with an osteotome was performed and the wound left open, packed with dressing soaked in wine. Splintage thereafter was done in a fashion so as to ensure a WINDOW at the site of the wound. If suppuration was to ensue, then it was advisable to place the limb in a position that would encourage gravitational drainage of the pus. For neglected compounded fractures with established infection of the protruding bone only topical application of the wound was recommended as the bone usually sequestrated within 20 to 30 days. In the main, this is akin to modern day management. In fracture treatment, the general well being of the patient was not to be overlooked. Nutritious diet in the form of fowl, mutton, trotters, eggs, fresh vegetables and fish with rice and porridge possessing high protein and vitamin C content with abundant restorative properties were prescribed. For the disuse atrophy of the limb, the treatment regime comprised passive massage, contract bath and application of pitch. Complications of fractures were equally recognised. For post traumatic myositis ossificans limiting the range of motion in a joint when seen early, he advocated immobilisation until the callus had reduced or disappeared. In delayed cases with hard callus he practiced surgical excision. For malunions he was reluctant to practice refracture and resetting of the bone as the results were generally poor. However, he conceded that if one is forced to undertake the correction of a malunion then perhaps CHISELLING (osteotomy) of the bone is likely to confer beneficial COSMETIC results. These are the documentations of an Islamic physician about nine centuries ago. With strict scrutiny the revealing factors that emerge are that his definition, classification and concept of bone healing in days before x'ray and microscope are in general agreement with modern ideas. And, his management regime encompass the three cardial principles of reduction, immobilisation and rehabilitation. Therefore, I conclude that the enormity of the contributions of Abul Qasim in the management of long bone fractures is self-evident in his enunciations that has sustained the test of time for nine centuries. REFERENCES |
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