Ashtanga Hridayam UttaraSthanam Chapter 27: Bhanga Prathishedha (Treatment of fractures)

The 27th chapter of Uttara Sthanam of Ashtanga Hridayam is named as Bhanga Pratishedha. This chapter deals with the explanation of ‘Treatment of fractures.’

The topics covered in this chapter include –

• Nirukti Bheda – definition and kinds
• Nirukti Bheda – definition and kinds
• Asadhya Lakshana
• Fracture of pelvic and pubic bone
• Kinds of fracture in different bones
• Chikitsa of Sandhigata Bhanga
• Phalinyadi Churna
• Shayana – bedding for fracture patients
• Treatment of dislocation
• Treatment of mal-union of fractures
• Ripening of fractures
• Use of medicated fats mentioned in Vata Vyadhi Cikitsa
• Beneficial foods
• Unwholesome foods and activities
• Gandha Taila

Pledge by the author(s)

अथातो भङ्गप्रतिषेधं व्याख्यास्याम: ।
इति ह स्माहुरात्रेयादयो महर्षय: ।
After having offered prayers to the God, henceforth we are going to explain the chapter pertaining to the explanation of ‘Treatment of fractures. Thus, say (pledge) Atreya and other sages.

Nirukti Bheda: Definition and kinds

पातघातादिभिर्द्वेधा भङ्गोऽस्थ्नां सन्ध्यसन्धितः ।
प्रसारणाकुञ्चनयोरशक्तिः सन्धिमुक्तता ॥ १ ॥
इतरस्मिन् भृशं शोफः सर्वावस्थास्वतिव्यथा ।
अशक्तिश्चेष्टितेऽल्पेऽपि पीड्यमाने सशब्दता ॥ २ ॥
समासादिति भङ्गस्य लक्षणं बहुधा तु तत् ।
भिद्यते भङ्गभेदेन
Bones get broken (fractured) from a fall from height, assault etc.; it is of two kinds, a. Sandhigata- localized in the joint and b. Asandhigata – in places other than the joints; inability for expansion (extension) and contraction (flexion etc.) and dislocation of the joint are the features of the first kind; whereas in the second kind, profound swelling and severe pain in all positions, inability even for slight movement, production of cracking sound on rubbing are the features of fractures in brief. It is of many kinds, classified based on the nature of fractures.

Treatment

तस्य सर्वस्य साधनम् ॥ ३ ॥
यथा स्यादुपयोगाय तथा तदुपदेक्ष्यते ।
Those treatments which are common to all kinds and which are useful as a routine will be described here.

Asadhya Lakshana

प्राज्याणुदारि यत्त्वस्थि स्पर्शे शब्दं करोति यत् ॥४॥
यत्रास्थिलेशः प्रविशेन्मध्यमस्थ्नो विदारितः ।
भग्नं यच्चाभिघातेन किञ्चिदेवावशेषितम् ॥ ५ ॥
उन्नम्यमानं क्षतवद्यच्च मज्जनि मज्जति ।
तद्दुःसाध्यं कृशाशक्तवातलाल्पाशिनामपि ॥ ६ ॥
The bone which has been crushed into very small pieces, that which causes sound on touching, in which pieces of bones that are broken have entered into the marrow cavity, the fracture which is caused due to injury, the fractured portion of bone is left inside the body, that condition in which the fractured portion is raised similar to an injury, makes it sink into the marrow all these kinds are difficult to cure; so also those found in persons who are emaciated, debilitated, having predominance of Vata in their body and who consume very little food.

Fracture of pelvic and pubic bone

भिन्नं कपालं यत्कट्यां सन्धिमुक्तं च्युतं च यत् ।
जघनं प्रति पिष्टं च भग्नं यत्तद्विवर्जयेत् ॥ ७ ॥
Fracture of the pelvic bone in flat portion, dislocation of joints of the waist and crushing fracture of pubic bone should be refused.

Asadhya Lakshana

असंश्लिष्टकपालं च ललाटं चूर्णितं तथा ।
यच्च भग्नं भवेच्छङ्खशिरःपृष्ठस्तनान्तरे ॥ ८ ॥
Skull bones, not knit together and the forehead getting crushed into powder, fracture which has occurred in the middle of the temples, head, back and between the breasts should be rejected.

सम्यग्यमितमप्यस्थि दुर्न्यासाद्दुर्निबन्धनात् ।
सङ्क्षोभादपि यद्गच्छेद्विक्रियां तद्विवर्जयेत् ॥ ९ ॥
आदितो यच्च दुर्जातमस्थि सन्धिरथापि वा ।
That bone, which in spite of proper control (by the use of splints etc.) becomes irregular (distorted) by improper joining, bandaging and exertion (functioning of the affected art) should be refused treatment; so also the bone and the joint which is ill-formed from the beginning itself.

Kinds of fracture in different bones

तरुणास्थीनि भुज्यन्ते भज्यन्ते नलकानि तु ॥१०॥
कपालानि विभिद्यन्ते स्फुटन्त्यन्यानि भूयसा ।
Cartilages bend, tubular bones break, flat bones get punctured and others get cracked most of the time.

Chikitsa of Sandhigata Bhanga

अथावनतमुन्नम्यमुन्नतं चावपीडयेत् ॥११॥
आञ्छेदतिक्षिप्तमधोगतं चोपरि वर्तयेत् ।
आञ्छनोत्पीडनोन्नामचर्मसङ्क्षेपबन्धनैः ॥१२॥
The portion of bone which is displaced down, should be raised up and that which is displaced up should be pulled down; that which has moved away to other places should be pulled to its normal place, that which is displaced below should be brought up by pulling, kneading, raising, constricting the skin and banding.

सन्धीञ्छरीरगान् सर्वांश्चलानप्यचलानपि ।
इत्येतैः स्थापनोपायैः सम्यक् संस्थाप्य निश्चलम् ॥१३॥
पट्टैः प्रभूतसर्पिर्भिः वेष्टयित्वा सुखैस्ततः ।
कदम्बोदुम्बराश्वत्थसर्जार्जुनपलाशजैः ॥ १४ ॥
वंशोद्भवैर्वा पृथुभिस्तनुभिः सुनिवेशितैः ।
सुश्लक्ष्णैः सप्रतिस्तम्भैर्वल्कलैः शकलैरपि ॥ १५ ॥
कुशाह्वयैः समं बन्धं पट्टस्योपरि योजयेत् ।
शिथिलेन हि बन्धेन सन्धिस्थैर्यं न जायते ॥ १६ ॥
गाढेनाति रुजादाहपाकश्वयथुसम्भवः ।
All the joints of the body, whether movable or immovable should be placed in their normal position by these methods and immobilized by bands of cloth soaked in plenty of ghee, spread out (covered with) comfortably large, thin and smooth pieces of inner bark of kadamba – Neolamarckia cadamba, udumbara – Ficus racemosa­, aśvattha – Ficus religiosa, sarja – resin of Vateria indica, arjuna – Terminalia arjuna and palāśajaiḥ – Butea monosperma or even pieces of Bambusa bambos, are placed evenly upon the cloth; bandage as kusha (splints) and then bandaged again, as if pressing firmly over it. By loose bandaging, stability (immobility) of the joint is not achieved and by very tight bandaging there is the possibility of pain, burning sensation, ripening, ulceration/suppuration, or manifestation of swelling.

Removal of bandage

त्र्यहात्त्र्यहादृतौ घर्मे सप्ताहान् मोक्षयेद्धिमे ॥ १७ ॥
साधारणे तु पञ्चाहाद्भङ्गदोषवशेन वा ।
In summer, bandages should be removed every third day, in cold season once in seven days, in moderate season once in five days or at such intervals depending on the condition of the fracture and the dosha.

Chikitsa of Sandhigata Bhanga

न्यग्रोधादिकषायेण ततः शीतेन सेचयेत् ॥ १८ ॥
तं पञ्चमूलपक्वेन पयसा तु सवेदनम् ।
It (fracture) should be bathed either with cold decoction of herbs of Nyagrodhadi Gana (chapter 15 of Sutrasthan) and when there is pain, with milk boiled with herbs of Panchamula.

सुखोष्णं वावचार्यं स्याच्चक्रतैलं विजानता ॥ १९ ॥
विभज्य देशं कालं च वातघ्नौषधसंयुतम् ।
प्रततं सेकलेपांश्च विदध्याद्भृशशीतलान् ॥ २० ॥
Or after carefully considering the nature of the land and season, chakrataila added with herbs which mitigate Vata, may be poured over the place comfortably warm, pouring decoctions and application of paste of herbs should be continuous both in very cold state.

गृष्टिक्षीरं ससर्पिष्कं मधुरौषधसाधितम् ।
प्रातः प्रातः पिबेद्भग्नः शीतलं लाक्षया युतम् ॥२१॥
The patient of fracture should drink Gristikshira (milk of the cow which has delivered the calf within seven days) every morning, added with ghee and boiled with herbs of sweet taste lākṣayā – and Laccifer lacca and then cooled.

सव्रणस्य तु भग्नस्य व्रणो मधुघृतोत्तरैः ।
कषायैः प्रतिसार्योऽथ शेषो भङ्गोदितः क्रमः ॥ २२ ॥
In case of fracture with a wound, the wound should be bathed with decoction of herbs of astringent taste added with more of honey and ghee. remaining treatment is like that described for fractures.

लम्बानि व्रणमांसानि प्रलिप्य मधुसर्पिषा ।
सन्दधीत व्रणान् वैद्यो बन्धनैश्चोपपादयेत् ॥ २३ ॥
Muscles which are hanging loose in the wound should be smeared with honey and ghee and then the wounds are cut, sutured and bandaged appropriately by the physicians.

Phalinyadi Churna

तान् समान् सुस्थिताञ्ज्ञात्वा फलिनीलोध्रकट्फलैः ।
समङ्गाधातकीयुक्तैश्चूर्णितैरवचूर्णयेत् ॥ २४ ॥
धातकीलोध्रचूर्णैर्वा रोहन्त्याशु तथा व्रणाः ।
Observing that these are well adhered, fine powder of either phalinī – Callicarpa macrophylla, lodhra – Symplocos racemosa, kaṭphalaiḥ -­ Myrica nagi, samaṅgā – Rubia cordifolia and dhātakīyuktai: – Woodfordia fruticosa; or powder of dhātakī – Woodfordia fruticosa and lodhra – Symplocos racemosa should be sprinkled over them; by this the wounds heal quickly.

इति भङ्ग उपक्रान्तः स्थिरधातोरृतौ हिमे ॥ २५ ॥
मांसलस्याल्पदोषस्य सुसाध्यो दारुणोऽन्यथा ।
Thus, was described the treatment of Bhanga; it is easily curable in those who have strong tissue, during autumn, in persons who are muscular and who have mild aggravation of dosha; the opposite of all these are either very difficult or impossible to cure.

पूर्वमध्यान्तवयसामेकद्वित्रिगुणैः क्रमात् ॥ २६ ॥
मासैः स्थैर्यं भवेत्सन्धेर्यथोक्तं भजतां विधिम् ।
By adopting the treatment described earlier,persons of early, middle and late ages should attain strength in the (fractured) joints in one, two and three months respectively.

Shayana: Bedding for fracture patients

कटीजङ्घोरुभग्नानां कपाटशयनं हितम् ॥२७॥
यन्त्रणार्थं तथा कीलाः पञ्च कार्या निबन्धनाः ।
जङ्घोर्वोः पार्श्वयोर्द्वौ द्वौ तल एकश्च कीलकः॥२८॥
श्रोण्यां वा पृष्ठवंशे वा वक्षस्यक्षकयोस्तथा ।
For fractures of the waist, forelegs and thighs, it is beneficial to lie on a hard wooden box fitted with five pegs to control (immobilise the leg), two each for the forelegs (calves) and thighs and one for the sole. In the same way (in fractures) of the pelvis, vertebral column, chest or the collar bone.

विमोक्षे भग्नसन्धीनां विधिमेवं समाचरेत् ॥ २९ ॥
This method may be followed in cases of dislocation and fracture of the joints.

Treatment of dislocation

सन्धींश्चिरविमुक्तांस्तु स्निग्धस्विन्नान् मृदूकृतान् ।
उक्तैर्विधानैर्बुद्ध्या च यथास्वं स्थानमानयेत् ॥ ३० ॥
Dislocation of the joints which has become old, should be made soft by anointing with oil and fomentation and then placed in the normal position by the methods described above by using intelligence.

Treatment of mal-union of fractures

असन्धिभग्ने रूढे तु विषमोल्बणसाधिते ।
आपोथ्य भङ्गं यमयेत्ततो भग्नवदाचरेत् ॥ ३१ ॥
A fracture which is not located in the joints and has healed improperly (malunion) and aggravated, should be treated by breaking (compressing) the fracture again, made to restrain and treat on the lines of treating fractures properly.

Ripening of fractures

भग्नं नैति यथा पाकं प्रयतेत तथा भिषक् ।
पक्वमांससिरास्नायुः सन्धिः श्लेषं न गच्छति ॥३२॥
The physician should make all attempts, so as to not allow ripening (suppuration) in the fracture site; since muscle, veins, tendons, joints which develop pus do not stick together.

Use of medicated fats mentioned in Vata Vyadhi Chikitsa

वातव्याधिविनिर्दिष्टान् स्नेहान् भग्नस्य योजयेत् ।
चतुष्प्रयोगान् बल्यांश्च वस्तिकर्म च शीलयेत् ॥३३॥
In treatment of fractures, medicated fat described in the treatment of Vata Vyadhi (chapter 21 of Cikitsa Sthana) should be made use for the four therapies (drinking, nasal drops, anointing and enema), which give strength to the body and enema therapy should be adopted.

Beneficial foods

शाल्याज्यरसदुग्धाद्यैः पौष्टिकैरविदाहिभिः ।
मात्रयोपचरेद्भग्नं सन्धिसंश्लेषकारिभिः ॥ ३४ ॥
The patient of fracture should be served with proper quantities of foods such as rice, ghee, juice of meat, milk etc. which are nourishing the body, which do not cause heartburn and which bestow sturdiness to the joints.

Unwholesome foods and activities

ग्लानिर्न शस्यते तस्य सन्धिविश्लेषकृद्धि सा |
लवणं कटुकं क्षारमम्लं मैथुनमातपम् |
व्यायामं च न सेवेत भग्नो रूक्षं च भोजनम् ॥३५॥
Exertion (over-activity of the fractured part) is not good for him; for it will produce dislocation of the joint. The patient of fracture should not indulge in things which are salty, pungent, alkaline and sour; copulation, exposure to sunlight, exercise and dry (non-fatty).

Gandha Taila

कृष्णांस्तिलान् विरजसो दृढवस्त्रबद्धान् सप्त क्षपा वहति वारिणि वासयेत् ।
संशोषयेदनुदिनं प्रविसार्य चैतान् क्षीरे तथैव मधुकक्वथिते च तोये ॥ ३६ ॥
पुनरपि पीतपयस्कांस्तान् पूर्ववदेव शोषितान् बाढम् ।
विगततुषानरजस्कान् सञ्चूर्ण्य सुचूर्णितैर्युञ्ज्यात्॥३७॥नलदवालकलोहितयष्टिकानखमिशिप्लवकुष्ठबलात्रयैः ।
अगुरुकुङ्कुमचन्दनसारिवासरलसर्जरसामरदारुभिः॥३८॥
पद्मकादिगणोपेतैस्तिलपिष्टं ततश्च तत् ।
समस्तगन्धभैषज्यसिद्धदुग्धेन पीडयेत् ॥ ३९ ॥
शैलेयरास्नांशुमतीकसेरुकालानुसारीनतपत्रलोध्रैः ।
सक्षीरशुक्लैः सपयः सदूर्वैस्तैलं पचेत्तन्नलदादिभिश्च ॥ ४० ॥
गन्धतैलमिदमुत्तममस्थिस्थैर्यकृज्जयति चाशु विकारान् ।
वातपित्तजनितानतिवीर्यान् व्यापिनोऽपि विविधैरुपयोगैः ॥ ४१ ॥
kṛṣṇān tilān – Black sesamum indicum, well cleaned is tied into a bundle with a thick cloth and allowed to stay in flowing water for seven days. Then it is soaked in milk and decoction of Glycyrrhiza glabra daily and dried in the shade. This continued for seven days; once again it is soaked in milk and decoction of Glycyrrhiza glabra daily and dried in the shade as done previously, removed of its husk free from impurity and powdered, it is then mixed with the fine powder of nalada – Nardostachys jatamamsi, vālaka – Coleus vettiveroides, lohita yaṣṭikā – Rubia cordifolia, nakha – Capparis sepiaria, miśi – Peucedanum graveolens, plava – Cyperus bulbosus, kuṣṭha – Saussurea lappa, balātrayaiḥ – Bala – Sida cordifolia, Atibala – Abutilon indicum and Nagabala – Sida veronicaefolia, aguru – Aquilaria agallocha, kuṅkuma – Crocus sativus, candana – Santalum album, sārivā – Hemidesmus indicus, sarala – Pinus longifolia, sarjarasā – Resin of Vateria indica, maradārubhiḥ – Cedrus deodara and the herbs of Padmakadi Gana and also paste of tila (sesame seeds), all herb of fragrant smell (Eladigana) and macerated with milk; naladādi– With Nelumbo nucifera, medicated oil should then be cooked with the above herbs, added with the paste of śaileya – Parmelia perlata, rāsnā – Pluchea lanceolata, aṃśumatī – Desmodium gangeticum, kaseru – Scirpus grossus, kālānusārī – Trigonella foenum graecum, nata – Valeriana wallicii, patra – Cinnamomum tamala, lodhraiḥ – Symplocos racemosa, sakṣīra śuklaiḥ – Pueraria tuberosa, sapayaḥ – Roscoea purpurea, sadūrvai: – Cynodon dactylon, ­This oil known as Gandha Taila is good for sturdiness to the bones, cures disease produced by Vata and Pitta quickly, though powerful and spread all over the body by using it in different methods of therapies.

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहितायां षष्ठे उत्तरस्थाने भङ्गप्रतिषेधो नाम सप्तविंशोऽध्याय:॥२७॥
Thus, end the chapter- Bhanga Pratishedha the twenty seventh in Uttarasthana of Ashanga Hridaya Samhita, composed by Srimad Vagbhata, son of Vaidypati Simhagupta.