Sushruta Samhita, volume 4: Cikitsasthana
Chapter III - The medical treatments of fractures and dislocations
A fracture or dislocation (Bhagna) occurring in a person of a Vatika temperament, or of intemperate habits, or in one who is sparing in his diet, or is affected with such supervening disorders (as fever, tympanites, suppression of the stool and urine, &c.) is hard to cure. A fracture-patient must forego the use of salt, acid, pungent and alkaline substances and must live a life of strictest continence, avoid exposure to the sun and forego physical exercises and parchifying (devoid of oleaginous) articles of food. A diet consisting of boiled rice, meat-soup, milk, clarified butter, soup of Satina pulse and all other nutritive and constructive food and drink, should be discriminately given to a fracture-patient. The barks of Udumbara, Madhuka, Ashvattka, Palasha, Kakubha, Bamboo, Vata or Sala trees should be used as splints (Kusha). Manjishtha, Madhuka, red sandal wood and Sali- rice mixed with Shata-Dhauta clarified butter (i.e., clarified butter washed one hundred times in succession) should be used for plastering the fracture. 2–6.
Fractures should be (dressed and) bandaged once a week in cold weather, on every fifth day in temperate weather (i.e., in spring and autumn), and on every fourth day in hot weather (i.e., in summer), or the interval of the period for bandaging should be determined by the intensity of the Doshas involved in each individual case. An extremely loose bandage prevents the firm adhesion of a fractured bone, a light bandage gives rise to pain, swelling and suppuration of the local skin, &c. Hence in cases of fractures, experts prefer a bandage which is neither too tight nor too loose. 7–8.
A cold decoction of the drugs of the Nyagrodhadi group should be used in washing (the affected part), whereas in the presence of (excessive) pain, (the part) should be washed with milk boiled with the drugs of the (minor) Pancha-mula, or simply with the oil known as the Chakra-taila made lukewarm. Cold (or warm) lotions and medicinal plasters (Pradehas)of Dosha- subduing drugs should be prescribed with due regard to the nature of the season and the Doshas involved in each case. 9-10.
A preparation of milk from a cow, delivered for the first time, boiled with the drugs of the Madhuradi group and mixed with powdered shellac and clarified butter (as an afterthrow) should be given (when cold) to a fracture- patient as a beverage every morning. In a case of fracture attended with ulcer on the part, an astringent plaster plentifully mixed with honey and clarified butter should be applied; and the rest (diet and regimen of conduct) should be as laid down in the case of a (simple) fracture. 11–12.
A case of fracture occurring in a youth or a person with slightly deranged Doshas or in winter, is held to bs easily curable (with the help of the aforesaid medicines and diet). A fractured bone in a youth is joined by the aforesaid treatment in the course of a month, in two months in the case of a middle- aged man and in three months in one of old age. 13–14.
An elevated and fractured joint should be reduced by pressing it down, while one hanging down should be set by raising it up, by pulling it in the case of its being pushed a fide, and by reinstating it in its upward (proper) position in the event of its being lowered down. An intelligent physician should set all dislocated (Bhagna) joints, whether fixed or movable, by the mode of reduction, known as Anchhana, Pidana, (pressure), Sankshepa and Vandhana (bandaging). 15–16.
A crushed or dislocated joint should not be shaken should be kept at rest) and cold lotions or washes and medicated plasters (Pradeha) should be applied to the part. A joint is spontaneously reset to its natural or normal state or position after the correction of its deformity incidental to a blow or hurt having been effected. The fractured or dislocated part should be first covered with a piece of linen soaked in clarified butter. Splint should then be placed over it and the part properly bandaged. 17–19.
Treatment of fractures in particular limbs:—
Now we shall discourse on the measures to be adopted in fractures occurring in each particular limb. In the case of a nail-joint, being in any way crushed or swollen by the accumulation of the deranged blood (in the locality), the incarcerated blood should be first let out with the help of an awl (Ara) and the part should be plastered with a paste of Sali-rice. A finger or phalanx bone put out of joint or fractured should be first set in its natural position and bandaged with a piece of thin linen and should be then sprinkled over with clarified butter. In the case of a fracture in the foot the fractured part should be first lubricated with clarified butter, then duly splinted up, and bandaged with linen. Such a patient should forego all kinds of locomotion. In the case of a fracture of the knee-joint or thigh-bone the affected part should be lubricated with clarified butter and carefully pulled straight, after which it should be splinted with barks (of Nyagrodha, etc.) and bandaged with clean linen. In case of the fracture projecting out a thigh-bone should be reset with the help of a circular splint and bandaged. In the case of Sphutita (cracked) or Piccita (bruised) thigh-bone, the part should be also bandaged in the aforesaid manner. 20-24.
In a case of a fracture in the Kati (Ilium-bone), it should be reduced by the fractured bone being raised up or pressed down (as the case may be) and the patient should then be treated with Vasti (enematas of medicated oils or Ghritas;. In the case of a fracture of one of the rib-bones (Parshaka), the patient should be lubricated with clarified butter. He should then be lifted up (in a standing posture) and the fractured rib (bone), whether left or right, should be relaxed by being rubbed with clarified butter. Strips of bamboo or pad (Kavalika) should be placed over it and the patient should be carefully laid in a tank or cauldron full of oil with the bamboo splint duly tied up with straps of hide. In the case of a dislocation of the Amsa- Sandhi (shoulder-joint), the region of the Kaksha (arm-pit) should be raised up with an iron-rod (Mushala) and the wise physician should bandage the part, thus reduced, in the shape of a Svastika (8-shaped) bandage. A dislocated elbow-joint should be first rubbed with the thumb, after which it should be pressed with a view to set it in its right place by fixing and expanding the same. After that the affected part should be sprinkled over with any oleaginous substance. The same measures should be adopted in the case of a dislocation of the knee-joint (Janu-sandhi), the wrist-joint (Gulpha- sandhi) and the ankle-joint (Mani-vandha). 25-29.
In the case of fractured bones in the palms of the hands, the two palms should be made even and opposed, and then bandaged together and the affected parts should be sprinkled with raw and unmedicated oil (ama-taila). The patient should be made later first to hold a ball of cow-dung, then a ball of clay and then a piece of stone in his palms and so on, with the progressive return of strength (to the affected parts). In a case of a fracture of the Akshaka, the affected part should be first fomented and then reduced by raising it up with a Mushala (iron-rod) in the arm-pit or by pressing it down (as the case may be) and should be firmly bandaged. A case of fractured arm-bone should be treated according to the directions given in the case of a fractured thigh-bone. 30–32.
In the case of a bending (twisting) or intussusception of the neck downward, the head should be lifted up by putting the fingers into the hollow (Avatu) above the nape of the neck and at the roots of the jaw-bones (Hanu). Then the part should be bandaged with a piece of linen after having evenly put the splint (Kusha round the neck). The patient should be caused to lie constantly on his back for a week. In a case of a dislocation of the joints of the jaw-bones (Hanu), the jaw-bones should be fomented and dulyset in their right position, bandaged in the manner of a Panchangi-vandha, and a Ghrita boiled and prepared with (the Kalka and a decoction of) the Madhura (Kakolyadi) and Vayu-subduing (Chavyadi) groups should be used as errhines by the patient. 33-3
A tooth of a young person, not broken but loose, should be plastered with a cooling paste on its outside after having pressed out the accumulated blood at the root. The tooth should be sprinkled or washed with cold water and treated with drugs having Sandhaniya (adhesive) properties. The patient should be caused to drink milk with the help of a lotus stem. The loose tooth of an old man should be drawn. A nose sunk down or depressed (by a blow) should be raised up with the help of a rod or director, while it should be straightened in a case of simple bending. Then two tubes, open at both ends, should be inserted into the nostrils (to facilitate the process of breathing) and the organ should be bandaged and sprinkled with clarified butter. In the case of (the cartilage of) the ear being broken, the organ should be rubbed with clarified butter straightened, and evenly set in its right position and bandaged. Measures and remedial agents mentioned in connection with Sadyo-vrana, should be likewise adopted and employed in the present instance. 37.
In a case of a fracture of the bone of the forehead unattended by any oozing out of brain matter, the affected part should be simply rubbed with honey and clarified butter and then duly bandaged. The patient should take clarified butter for a week 38.
Cooling plasters and washes should be applied to a part of the body, swollen but not in any way ulcerated on account of a fall or a blow. In the case of a fracture of the bone in the leg and in the thigh, the patient should be laid down on a plank or board and bound to five stakes or pegs in five different places for the purpose of preventing any movements of his limbs. The distribution of the (bindings) pegs in each case should be as follows. In the first case (fractured leg-bone), two on each side of the two thighs making four and one on the exterior side of the enguinal region of the affected side. In the second case (fracture of knee-joint) two on each side of the ankle-joints making four and one on the side of the sole of the affected leg. The same sort of bed and fastenings should be used in cases of fractures and dislocations of the pelvic-joint, the spinal column, the chest and the shoulders. In cases of long-standing dislocations, the joint should be lubricated with oily or lardaceous applications, fomented and softened (with proper medicinal drugs) in the manner mentioned above in order to reduce it to its natural state. 39-40.
In the case of a faulty union of a (fractured) bone lying between two joints (Kanda-bhagna), the union should be again disjointed, and the fractured bone should again be set right and treated as a case of ordinary fracture. In the case where a fractured bone would be found to have protruded out of the ulcerated part and dried, it should be carefully cut off near the margin of the (incidental) ulcer, (so as not to create a fresh ulcer on any other spot of the affected part) and subsequently treated as a case of fractural ulcer. A fracture occurring in the upper part of the body should be treated with applications of Mastikya-Shirovasti [oil-soaked pads on the head] and pourings of oil into the cavity of the ears. Potions of clarified butter, errhines and Anuvasana (enematas) should be prescribed in cases of fractures in the extremeties. 41-43.
Now we shall discourse on the recipe of a medicated oil, capable of bringing about the union of fractured bones. A quantity of black sesamum-seeds (tied up into a knot with a piece of linen) should be kept immersed at night in a stream of running water and taken out and dried in the sun (for seven consecutive days). It should then be saturated with cow’s milk (at night and dried in the sun, during the second week). During the third week the sesamum-seeds should be saturated with a decoction of Yashti-madhu (at night) and dried in the sun the next day. Then (during the fourth week) it should be again saturated with cow's milk and dried and powdered. The said sesamum-powder and powder of the drugs, constituting the Kakolyadi Gana as well as Yasthi-madhu, Manjishtha, Sariva, Kushtha, Sarja-rasa, Mansi, Deva-daru, (red) Chandana, and Shatapushpa should be mixed together. Then a quantity of cow’s milk boiled with the aromatic drugs (of the Eladi group) should be used with the preceding pulverised compound for the purpose of pressing out the oil therefrom. The oil thus pressed out should be boiled in four times the quantity of cow’s milk with the drugs such as Ela, Shalparni, Tejapatra, Jivaka, Tagara, Rodhra, Prapaundarika, Kalanusari, (Tagara), Sazreyaha, Kshira-Vidari, Ananta, Madhulika, Shringa- taka, and those of the aforesaid list (Kakolyadi group and Yasthi-madhu, etc., up to Shatapushpa) pasted together. The oil should be duly cooked over a gentle fire and is called the Gandha-Taila. This oil should be administered with good results in possible ways (e.g., as potions, liniments, unguents and errhines) to a fracture-patient. Its efficacy is witnessed in cases of convulsions, hemiplegia, parchedness or atrophy of the palate, in Ardita (facial paralysis) as well as in Manya-stambha (Paralysis or stiffness of the neck), in diseases of the head (cephalagia), in ear-ache in Hanu-graha, in deafness and in blindness and in emaciation due to sexual excesses. Administered in food or drink, or employed as a liniment, in Vasti-karma (enemata measures) or as an errhine, it acts as a sovereign restorative. Rubbed over the neck, chest and shoulders, it adds to the strength and expansion of those parts of the body, makes the face fair and lovely like a full-blown lotus and imparts a sweet fragrance to the breath. It is one of the most powerful remedial agents in disorders of the aggravated Vayu (diseases of the nervous system). It may be used even by kings and for them it should be specially prepared. 44–45.
The expressed oil of the seeds of the Trapusha, Aksha and Piyala should be cooked with a decoction of drugs of the Madhura group (Kakolyadi gana) and with ten times the quantity of milk. A quantity of lard if available, should be poured into it (during the process of cooking). It is an excellent medicated oil and used as a potion for anointing, and as an errhine, Vasti-karma and washes, it speedily brings about the union of fractured bones. 46.
A physician should exert his utmost to guard against the advent of any suppurative setting in in a fractured bone, since a suppuration of the local veins, nerves and muscles is difficult to cure. A complete union of a fractured joint should be inferred from its painless or unhurt character, from its full and perfect development (leaving no detectable signs of its once fractured condition), from the absence of all elevation (unevenness) and from its perfect freedom in flexion and expansion, etc. 47–48.
Thus ends the third Chapter of the Chikitsita Sthana in the Sushruta Samhita which deals with the medical treatment of fractures and dislocations.
Footnotes / commentary:
Jejjata does not read the first verse, but Gayi does.
As a general rule, milk should not be prescribed to a patient suffering from an ulcer (Vrana) in general; but a case of fracture forms an exception thereto. Some authorities hold that tepid milk may be given to a fracture-patient, if there be no ulcer (Vrana). Others, on the contrary, are of opinion that milk should not, in any case, be given to a fracture-patient for fear of suppuration and the setting in of pus.
Others, however, take “Kshira-sarpih” to be a compound word and explain the term to mean the clarified butter prepared from milk (as distinguished from that prepared from curd).
But experience tells us that in cases of excessive weakness or emaciation, milk may be given without any hesitation—Ed.
In winter and where the aching pain is present due to Vayu and Kapha.
Consisting of the drugs of the Kakolyadi group weighing two Tolas, milk sixteen Tolas, water sixty-four Tolas, boiled together with the water entirely evaporated.
In the Nidana-Sthana—Chap. XV., 9—it is stated that a case of fracture in the Kati should be given up (Varjjayet). Jejjata, however, explains “Varjjayet” as “hard to cure.”
The text has “Ubhe tale same kritva.” Jejjata explains “Ubhe tale” to mean “palms of the hands and soles of the feet;” Gaya Dasa explains it to mean “the palms of both the hands.”
According to Gayi, the lifting up of the head by putting fingers in the Avatu and in the Hanus should be made in cases of bending and intussusception of the neck respectively.
Honey, clarified butter, and drugs of the Nyagrodhadi group.
In the case of such an emission or oozing out a plug of bristles or hair as described in the preceding chapter and remedial agents laid down in connection therewith, should be used.
The principle of splintering and bandaging may be profitably compared with those followed in Agnur’s splint.
According to Jejjata, not only Anuvasana-enematas but potions of clarified butter and errhines also should be prescribed in cases of fractures in the extremeties.
There should be three parts of sesamum powder and one part of the powders of Kakolyadi, Yashti-madhu, Manjishtha, etc. (combined). But Shiva Dasa says that four parts of sesamum-powders should be taken.
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