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Chapter 44 – Bhagna Nidanam

The 44th chapter of Madhava Nidana is Bhagna Nidanam which deals with Fractures of Bones.

Skeletal Injuries and Types of Dislocations —

भग्नं समासाद् द्विविधं हुताश ! काण्डे च सन्धौ च हि तत्र सन्धौ |
उत्पिष्ट – विश्लिष्ट – विवर्तितं च तिर्यग्गतं क्षिप्तमधश्च षट् च || १ ||

 bhagnaṁ samāsād dvividhaṁ hutāśa ! kāṇḍē ca sandhau ca hi tatra sandhau |
utpiṣṭa – viśliṣṭa – vivartitaṁ ca tiryaggataṁ kṣiptamadhaśca ṣaṭ ca || 1 ||

There are two kinds of fractures (Bhagna) —

  • One at the shaft or body of bones (kanda) and
  • The other at the meeting place of two bones (sandhi).

There are six kinds of Sandhibhagnas including the ones named as —

  •  Utpishta
  • Vishlishta
  • Vivartita
  • Tiryaggata
  • Kshipta and
  • Adhahkshipta. 1
General Clinical features of Dislocations —

प्रसारणाकुञ्चन – वर्तनोग्रा रुक् स्पर्श विद्वेषणमेतदुक्तम् |
सामान्यतः सन्धिगतस्य लिङ्ग – 

prasāraṇākuñcana – vartanōgrā ruk sparśa vidvēṣaṇamētaduktam |
sāmānyataḥ sandhigatasya liṅga —

Features of fracture at the sutures (Sandhi bhagna) include the following —

  • Severe pain during extension, contraction and rotation,
  • Guarding against touch.
Specific Clinical features of Dislocations —

— मुत्पिष्टसन्धेः श्वयथुः समन्तात् || २ ||
विशेषतो रात्रिभवा रुजा च, विश्लिष्टजे तौ रुजा च नित्यम् |
विवर्तिते पार्श्वरुजश्च तीव्रास्तिर्यग्गते तीव्ररुजो भवन्ति || ३ ||
क्षिप्ते अति शूलं विषमत्वमस्थ्नोः, क्षिप्ते त्वधो रुग्विघटश्च सन्धेः | 

— mutpiṣṭasandhēḥ śvayathuḥ samantāt || 2 ||
viśēṣatō rātribhavā rujā ca, viśliṣṭajē tau rujā ca nityam |
vivartitē pārśvarujaśca tīvrāstiryaggatē tīvrarujō bhavanti || 3 ||
kṣiptē ati śūlaṁ viṣamatvamasthnōḥ, kṣiptē tvadhō rugvighaṭaśca sandhēḥ |

  • There could be swelling all round and severe nights in utpista type;
  • In vislista type, swelling and pain appear both in day and night;
  • In vivartita type severe pain appear at both the sides of the fractured site;
  • In Tiryaggata type, there is very severe pain;
  • In Kshipta Type, there is pain and curvature of the bones while bones riding one over the other are seen in Adhakshipta. 2-3
Types of fractures and general clinical features —

 काण्डे त्वतः कर्कटकाश्वकर्ण – विचूर्णितं पिच्चितमस्थिच्छल्लिका || ४ ||
काण्डेषु भग्नं ह्यतिपातितं च मज्जागतं च स्फुटितं च वक्रम् |
छिन्नं द्विधा द्वादशधा अपि काण्डे स्रस्ताङ्गता शोथ – रुजातिवृद्धिः || ५ ||
संपीड्यमाने भवतीह शब्दः स्पर्शासह – स्पन्दन – तोद – शूलाः |
सर्वास्ववस्थासु न शर्मलाभो भग्नस्य काण्डे खलु चिन्हमेतत् || ६ ||

kāṇḍē tvataḥ karkaṭakāśvakarṇa – vicūrṇitaṁ piccitamasthicchallikā || 4 ||
kāṇḍēṣu bhagnaṁ hyatipātitaṁ ca majjāgataṁ ca sphuṭitaṁ ca vakram |
chinnaṁ dvidhā dvādaśadhā api kāṇḍē srastāṅgatā śōtha – rujātivr̥ddhiḥ || 5 ||
sampīḍyamānē bhavatīha śabdaḥ sparśāsaha – spandana – tōda – śūlāḥ |
sarvāsvavasthāsu na śarmalābhō bhagnasya kāṇḍē khalu cinhamētat || 6 ||

The fractures have been classified into 12 types. Their names include —

  • Karkataka (Sub – periosteal fracture)
  • Ashvakarna (Oblique fracture)
  • Vichurnita (Comminuted Fracture)
  • Picchita (Complicated fracture)
  • Asthichalika (Longitudinal fracture)
  • Kanda bhagna (Transverse fracture)
  • Atipatita (Multiple fracture),
  • Majjagata (Impacted fracture),
  •  Sphutita (Fissured Fracture)
  • Vakra (Greenstick Fracture) and
  • 2 types of Chinna (i.e., dislocations, depending on their size, minor or major)

In terms of the symptoms of fractures, it may be noted that there is

  • Looseness in the related limbs of the body.
  • Severe pain
  • Pain increases if the affected limb is pressed and there could appear a sound as well from within.
  • Touching the affected limb produces an unbearable pain
  • The nerves of the patient reflect an abnormal movement and there is piercing pain.
  • The patient of fracture does not find relief in any posture. 4-6
 Specific clinical features of Fractures —

 भग्नं तु काण्डे बहुधा प्रयाति समासतो नामभिरेव तुल्यम् || ७ || 

bhagnaṁ tu kāṇḍē bahudhā prayāti samāsatō nāmabhirēva tulyam || 7 ||

Apart from what has been narrated above, there are several other kinds of fractures. They have features identical to their respective names. 7

Factors causing delayed healing —

 अल्पाशिनो अनात्मवतो जन्तोर्वातात्मकस्य च |
उपद्रवैर्वा जुष्टस्य भग्नं कृच्छ्रेण सिध्यति || ८ || 

alpāśinō anātmavatō jantōrvātātmakasya ca |
upadravairvā juṣṭasya bhagnaṁ kr̥cchrēṇa sidhyati || 8 ||

Fractures heal with difficulty in persons who have dietary deficiency, who have no self control, who are of the Vatika constitution and have other complications as well. 8

Incurable Fractures —

भिन्नं कपालं कट्यां तु सन्धिमुक्तं तथा च्युतम् |
जघनं प्रतिपिष्टं च वर्जयेद्धि विचक्षणः || ९ ||
असंश्लिष्टकपालं च ललाटे चूर्णितं च यत् |
भग्नं स्तनान्तरे पृष्टे शङ्खे मूर्ध्नि च वर्जयेत् || १० || 

bhinnaṁ kapālaṁ kaṭyāṁ tu sandhimuktaṁ tathā cyutam |
jaghanaṁ pratipiṣṭaṁ ca varjayēddhi vicakṣaṇaḥ || 9 ||
asanśliṣṭakapālaṁ ca lalāṭē cūrṇitaṁ ca yat |
bhagnaṁ stanāntarē pr̥ṣṭē śaṅkhē mūrdhni ca varjayēt || 10 ||

The fractures that are not curable ones and that must be rejected for treatment —

  • Fracture of the hip bone,
  • Fracture at the sutures of the hip bones,
  • Utpishta type of fracture at the pelvis in its interior,
  • fractures of the forehead, chest, back, temporal region and vault of the head. 9 – 10

सम्यक् सन्धितमप्यस्थि दुर्निक्षेप – निबन्धनात् |
सङ्क्षोभाद्वा अपि यद्गच्छेद्विक्रियां तच्च वर्जयेत् || ११ ||

 samyak sandhitamapyasthi durnikṣēpa – nibandhanāt |
saṅkṣōbhādvā api yadgacchēdvikriyāṁ tacca varjayēt || 11 ||

One must reject treatment of such cases of fractures that once healed but subsequently have reappeared due to bad position, bandaging or violent activity by the careless patient resulting in loss of function (of the bone in question). 11

Types of fractures in different bones–

 तरुणास्थीनि नाम्यन्ते, भिध्यन्ते नलकानि च |
कपालानि विभज्यन्ते, स्फुटन्ति रुचकानि च || १२ || 

taruṇāsthīni nāmyantē, bhidhyantē nalakāni ca |
kapālāni vibhajyantē, sphuṭanti rucakāni ca || 12 ||

Young bones (cartilage) bend, long bones break in the middle, flat bones crack in their body and the teeth splinter off. 12

 इति श्री माधवकरविरचिते माधवनिदाने भग्ननिदानं समाप्तम् || ४४ ||  

iti śrī mādhavakaraviracitē mādhavanidānē bhagnanidānaṁ samāptam || 44 ||

Thus concludes the Chapter on Bhagna.