Special issue with the Sunday Magazine
From the publishers of THE HINDU

Indian health traditions: October 08, 2000

---

A tradition of bone setting

Dr. M. Radhika

The author is an ayurvedic physician in Chennai and has authored several books on Ayurveda.

Indigenous systems of medicine do not limit themselves to just fullfilling the needs of primary health care, but also reach out to specialised areas like treatment of eye diseases, poisons (snake and insect bites), bone setting, marma chikitsa (ancient acupressure) and so on. Unfortunately these specialised areas are not so well known.

1. (karkataka) depressed fracture; 2. (aswakarna) oblique fracture;3. (curnita) communited fracture; 4. (chinna) incomplete fracture;5. (patita) comminuted fracture of flat bones; 6. (sphutita) fissured fracture;7. (majjanugata) impacted fracture; 8. (atipatita) complete compound fracture;9. (vakra) greenstick fractures; 10. (piccita) fracture by compression;11. (asthichallita) avulsion fracture; 12. (kandabhagna) spiral fracture

One such popular but little known area is that of bone-setting. Many interesting facts have been described in ancient ayurvedic classics on the management and treatment of fractures including the different kinds of bandages and slings to be used. Orthopaedic cases like fractures - both simple and compound, dislocations and sprains are common in rural and tribal areas.

Revitalising the existing precious science of bone setting would be a cost-effective alternative for the costly "state of the art" techniques of surgical reduction, heavy Plaster of Paris plasters and long periods of immobilisation.

The science of bone setting is included in ayurveda) where it is termed Bhagna. To begin with, there is a detailed study of the types and number of bones. There are five types of bones Kapala (flat bones), Ruchaka (small cubical bones), Taruna (cartilages), Valaya (curved bones like rib bones), and Nalaka (long or tubular bones).

The effect of trauma on these kinds of bones also differ. For example, Ruchaka or the cubical bones are fragmented while the valaya or curved bones break or crack under the same fall or trauma.

Bone injuries have also been classified into two major types - Savrana i.e. is open or Compound fracture and Avrana or closed or simple fracture. The latter is further classified as Sandhimuktha or dislocations and Kandabhagna or fractures. Dislocations are divided into six types and fractures into 12 types. This shows how much knowledge existed and how well organised it was so many centuries ago.

Clinical Features of Ideally United Fractures

1. absence of gap between the broken fragments;2. no shortage of limbs;3. no deformity;4. easy movements

The six types of dislocation are also six types - Utpista or fracture dislocation; Vislista or dislocations of joints due to ligamental tears; Vivartita or anterior-posterior dislocation of the head of the humerus; Avakshipta or downward displacement of the head of the humerus; Atikshipta or marked displacement of any articulation surface usually found in the knee joint and Tiryakshipta or oblique dislocation in one of the articulating bones.

Khanda Bhagna, or fractures in general, show swelling, twitching, rotational deformity, tenderness, crepitus, various types of pain, continuous restlessness and loss of function of the affected part. All these features were mentioned by Susrutha 3,000 years ago and are still found as definitions in any standard modern textbook of orthopaedics.

Twelve types of fractures have been mentioned and fully described by Susrutha. They are Karkataka - depressed fracture; Aswakarna - oblique fracture; Curnita - Comminuted fracture; Piccita - fracture due to compression; Asthichallita - usually due to sudden passive flexion for example in interphallangeal joints if hit by a ball, Khanda Bhagna - spiral fracture; Majjanugatha - impacted fracture; Atipatita - complete compound fracture usually due to severe injury; Vakra - green stick fracture; Chinna - incomplete fracture; Patita - Comminuted fracture on the flat bone where it may be difficult to bring about permanent repair and Sphutita - fissured fracture.

Susrutha has also given due consideration to the age factor in deciding the prognosis. According to him, skeletal injuries take one month to heal in young patients, two months in middle-aged patients and three months in old people. Dealing with the principles of treatment, Susrutha gives four basic steps that is Anchana or traction; Peedana or manipulation by local pressure; Samkshepa or opposition and stabilisation and Bandhana or immobilisation. Detailed explanations on each of the above steps are given. He also stresses that the splinting should be proper. The splint should not be too loose or too tight. A loose splint will not serve the purpose while a tight one may causes pain and suppuration of the underlying tissues.

Special techniques like management of compound fractures have been dealt with separately. The wounds are dressed before immobilising the fracture.

1. (kosa) Sheath bandage for finger and toes;2. (dama) Bandage for thigh tied at the hip and knee;3. (swastika) A cross bandage used in joints;4. (anuvellita) Spiral bandage for extremities;5. (pratoli) Bandage for penis and neck;6. (mandala) A type of circular bandage;7. (sthagika) Sheath bandage for fingers, toes and penis;8. (yamaka) Bandage for two wounds simultaneously;9. (khatva) Four-tailed bandage for chin and face;10. (cina) Four-tailed bandage for eye injuries;11. (vibandha) Bandage employed for the trunk;12. (vitana) Cephaline bandage;13. (gophana) bandage for perineal region;14. (pancangi) Bandage with five tails;15. (utsanga) Sling bandage.

There is an indication of the use of practical physiotherapy in the traditional texts. An interesting feature in Susrutha's technique of dealing with fractures is the method of immobilising the injured limbs by using fracture bed. It is important to mention that Susrutha has treated fracture and dislocations of cervical spinal bones correcting the deformity.

After the actual treatment is over, Susrutha also defines a properly united fracture like absence of gaps between the broken fragments, shortening deformity and return of painless, easy movements.

Only when a surgeon is satisfied that these four features exist clinically, should the bone injury be declared as ideally healed. Susrutha's bandaging techniques are also interesting. He has described 15 types of bandages for use in different parts of the body. Kosa - sheath bandage for limbs and fingers; Dama - sheath bandage for thighs; Swartika - cross bandage for joints; Anuveellita - spiral bandage for limbs; Pratoli - bandage for soft parts like neck and male genitalia; Mandala - circular type for thoracic region; Sthagika - sheath bandage for fingers and toes; Yamaka - bandage to cover two wards at a time; Katra - four-tailed bandage used on the chin and face; Cina - four-tailed bandage for the eyes; Vibandha - bandage fo the trunk to be tied at the back; Vitana - cephaline bandage for head injuries; Gophana - "T"-shaped bandage used on the perinium and anal region; Panchangi - five-tailed bandage employed around the neck and chin and tied above the head; and Utsangi - a sling bandage used for immobilising the upper limbs.

Here you can see the conventional cuff and collar sling used by modern orthopaedic practitioners. Dr. Natrajan has adopted the Puthur type cuff-and-collar sling, which consists of two slings, one tied at the wrist joint and the other tied at the angle of the thumb and the palm.
These two slings are tied together above the wrist.

A close-up of the Puthur bandage, which prevents the wrist dropping and thereby enhances the healing of fractures of the forearm.

These traditional bone setting measures are practicised even today in many centres in South India. The well known ones are Puthur in Chittor district; Mamsapuram in Kamarajar district and Olakkade in Kanyakumari district. Other than these are centres in the heart of the city very near the Ayurveda college in the Trivani Hospital at Thiruvananthapuram. Each centre has its own special oil or medication which they claim is the cause for the successful healing.

Plants used in traditional bone setting are Ampelocissuslatifolia, Anetemisla lacniata and Banbase Ceiba and a red coloured powder (which they call a disinfectant) and cover it with a thick layer of cotton over which splints are placed and kept in place by another bandage.

The bone setters at Mamsapuram are well experienced and specialise in compound fractures. They have medicines to heal external wounds also. The asans of Ollakode use small pieces of earthern ware, or even plaster of paris pieces to give splintage instead of bamboo splints. These are kept in place by a white cotton cloth bandage tucked with pins. Then Murivenna (a special oil) is poured into the bandage. The other centres of Kerala also use Murivenna. Though of course each centre may have a special or slightly different formula.

The speciality of another centre in Tamil Nadu, at Telungupalayam, is that the vaidya also treats polio, myopathy and other neuromuscular ailments. This centre has medicinal oil preparations for various ailments. The vaidyas in Kerala districts are mostly "Varma asans" - practitioners of Marma Chikitsa - so they use their knowledge of "marma" points also in healing the fractures and dislocations and in minimising the pain.

The astonishing thing in most traditional centres is that the chief physician is not a qualified vaidya from an institution but carries on the hereditary service of his ancestors. They do not have a prescribed fee pattern. Each patient gives what he can afford as an offering. These centres render invaluable service to the people in their neighbourhood who are mostly villagers, farm workers and tree climbers who definitely cannot afford treatment for fracture in a modern orthopaedic hospital.

To conclude, India is not the only country which has a tradition in bone-setting. In England, in the 19th century, Hugh Owen Thomas was a traditional bone setter from Liverpool. He is still known as the Father of Orthopaedics in England. He published a book outlining some of his techniques and methods to treat fractures.

China also has a rich tradition in the healing art, and bone setting was also practised by traditional Chinese healers. Recently the Chinese have made significant efforts to integrate traditional with modern methods in the treatment of fractures. Excellent results have been obtained for certain conditions like periarthritis of shoulder, tennis elbow and acute lumbar sprain.

In India too, there has been a revival of interest in traditional bone-setting practices. The well known orthopaedic surgeon Dr. M. Natarajan of Chennai has visited and observed a number traditional bone setting centres, he has also adopted the same techniques used by traditional bone setting practitioners in the management of fractures.