सप्तविंशोऽध्यायः अथातः शल्यापनयनीयमध्यायं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः ॥१॥
Now we shall discourse on the chapter which deals with the modes of extracting splinters (Salyapanayaniya-adhyaya). 1
शल्यं द्विविधमवबद्धमनवबद्धञ्च । तत्र समासेनानवबद्धशल्योद्धरणार्थं पञ्चदश हेतून् वक्ष्यामः ।
तद्यथा-स्वभावः पाचनं भेदनं दारणं पीडनं प्रमार्ज्जनं निर्मापनं वमनं विरेचनं प्रक्षालनं प्रतिमर्षः प्रवाहणमाचूषणमयस्कान्तो हर्षश्चेति ॥ २॥
There are two kinds of Salyas. A Salya is either loose or firmly fixed to its seat within the body. We shall presently speak of the fifteen different modes of extracting a loose salya, which are as follows, viz.: Extraction by natural expulsive functions of the body (Svabhava), by suppuration or putrefication (Pacana), by excising (Bhedana), by bursting (Darana), by pressing (Pidana), by rubbing (Pramarjana) by blowing with the mouth of medicinal powders into the affected part (Nirdhmapana), by the administration of emetics (Vamana), by an exhibition of purgatives (Virecana) by washing (Praksalana), by friction with the fingers (Pratimarsa), by straining as at the time of defeeation (Pravahana) by sucking (Acusana), by applying a magnet (Ayaskanta) and by exhilarating (Harsa). 2
तत्रानुक्षवथूद्गारकासमूत्रपुरीषानिलैः स्वभावबलप्रवृत्तैर्नयनादिभ्यः पतति । मांसावगाढं शल्यमविदह्यमानं पाचयित्वा प्रकोपा – (था) – त्त स्य पूयशोणितवेगाद् गौरवाद् वा पतति । पक्वमभिद्यमानं भेदयेद् दारयेद् वा भिन्नमनिरस्यमानं पीडनीयैः पीडयेत् पाणिभिर्वा । अणून्यक्षशल्यानि परिषेचनाध्मापनैर्बालवस्त्रपाणिभिः प्रमार्ज्जयेत् । आहारशेषश्लेष्महीनाणुशल्यानि श्वसनोत्कासनप्रधमनैर्निर्धमेत्, अन्नशल्यानि वमनाङ्गलिप्रतिमर्षप्रभृतिभिः, विरेचनैः पक्वाशयगतानि, व्रणदोषाशयगतानि प्रक्षालनैः । वातमूत्रपुरीषगर्भसङ्गेषु प्रवाहणमुक्तम् । मारुतोदकसविषरुधिरदुष्टस्तन्येष्वाचूषणमास्येन विषाणैर्वा । अनुलोममनवबद्धमकर्णमनल्पव्रणमुखमयस्कान्तेन । हृद्यवस्थितमनेककारणोत्पन्नं शोकशल्यं हर्षेणेति ॥ ३ ॥
An embedded foreign matter is usually expelled from the eyes, etc., by inducing lachrymation, sneezing, eructation, coughing, micturition, defaecation, and the emission of flatus.
A Salya, or any other foreign matter which has penetrated into the deeper tissues of flesh, should be extracted by setting up suppuration in the affected locality. The putrid flesh would loosen the fixture of the Salya, the weight of the secreted pus and blood causing it to drop down.
The seat or the locality of a fixed Salya should be opened by an incision in the event of its not being ejected even after the establishment of the local suppuration. If the Salya fails to come out even after the incision, the affected part should be pressed with the fingers, or medicines, endued with the virtue of exerting pressure, should be applied over its surface. A particle of any fine matter, accidentally dropped into the eye, should be removed with sprays of cold water, or by blowing into it with the mouth, or by rubbing it with hair or the fingers.
A residue of digested food or mucous, a remnant of any food matter (Aharasesa) misdirected into the nostrils, or any small splinter loosely pricking there to (Anu-salya), should expelled by breathing. hard, or by coughing upward through the nostrils (Utkasa), or by blowing through the nose. A morsel of food, acting as an obstructing Salya in the cavity of the stomach (Amasaya), should be ejected by rubing (Pratimarsa) the fingers against the lining of the throat, or against the region of the epiglottis, while such a morsel brought down into the intestines, should be evacuated by administering purgatives (Virecana).
The pus or any other morbid matter found within the cavity of an ulcer should be removed by washing it, while incarcerated flatus, or obstructed scybala or retained urine, or obstructed foetus, should be borne down and expelled by means of straining.
Any deranged Vayu or watery secretion incarcerated in any part of the body, as well as poisoned blood or vitiated breast-milk, should be sucked off with the mouth, or with a horn.
A loose, unbarbed arrow, lodged in a wound with a broad mouth and lying in an Anuloma direction, should be withdrawn by applying a magnet to its end. A shaft of grief, driven into the heart by any of the multifarious emotional causes, should be removed by exhilaration and merry-making. 3
सर्व्वशल्यानान्तु महतामणूनां वा द्वावेवाहरणहेतू भवतः प्रतिलोमोग्नुलोमच । तत्र प्रतिलोममर्व्वाचीनमानयेत्, अनुलोमं पराचीनम् । उत्तुण्डितं छित्त्वा निर्घातयेच्छेदनीयमुखम् । छेदनीयमुखान्यपि कुक्षिवक्षःकक्षावङ्खणपर्शुकान्तरपतितानि च हस्तशक्यं यथामार्गं हस्तेनैवापहर्त्तुं प्रयतेत । हस्तेनैवापहर्त्तुमशक्यं विशस्य शस्त्रेण वा यन्त्रेणापहरेत् ॥ ४॥
A shaft (Salya), whether large or small, may be withdrawn from its place in either of the two ways known as the Anuloma and Pratiloma. The Anuloma consists in withdrawing a Shalyam through a way other than that of its penetration, while the contrary is called the Pratiloma.
A Salya lodged in a place lying close to the spot of its penetration (Arvacina) should be extracted through the way by which it has entered (Pratiloma). On the other hand, a shaft or Salya, piercing deep into any part of the body, but not coming out by the other side (Paracina), should be drawn out through a way other than that of its penetration (Anuloma).
A shaft, piercing deep into any part of the body so as to reach the other side of the wounded limb or part, (but not cutting out clean through it owing to the diminution of its original momentum), and remaining protruded in the heaved up flesh, should be extracted through a channel other than that by which it has originally penetrated (Anuloma), and by stirring or striking it with the hand or a hammer. The heaved up flesh should be opened with an incision, when found possible of being so opened, and the embedded Salya should be drawn out by stirring or striking it with the hand as laid down before.
A Salya, lodged in any soft part of the abdomen, chest, arm-pits, inguinal regions or ribs, should not be cut open or struck with hammer, but should be tried to be removed with the hands through the way of its penetration (Pratiloma), in failure where of the Salya should be extracted with surgical appliances (Sastra) or any other surgical instruments (Yantras). 4
भवति चात्र शीतलेन जलेनैनं संरक्षेदस्य मर्माणि मूर्च्छन्तमवसेचयेत् । मुहुराश्वासयेच्च तम् ॥५॥
Authoritative Verse on the Subject: A patient, fainting away (during the course of such a surgical operation), should be enlivened by dashing cold water over his face. He should be solaced with many a hopeful and cheering word, and a nourishing diet such as, milk, etc. should be given him, and his vital parts should be protected. 5
ततः शल्यमुद्धृत्य निर्लोहितं व्रणं कृत्वा स्वेदार्हमग्निघृतप्रभृतिभिः संस्वेद्य विदह्य प्रदिहा सर्पिर्मधुभ्यां बद्ध्वाचारिकमुपदिशेत् ।।६।।
Then having extracted the Salya, the incidental wound or ulcer, the blood having been wiped of, should be fomented with heat or by applying warm clarified butter to its surface in the event of it being found fit to be so treated i.e., devoid of pain and unattended with further bleeding). Cauterisation should be resorted to where the condition of the wound would indicate such a measure. After that, the wound should be plastered (Pradeha) with honey and clarified butter, and bandaged with a piece of clean linen; and directions as to the diet and nursing of the patient should be given (as previously laid down). 6
(शिरास्नायुविलग्नं शलाकादिभिर्विमोच्यापनयेत्, श्वयथुग्रस्तवारङ्गं समवपीडच श्वयथुं दुर्बलवारङ्गं कुशादिभिर्बद्ध्वा ।) हृदयमभितो वर्त्तमानं शल्यं शीतजलादिभिरुद्वेजितस्यापहरेद् यथामार्गम् । दुरुपहरमन्यतोऽपबाध्यमानं पाटयित्वोद्धरेत् ॥ ७ ॥
A Salya, lodged in a vein or a ligament (Snayu), should be extracted with the help of a probe. The shaft ( Salya), lodged in the body and lying buried under the incidental swelling, should be extracted by firmly tying blades of Kusa grass around its body. A shaft (salya), lodged in a spot situated anywhere close to the heart, should be withdrawn by the way by which it has entered; and the patient should be enlivened with sprays of cold water, etc. during the operation. A Salya, lodged in any other part of the body and that is difficult to extract, and that produces pain and local inflammation, should be removed by cutting the part open. 7
अस्थिविवरप्रविष्टमस्थिविदष्टं वाऽवगृह्य पादाभ्यां यन्त्रेणापहरेत् । अशक्यमेवं वा बलवद्भिः सुपरिगृहीतस्य यन्त्रेण ग्राहयित्वा शल्यवारङ्गं प्रविभुज्य धनुर्गुणैर्बद्ध्वैकत्श्चास्य पञ्चाङ्गयामुपसंयतस्याश्वस्य वक्त्रकविके वा बघ्नीयादथैनं कशया ताडयेद् यथोन्नामयञ् शिरो वेगेन शल्यमुद्धरति । दृढां वा वृक्षशाखामवनम्य तस्यां पूर्ववद् बद्ध्वोद्धरेत्॥८॥
In the case of a shaft (Salya) which has pierced into the cavity of a bone, the surgeon should firmly press the affected bone with his legs, and pull out the embedded shaft with all his might by gripping it with a surgical instrument, in failure whereof a strong man should be asked to firmly catch hold of the patient, and the Shalya should be pulled out with the help of a gripping surgical instrument as before.
As an alternative, the bottom of the shaft should be tied to the string of a bow, strung and fully bent down; and the Salya should be ejected with the means of a full twang. As an alternative, a horse should be harnessed in the fashion known as the Pancangi-bandhana (lit. bound in the five parts of the body), and the end of the Salya should be bent down and tied to the bridle. Then the horse should be so whipped as to raise its head first, thus pulling out the embedded shaft (Salya) from its seat of lodgment by the jerk of its head. As an alternative, a high and tough bough of a tree should be lowered down and tied to the bent end of the shaft as in the preceding case. The bo should be then let loose, thus pulling out the shaft (Salya) with its rebounding force. 8
अदेशोत्तुण्डितमष्ठीलाश्ममुद्गराणामन्यतमस्य यथामार्गमेव यन्त्रेण ।। ९ ।। प्रहारेण विचाल्य
A shaft (Salya), lodged in a bone and lying protruded in the heaved up local flesh (situated in a place other than the inguinal regions, abdomen, or arm-pits, etc.), should be stirred by striking it on the head with an Asthila a round stone, – a short hammer according to certain authorities), or with a stone or hammer, and should be taken out by the way of its penetration. 9
विमृदितकर्णानि कर्णवन्त्यनाबाधकरदेशोत्तुण्डितानि पुरस्तादेव ।। १० ।।
The feather of a barbed shaft, lying embedded in a bone situated at a part of the organism where the existence of such a foreign matter is calculated not to create any special discomfort, should be first crushed by putting pressure on the heaved up or protruded flesh, and the shaft then should be gently pulled out of its seat of lodgment. 10
जातुषे कण्ठासक्ते कण्ठे नाडीं प्रवेश्याग्नितप्ताञ्च शलाकां तथावगृह्य शीताभिरभिः परिषिच्य स्थिरीभूतामुद्धरेत् । अजातुषं जतुमधूच्छिष्टलिप्तया शलाकया पूर्व्वकल्पेनेत्येके ॥११॥
In the case of a bit of shellac being accidentally pricked into the pharynx, a metal tube should be first inserted into the passage, and then a heated metallic rod should be reached down to the obstructing shellac through its inside. The shellac, thus melted by the heat of the inserted rod, would naturally stick fast to it, which should be then condensed by an injection of cold water poured down through the aforesaid tube; after that the rod should be withdrawn thus carrying away the melted shellac at its end.
According to certain authorities, any other obstructing foreign matter accidentally introduced into the pharynx should be withdrawn with the help of a rod, soaked in melted wax or shellac, and then inserted into that passage, all other procedure being the same as in the preceding instance. 11
अस्थिशल्यमन्यद् वा तिर्य्यक्कण्ठासक्तमवेक्ष्य केशोण्डुकं दृढैकसूत्रबद्धं द्रवभक्तोपहितं पाययेदाकण्ठात् । पूर्णकोष्ठं वामयेद् वमतश्च शल्यैकदेशसक्तं ज्ञात्वा सूत्रं सहसा त्वाक्षिपेत् । मृदुना वा दन्तधावनकूर्च्चकेनापहरेत् प्रणुदेवान्तः । क्षतकण्ठाय च मधुसर्पिषी लेढुं प्रयच्छेत् त्रिफलाचूर्णं वा मधुशर्करामिश्रम् ॥ ॥ १२ ॥
In the case of a bone Salya (such as the bone of fish etc.) having accidentally stuck fast in the throat, a bundle of hair, tied to a string of thread, should be inserted into the gullet of the patient, the physician holding the other end of the string in his hand. Then a copicus quantity of water, or of any other liquid substance, should be poured down into his throat, so as to entirely fill his stomach. After that some kind of emetic should be given to the patient, and the string should be pulled out as soon as the bundle of hair would be felt to have struck below the obstructing bone or Salya, which would naturally come out with the pull. As an alternative, the top end of a soft twig, as is generally used in cleansing the teeth, should be bruised into the shape of a brush, and the thorn or the Salya should be removed with its help. The incidental wound should be treated by making the patient lick a compound of clarified butter and honey, or of the powders of the Triphala, saturated with honey and sugar. 12
उदकपूर्णोदरमवाक्शिरसमवपीडयेद् धुनीयाद् वामयेद् वा भस्मराशौ वा निखनेदामुखात् ।।१३।।
The body of the patient should be pressed or rubbed, or he should be whirled round by the ankles or generally measures, calculated to induce vomiting, should be adopted in a case where he would be found to have swallowed a stomachful of water (as in a case of drowning). As an alternative, he should be buried under the ashes up to his chin. 13
ग्रासशल्ये तु कण्ठासक्ते निःशङ्कमनवबुद्धं स्कन्थे मुष्टिनाभिहन्यात् स्नेहं मह्यं पानीयं वा पाययेत् । बाहुरज्जुलतापाशशल्ये तु कण्ठपीडनाद् वायुः प्रकुपितः श्लेष्माणं कोपयित्वा स्रोतो निरुणद्धि, लालास्रावं फेनागमनं संज्ञानाशञ्चापादयति । तमभ्यज्य संस्वेद्य शिरोविरेचनं तस्मै तीक्ष्णं दद्याद्रसञ्च वातघ्नं विदध्यादिति ॥ १४ ॥
Strong wine should be given to the patient, or he should be slapped on the shoulders, so as to cause him to suddenly start in a case where a morsel of food would be found to have obstructed and stuck fast in his gullet. A tight gripe about the throat of a person with a creeper, rope or the arm of an antagonist, tends to enrage the local (Kapha), which obstructs the cavity of the passage (Srota ) producing salivation, foaming at the mouth and loss of consciousness. The remedy in such cases consists in lubricating and diaphorising the body of the patient with oil and heat, and in administering strong errhines (Siro-Virecana), and the juice or extract of meat which is possessed of the virtue of subduing the deranged Vayu. 14
शल्याकृतिविशेषांश्च स्थानान्यावेक्ष्य बुद्धिमान् । तथा यन्त्रपृथक्त्वञ्च सम्यक् शल्यमथाहरेत् ॥ १५ ॥
कर्णवन्ति तु शल्यानि दुःखाहार्य्याणि यानि च। आददीत भिषक् तस्मात् तानि युक्तया समाहितः ।।१६।।
Authoritative Verses on the Subject: An intelligent physician should removed a Salya with due regard to its shape, location and the adaptability of the different types of surgical instruments to the case under treatement. A physician should exercise his own discretion in extracting feathered shafts (Salyas) from their seats of lodgment, as well as those that are difficult of extraction. 15-16
ए तैरुपायैः शल्यन्तु नैव निर्घात्यते यदि । मत्या निपुणया वैद्यो यन्त्रयोगैश्च निर्हरेत् ।।१७।।
शोफपाकौ रुजश्नोग्राः कुर्य्याच्छल्यमनिहृतम् । वैकल्यं मरणञ्चापि तस्माद् यत्नाद् विनिर्हरेत् । । १८ ।।
A physician is at liberty to exercise his own skill and wisdom, and to devise his own original means for the extraction of a Salya with he help of any surgical instrument when the abovesaid measures would prove abortive. A Salya, not removed from the body and left in its place of lodgment, brings on swelling, suppuration, mortification of the affected part, and a sort of excruciating pain, and may ultimately lead to death. Hence a physician should spare no pain to extract a Shalyam from its seat of lodgment. 17-18
इति सुश्रुतसंहितायां सूत्रस्थाने शल्यापनयनीयो नाम सप्तविंशोऽध्यायः ॥२७॥
Thus ends the twenty-seventh Chapter of the Sutrasthana in the Susruta Sambita, which treats of extraction of Salya.