Ashtanga Sangraha Sutrasthana Chapter 37 – Shalyaharana vidhi – methods of removal of foreign bodies, thus said Atreya and other great sages. (1)
अथातः शल्याहरणविधिं नामाध्यायं व्याख्यास्यामः । इति ह स्माहुरात्रेयादयो महर्षयः ॥१॥
Shalya gati – movement of foreign bodies
त्रिविधा हि गतिः शल्यानामूर्ध्वमधस्तिर्यक् च । सा पुनः प्रत्येकमृजुवक्रभेदेन द्विविधा ॥२॥
The direction of (of movement) of foreign bodies are three; upward, downward and sideward. These are again of two kinds-straight and curved (zigzag ) . ( 2 )
Sashalya vrana laksana – features of wounds having a foreign body
तत्र ध्यामं पिटकाचितं शोफवेदनान्तं मुहुर्मुहुः शोणितास्त्राविणं बुद्बुदवदुद्गतं मृदुमांसं च व्रणं सशल्यं विद्यात् ॥३॥
The wound having a foreign body inside will be black in colour, studded with eruptions, swollen, painful, bleeding often, raised up like a buble and having soft muscles. (3)
विशेषतस्तु त्वग्गते शल्ये विवर्णः शोफो भवत्यायतः कठिनश्च ।
मांसगते शोफाभिबृद्धिः शल्यमार्गानुपसंरोहः पीडनासहिष्णुता चोष: पाकश्च ॥४॥
पेश्यन्तरस्थे शोफवर्ज्यं मांसप्राप्तवत् । सिरागते सिराध्मानं शूलं च । स्नावगते स्नावजालावक्षे पणं संरम्भश्चोग्ररुक ॥५॥
In particular if the foreign body is in the skin will produce discolouration, broad hard swelling all around; (if) in the muscles there will be increased swelling, closing of the orifice of entry of the foreign body, inability to withstand touch, local burning sensation and ulceration; (if) it is inside a muscle all the above symptoms except swelling will be seen; (if)it is in the veins, there will be swelling of the vein and pain; if it is in the tendons, it will cause construction of the network, violent movement and severe pain. (4-5)
स्त्रोतोगते स्त्रोतसां स्वकर्मगुणहानिः । धमनीस्थे सफेनं रक्तमीरयन्ननिलः सशब्दो निर्गच्छत्यङ्गपीडाहृल्लासश्च ।
अस्थिगते विविधावेदनाः शोफश्च ॥ ६ ॥
(If) it is in the srotas ( channels, pores etc.) there will be loss of the normal functions and features of those channels; (if) it is in the arteries, the blood comes out forced by vata, mixed with froth, sound and also accompanied with pain all over the body and oppression in the chest; (if) it is in the bones it causes different kinds of pains and swelling. (6)
सन्धिगतेऽस्थिवच्चेष्टोपरोधश्च । अस्थिसन्धिगते ऽस्थिपूर्णता सङ्घर्षो बलवांश्च ॥७॥
(If) it is in the joints there will be symptoms similar to that of the bone along with absence of movement; (if) it is inside the bony joints, it causes filling up of bones and severe friction (inside). (7)
कोष्ठगते त्वाटोपानाहौ मूत्रपुरीषाहारदर्शनानि च व्रणमुखाद्भवन्ति । मर्मगते मर्मविद्धवत् ॥ ८ ॥
(If) it is in the alimentary tract it produces gurgling noise, destention, and urine, faeces and food coming out of the orifice of the wound. (If) it is lodged in the vital spots, the features of their damage appear. (8)
शल्यमुपलक्षयेत् । सूक्ष्मगतिषु शल्येष्वेतान्येव यथायथं चोपदिष्टैः परित्रावैस्त्वगादिषु लक्षणान्यविस्पष्टानि भवन्ति ॥ ९ ॥
The presence of foreign bodies in the skin and other places can be determined by the exudations of those places. If the foreign bodies are small or their direction inside is not visible, the symptoms described so far will manifest slightly (not prominently). (9)
शुद्धदेहानामनुलोमसन्निविष्टान्युपरुह्यन्ते । दोषप्रकोपव्यवायव्यायामाभिघातेभ्यश्च प्रचलितानि पुनराबाधयन्ति ॥१०॥
Those foreign bodies which enter into persons who have a healthy body or those which take a downward course inside, usually remain inside the body silently for long time but will cause discomforts when they are disturbed by the increase of the doshas, movements of sexual intercourse, exercises and trauma (10)
Pranasta Shalya vijnana – determination of site of foreign body
तत्र त्वक्प्रनष्टे स्निग्धस्विन्नायां मृन्माषयवगोधूमगोमयचूर्णमर्दितायां त्वचि यत्र संरम्भो वेदना वा भवति यत्र वा स्त्यानं सर्पिर्निहितमाशु विलीयते प्रलेपो वा शुष्यति तत्र शल्यं जानीयात् । मांसप्रनष्टे स्नेहादिभिः क्रियाभिरातुरमुपपादयेत्। कर्शितस्य च शिथिलीभूतमनव बद्धं क्षुभ्यमानं यत्र यत्र संरम्भं वेदनां वा जनयति तत्र शल्यम् ॥११॥
If the foreign body is lodged in the skin its site can be determined thus – the skin should be annointed with oil and then fomentation done. It should then be massaged with powder of mud, flour of black gram, barley, wheat or powder of cowdung. The spot where the patient obstructs the movement (gaurding) or feels severe pain, that will be the site of the foreign body; the place where a lump of solid ghee melts quickly or where moist pastes applied, dry up quickly are the places of the foreign body.
In case the foreign body is lodged in the muscles, the patient should be administered therapies like lubrication etc., and made thin (weak). In such an emaciated (weak) person, the places where foreign bodies are lodged, will be found to be loose (flabby, soft) not held tight (drooping, loose ), undergoing change in shape, movement, causing violent movements or pain. (11)
एवं कोष्ठास्थिपेशीविवरेष्वपि ॥ १२ ॥
Similarly, those lodged in the alimentary tract and cavities of the bones and muscles. (12)
सिरात्रोतोधमनीस्त्रावप्रणष्टे खण्डचक्रमश्वयुक्तं रथमारोप्यातुरं विषमेऽध्वनि शीघ्रं नयेत् । ततः संरम्भादिभिर्जानीयात् ॥ १३ ॥
If the foreign bodies are lodged in veins, srotas (channels), arteries, tendons etc., the patient should be asked to sit on a horse chariot with broken wheels and taken for a fast ride on an uneven road; the place which the patient points out, as having the pain etc., ( gaurding ) will be the site of the foreign body. (13)
सन्धिप्रणष्टे स्नेहस्वेदोपपन्नं सन्धिं प्रसारणाकुञ्चनबन्धनपीडनैरुपाचरन् पूर्ववदवगच्छेत् । अस्थिप्रणष्टे स्निग्धस्विन्नान्यस्थीनि बन्धनपीडनाभ्यां भृशमुपचरंस्तद्वदुपलक्षयेत् ॥१४॥
The lodging of the foreign body in the joints can be decided by manifestation of pain etc., when the part is extended, flexed, bandaged or squeezed after the place is anointed with oil and given formentation.
If it is in the bone, the affected part may be given lubrication and sudation therapies and the place determined by bandaging or squeezing it fast and consequent appearance of pain etc. (14)
मर्मप्रणष्टे त्वनन्यभावान्मांसादिभ्यो मर्मणामुक्तं परीक्षणं भवति ॥१५॥
The symptoms of foreign bodies lodged in the vital spots will be the same as indicated for tissues like muscle etc., as these vital spots are not apart from such tissues. (15)
सामान्यलक्षणं तूच्छ्रितहस्तिस्कन्धाश्वमाद्गुरोहणद्रुतयानलङ्घनप्लवनव्यायामैजृम्भोद्गारकास क्षवथुष्ठीवनहसनप्राणायामैर्मलशुक्रोत्सर्गैर्वा यत्र संरम्भो वेदना वा भवति यत्र वा स्वल्पेऽप्यायासे स्वापो गौरवं घट्टनं शोफो वा स्यात्तत्र शल्यमादिशेत् ॥१६॥
The symptoms commonly found at the place of lodging of the foreign body are: gaurding and feeling of pain at the place, when the person is made to climb up on an elephant or a horse, or a tree, when he does fast riding, leaping, jumping, exercises; when he is asked to yawn, belch, cough, sneeze, spit, laugh and control breathing; or at the time of elimination of faeces and semen; even with slight strain there will be loss of sensation feeling of heaviness, friction or swelling in that particular place. (16)
Chaturvidha Shalya – four kinds of foreign bodies
समासतश्चतुर्विधं शल्यं भवति । वृत्तद्वित्रिचतुरस्त्रभेदेन । तददृश्यमानं वृत्तसंस्थानादनुमिमीत ॥१७॥
Generally the foreign bodies are of four types : round (cylindrical) or with two, three or four faces. The invisible ones are to be presumed as being round. (17)
Shalyaharana gati – routes of removal
सर्वशल्यानां महतामाहरणे द्वावेवोपायौ प्रतिलोमोऽनुलोमश्च ॥ १८ ॥
The modes (routes) of removal of all big sized foreign bodies are only two : removal in the upward direction and removal in downward direction. (18)
तत्र प्रतिलोममर्वाचीनमानयेदनुलोमं पराचीनम् । तिर्यग्गतं यतः सुखाहार्यं भवति ततः छित्वापहरेत् ॥ १९ ॥
The foreign material which has entered the human body from below upwards should be removed from above and that which has entered from above downwards should be removed from below, that which has entered from the sides should be removed in a convenient and easy way even after cutting it. (19)
Notes In the above verses two directions of removal of foreign bodies are mentioned viz., Pratiloma and Anuloma – which literaly mean “reverse” and “in the same route”, respectively. Indu the commentator defines pratiloma as pulling out the foreign body in the reverse direction of its entry (in other words pulling it backwards) and Anuloma as pulling out in the same direction of its entry (in other words pulling it forwards). In ancient days the arrow was the chief foreign body especially in the battle field. If it should be removed it could be done in only one way, that is pulling it out in the same direction as of its entry, because the arrow head is triangular in shape. Other types of foreign bodies could be pulled out in the opposite direction also.
प्रतिलोममनुत्तुण्डितं छेदनीयं पृथुमुखं च शल्यं न निर्घातयेत् । तथा कक्ष्यावङ्क्षणोरः परशुकान्तरपतितानि ॥२०॥
The foreign body which has a reverse direction, whose tip is not visible, which is to be cut for its removal and which has a big face should not be removed. so also, those which have lodged in the axilla, groin, chest and in between the ribs. (20)
नैव चाहरेद्विशल्यघ्नं मर्मप्रणष्टं वाऽशोफवेदनं पाकविरहितम् ॥ २१ ॥
Similarly, those which cause death immediately after removal, which are lodged in the vital organs, which have not caused swelling and pain and which do not undergo digestion (not forming pus) should also not be removed). (21)
Shalyaharana krama – method of removal of foreign bodies
अथ हस्तप्राप्यं शल्यं हस्तेनाहरेत् । तदशक्यं यथायथं यन्त्रेण । तथाप्यशक्यं शस्त्रेण विशस्य ततो निर्लोहितं व्रणं कृत्वाग्निघृतमधुप्रभृतिभिः स्वेदयित्वावदह्य तर्पयित्वा सर्पिर्मधुभ्यां बध्वाचारिकमादिशेत्। सिरास्त्रावलग्नं शलाकाग्रेणाभिमोच्याहरेत्। हृदयेऽभिर्वर्तमानं शल्यं शीतजलादिभिरुद्वेजितस्याहरेत् । यथामार्गं दुराहरमन्यतोऽप्येव माहरेत् ॥२२॥
The foreign body accessable to the hand should be removed by the hand itself and if it is not possible it should be removed by the use of blunt instruments, and those which are not possible even by blunt instruments, should be removed by making use of sharp instruments and cutting the body part. The hairs on the part should be removed, the blood in the wound wiped clean, the wound given formentation by fire, hot ghee or honey, touched with red hot iron if necessary, and the wound soaked with ghee and honey and bandaged firmly. The patient should then be instructed to follow the regimen prescribed for surgical treatment.
Foreign bodies which are stuck up in veins and tendons should be freed with the help of a metal rod and then removed out. That which is lodged in the heart should be removed only after the patient becomes conscious by the sprinkling of cold water on the face and other methods.
That which can not be pulled out in the usual route, should be pulled out by any other route. (22)
अस्थिविवरप्रणष्टमस्थिविदष्टं वाऽवगृह्यपद्भ्यां पुरुषं यन्त्रेणापकर्षत् । अशक्यमेवं वा बलवद्भिः सुगृहीतस्य यन्त्रेण ग्राहयित्वा शल्यवारङ्गं प्रतिभुज्य वा धनुर्गुणैरेकतो बध्वान्यतश्च पञ्चाङ्ग्यासुसंयतस्याश्वस्य वक्त्रकटके बध्रीयात् । अथैनमेवं कशया ताडयेद्यथोन्नमयञ्छिरो वेगेन शल्यमुद्धरति ॥२३॥
That which is lodged in the cavity of the bone or that which is impacted between two bones, should be extracted by instruments, holding the patient tight and pressed by the legs. If this method is found to be useless, the patient shoud be held tight by strong persons, the foreign body held by the instrument, the handle of the instrument tied firmly with a rope to the rib of a bow, at one end and its other end to the string of the bow, which should be tied to the bridle of a good (strong) horse. Then the horse is whipped. The sudden upward jerk of its head will pull out the foreign body. (23)
दृढां वा वृक्षशाखामवनम्य तस्यां पूर्ववद् बध्वोद्धरेत् ॥२४॥
Or a strong branch of a tree should be bent down with force and the rope fastened to the handle of the instrument tied to the bent branch and then the branch is let off. This will be another method of pulling out. (24)
दुर्बलवारङ्गं तु कुशाभिर्बध्वा । श्वयथुग्रस्तवारङ्गमुत्पीड्य श्वयथुम् ॥ २५ ॥
If the handle of the instrument is weak it should be wrapped with kusa grass and if it is having any elevations on it, they should be removed before tieing it with the rope. (25)
अदेशोत्तुण्डितमश्ममुद्गरप्रहारेण विचाल्य यथामार्गमेव ॥ २६ ॥
If the foreign body is not visible, it should be made visible by cutting off or puncturing the site of its lodging, then moving it by hitting with a stone or baton and pulling it out in the same dirction. (26)
कर्णवत्तु यन्त्रेण विमृदितकर्णं कृत्वा । नाडीयन्त्रेण वा बहुमुखेन यथास्वमुपसङ्गृह्य शलाकायन्त्रेणान्येन वा पूर्ववदाहरेत् । अनुलोममकर्णमनल्पव्रणमुखमयस्कान्तेन । पक्काशय गतं विरेचनेन ॥२७॥
If the foreign body is having earr-like protrusions, they should be cut off first, before removing the foreign body or it should be pulled out by inserting a tubular instrument of many orifices and held by a rod.
Those which are facing down, which have no protrusions and where the mouth of the wound is wide, they should be removed by using a magnet. (27)
Those which are inside the large intestines should be removed by the administration of purgatives.
वातविण्मूत्रगर्भसङ्गं प्रवाहणेन । दुष्टवातविषस्तन्यादीन्यास्यविषाणचूषणेन ॥२८॥
The obstruction of flatus, faeces, urine and foetus should be removed by asking the patient to strain (bear down); obstruction of bad air, poison and breast milk should be removed by sucking them either by mouth or by the use of a sucking horn. (28)
कण्ठस्त्रोतोगते तु शल्ये बिसं सक्तं सूत्रं कण्ठे प्रवेशयेत् । अथ तद्गृहीतं विज्ञाय शल्यं सममेव सूत्रं बिसं चाक्षिपेत् । बिसाभावे मृणालेऽप्ययमेवविधिः । जातुषे तु कण्ठसक्ते कण्ठे नाडीं प्रवेशयेत्तदा चाग्नितप्तां सूक्ष्ममुखीं शलाकामथ तां गृहीतशल्या शीताभिरद्भिः परिषिच्य स्थिरीभूतामाहरेत् । अजातुषेऽप्येवमेव प्रतप्तां जतुमधूच्छिष्टान्यतरप्रदिग्धां शलाकाम् । मत्स्यकण्टकमन्यद्वा तादृगस्थिशल्यं कण्ठलग्नं सूत्रेण सूत्रप्लोतेन वा वेष्टितयाङ्गल्यापहरेत् । अथवा केशोण्डुकं दृढदीर्घसूक्षबद्धं द्रवोपहितं पाययेद्वामयेच्च । मृदुना वा दन्तधावनकूर्चे नापहरेत् । परतो वा प्रणुदेत् । वालोण्डुके विलग्ने तद्वत् कण्टकम् ॥ २९ ॥
क्षतकण्ठश्च त्रिफलाचूर्णं मधुघृतसितोपेतमनुकण्ठयन् लिह्यात् ॥ ३० ॥
If the foreign body is lodged in the throat, the patient is made to swallow the stalk of the louts plant which is tied to a thread. When the foreign body is found to be sticking to the lotus stalk, the stalk should be pulled out alongwith the thread; in the absence of the lotus stalk, the root (of the lotus) may be used.
If the foreign body stuck up in the throat is made of lac, a tubular instrument should be passed into the throat first, then a heated iron (rod) is introduced through it and the foreign body touched. When it melts and adheres to it, cold water should be put into mouth to harden the lac and then it should be pulled out. If the foreign body is not of lac but of bitumen, bees – wax etc., the same procedure holds good. The fish hook or any other like it made of bone, sticking in the throat should be removed by the use of threads or by inserting the finger wrapped with thread or cloth.
Or, the patient should be made to swallow a small ball of hairs tied with a long thread and then drink large quantity of water. He should then be made to vamit; during the act of vomitting when the foreign body sticks to the ball of hair, it should be pulled out by the thread, quickly or by the use of a soft tooth-brush. If the foreign body does not stick on to the ball of hair for the first time, it should be introduced again and the same process repeated. If the throat becomes bruised the patient should be given the powder of triphala mixed with honey, ghee and sugar to lick slowly (to smear to the throat fully). (29-30)
अपां पूर्णं पुरुषमवाक् शिरसमवपीडयेद्धुनुयाद्वामयेच्च भस्मराशौ वा निखन्यादामुखात् | अन्यथा ह्यन्मार्गगामिभिरद्भिराध्मानकासश्वासपीनसेन्द्रियोपघातज्वरादयः श्लेष्मविकारा मत्युश्च । तत्र यथास्वं कफे प्रतिकुर्यात् । ग्रासशल्यमम्बुना प्रवेशयेत् । स्कन्धे वा मुष्टिनाभिहन्यात् । कण्ठस्थं श्लेष्माणमन्नलवं वा प्रधमनोत्कासनापकसनैर्विधमेत् ॥ ३१ ॥
The person who has swallowed large quantities of water (by drowning) should be held with his head down, his abdomen squeezed and the body shaken to make him vomit all the water. Then after, he should be placed inside a pit which is filled with ash upto his neck. Otherwise, the water travelling upwards will produce distension of the abdomen, cough, dyspnoea, rhinitis, loss of function of the sense organs, fever, many other disorders of kapha origin and even death. The treatment of kapha should also be done suitably.
If the foreign body is obstructing the passage of the throat, it should be pushed into (the oesaphagus) with the help of water (drinking) or by giving blows with the fist on the patient’s neck and shoulders. The materials obstructing, if happness to be (solid) kapha or particles of food, they should be removed either by sucking air, or by outward coughing or inward coughing. (31)
सूक्ष्ममक्षि शल्यं लेखनप्रधमनवालजलवस्त्रजिह्वाभिरपनयेत् । तथा निर्भुज्य वर्त्म वर्त्मगतमपनीय चोष्णाम्बुवाष्पस्वेदं समधुमधुकक्वाथेन सर्पिषा च परिषेकं कुर्यात् । स्वयमपि शल्यम श्रुक्षवथुकासोद्गारमूत्रपरीषानिलैर्नयनादिभ्योऽङ्गावयवेभ्यः पतति ॥ ३२ ॥
Small sized foreign bodies in the eyes, should be removed by scraping, blowing of air, use of hair, water, cloth, or the tongue. Those which are under the lids should be removed by everting the lids and then the lids washed with warm water, steam, decoction of madhuka mixed with honey or by ghee alone.
Some times foreign bodies in the eye and other parts of the body come out of their own accord during the flow of tears, sneezing, coughing, belching, elimination of urine, faeces, and flatus etc. (32)
कीटे कर्णस्त्रोतः प्रविष्टे तोदो गौरवं भरभरायमाणं च भवति स्पन्दमाने चाप्यधिकं वेदना । तत्र सलवणेननाम्बुना मधुकयुक्तेन मद्येन वा सुखोष्णेन पूरणम् । निर्गते च कीटे तदुत्सर्जनम् । तत्रैव तु मृते पाककोथक्लेदा भवन्ति । तेषु कर्णस्त्रावोक्तं कुर्यात् प्रतीनाहोक्तं च । तोयपूर्णं कर्णं हस्तोन्मथितेन तैलाम्बुना पूरयेत् । पार्श्वावनतं वा कृत्वा हस्तेनाहन्यान्नाड्या वा चूषयेत् । भवन्ति चात्र श्लोकाः ॥३३॥
Living insects entering into the ears will produce pain, feeling of heaviness and purring sound, the pain being severe when they flutter inside. In such cases, the ears should be filled with warm salt water, decoction of madhuka or wine till the insect comes out. If it dies inside, then ulcerations, putrifaction and exudations appear. In such conditions the treatment prescribed for karnasrava and pratinaha should be done.
If water has accumulated in the ears, it should be removed by filling the ear with a little quantity of water and oil, mixed well in the hand, or the patient should be asked to tilt the head and given a blow on the opposite side or the water sucked out with tube. (33)
Some more verses further :
जातुषं हेमरूप्यादिधातुजं च चिरस्थितम् । ऊष्मणा प्रायशः शल्यं देहजेन विलीयते ॥३४॥
Foreign bodies made lac or gold and other metals, which remain inside for long time will get dissolved by the heat of the body. ( 34 )
विषाणवेणुदार्वास्थिदन्तवालोपलानि तु । शल्यानि न विशीर्यन्ते शरीरें मृन्मयानि च ॥३५॥ विषाणवेण्वयस्तालदारुशल्यं चिरादपि । प्रायो निर्भुज्यते तद्धि पचत्याशु पलासृजी ॥३६॥
Those which are made of horns of animals, bamboo, wood, bones, teeth, hairs, stones or mud will not dissolve in the body. Those made of horns, bamboo, tala tree and wood, remaining inside will usually become bent and cause pus formation in the muscles and blood. (35-36)
शल्ये मांसावगाढे चेत् स देशो न विदह्यते । ततस्तं मर्दनस्वेदशुद्धिकर्शनबृंहणैः ॥३७॥ तीक्ष्णोपनाहपानान्नघनशस्त्रपदाङ्कनैः । पाचयित्वा हरेच्छल्यं पाटनैषणपीडनैः ॥ ३८ ॥
Foreign bodies lodged in fleshy parts will not produce pain, so the parts should be squeezed, fomented, the patient administered purificatory therapies, emaciating but nourishing foods, strong poultices should be applied over the part, pungent food and drinks should be allowed; the part beaten with thick weapons, trampled by the feet; the part made soft by these methods, should be cut open with sharp instruments, the foreign body searched and extracted. (37-38)
शल्यप्रदेशयन्त्रणामवेक्ष्य बहुरूपताम् । तैस्तैरुपायैर्मतिमान् शल्यं विद्यात्तथाहरेत् ॥ ३९ ॥
The intelligent physician should adopt many methods to remove the foreign bodies after carefully noting the nature of the site of the foreign body, and the different shapes of the instruments (available at hand). (39)
व्रणे प्रशान्ते प्रान्तेषु नातिस्पर्शासहिष्णुषु । अल्पे शोफे च तापे च निःशल्यमिति निर्दिशेत् ॥४०॥
Healing of the wound, absence of tenderness, diminishen in size and pain of the swelling-are the features of the part devoid of foreign body. (40)
काय एव परं शल्यं निजदोषमलाविलः । शल्ये शल्यं शराद्यं तु विशेषात्तेन चिन्त्यते ॥४१॥
Human body full of its own natural doshas and malas (waste products) is by itself a foreign body; in the science of Shalya (surgery) arrow and others are the foreign bodies specially. Hence this long discussion (description). (41)
॥ इति सप्तत्रिंशोऽध्यायः ॥
Thus ends the 37th chapter of Ashtanga Sangraha Sutrasthana.