Exploring Surgical Procedures – Ashtanga Sangraha Chapter 38 – Shastra karma vidhi – procedure of surgical operation; thus said atreya and other great sages. (1)
अथातः शस्त्रकर्मविधिं नामाध्यायं व्याख्यास्यामः । इति ह स्माहुरात्रे यादयो महर्षयः ॥१॥
द्विविधे हि व्याधावुपायापेक्षे निज आगन्तो वा भेषजविषयातीते शस्त्रकर्म प्रयुज्यते ॥२॥
In both types of diseases – Nija (endogenous-organic) and agantu (exogenous traumatic), which are beyond the scope of medicinal treatment, resort to surgical treatment is indicated. (2)
Amasopha chikitsa – treatment of unripe swelling
स चामय: प्रायेण श्वययुपूर्वकोभवत्यतः शोफावस्थस्यैव वातपित्तकफरक्तसंसर्गसन्निपातात्मक तामुपलक्ष्य पाक भयाद्यथास्वमुपवासलेपसेकासृङ्मोक्षकषायघृतपानशोधनानि प्रयुञ्जीत ॥३॥
A surgical disease usually commences with appearance of swelling; so during that stage of swelling itself, it should be treated with therapies such as fasting, topical application, fomentation, blood–letting, drinking of decoction of drugs, and medicated ghee and other purificatory therapies appropriate to the increase of the doshas individually or in combination of two or three together; otherwise, the risk of paka (pus formation ) is sure. (3)
तथाप्यनुशाम्यति प्रविलयनम् । अविलीयमाने चोपनाहनम् ॥४॥
If by these treatments the swelling does not subside, next will be vilayana (liquification, softening) followed by upanaha(fomentation, poultices etc ). (4)
तत्र शोफस्यामलक्षणमल्पता चाल्पोष्मरुजत्वं त्वक्सवर्णता स्थैर्यं च ॥५॥
Mild (slight) swelling, slight (mild) temperature and pain, appearance of normal colour of the skin and hardness are the features of an Ama (unripe) swelling (early or first stage). (5).
Pachyamana sopha – ripening swelling
पच्यमानस्तु विवर्णौ बस्तिरिवाततः संरम्भशूलरागदाहोषारुचितृष्णाज्वरारतिस्पर्शासहत्वानि द्रतासमन्वितो विषयन्दयति सर्पिः शोषयति प्रदेहं सर्षपकल्कोपलिप्त इव चिमिचिमायते पिपीलिकाभिरिव संसर्प्यते पीड्यत इव पाणिना घट्यत इवाङ्गल्या ताड्यत इव दण्डेन तुद्यत इव सूचीभिर्भिद्यत इव शक्तिभिश्छिद्यत इव शस्त्रेण दश्यत इव वृश्चिकैर्दह्यत इवाग्निक्षाराभ्यां मथ्यत इवोमुल्केन ॥६॥
During the process of pachyamana (inter-mediary stage), the swelling will become discoloured, and enlarges like a bladder, accompanied by symptoms such as guarding of the place, pain, redness, burning sensation, localised burning, loss of taste, thirst, fever, restlessness, tenderness and loss of sleep.
A lump of solid ghee kept on the swelling melts, the application of paste dries up, there will be mild irritation as though the part is smeared with a paste of mustard, as though ants are crawling over, as though squeezed by the hand, pinched with the fingers, hit by a rod, pricked by needles, divided by an exe, cut by a knife, stung by scorpion, burnt by fire or alkalies and churned with a churner. ( 6 )
Pakvasopha – ripened swelling
पक्के तु गतवेगत्वं प्रम्लानता त्वशिथिलता वलीप्रादुर्भावः पाण्डुता मध्योन्नतताङ्गल्यवपीडित मुक्ते प्रत्युन्नमनं बस्ताविवोदकस्य पूयस्य सञ्चरणं कण्डूः संरम्भशूलाद्युपशमश्च ॥७॥
When the swelling is pakva (ripe, or the third stage) there will be disappearance of all troublesome symptoms, the swelling appears dull, the skin becomes loose, develops wrinkles, becomes yellowish-white in colour, develops depression in the centre, pit made by pressing with fingertip fills quickly, movement of pus inside the swelling is felt similar to the movement of water in a leather bag, itching and decrease in the severity of guarding, pain etc. (7)
शूलं नर्ते ऽनिलाद्दाहः पिताच्छोफः कफोदयात् । रागो रक्ताश्च पाकः स्यादतो दोषैः सशोणितैः ॥ ८ ॥
There will be no pain without the involvement of vata, no burning sensation without pitta, no swelling without kapha, no redness and pus formation without rakta (blood); hence in swelling all three doshas and also blood is involved. (8)
पाकेऽतिवृत्ते सुषिरस्तनुत्वग्दोषभक्षितः । बलीभिराचितः श्यावः शीर्यमाणतनूरुहः ॥९॥
If the process of pus formation is allowed to continue, it will create cavities (sinuses) inside, thinning of the skin, full of wrinkles, blue in colour and falling of the hairs on the part- all due to eating away (destruction) by the doshas. (9)
कफजेषु तु शोफेषु केषुचित् गम्भीरत्वाद्रक्तमेव विपच्यते । ततश्चास्पष्टं पक्कलिङ्गं भवति । यत्र हि त्वक्सावर्ण्यं शीतशोफताल्परुजताश्मवच्च घनता न तत्र मोहमुपेयात् । तं रक्तपाकमित्याचक्षते ॥ १० ॥
In swelling in which kapha is predominant, the swelling being deep inside, will cause pus formation in the blood itself, hence there will not be clear manifestation of pus formation. But at the place of swelling, the colour of the skin is normal, the swelling is cold to touch, with very little pain but hard like stone. The physician should not get confused, coming across such a condition which is known as Raktapaka. (10)
Amapatana apaya dangers of premature surgical operation
अथैनं सम्यकपक्वमवधार्य भीरुवृद्धाबालदुर्बलक्लीबक्षीणगर्भिणीविषार्दितशस्त्रक्षामेषु पाकोद्धत दोषेषु च पिण्डितेषु सन्धिमर्माश्रितेष्वल्पेषु वा शोफेषु तीक्ष्णोष्णद्रव्यैर्दारणं कुर्वीत । इतरेषु तु पाटनम् ॥११॥
Coming across the above condition in persons who are frightful, the aged, the children, the debilitated, the impotent, the emaciated, the pregnant lady, those suffering from effects of poison and those who cannot withstand surgery, the physician should note the full formation of pus, and create darana (bursting by applying paste of drugs possessing penetrating and hot properties. In others (or in other situations) a deep cut should be done. (11)
आमपाटने सिरास्नायुव्यापादनं शोणितातिप्रबृत्तिर्वेदनातिवृद्धिरबद्रणं क्षतविसर्पो वा स्यात् । भवति चात्र ॥१२॥
Cutting open the swelling in its unripe stage will lead to injury of the veins, tendons etc., too much bleeding, a great increase of pain, gaping of the wound or even spreading of the ulcer to other parts. (12)
तिष्ठन् पक्के पुनः पूय: सिरास्त्राय्वसृगामिषम् । विवृद्धोदहति क्षिप्रं तृणोलपमिवानलः ॥१३॥
Pakva upeksana – Dangers of delaying the operation
The pus if allowed to remain inside even after it is fully formed, getting increased in quantity eats away the veins, tendons, blood, muscles, etc, just like the fire fed with dried grass etc. (devours the whole forest). (13)
यश्छिनत्त्याममज्ञानाद्यश्च पक्वमुपेक्षते । श्वपचाविव विज्ञेयौ तावनिश्चितकारिणौ ॥१४॥
He (the physician) who by his ignorance cuts the swelling in its unripe stage and he who neglects the ripened stage (without cutting) are very mean fellows because both are unpredictable in their actions. ( 14 )
Shastrakarma Vidhi – preparing and conductiong surgical operation
प्राक् शस्त्राद्भोजयेदिष्टं तीक्ष्णं मद्यं च पाययेत् । न मूर्छत्यन्नसंयोगान्मत्तः शस्त्रं न बुध्यते ॥ १५ ॥ अन्यत्र मूढगर्भोदराश्मरीमुखरोगेभ्यः ।
Before undertaking a surgical operation, the patient should be given the food he desires and also strong alcoholic drinks; because the patient does not collapse due to strength of the food and does not feel (the pain of) the knife when he becomes unconscious (due to the effect of alcohol). But food and alcohol should not be given to persons suffering from obstructed labour, enlargement of abdomen, urniary calculi and diseases of the mouth. (15)
अथोहृतयन्त्रशस्त्रक्षाराग्निजाम्बवौष्ठपिचुप्लोतपत्रसूत्र चर्मपट्टमधुस्नेहकषायालेपकल्कसेकोदकुम्भशीतोष्णोदककटाहव्यजनादिव्रणोपयोगिसर्वोपकरणमाश्रितशयनीयमुपस्थितस्थिरस्नेहबलवदवलम्बकपुरुषमिष्टे ऽपनिमुहूर्ते च दध्यक्षतान्नपानरु क्मरत्नार्चितविप्रं प्रणतेष्टदेवतं कृतमङ्गलं भुक्तवन्तमातुरं प्राङ्मुखमुपवेश्य संवेश्य वा यन्त्रयित्वा प्रत्यङ्मुखो वैद्यो मर्मसिरास्नायुसन्ध्यस्थिधमनीः परिहरन्ननुलोमं शस्त्रं निदध्यादापूयदर्शनात् । सकृदेवाहरेच्छस्त्रमाशु च ॥१६ ॥
Earlier to the commencement of the operation all kinds of equipments such as blunt instruments, sharp instruments, alkalies, fire, wooden laddles, pads of coton, pieces of cloth, leaves, thread, sheets of leather, honey, oil or ghee, decoction, pastes and moist bolus of drugs, materials for fomentation, pots filled with water, big vessels containing cold and hot water, fan and all other things required for the treatment of a wound should be kept ready nearby. So also some attendants who are subordinate, of unwavering affection and loyal to the patient and who are physically strong should also be present nearby.
On the scheduled day and at the auspicous time, the patient should be instructed to worship the brahmanas giving them gifts of curds, grains, foods and drink, gold and gems; bow to his personal god, perform auspicious ceremonies, and then take food. After these, he should be auspicious ceremonies, and then take food. After these, he should be made to sit or lie down, facing east and restrained by the attendants (held tight without allowing movement of either any part or whole of the body); the physician sitting facing west, should put the incision with the sharp instrument, in a downward direction, deep inside till the pus is seen, carefully avoiding injury to vital parts, veins, tendons, joints and arteries. The sharp instrument should be removed quickly. (16)
महत्वस्वपि च पाकेषु द्व्यङ्गलं शस्त्रपदमुक्तम् । द्व्यङ्गुलान्तरं त्र्यङ्गुलान्तरं वाभिसमीक्ष्य विवृत्ते प्रदेशे वामप्रदेशिन्यैषित्वा नातिविवृत्ते गम्भीरमांसले चैषण्या | विपरीते करीरादिनालेना तिसंवृते सूकरवालेन वा ॥१७॥
Even for large swellings and those which are fully ripe, an incision of two angulas is indicated. If more than one incision is necessary it should be done at a distance of two or three angulas. The physician should then insert his left index finger and widen the orifice; at places which have deep seated muscles, a metal probe may be used for widening; at places which are narrow the hollow twigs of karlra plant or hairs of the boar may be used (for widening). (17)
यतो गतां गतिं विद्यादुत्सङ्गो यत्र यत्र च । तत्र तत्र व्रणं कुर्यात् सुविभक्तं निराशयम् ।
आयतं च विशालं च यथा दोषो न तिष्ठति ॥१८॥
The movement of collected pus should be expected, wherever there is swelling. So incisions should be made in all such places, the orifices made wide and deep and pus drained out without allowing any residue. (18)
शौर्यमाशुक्रिया तीक्ष्णं शस्त्रमस्वेदवेपथू । असम्मोहश्च वैद्यस्य शस्त्रकर्मणि शस्यते ॥१९॥
Courage, quickness, keeping the instruments sharp, absence of sweating, shaking and calmness are the qualities of an efficient surgeon. (19)
तत्र भ्रूगण्डललाटाक्षिकूटौष्ठदन्तवेष्टमन्याकण्ठजत्रुकक्ष्याकुङ्क्षिवङ्क्षणेषु तिर्यक्छेद इष्टः । अन्यत्र तु सिरास्त्रायूपघातोऽतिवेदना चिराद् व्रणसंरोहो मांसस्कन्दी च तिर्यकछेदात् भवन्ति ॥ २० ॥
In places like the eyebrows, cheeks, forehead, eyesocket, lips, gums, neck, throat, shoulders, axilla, lower abdomen and groins, a horizontal incision is desirable. In other places horizontal incision will causes injury to the veins and tendons, severe pain, delay in healing of the wound and formation of a muscular tumor ( 20 )
Paschyat karma – post-operative procedure
ततः शस्त्रमवचार्य शीताभिरद्धिरातुरमाश्वास्यमन्तात् प्रतिपीड्यङ्गुल्या व्रणमपि प्रक्षाल्य कषायेण व्रणात्प्लोतेनाम्भोऽपनीय वेदनारक्षोघ्नैर्गुग्गुल्बगरुसेर्जरसवचागौरसर्षपहिङ्गुलवणनिम्बपत्रैः सघृतैर्व्रणं धूपयित्वा यथास्वमौषधेन मधुघृततिलकल्कैश्चदिग्धं वर्तिं प्रणिधाय कल्केन पूरयित्वा नातिभृष्टयवसक्तुभिर्घृताक्तैर्भाजनान्तेऽम्भसा दक्षिणाङ्गुलीभिः सुगृदितैरवच्छाद्य घनां कवलिकां दत्वा सव्यदक्षिणान्यतरपार्श्वे ऋजुमनाविद्धमसङ्कुचितं मृदुपट्टं निवेश्य बीयात् ॥ २१ ॥
After the surgical operation, the patient is comforted with cold water (sprinkling over the face, drinking etc ), massaged mildly with the fingers. The wound should be washed with decoction of drugs and the moisture wiped well with cloth. It is then fumigated with the smoke of pain-relieving and evil-destroying drugs such as guggulu, aguru, sarjarasa, vaca, gaura sarsapa, hingu, lavana (saindhava salt), nimbapatra mixed with ghee. Then, other suitable drugs are rubbed together along with honey, ghee and sesamum and spread over a piece of cloth, which is then packed into the sound. Flour of slightly fried barley mixed with a little ghee is put into a vessel, water added and made into a thick mass kneading with the fingers of the right hand. The wick-like cloth containing the paste of drugs is placed first inside the wound, and then the wound is covered on all sides with a thick pad of plaster of barely flour. Over this a comfortable position. The knot should be tied at a side either right or left. (21)
वातश्लेष्मोद्भवांस्तत्र द्विस्त्रिर्वावेष्टयेद् व्रणान्। सकृदेव परिक्षिप्य पित्तरक्ताभिघातजान् ॥२२॥
Bandaging the wounds which are of vata and kapha origin should be done two or three times whereas for those of pitta, rakta and of traumatic origin it should be once only and that too immediately. (22)
शस्त्रक्षरुजायां तु प्रततायां यष्टीमधुकसर्पिषोष्णेन व्रणं सिञ्चेत् । उदकुम्भाच्चापो गृहीत्वा प्रोक्षयन् पतिरो विकीर्य पर्णशवर्यादिभिरस्य रक्षां कुर्याढक्षोऽभिभवनिषेधार्थम् । तेभ्यश्च बलिमुपहरेत् । धारयेच्च शिरसा ॥२३॥
लक्ष्मीं गुहामतिगुहां जटिलां ब्रह्मचारिणीम् । वचां छत्रामतिच्छत्रां दूर्वां सिद्धार्थकानपि ॥२४॥
If the person is suffering much from the pain of the operation, the wound should be sprinkled with warm ghee processed with yastmadhuka. Sacred water from the pot should be sprinkled all around with the sacred hymns of Pranasabari- to protect the patient from the attack of the just-born evil spirits (bacteria); oblations (or offerings) should be given to them. The patient should then wear the following herbs on his head – laksmi, guha, atiguha, jatila, brahmacarini, vaca, chitra, atichitra, durva and siddharthaka. (23-24)
गग्गुल्वादिभिरेवं शयनासनादि द्विरह्नो धूपयेत् । तथा स्त्रहोक्तं दिचर्योक्तं चाचारमनुवर्तेत ॥ २५ ॥
The room and the furniture used by the patient should be fumigated at both times (day and night). The patient should be instructed to follow the regimen of lubrication therapy as well as those of dinacharya (the daily regimen of a healthy person). (25)
विशेषताश्च दिवास्वप्नाद् व्रणे शोफकण्डूरागरुक्पूयवृद्धिः ॥२६॥
Especially, there will be profound increase of swelling, itching, redness, pain and quantity of pus by sleeping during day ( so it should be avoided). (26)
स्त्रीणां तु स्मृतिसंस्पर्शनश्चलिते स्रुते । शुक्रे व्यवायजान् दोषानसंसर्गेऽप्यवाप्नुयात् ॥ २७ ॥
Remembrance, touch and sight of women by themselves are enough to dislodge the semen and expel it out and he (the patient who has undergone operation) will derive all the bad effects of sexual intercourse even without actually indulging in it. (27)
भोजयेच्चैनं यथासात्म्म्यं समातीतशालिषष्टिकयवगोधूमान्यतम मुद्गमसूराढकीसतीनयूपजाङ्गल रसोपेतं जीवन्तीसुनिषण्णकतण्डुलीयकवास्तुकवार्ताकपटोलकारवेल्लकबालमूलकशाकयुक्तं दाडिममामलकसैन्धवसहितं सर्पिःस्निग्धं लघ्वल्पमेणोदकोत्तरं च । एवमस्य सम्यगशितं जरामुपति। अजीर्णादनिलादीनां विभ्रमो बलवान् भवेत् । ततः शोफरुजापाक दाहानाहानवा प्रुयात् ॥ २८ ॥
The patient should next be given foods accustomed and suitable to him such as rice, rice which matures in sixty days, barley, sheat or any other which is more than one year old, soup prepared from mudga, masura, adhaki and satina, soup of meat of animals leaving in desert like regions, condiments prepared from leaves of jivanti, sunisannaka, tandliyaka, vastuka, vartaka, patola, karavella and tender mulaka mixed with dadima, amalaka, saindhava added with ghee, thus made easily digestible. The food should be little in quantity and followed with drink of warm water. By this, the food will get digested properly.
By indigestion, vata and other doshas get increased, become powerful and make for the increase of swelling, pain, pus formation, burning sensation and widening of the wound. (28)
नवधान्यमाषकलायकुलत्थनिष्पावशिम्बीशीताम्बुमद्येक्षुक्षीरपिष्टतिलंविकृतिशुष्कशाकपिशित हतिपाकाम्ललवणकटुकक्षारानूपामिषाणि वर्जयेत् ॥ २९ ॥
Freshly harvested grains, legumes such as masa, (blackgram) kalaya (roundpea),kulattha(horse gran) and nispava(cow-bean); cold water, alcoholic beverages, {{sugar-cane juice, eatables prepared from sesame pastry/ milk, dried vegetables, ● meat and leafy vegetables; sour, salt, pungent and alkaline substances and of animals living in marshy regions should all be avoided.
वर्गोऽयं नवधान्यादिव्रणिनः सर्वदोषकृत् सर्वदोषकत्। मद्यं तीक्षणीष्णरूक्षाम्लमाशुव्यापदयेद् व्रणम् ॥ ३०॥
This group of fresh grains etc., will cause increase of all the doshas in a wounded person; alcoholic drinks which are strong, hot in potency, viscid and sour will kill the patient of wound very quickly. (30)
वालोशरिश्च वीज्येत नचैनं परिघट्टयेत्। न तदुन्नेच कण्डूयेच्चेष्टमानश्च पालयेत्
The patient (and the wound also) should be fanned with a fan prepared from tender (green) usira grass, the wound should not be touched, pricked or scratched and is be protected from movement.
स्निग्धवृद्धद्विजातीनां कथाः शृण्वन्मनःप्रियाः । आशवान् व्याधिमोक्षाय क्षिप्रं व्रणमपोहति ॥ ३२ ॥
The patient who spends his time hearing the pleasantstories of the liked, the { elderly persons, of the twice born category (branihans, ksatriyas and vaisyas) and who has high hopes of recovery from the disease will surely get rid of the wound quickly (32)
Vranopachara – treatment of wounds
॥ॐ पुनश्च तृतीयेऽहनि प्रक्षालनादि पूर्ववत् व्रणकर्म कुर्यात् । द्वितीये दिवसे मोक्षणाद्विग्रथितो व्रणश्चरादुपरोह॒त्युग्ररुजश्च भवति ॥३३॥
on the third day, the wound is to be treated with washing and other procedures Opening the wound on the second day will cause hardness pain, and long time to heal. (33)
न च विकेशिकामौषधं वातिस्निग्धस्तीमतिश्लथमतिगाढमश्लक्ष्णं) दुधस्तं वा दद्यात्ता अतिबेहात क्लेदः) अतिरौक्ष्यात छेदो वेदना च। अतिएलथत्वादपस्शुिक्तिना संभ रत्वाद्दुर्व्यासाच्च व्रणवर्सोपघर्षणम् ॥३४॥
The cloth smeared with paste of drugs of the medicines to be applied to it should be either very greasy nor dry, very thin or very thick, very rough or ill-placed; very fatty ones will cause moistness (exudation), very dry ones cause splitting or more pain in the wound, too thin paste will not help proper cleansing, very thick paste causes severe tremors; rough ones and ill places ones will cause friction of the edges of the wound. (34)
अवश्यं साशये व्रणे विकेशिकां दद्यात् । संपूतिमांसं सोन्सङ्गं सगतिं पूयगर्भिणम् व्रणं शोधयते शीघ्रं स्थिता ह्यन्तर्विकेशिका ॥३५॥
The cloth smeared with drugs shoud invariably be inserted into wounds which have cavities inside, for that will clear the bad smell, swelling, movement of pus inside, and cleanses the wound quickly. ( 35 )
व्यम्लं तु पाटितं शोफं पाचनैः समुपाचरेत् । भोजनैरुपनाहेश्च नातिव्रणविरोधिभिः ॥३६॥
If an unripe swelling has been cut (inadvertantly) it should be maded to ripen by administration of drugs, fodds and external applications which cause such ripening but which are not antagonistic to the wound. ( 36 )
Vranasivana – suturing of wound
यस्तु सोव्यो व्रणस्तत्र चलास्थिल्यपांसुतृणरोमशुष्करक्तादीनपाह्य विच्छिन्न प्रविलम्बितं मांसं सन्ध्यस्थीनि च यथास्थानं सम्यक् स्थापयित्वा स्थिते रक्ते यथार्हं सूच्योपहृतेन स्नायुसूत्रवाला न्यतमेन सीव्येत् । शरणाश्मन्तकमूर्वातसीनां वा वल्कैः ॥३७॥
If the wound is found suitable for suturing, it should be well cleaned to remove pieces of bones, foreign bodies, mud, grass, hairs, clotted blood etc., the severed, hanging and loose muscles, joints, bones etc., should be placed at their proper places, the blood stopped, then the edges of the wound are to be sutured together with the help of needles, using the tendon, thread, hair etc., as the suturing material; the threads of sana (jute) as mangaka, murva or atasi can also be used. ( 37 )
सीवनविकल्पास्तु समासेन चत्वारः । तद्यथा गोष्फणिकातुन्नसीवनवेल्लितकरजुग्रन्थिबन्धनमिति । तेषां नामभिरेवाकृतिविभागः । प्रहारवशाच्चोपयोगः । न चातिसन्निकृष्टां विप्रकृष्टामत्यल्पबहुग्रहिणीं वा सूचीं पातयेत् । एवं सम्यक्स्यूतमवेक्ष्य मधुघृतयुक्तैरञ्जन मधुकनिम्बलोध्रप्रियङ्गुसल्लकीफलक्षौममषी चूर्णैरवकीर्य पूर्वक्द् बन्धादियोजयेत् ॥३८॥
In brief, the kinds of sutures are four viz Gosphanika, Tunnasivana, Vellitaka and Rajjugranthi; their nature is implied in their names and are to be employed as found appropriate to the nature of the wound (or weapon causing the sound); the needle placings (places of puncture) should not be very close, very far, holding the tissues very loose or holding them very tight.
Having sutured the wound properly, it is to be given a coating of paste of anjana, madhuka, nimba, lodhra, priyangu, sallakiphala, ash of hemp – all nicely powdered and mixed with honey and ghee; then the wound should be bandaged in the usual manner. (38)
Notes: Indu the commentator expalains the four types of sutures as follows, Gosphana-stitches to be made at all four corners of the wound; (sling-like suture), Tunnasivana – two edges which are very close are drawn together and sewn just like stitching the cloth. (continuous suture) Vellitala – holding the edges of the wound together inverted and stitching in a circular manner; (winding suture) Rajju granthi – is like a knot of a rope, puncturing only once. ( Kantted suture )
असीव्या वड्ङ्क्षणवक्षः कक्षादिषु प्रचलेष्वल्पमांसेषु च वायुनिर्वामिणोऽन्तर्लोहितशल्या विषाग्रि क्षारकृताश्च व्रणाः ॥३९॥
Wounds situated in the groins, chest, axilla and places which are moving (having movement), which are less muscular, which emit air ( gas) often, which have accumulation of blood or a foreign body inside, which are caused by poisons, fire and caustic alkalies should not be sutured. (39)
सीव्यास्तु मेदस्समुन्थिता भिन्नलिखिताः कफग्रन्थिरल्पपालिकः कर्णः सद्याव्रणाश्च | शिरोललाटाक्षिकूटकर्णनासागण्डौष्ठकृकाटिकाबाहूदरस्फिक्पायुषप्रजननमुष्कादिष्वचलेषु मांसवत्सु च प्रदेशेषु ॥४०॥
The wounds which are caused by disorders of fat tissue, which are gaping, the tumors produced by kapha, the ear with thin or small pinna and wounds due to assault by weapons, those situated in the head, forehead, socket of the eyes, those on the ears, checks, lips, centre of the neck, arm, abdomen, buttocks, rectum, genital organs, scrotum and such other places which have no movement and which are muscular should be sutured. (40)
Bandha- bandages
कोशदामोत्सङ्गस्वस्तिकानुवेल्लितमुत्तोलीमण्डलस्थविकायमकखट्वाचीनविबन्धवितानगोष्फ णाः पञ्चाङ्गी चेति पञ्चदश बन्धविशेषाः । तेषां नामभिरेवाकृतयः प्रायेण व्याख्याताः ॥४१॥
Kosa, Dama, Utsanga, Swastika, Anuvellita, Muttoli, Mandala, Sthavika, Yamaka, Khatva, Cina, Vibandha, Vitana, Gosphana and Pancangi are the fifteen, kinds of bandages, their features (shapes) are mostly implied in their names (41)
खट्वा तत्र कोशमङ्गुलीपर्वसु विदध्यात्। दाम सम्बाधेऽङ्गे| उत्सङ्गं विलम्बिनि स्वस्तिकं सन्धिकूर्चभ्रूस्तनान्तरकु क्ष्यक्षिकपोलकर्णेषु। अनुवेल्लितं शाखासु । मुत्तोलीं ग्रीवामेट्र्यो । मण्डलं वृत्तेऽङ्गे। स्थविकामङ्गुष्ठाङ्गुलिमेढाग्रमूत्रवृद्धिषु। यमकं यमलव्रणयोः। हनुशङ्खगण्डेषु। चीनमपाङ्गयो । विबन्धमुदरोरुपृष्ठेषु वितानं मूर्धादौ पृथुलेऽङ्गे । गोष्फ नासौष्ठचिबुकसन्धिषु। पञ्चाङ्गी अर्ध्वमिति । यो यस्मिन् प्रदेशे सुनिविष्टो भवति तं तस्मिन् ॥ कुर्वीत। न तु व्रणस्योपरि न चाबाधकरो यथा स्यात् ॥ ४२ ॥
Kosa type of bandage should be used for the joints of of the fingers. Dama for the parts which are painful, Utsanga for parts which are drooping down; Swastika at the joints, aponeroses, eyebrows, in between the nipples, lower abdomen, eyes, checks and ears; Anuvellita for the extremeties; Muttoli for the neck and the penis, Mandala for the round shapped parts; Sthavika for the thumb, fingers’, ‘glans-penist and in hydrocele; Yamaka in cases of twin wounds, Khatva for the lower jawil temples and checks, Cina for the outer angle of the pye: Vibandha for the abdomen, thighs and back. Vitana in large parts such as the head cc; Gosphana for the nose, a lips, beard and joints and Pancangi for the parts above the shoulders. That kind, wihci remains tight in any part and so found convenient should be selected and applied. It should not be tied directly over the wound.
बन्धस्त्विष्टोऽनिले दुष्टे दष्टे भग्ने व्रणेषु
घोष च। तंत्रान्त्ययोर्द्विधा बन्धः सव्यदक्षिणभेदतः ॥४३॥
Tieing a bandage is also indicated in diseases produced by increase of vata;
in bites by snake etc, in fracture and wounds. For the last one (wound) it is of two types one from the right side and the other from the left. (43)
Notes: In diseases of vata origin producing severe pain such as headache muscular) twitchings, intermittent claudication, sprains etc. tieing a tight bandage over the affected pat will greatly minimise the pain, in cases of snake bite tight bandage above the site of bite prevents the spreading of poison to other parts in case of fracture of bones bandaging gives rest to the part by preventing movements of the par and so helps to heal. and. insa wounds it prevents infection and helps healing)
त्रिविधस्त्वेव सर्वत्र गाढः श्लथसमत्वतः । कफवाते घनो गाढ: पित्तरक्ते तनुश्लयः ॥४४
वातपित्ते समो बन्धः कफपित्तं व्रणेषु च ।
The nature of bandaging is three kinds: tight, loose and moderate; in causes of combination of kapha and vata, the Bandaging should be thick and tight, in the combination of pitta and rakta it should be thin and loose, in a combination of vata and pitta and wounds due to a combination of kapha and pitta- it should be moderately)
शाखाबदनकण्ठकर्णमेहपृष्ठ तथा स्फिककक्ष्यावडक्षणोकहासु गादं बधीयात पार्श्वोदरोरस्सु समम् ।
अक्ष्णोः सन्धिषु च शिथिलम् ॥ ४५ ॥
At the buttocks, flanks, groins, thighs and head it should be tight; in the extremetics, throat, ears, Penis, scrotum back, flanks, abdomen and chest, it should be moderate (medium), on the eyes and joints it should be loose.
वातश्लेष्मजेषु शिथिलस्थाने समम् । समस्थाने गादम् । गाढस्थाने पाढतरम् । तथाlsari शीतवसन्तयोस्त्रयहात् । पित्तरक्तेषु तु गाढस्थाने समम् । समस्थाने शिथिलम् । शिथिलस्थाने नैव । तथा शरद्ग्रीष्मयोः सायं प्रातश्च । अबध्यमानः विधाप्रवाहुती दुष्टवणतामुपैति । स्नेहश्चात्र न चिरं तिष्ठति । भेषजमचिरा तृणकाष्ठपासायी पादिसम्पर्काद्विविधाप्रवोद्रुतो च्छुष्यति । कृच्छ्रेण सेहति। रूढे च वैवर्ण्य भवतिः अपि च ॥४६॥
In wounds caused by vata and kapha if located on soft (flabby) parts, bandaging shall be even (moderately tight) if on other even parts it will be tight if on hard parts, it shall be very tight, during cold and spring seasons, it (bandaging) shall be once in three days.
In wounds caused by pitta and rakta if located on hard parts bandaging shall be moderately tight, if located on even parts bandaging shall be loose, if situated, on soft (flabby) parts, if bandaging is needed, during sarat (autumn) and grisma (summer) it should done both in the morning and evening.
Wounds, if not bandaged develop the features of bad ulcer by the bites of musquitoes etc., contact with grass, sticks, sand (mud), cold breeze, sunlight etc., and gives rise to many combinations (secondary diseases); medicated fats applied to them do not remain there for long, drugs (in the form of pastes) dry up soon, the wound heals with difficulty and even after healing discolouration persists. (46) And further :
चूर्णितं मथितं भग्नं विश्लिष्टमथ पाटितम् । अस्थिस्नायुसिराच्छन्नमाशु बन्धेन रोहति ॥४७॥
Curnita (crushed) and matita (twisted) types of bhagna (fractures), vislista (dislocation of joints) and surgical cutting of bones, tendons, veins cut or torn will heal quickly by bandaging. (47)
उत्थानशयनाद्यासु सर्वेहासु न पीड्यते। उद्वृत्तौष्ठः समुत्सन्नो विषमः कठिनोऽतिरुक ॥४८॥ समो मृदुररुक् शीघ्रं व्रणः शुध्यति रोहति ।
A which does not cause pain while getting up, lieing down and other postures, and having raised edges is known as Utsanna (going to heal); a wound which is uneven (irregular), hard, and very painful is known as Visama (bad, not healing) and a wound which is soft and painless is known as Sama (healing) vrana which is clean and also heals quickly. (48)
स्थिराणामल्पमांसानां रौक्ष्यादनुपरोहताम् । प्रच्छाद्यमौषधं पत्रैर्यथादोषं यथर्तु च ।।४९ ।। अजीर्णातरुणच्छिद्रैः समन्तात् सुनिवेशितैः । धौरैरकर्कशैः क्षीरीर्जार्जुनकद्मबजैः ॥५०॥ 614
Wounds which are hard (or static), which have very little of muscles in them which are not healing due to dryness (absence of moisture) should be scraped with rough leaves and then filled in with drugs appropriate to the doshas and the season. Such leaves should neither be old nor too young, not have any holes, not rough, belonging to trees like bhurja, arjuna, kadamba and such other which have a milky sap; the leaves should be washed well and used. (49-50)
कुष्ठिनामग्निदग्धानां पिटकामधुमेहनाम् । कर्णिकाश्चोन्दुरुविषे क्षारदग्धा विषान्विताः ॥५१॥ मांसपाके न बद्धव्या गुदपाके च दारुणे । शीर्यमाणाः सरुग्दाहाः शोफावस्थाविसर्पिणः ॥५२॥
Bandaging should not be done to wounds of leprosy, burns, diabetic eruptions; those caused by the poison of karnika of rat bite; alkalies, those which have poison inside, which cause pus formation in the muscles; severe ulceration of the rectum, those which cause mutilation of the body, those having pain, burning sensation, swelling ans those which spread to other places. (51-52)
Vrana raksana protection of wounds
अरक्षया व्रणे यस्मिन् मक्षिका निक्षिपेत् क्रिमीन् । ते भक्षयन्तः कुर्वन्ति रुजाशोफास्त्रसंस्त्रवान् ॥५३॥ सुरसार्दि प्रयुञ्जीत तत्र धावनपूरणे | सप्तपर्णकरञ्जार्कनिम्बराजादनत्वचः ॥५४॥ गोमूत्रकल्कितो लेपः सेकः क्षाराम्बुना हितः । प्रच्छाद्य मांसपेश्या वा व्रणं तानाशु निर्हरेत् ॥५५॥
Flies deposit worms ( bacteria) in the wounds which have not been protected. They (bacteria) begin to eat the tissues and produce pain, swelling and haemorrhage. For such a condition, the decoction of drugs of surasadigana (vide chapter 16 ) should be used for washing and filling the wound. A paste prepared with the bark of saptaparna, karanja, arka, nimba, rajadana, along with cow’s urine should be applied to the wound. It is ideal to sprinkle with a solution of alkalies. If they are (bacteria) still present, they should be removed quickly by scrapping the muscles (53-55)
उत्पद्यमानासु च तासु तास्ववस्थासु दोषादीनपेक्ष्य यथास्वमुपक्रमैरुपक्रमेत् ॥५६॥
The wonuds are to be treated with suitable drugs and therapies which are inappropriate to the doshas, in the different stages of the wound: (56)
चैनं त्वरमाणः सान्तदोषमुपसरोहयेत् । स ह्यल्पेनाप्यपचारेणान्तरुत्सङ्गं कृत्वा भूय विकुरुते तस्मात्पुशुद्ध रुपयेत
They should not be made to heal hurriedly alowing the doshas to remain inside. such residual doshas get excited (increased) leven with little unhealthy activities, and causeswelling and a severe wound Hence healing of wounds done should be only after purifying the wound (removing the dosha completely). (57)
“रूढऽप्यजीज व्यायामव्यवायादीन्विवर्जयेत् । मासान् षट् सप्त वा नृणां विधिरेष प्रशस्यते ॥५८ ॥
After healing of the wound, the person avoid indigestion, excerises, etc., for a period of six or seven months, this will be the ideal procedure to be followed. (58)
इतीदं व्रणमाश्रित्य दिङ्मात्रमुपदर्शितम् । उत्तरे विस्तरस्तस्य वृक्ष्यते साधनं प्रति ॥५९॥ ॥७१२
Whatever has been said so far about wounds, is only a pointer it will be described in detail along with thier management in Uttarasthana (the last section of the text)
इति अष्टत्रिंशोऽध्याय:
This is Ashtanga Sangraha Chapter 38.
