Procedure of surgical operation: Ashtanga Hrudaya Sutrasthana 29

This chapter explains about different surgical methods and operations of ancient times. This is the 29^th chapter of Ashtanga Hrudaya Sutrasthana, written by Acharya Vagbhata, son of Vaidyapathi Simhagupta. The chapter name is Shastrakarma Vidhi.

Shloka recitation video

Due to Paka (suppuration) of inflammation, Vranashotha (inflammatory ulcer) develops. Hence, swelling should be treated first, preventing the formation of pus, by all efforts, such as
Susheeta lepa – application of cold poultices,
Seka – bathing the part with cold decoction of drugs,
Asramoksha – blood letting,
Samshodhana – Purifying Panchakarma therapies. 1

Three stages of swelling

Trividha Sopha – three stages of swelling :-
Shopha – Swelling – is of three types –
Ama shopha – unripe, raw, initial stage, without pus formation
Pachyamana shopha – with symptoms of inflammation, initial stage of pus formation
Pakva shopha – with full pus formation.

Ama Shopha

Ama shopha – (unripe swelling) mild with slight heat and pain, The swelling will have the same colour as the skin. The swelling is immovable. 2

Pachyamana Shopha

Vivarna – The swelling gains a different color than that of the skin,
Ragi – it is usually red coloured,
Bastiriva – It enlarges like an animal bladder,
Nistoda – continuous bursting type of pain,
Angamarda – aches all over the body,
Vijrumbhika – excess of yawning,
Samrambha – different kinds of distressing symptoms,
Aruchi – anorexia,
Daha – burning sensation all over the body,
Usha – increased temperature,
Trut – excessive thirst,
Jvara – fever,
Anidra – loss of sleep,
Quick melting of solid ghee placed on the swelling and
Intolerance to touch – tenderness just as in an ulcer 3 – 4.

Pakva Shopha

Pakva Shotha – ripe swelling is
Alpavegata – mild in nature,
Mlani – reduced in size,
Panduta – white colour,
Valisambhava – has wrinkles on it,
Depressed all round but elevated at its center,
Kandu – itching,
Shopha – mild swelling,
Mardava –softness,
Movement of pus can be understood by touch just as movement of water in a bladder. 5.

Dosha-wise symptoms in Shopha

Shula – pain due to Vata
Daha – burning sensation due to Pitta imbalance
Shopha – inflammation due to Kapha imbalance
Raga – redness and Paka – suppuration due to Rakta vitiation. 6.

When pus formation further increases with lapse of time there is cavity formation inside the swelling, the skin becomes thin and destroyed by the Doshas, it is covered with wrinkles, black in colour and body hairs fall off. 7.

If the swelling is produced by predominance of Kapha, ripening takes place slowly, hence signs of ripening do not manifest clearly, the swelling which is cold to touch, of the same colour as of the skin with mild pain, hard to touch, like a stone. It is also known as Raktapaka. 8 – 9.

Procedure of surgical operation

Shastra Karma Vidhi – Procedure of surgical operation:-

In persons with weak mind, who are debilitated, in children, or when the swelling is elevated by accumulation of pus, when it is located on vulnerable spots, joints etc., the treatment is
Darana – making the abscess burst by application of Alkalies (Kshara) whereas in other cases except the above, the treatment is –
Patana – cutting open by sharp instruments. 10.

Cutting an unripe swelling leads to diseases of the veins and tendons, profuse bleeding, immense pain, tearing of the skin or Visarpa (spreading ulcers).
The pus remaining inside and increasing in quantity, quickly burns away the veins, tendons blood and muscles, just as a spark of fire burns away a hay stack. 11 – 12.

The surgeon who by ignorance cuts open an unripe swelling and he who neglects a ripe swelling – without cutting open – both should be considered as mean surgeons performing indiscriminate acts. 13.

Pre-operative procedures

Purvakarma – Pre-operative procedures:-

Before undertaking surgical opening of an abscess the patient should be given the food he likes;
The person accustomed to alcoholic drinks may be given a drink of strong wine which makes him withstand the pain. 14 – 15.

For those patients suffering from obstructed delivery, renal calculus, diseases of the mouth and the abdomen – such patients should be given neither food nor wine before the operation. 15½.

Operative procedure

Pradhana Karma – Operative procedure :-

Next, keeping all the equipments required, the physician should make the patient sit facing east.
Sitting in front of him and facing him, the physician should incise the swelling with his well sharpened instrument,
Incision being made in the direction of the hair – downward, avoiding vulnerable parts, deep enough till the pus is seen, and then removing the instrument quickly. 16 – 17

If the area of pus formation is great, the incisions may be either one, two or three Angula (fingers breadth) apart;
The interior is then thoroughly excavated with either a probe, finger, tube or hairs of animals, as appropriate to the site and area of the swelling,
The pus path is determined, cutting through the bulge of the wounds, creating a well cleaned, wide and deep wound so that no vitiating material can remain inside. 18 – 20.
Shaurya – Courage,
Ashukriya – quickness of action,
Teekshna shastra – keeping his instruments very sharp,
Asveda – not sweating,
Avepathu – not trembling,
Asammoha – not getting confused
These are the qualities best desired of the surgeon. 21

Tiryak Cheda – The incision should be made horizontally curved in places such as the forehead, brows, gums of teeth, shoulders, abdomen, axillae, eye sockets, lips, cheeks, throat and groins; horizontal incision, in other places might lead to cutting of the veins, tendons etc. 22 – 23.

Post-operative procedures

Sastrakarmottara Vidhi – Paschat Karma – Post-operative procedures

After removing the sharp instruments, the patient should be comforted with encouraging words and cold water;
The area all around should be squeezed,
The wound is washed with decoction of drugs
Moisture is removed by wiping with cotton wool.
The wound should be fumigated with the smoke of Guggulu, Aguru, Siddhartha, Hingu (Asa foetida), Sarjarasa, Patu (Salt), Sadgrantha (Acorus calamus) or leaves of Nimba (neem), mixed with ghee;
Then a wick prepared from paste of Tila, ghee, honey and appropriate drugs should be placed inside the wound and also covered over.
A thick plaster prepared from corn flour and ghee is put on and bandaged with a thick sheet of cloth, winding it either from right to left or left to right but not from either top or bottom. 24 – 28.

The bandage cloth should be clean, thin and strong; the medicinal wick should consist of cotton threads which are fumigated, soft, smooth and devoid of folds, these are beneficial to the ulcers. 29.

Ulcer should be protected from the invasion of bad evils (microbes), insects, flies which feed on blood. They should be offered oblations. 30

The patient should always wear on his head, potent herbs such as Lakshmi, Guha, Atiguha, Jatila, Brahmacharini, Vacha, Chatra, Atichatra, Durva or Siddharthaka.
He should be made to follow the regimen prescribed for the day of oil drinking as part of Snehana therapy;
Sleeping during day leads to production of itching, redness, pain, swelling and pus in the ulcer. 31 – 32.

Remembrance, touch and sight of women, which produce ejaculation of semen leads to other bad effects of intercourse, though not indulged into actually. 33.

Swelling gets increased in an ulcer by strenuous activities,
Redness increases by keeping awake at night,
Pain increases by sleeping during day,
Death occurs by indulging in copulation.

Diet after surgery

Diet after surgery – The food of the patient should be that which is accustomed such as barley, wheat, rice ripened in sixty days (shashtika shali), Masura – lentil, Mudga (green-gram), Tuvari – (tur dal), Jivanti, Sunisannaka, tender Mulaka (Radish), Vartaka, Tanduliyaka, Vastuka, Karavella (bitter gourd), Karkota, Patola (Pointed gourd) , Katukaphala – fruit of Katurohini, Saindhava (Black salt), Dadima (pomegranate), Dhatri (Amla), Ghrita (ghee), water boiled and cooled.
A mass prepared from old rice added with fats consumed in little quantity along with meat of animals of desert like regions, followed by drinking of warm water helps for the quick healing of ulcers. 34 – 36.

Food, to be consumed in limited quantity at the appropriate time and which is healthy, undergoes digestion properly, Indigestion by over eating etc. leads to disorders of Vata and other Doshas which might be powerful so as to cause increase of swelling, pain, putrefaction, burning sensation and distension of the abdomen. 37 – 38.

Food to be avoided – Fresh grains, Tila (sesame), Masha (black gram), wines, meat other than that of animals of desert like regions, products of milk and sugarcane, substances which are sour, salty and pungent should be avoided;
Any other substance which causes constipation, burning sensation during digestion, which are not easy to digest and which are cold in potency;
This group of substances gives rise to aggravation of all the Doshas in persons suffering from ulcers. 39 – 40.

Strong, penetrating, hot wines, with high percentage of alcohol, dry – non-unctuous and sour, quickly cause death of the patient of ulcers. 40½.

The ulcer site should be fanned either with tuft of hairs of animals or with that of Ushira (Vetiver) grass.
It should not be beaten, poked, or scratched with nails, it should be protected from injury while doing other activities;
The person who engages himself in hearing pleasant stories, meeting with virtuous elderly persons of the twice born castes (Brahmin), he who is hopeful of cure of the disease gets rid of the ulcer quickly. 41-42.

On the third day, the same treatment such as washing the ulcer etc. are done, as explained earlier;
These should not be done on the second day as that will give rise to severe pain, formation of tumors and delayed healing of the ulcer. 43 – 44.

The wick of cotton threads smeared with paste of drugs and also the paste of drugs should neither be very unctuous (oily) nor very dry; neither flabby nor very thick – hard and should not be improperly placed;
Because unctuousness (oily, fatty) increases moistness, dryness causes tears in the muscles, severe pain, lacerations and bleeding.
Flabby, hard and improperly placed wick produces friction of the edges of the ulcer. 45 – 46.

When the medicinal wick remaining along inside the ulcer produces putrefaction of the muscles, elevated surface, loss of tissues and accumulation of pus inside, then the ulcer should be cleaned – cleared of its contents quickly. 47.

When an unripe swelling has been cut open by ignorance it should be treated with foods and poultices which bring about ripening but which are not very opposed / harmful to the ulcer. 48.

Traumatic wound treatment

Sadyovrana Chikitsa – treatment of traumatic wounds –

Traumatic wounds which are recent and wide should be sutured immediately;
So also the ulcers which are made by scraping fatty tumors, Pinna of the ears which are thin, ulcers located on the head, eye-sockets, nose, lips, cheeks, ears, arms, neck, forehead, scrotum, buttocks, penis, rectum, abdomen etc which are situated on important fleshy and immovable parts should be sutured. 49 – 50.

Wounds that should not be sutured immediately –
That are on groins, axilla, etc, which are less muscular and movable, ulcers which emit air (gas), which have foreign body inside, which are produced by alkalies (kshara), poisons and fire should not be sutured. 51.

Suturing should be done only after removing loose pieces of bones, dried blood clots, grass, hairs etc; by placing the torn and hanging pieces of muscles in their proper places, keeping the joints of bones and bones fractured in their normal positions and after the stoppage of bleeding; by making use of tendons of animals, threads of cotton, silk, flax etc. or inner fibres of bark of trees;
Suturing being done neither very far apart nor very close, holding neither very much of the tissues nor very little. 52 – 53½.

After suturing, having comforted the patient with encouraging words, cold water drink, fanning etc. the ulcer should be covered with cotton swab soaked in a mixture of honey, melted ghee, Anjana – Srotonjana, ash of Ksyauma (flax), Phalini, fruit of Shallaki, Rodhra and Madhuka; then bandaging and other measures done as described previously. 54 – 55.

The edges of the ulcer which are not bleeding should be scraped a little to induce bleeding and sutured when the blood is flowing; for the blood is the cause – agent for healing of the ulcers. 56.

Bandaging, types

Bandhana – bandages:-
Bandages suitable to the site of the ulcer / organs of the body should be made use of.
Among them, that prepared from sheep’s skin, and silk is hot.
Bandage from flax is cold,
That from silk-cotton, cotton, tendons of animals – aponeuroses, sheaths, thin layers of tendons etc. and bark of trees is both hot and cold;
Wounds which have more of fat and Kapha, should be covered with thin sheets of copper, iron, zinc, or lead; so also the fractures;
In case of fractures, bandaging should be done by using leather, bark of trees and splints – hard and flat pieces of bamboo, wood, metal etc. 57 – 58.

Bandages are of the same shapes implied in their very names and are fifteen in number; they are
Kosha, Swasthika, Muttoli, China, Dama, Anuvellita, Khatva, Vibandha, Sthagika, Vitana, Utsanga, Gosphana, Yamaka, Sthagika, Mandala and Panchangi;
Kosha kind should be used for the joints of fingers,
Swastika for the ears, Axilla etc. for breasts and joints;
Muttoli for the penis, neck etc.;
China for the outer canthus of the eyes;
Dama at places of junction of body parts such as groins etc.;
Anuvellita for the extremities,
Khatva for cheeks, lower jaw and temples;
Vibandha for the back and abdomen;
Sthagika for the thumb, fingers, tip of the penis, and in hernia in the groins;
Vitana for organs which are thick and also for the head;
Utsanga for hanging parts;
Gosphana for the nose, lips, joints etc;
Yamaka for places having two adjacent ulcers;
Mandala for parts which are round;
Panchangi for parts above the shoulders.

An intelligent physician should apply, that type of bandage which is most suitable to the place of the body. 59 – 61.

Tightness of bandage, indications

Tight bandage – Bandage should be tied tight over the thighs, buttocks, axillae, groins and head; it should be moderate over the extremities, face, ears, chest, back, flanks, neck, abdomen, penis and scrotum;
On places which are even neither hard nor flabby it should be tight, it should be very tight if the ulcer is situated on the seats – organs of Vata and Kapha.

Moderate tight bandage – it should be moderately tight over the eyes, joints etc;
So also on places which are flabby, on places where the ulcer has been produced by Vata and Kapha it should be moderate, bandage should be removed once in three days during Sita – cold and Vasanta (spring) seasons.

Loose bandage – Bandage should be tied moderately tight on hard parts if the ulcer on them are produced by Pitta and Rakta, and on even-parts, it should be loose; on places where loose bandaging is prescribed, it should not be tied at all; during Grisma – summer and Sarat – autumn bandage should be removed in the evening and morning. 62 – 65½.

If the ulcer is not bandaged, it gets contaminated by the bite of mosquitoes, cold breeze etc., the fats and medicines applied to the ulcer do not stay on, the ulcer requires long time to become clean without pus etc. and get healed, and even after healing it will be discoloured – the skin over the area does not get back the normal colour of the body. 66 – 67.

Bandaging helps easy and quick healing of wounds in which the bones are found crushed or fractured, joints are dislocated, which are cut up by the physician, in which tendons and veins are severed, by bandaging there will be no pain during getting up, lying down and such other acts; swelling of the part of the body which are either uneven, hard and very painful or even soft, and painless – all become clean and heal quickly. 69.

Ulcers which are persisting for long, which have very little of muscular tissue, which do not heal to dryness (absence of moisture) should be applied with medicines which are wrapped in leaves of trees, appropriate to the Doshas involved and the seasons; the leaves should not be ripened ones but should be young – tender ones, not having holes, good in all respects, washed well and not rough, should belong to trees which have milky sap, Bhurja, Arjuna or Kadamba. 70 – 71.

Bandaging contraindications

Bandaging contra indication – Bandaging should not be done for ulcers which are of leprosy or burns by fire, of diabetes mellitus, of rat bite, burnt by alkalies, caused by poison, which involves putrefaction of the muscles, severe ulcerations of the rectum, which are degenerating with loss of tissues which have pain and burning sensation, which retain the swelling over long period and which spread to other parts. 72 – 73.

Flies deposit worms, bacteria etc. inside the ulcers which are not protected by bandaging, they by devour the tissues producing pain, swelling and bleeding; for washing and filling of such septic ulcers the drugs of Surasadigana – vide chapter 15 should be used. Rajadana prepared with cows urine should be applied, bathing the ulcer with solution of alkalies is beneficial or scarification of the muscle tissues, by these measures the worms – bacteria etc. should be removed out quick. 74 – 76.

Hasty healing of the ulcer which has residue of the Doshas inside, should not be attempted; for it will flare up greatly even with a slightly improper regimen. 77.

Even after the ulcer has healed the patient should avoid indigestion, physical activities, copulation etc; great rejoicing, anger, fear etc. till he attains his full strength. He should lead a disciplined life for at least six or seven months. 78 – 79.

Such other conditions which manifest should be managed with methods appropriate to the strength of the Doshas etc., in the light of the details furnished on the Uttara Tantra – the last section of this treatise (vide chapter 25 – 27) 80.

Thus ends the chapter named Shastrakarma Vidhi – 29^th of Sutrasthana of Astangahridayam.