Sushruta Samhita Sutrasthana Chapter 5: Agropaharaniya Adhyaya (Collection of Materials)

The 5th chapter of Sutrasthana of Sushruta Samhita is named as Agropaharaniya Adhyaya. This chapter deals with the Collection of Materials.

अथातः प्रभाषणीयमध्यायं व्याख्यास्यामः ॥१॥
यथोवाच भगवान् धन्वन्तरिः ॥२॥ 

We will now expound the chapter named Agropharaniya – collection of important materials required for surgical operation, as revealed by the venerable Dhanvantari.

Trividha Karma: Three kinds of procedures

त्रिविधं कर्म-पूर्वकर्म,प्रधानकर्म,पश्चात्कर्मेति,तद्वयाधिं प्रत्युपदेक्ष्यामः ॥३॥
Actions (surgical actions) or procedures are of three kinds viz –

–        Purva Karma – pre-procedures or early actions are the procedures which are done before the main surgery which includes preparation of the patient etc

–        Pradhana Karma – main procedure or main action in surgery includes the main surgical procedure conducted on the patient.
–        Paschat Karma – post-procedures, post-op procedures or follow up procedures or later actions includes all those procedures or measures undertaken or implemented after the completion of the main surgical process.

Later on, we shall describe these procedures in respect to each disease as and when needed.

Surgical activities (procedures) are the most important interventions in Shalya Tantra (surgery)

अस्य तु शास्त्रस्य शस्त्रकर्मप्रधान्याच्छस्त्रकर्मैव तावत् पूर्वमुपदेक्ष्यामस्तत्सम्भारांश्च ॥४॥
In this science i.e. Shalya Tantra, Sastra Karma i.e. surgical procedures itself is the main. Therefore, only Shastra Karmas – surgical techniques or procedures and all the materials and equipment needed for the same shall be described first.

Ashta Vida Sastra Karma: Eight kinds of surgical techniques

तच्च शस्तकर्माष्टविधं: तद्यथा – छेद्यं भेद्यं लेख्यं, वेश्यं, एष्यं, आहार्थं, विस्राव्यं, सीव्यमिति ॥५॥

Shastra Karma – Surgical activity (techniques) are eight kinds viz,

Purva Karma: Pre-operative activities

Agra Sangrahana: Collection of materials required beforehand

अतोऽन्यतं कर्म चिकीर्षता वैद्येन पूर्वमेवोपल्पयितव्यानि भवन्ति,तद्यथायन्त्रशस्त्रक्षारग्रि शलाकाश्रृङ्गजलौकालाबूजाम्बवौष्ठपिचुप्रोतसूत्रपत्रपट्टमधुधृतवसापयस्तैल तर्पणकषायालेपनकल्कव्यजनशीतोष्णोदककटाहादीनि,परिकर्मिणश्च स्निग्धाः स्थिग्धाः स्थिरा बलवन्तः ॥६॥
The materials required for surgery should be collected beforehand by the surgeon desirous of performing any of the above said surgical procedures.

This is called as agra sangrahana i.e. beforehand collection of materials. Below mentioned are the important materials which a surgeon needs ot collect before hand

Pradhana Karma-main activity

ततः प्रशस्तेषु तिथिकरणमुहूर्तनक्षत्रेषु दध्यक्षतात्रापानरत्नैरग्निं विप्रान् भिषजश्चार्चयित्वा,कृतबलिमङ्गलस्वस्तिवाचनं लघुभुक्तवन्तं प्राड्मुखमातुरमुपवेश्य,यन्त्रयित्वा,प्रत्यड्मुखो वैद्यो मर्मसिरास्नायुसन्ध्यस्थिधमनीः परिहरन्,अनुलोमं शस्त्रं निदध्यादापूयदर्शनात् ,सकृदेवापहरेच्छस्त्रमाशु चः महत्स्वपि च पाकेषु द्व्चङ्गुलान्तरं त्र्यङ्गुलान्तरं वा शस्त्रपदमुक्तम् ॥७॥

Next, on an auspicious tithi – day, karana – time and muhurta – stellar constellation, Agni (God of fire), Brahmana and Vaidya (physician) should be worshipped first. They should be worshiped by offering curds, sanctified rice, foods, drinks and gems.

Then, the patient who has offered oblations, performed sacrificial rituals, pronounced the word svasti (benediction), has consumed light (to digest) foods, should be made to sit facing east. He should then restrain the patient (prevent the patient) from making any movements of the limbs and body parts. Now the physician / surgeon sitting opposite to the patient – facing west, should insert the instrument (lancet, scalpel) in the direction of the hairs (from above downwards) while avoiding vital spots, veins, ligaments, joints, bones and arteries, and enter deep until the pus is seen. In this way, the physician should apply the instrument in the proper way, in the proper place (of the body) in one stroke and then remove the knife (taken out) once and quickly.

In ripened swellings in spite of them being big / broad (spread deep inside), another incision should be made at a distance (gap) of two or three angulas (finger breadths) in between.

Vaidyakrita Vrana guna: Features of a surgical wound

तत्रायतो विशालः समः सुविभक्तो निराश्रय इति व्रणगुणाः ॥८॥

The wound (made by the surgeon) should have the below mentioned ideal features –

Features of ideal wound

भवतश्चात्र
आयतश्च विशालश्च सुविभक्तो निराश्रयः ।
प्राप्तकालकृतश्चपि व्रणः कर्मणि शस्यते ॥९॥

One verse here:- 

The wounds are ideal when they are of

–        adequate length,
–        adequate width,
–        clear division i.e. edges separated,
–        absence of hollow space inside and
–        done at the proper time

Vaidya guna: Qualities of the Surgeon

शौर्यमाशुक्रिया शस्त्रतैक्ष्ण्यमस्वेदवेपथु ।
असंमोहश्च वैद्यस्य शस्त्रकर्मणि शस्यते ॥१०॥ 

Below mentioned are the ideal qualities of a surgeon (and the surgeon having these qualities alone is eligible to conduct surgery) –

–        Shaurya – courage / boldness
–        Ashu kriya – quickness in action
–        Shastra taikshnyam – keeping the knife and other surgical instruments sharp
–        Asweda – not sweating (out of fear)
–        Avepathu – not shivering
–        Asammohasca – not becoming confused (illusion) / the surgeon should not faint on seeing the aggravation of the disease meant to be treated surgically, or by seeing the surgical process or by seeing the wound or flow of blood

Need of making other incision

एकेन वा व्रणेनाशुध्यमाने  नाऽन्तरा बुद्ध्चाऽवेक्ष्यापरान् व्रणान् कुर्यात् ॥११॥

If the wound does not get cleared of pus etc by just one incision, another incision in the middle or near the previous incision shall be made considering the condition and suitability.

भवति चात्र:-
यतो यतो गतिं विद्यादुत्सङ्गो यत्र यत्र च ।
तत्र तत्र व्रणं कुर्याद्यथा दोषो न तिष्ठति ॥१२।

One verse here:-

Gati means route of the sinus, a channel for movement of pus. The surgical wound or incision shall be made after having determined the route of the sinus and site of bulging in such a way that the vitiating materials like blood, pus etc. do not remain inside, in the muscles and in other deeper tissues.

Different shapes of incision

तत्र भूगण्डशङ्खललाटाक्षिपुटौष्ठदन्तवेष्ठककक्षाकुक्षिवड्क्षणेषु तिर्यक् छेद उक्तः ॥१३॥
(चन्द्रमण्डलवच्छेदान् पाणिपादेषु कारयेत् ।
अर्धचन्द्रकृतींश्चापि गुदे मेढ्रे च बुद्धिमान् ॥१४॥
अन्यथा तु सिरास्नायुच्छेदनम् ,अतिमात्रं वेदना,चिराद्रणसंरोहो मांसकन्दीप्रादु भार्वश्चेति ॥१५॥                                                                       

If the incisions are not done in the above-mentioned way, the below mentioned effects can occur –

–        possibility of cutting of veins and ligaments
–        severe pain
–        long time for the wound to heal and
–        formation of muscular sprouts

Conditions wherein surgery should be done on empty stomach

मूढगर्भोदरार्शोऽश्मरीभगन्दरमुखरोगेष्वभुक्तवतः कर्मं कुर्वीत ॥१६॥
Surgical operation should be done on empty stomach i.e. when the patient has not taken the food in the below mentioned conditions / diseases –

Mudha Garbha – obstructed fetus,
Udara – abdominal enlargement,
Arsha – piles, hemorrhoids,
Ashmari – renal calculus,
Bhagandara – rectal fistula and
Mukharoga – diseases of the mouth

ततः शत्रमवचार्य,शीताभिरद्भिरातुरमाश्वास्य,समन्तात्,परिपीड्चाङ्गुल्या,व्रणमभीमृद्य(ज्य),प्रक्षाल्य कषायेण,प्रोतेनोदकमादाय,तिलकल्कमधुसर्पिः प्रगाढामौषधयुक्तां नातिस्निधां नातिरुक्षां वर्तिं प्रणिदध्यात्,ततः कल्केनाच्छद्य,घनां कवलिकां दत्वा,वस्त्रपट्टेन बध्नीयात्,वेदनारक्शोघ्नैर्धूपैर्धूपयेत्,रक्षओघ्नैश्च मन्त्रैः रक्षां कुर्वीत ॥१७।

After the incision has been done properly, the knife should be taken out. The physician / surgeon should sprinkle cold water on the face and limbs of the patient and should be comforted and assured.

The entire area around the incision (inside and outside) should be kneaded by the fingers and massaged mildly. Later the wound should be washed with decoction prepared with drugs which could instantly heal the wounds or cleanse them.

The remnant kashaya (decoction) left out in the wound shall be removed by using sterile cloth (putting the cloth inside the wound so that it absorbs the remaining liquid – decoction). Then a wick made from the paste of tila – sesame seeds and mixed with more honey, ghee and medicine. It should be neither too unctuous nor too dry should be inserted into the wound. Over this, another thick pad of cloth folded into many layers is placed over it and then tied up with a sheet of cloth i.e. bandage.

Then the wound is exposed to the fumes of drugs which relieves pain and destroys evil spirits i.e. bacteria, microorganisms etc. The patient is protected by chanting hymns which have the capacity to destroy or drive away the evil spirits.

Pascat Karma-post-operative activities

Fumigation

ततोगुग्गुल्वगुरुसर्जरसवचागौरसर्षपचुर्णैर्लवणनिम्बपत्रविमिश्रैराज्ययुक्तैर्धूपयेत्:आज्यशेषेण चास्य प्राणान् समालभेत ॥१८॥

Next, fumigation (of the room, cot, clothes etc used by the patient) should be done with the powder of Guggulu, Aguru, Sarjarasa and Gaura Sarsapa added with Lavana (saindhava lavana – rock salt), leaves of neem (Azadirachta indica) and ghee.

Lavana(saindhava), nimbi patra and ghee. Remaining ghee should be used for restoring the life of the patient (by applying and lightly massaging the ghee over the marma sthanas – vital organs and spots).  

Raksha karma: Protective rites

उदकुम्भाच्चपो गृहीत्वा प्रोक्षयन् रक्षाकर्मं कुर्यात् : तद्धक्ष्यामः ॥१९॥
कृत्यानां प्रतिघातार्थं तथा रक्षोभयस्य च ।
रक्षाकर्मं करिष्यामि ब्रह्मा तदनुमन्यताम् ॥२०॥
नागाः पिशाचा गन्धर्वाः पितरो यक्षरक्षसाः ॥
अभिद्रवन्ति ये ये त्वां ब्रह्माद्याघ्नन्तु तान्सदा ॥२१॥
पृथिव्यामन्तरिक्षे  च ये चरिन्तु निशाचराः ।
दिक्षु वास्तुनिवासाश्च पान्तु त्वां ते नमस्कृताः ॥२२॥
पान्तु त्वां मुनयो ब्रह्मया दिव्या राजर्षयस्तथा॥
पर्वताश्चैव  नद्यश्च सर्वाः सर्वेच सागराः ॥३॥
अग्री रक्षतु ते जिह्वा प्रणान् वायुस्तथैव च ॥
सोमो व्यानमपानं ते पर्जन्यः परिरक्षतु ॥२४॥
उदानं विद्युतः पान्तु समानं स्तनयित्नवः ॥
बलमिन्द्रो बलपतिर्मनुर्मन्ये मतिं तथा॥२५॥
कामांस्ते पान्तु गन्धर्वाः सत्त्वमिऽभिरक्षतु ॥
प्रज्ञां ते वरुणो राजा समुद्रो नाभिमण्डलम् ॥२६॥
चक्षुः सूर्योंः दिशः श्रोत्रे चन्द्रमाः पातु ते मनः ।
नक्षत्राणि सदा रुपं छायां पान्तु निशास्तव ॥२७॥
रेतस्त्वाप्याययन्त्वापो रोमाण्योषध्यस्तथा।
आकाशं खानि ते पान्तु देहं तव वसुन्धरा॥२८॥
वैश्वानरः शिरःपातु विष्णुस्तव पराक्रमम् ।
पौरुषं पुरुषश्रेष्ठो ब्रह्मऽऽत्मानं धुवो भ्रुवौ॥२९॥|
एता देहे विशेषेण तव नित्या हि देवताः ॥
एतास्त्वां सततं पान्तु दिर्धमायुरवाप्रुहि ॥३०॥
स्वस्तिते भगवान् ब्रह्मा स्वस्ति देवाश्च कुर्वताम् ।
(स्वस्ति ते  चन्द्रस्ययौच स्वस्ति नारदपर्वतौ।)
स्वस्त्यग्रिश्चैव वायश्च स्वस्ति देवाः सहेन्द्रगाः ॥३१॥
पितामहकृता रक्षा स्वस्त्यायुर्वर्धता तव ।
ईतयस्ते प्रशाम्यतु सदा भव गतव्यथः ॥३२॥
इति स्वाहा ॥
इतैर्वेदात्मकैर्मन्त्रैः कृत्याव्याधिविनाशनैः।
मयैवं कृतरक्षस्त्वं दीर्घमायुरवाप्रुहि ः ॥३३॥।

The protective rites shall be performed as described below after sprinkling a little quantity of water taken in the hand from the water pot, on the patient –

I am performing this protective rite in order to destroy the witch called Kritya and for removing the fear of Raksasa (demons / evil spirits). This will be approved by Lord Brahma.

“May Nagas, Pisacas, Gandharvas, Pitas, Yaksas and Raksasas who trouble you shall be destroyed by Lord Brahma and other Gods. The nisacaras (demons, evil spirits) which roam around on the earth, sky and in all directions and the raksasas (evil spirits) which stay in your quarters (open space) and in houses protect you by being pleased by your prayers. Many Brahmarshis, Devarsis and Rajarsis, the mountains, all rivers and oceans protect you. May Agni (God of fire) protect your tongue and Vayu (God of wind) protect your prana (life). May Soma (Moon God) protect your vyana vata and Parjanya (rainy clouds / God of rain) protect your apana vata. May Vidhyut (God of lightning) protect your udana vata. May Stanayitnava (clouds, God of clouds) protect your samana vata.

May Lord Balapati Indra protect your strength, and Manu the veins of your neck and intellect, Gandharva your desires and wishes and Lord Indra your mind. May Lord Varuna protect your consciousness, oceans (Lord of oceans) your umbilical region, Sun your eyes, the directions (quarters) your ears, Candra (moon god) your mind, Naksatras (stars) your form *beauty) and the Nisa (nights) protect your shade.

May Apah (waters) protect your semen, Aushadhis (medicinal plants) your hairs (body hairs), Akasa (sky, space) the orifices and hollow spaces inside your body and Vasundhara (earth) your body. Let Vaisvanara (fire god) protect your head, Lord Vishnu your valour, Purusa shresta / Purushottama your masculinity / virility (penis), Lord Brahma your atma (soul) and Dhruva (pole star) your eyebrows.

All the Gods mentioned above dwell in your body and always protect you constantly. May you obtain a long life (by their grace). May Lord Brahma always bestow goodness to you. May all Gods bestow goodness on you. May Sun and Moon do good to you. May Narada and Parvata, Agni, Vayu and other Gods together with Lord Indra bestow good on you.

May this protective hymn created by Lord Brahma bestow you with all the good and provide longevity, let all your troubles subside and you remain free from sorrow always, Svaha!”

 “By this sacred hymn revealed in the Vedas, which wards off sorcery and diseases, you have been protected by me; may you attain long life”.

ततःकृतरक्षमातुरमागारं प्रवेस्य,आचारिकमादिशेत्  ॥३४॥

The Raksha karma i.e. protective ritual is performed and finished properly following all rites as explained above. Following this, the patient shall be taken either into his house or into a special chamber constructed for him. He should be advised to stay therein and adhere to the regimen related to diet and other activities as advised by the surgeon.

 Vranitopasana: Care of the wounded

ततस्तृतियेऽहनि विमुच्यैवमेव बध्नीयाद्वस्त्रपट्टेत्न; न चैनं त्वरमाणेऽपरेद्युर्मोक्षयेत् ,द्वितीयदिवसपरिमोक्षणाद्विग्रथितो व्रणश्चिरादुपसंरोहति,तीव्ररुजश्च भवति ॥३५॥

On the third day, the bandage shall be removed. Now, the wound is again cleansed with medicated decoctions and the medicinal wick is kept in place into the wound as done earlier. A bandage cloth shall now be tied on it.

Care should be taken towards not removing the dressing in hurry on the second day itself. If it is hastily removed on the second day itself, the wound would develop hardness. It would also take a long time to heal and will also cause severe pain.

अतः ऊर्धंदोशकालबलादीनवेक्ष्य कषायालेपनबन्धाहाराचारान् विदध्यात् ॥३६॥

The wound should be properly treated with decoctions, application of medicinal pastes, bandaging and administration of suitable foods and activities which facilitate healing of wounds, after the third day. This shall be done after having considered the factors like condition of doshas affecting the wound, season, strength of the patient etc.

न चैनं त्वरमानः सान्तर्दोषं रोपयेत् : स ह्यल्पेनाप्यपचारेणाभ्यन्तरमुत्सग्ङ्ग कृत्वा भूयोऽपि विकरोति ॥३७॥

Sufficient time should be given for healing of wounds. They should never be made to heal in a hurry with a desire of getting relief in quick time, especially so, when the vitiated doshas are still present inside the wound. If it is pushed to heal quickly, elevations are produced inside the wounds even with slight violation of regimens and would give rise to many abnormalities.

तस्मादन्तर्बहिश्चैव सुशुद्धं रोपयेद् व्रणम् ।
रूढेऽप्यजीर्णव्यायामव्यवायदी विवर्जयेत्  ।
हर्षं क्रोधं भयं वसन्ते चापि मोक्षयेत् । ।
त्र्यहादुद्वच्य्ह्य्च्छरद्रीष्मवर्षास्वपि चबुद्धिमान् ॥३९॥
अतिपातिषु रोगेषु नेच्छेद्विधिमिमंभिषक् ।
प्रदीप्तागारवच्छीघ्रं तत्र कुर्यात् प्रतिक्रियाम् ॥४०॥
या वेदना शस्त्रनिपातजाता तीव्रा शरीरम् प्रदुनोति जन्तो।
घृतेन सा शान्तिमुपैति सिक्ता कोष्णेन यष्टीमधुकान्वितेन ॥४२॥

Therefore, as a rule, only that wound which is clean both outside and inside should be made to heal and not without cleansing the wound.

In spite of the wound having healed properly, the patient should avoid the below said until the wound is completely healed and the patient attains firmness –

–        indigestion
–        excessive physical exercise
–        indulgence in copulation
–        over excitement
–        anger
–        fear

The bandage shall be removed by an intelligent physician / surgeon –

–        after three days in Hemanta – early winter, Sisira – late winter and Vasanta – spring seasons
–        after two days – in Sarat – autumn, Grishma – summer and Varsa – rainy seasons

These rules need not be followed strictly by the physicians / surgeons in cases of emergency diseases or diseases caused by suppuration in wounds or in presence of life-threatening bleeding from the wounds. In emergencies, treatments which are urgently needed shall be done without delay, just like one would rescue a house caught on fire without delay.

The pain caused by the knife would greatly trouble the patient. To subside this pain, ghee which has been prepared with Yashtimadhu – Glycyrrhiza glabra shall be applied lukewarm.

इति श्रीसुश्रुतसंहितायां  सुत्र स्थ्हाने ऽग्रोपहरणीयो नाम पञ्चमोऽध्यायः ।

Thus, end the Fifth chapter by name Agropaharaniya- in Sutra Sthana Of Susruta Samhita.