Sushruta Samhita Sutrasthana Chapter 25: Ashtavidha Shastra Karmiya Adhyaya (Eight Kinds of Surgical Operations)

The 25th chapter of Sutrasthana of Sushruta Samhita is named as Ashtavidha Shastra Karmiya Adhyaya. This chapter deals with the information on facilitating the study.

Astavidha Sastra karma: Eight kinds of surgical operations

अथातोऽऽष्टिघशस्त्रकर्मीयमध्यायं व्याख्यास्याम ः ।
यथोवाच भगवान् धन्वन्तरिः ॥१

We will now expound the chapter by name Astavidha Sastra karmiya- the eight kinds of surgical operations; as revealed by the venerable Dhanvantari.

1.   Chedya  roga: Diseases requiring Excision 

 छेद्या भगन्दरा ग्रन्थिः श्लैष्मिकस्तिलकालकः ।
व्रणवर्त्मार्बुदान्यर्शश्चर्मकीलोऽस्थिमांसगम् ॥३॥
 शल्यं जतुमणिर्मांससंघातो गलशुण्डिका।
 स्नायुमांससिराकोथो वल्मीकं शतपोनकः ॥४॥
 अध्रुषश्चोपदंशाश्च मांसकन्द्यधिमांसकः ॥

Below mentioned is the list of diseases which can be treated by chedana – excision i.e. cutting and removing –

–        Bhagandara – fistula-in-ano,
–        Shlaishmika Granthi – cystic swelling / tumors arising from Kapha,
–        Tilakalaka – black moles,
–        Vrana – wounds (ulcers) / sinus ulcers,
–        Arbuda – tumors (ulcers of the eyelids),
–        Arsha – hemorrhoids,
–        Charmakila – warts of the skin,
–        Asthi mamsa shalya – foreign body lodged in the bones and muscles,
–        Jatumani – birthmark, pigmented patch,
–        Mamsa sanghata – benign tumor of palate,
–        Galashundika – enlargement of uvula;
–        Snayu mamsa sira kotha – putrefaction of ligaments, muscles and veins;
–        Valmika – actinomycosis of the foot and
–        Sataponaka – a variety of rectal fistula,
–        Adhrusa – palatitis
–        Upadamsa – ulceration of the penis,
–        Mamsakanda – fibroma of palate
–        Adhimamsa – impacted wisdom tooth

2.   Bhedya roga: Diseases requiring Incising / cutting open

भेद्या विद्रधयोऽन्यत्र सर्वजान्द्रन्थयस्त्रयः ॥५॥
आदितो ये विसर्पाश्च वृद्धयः सविदारिकाः ।
प्रमेहपिडकाः शोफः स्तनरोगोऽवमन्थकः ॥६॥
कुम्भीकाऽनुशयी नाड्चो वृन्दौ पुष्करिकाऽलजी।
प्रायशः क्षुद्ररोगाश्च पुप्पुटौ तालुदन्तजौ ॥७॥
तुण्डिकेरी गिलायुश्च पूर्वं ये च प्रणाकिणः ।
बस्तिस्तथाऽश्मरीहेतोर्मेदोजा ये च केचन ।८॥

Below mentioned are the diseases which can be treated by Bhedana i.e. incision or cutting open –

–        Vidradhi – all abscesses expect that produced by all the doshas together,
–        Granthi – three kinds of cystic swellings / tumors (vataja, pittaja and kaphaja),
–        Visarpa – the first three kinds of erysipelas (vataja, pittaja, kaphaja),
–        Vrddhi – all kinds of enlargement of scrotum (hernia),
–        Vidarika – pustule in groin and axilla,
–        Prameha Pidaka – diabetic eruptions / carbuncles,
–        Sopha – swelling (inflammatory),
–        Stana Roga – diseases of the breast,
–        Avamanthaka – disease of the penis,
–        Kumbhika – follicular conjunctivitis,
–        Anusayi – abscess of the foot,
–        Nadi – sinus ulcers,
–        Vrnda – the two kinds of vrnda (Vrnda and ekavrnda – small tumor of the throat),
–        Puskarika – a disease of the penis,
–        Alaji – inflammation of the penis,  
–        Kshudra Rogas – generally all kshudra rogas (minor diseases),
–        Talupupputa – tumor of the palate,
–        Danta Pupputa – gingivitis,
–        Tundikeri – tonsillitis,
–        Gilayu – tonsillar abscess,
–        Prapakinah – Those diseases which suppurate (mentioned earlier),
–        Basti tatho ashmari hetoh – The urinary bladder due to formation of calculus, and
–        Medoja – some diseases produced by fat tissue

3.   Lekhana roga: Diseases requiring Scraping

लेख्याश्चतस्त्रो रोहिण्यः किलासमुपजिह्वोका।
मेदोजो दन्तवैदर्भो ग्रन्थिर्वर्त्माधिजिह्विका॥९॥
अर्शांसि मण्डलं मांसकन्दी मांसोन्नतिस्तथा ॥

Below mentioned are the diseases which can be treated by Lekhana i.e. scraping –

–        Rohini – four kinds of rohini (vataja, pittaja, kaphaja, sannipataja)
–        Kilasa – leukoderma
–        Upajihvika – swelling of the tongue
–        Danta viadarbha caused by vitiated meda / fat – gingivitis
–        Medoja granthi – fatty cysts / tumors
–        Medoja vartma – fatty cysts or tumors of eyelids
–        Adhijihvika – adenoids
–        Arshas – haemorrhoids
–        Mandala – a type of skin disorder / leprosy
–        Mamsakanda – small tumors of muscles
–        Mamsonnati – thickening or elevations of muscles

4. Vedhya roga: Diseases requiring puncturing

वेध्याः सिरा बहुविधा मुत्रवृर्द्किद् रम् ॥१०॥

Below mentioned are the diseases which can be treated by Vedhana – puncturing –

–        Vedhya Sira – siras (veins) to be punctured in many diseases,
–        Mutra vrddhi – enlargement of scrotum – hydrocele,
–        Dakodara – ascitis

5. Eshya roga: Diseases requiring probing

एष्या नाड्चः  सशल्याश्च  व्रणा उन्मार्गिणश्च ये ।

Below mentioned are the diseases which are curable by Esana – probing –

–        Nadi – sinus ulcers,
–        Sasalya vrana – wound with foreign body inside) and
–        Unmargi vrana – sinus ulcer which spread side wards

6. Aharya roga: Diseases required extraction / removal

आहार्याः  शर्करास्तिस्त्रो दन्तकर्णमलोऽश्मरी ॥११॥
शल्यानि मूढगर्भाश्च पर्चश्च निचितं गुदे ॥

Below mentioned are the diseases which can be treated by aharana – extraction or removal –

–        Sarkara – three kinds of Sarkara – urinary gravel – vataja, pittaja, kaphaja,
–        Danta mala – tartar of the teeth,
–        Karna mala – ear wax,
–        Asmari – urinary calculi,
–        Salya – all kinds of foreign bodies,
–        Mudha garbha – impacted fetus and
–        Varchah cha nichitam gude – feces accumulated in the rectum

7. Sravya roga: Diseases requiring draining

स्राव्या विद्रधयः पञ्च भवेयुः सर्वजाद्दते ॥१२॥
कुष्टानि बायुः सरुजः शोफो यश्चैकदेशज ः ॥
पाल्यामयाः श्लीपदानि विषजुष्टं च शेणितम् ॥१३॥
अर्बुदानि विसर्पाश्च ग्रन्थयश्चादितश्च ते ॥
त्रयस्त्रयश्चोपदंशाः स्तनरोगा विदारिका॥१४॥
सुषिरो गलशालूकं कण्टकाः कृमिदन्तकः ॥।
दन्तवेष्टः सोपकुशः शीतादो दन्तपुप्पुटः ॥१५॥
पित्तासुक्कफजाश्चौष्टचाः क्षुद्ररोगाश्च भुयशः।

Below mentioned is the list of diseases which can be treated by Srava / Visravana – draining –

–        Vidradhi – five kinds of vidradhi (abscess) except that born from all the doshas together,
–        Kustha – leprosy / skin disorders,
–        Saruja vayu – vata or vata conditions associated with pain
–        Ekadesaja sopha – inflammatory edema confined to one place or one part of the body,
–        Palyamaya – diseases of the earlobe,
–        Slipada – filariasis,
–        Visajusta sonita – blood vitiated by poison,
–        Arbuda – all kinds of arbuda – benign tumors
–        Visarpa – erysipelas
–        Granthi – the first three kinds of granthi – cysts, benign tumors
–        Upadamsha – three kinds of upadamsa – syphilis – vataja, Pittaja, Kaphaja,
–        Stana roga – diseases of the breast, 
–        Vidarika – pustule in groin and axilla,  
–        Sausira – small sinus of the tooth,
–        Galasaluka – epiglotitis,
–        Kantaka / Jihvakantaka – inflammation of tongue,
–        Krimidanta – caries of the teeth,
–        Danta vesta – gingivitis,
–        Upakusa – ulcerative gingivitis,
–        Sitada – spongy gums / scurvy,
–        Danta pupputa – gingivitis,
–        Ostha kopa – arising from pitta, rakta and kapha – inflammation of the lips and
–        KsudraRogas – minor diseases, generally

8. Sivya roga: Diseases requiring Suturing

सीव्या मेदः समुत्थाश्च  भिन्नाः सुलिखिता गदा।
सद्योव्रणाश्च ये चैव चलसन्धिव्यपाश्रिताः ॥१६॥

Below mentioned are the diseases which can be treated by Sivana – suturing –

–        Meda samuttha – diseases arising from fat – such as tumors etc
–        Bhinnah – those which have been cut / inside
–        Sulikitha – those which have been scraped well,
–        Sadyovrana – traumatic wound and
–        Chala Sandhi Vyapashritah – diseases localized on moveable joints

Contraindications for suturing

न क्षाराग्रिविषैर्जुष्टा न च मारुतवाहिनः॥१७॥
नान्तर्लोहिरशल्याश्च तेषु सम्यग्विशोधनम् ।

Suturing should not be done in the below mentioned conditions –

–        Ksara Agni Visa Jushta – Diseases caused by ksara – alkali, agni – fire and visha – poison
–        Maruta vahinah – those which emit air or gas from inside of them,
–        Antarlohita shalya – presence of blood and foreigh body inside,

On the other hand, in these conditions, the accumulation inside them is removed and cleansed.

Precautions before suturing

पांशुरोमनखादीनै चलमस्थि भवेच्च यत् ॥१८॥
अहतानि यतोऽमूनि पाचयेयुर्भृशं व्रणम् ।
रूजश्च विविधाः कुर्युस्तस्मादेतान् विशोधयेत् ॥१९॥

Sand, hairs, nails etc, pieces of bones which are left over moving inside the wound, when not removed will cause excessive suppuration of the wounds and cause many kinds of pains in the wound. Therefore, they should be carefully and completely removed and the wounds should be cleared / cleansed entirely.

Sivana vidhi, Sivana vastu: Procedure of suturing and materials

ततो व्रणं समुन्नम्य स्थापयित्वा यथास्थितम् ।
सीव्येत् सूक्ष्मेण सुत्रेण वल्केनाश्मन्तकस्य वा ॥।१०॥
शणजक्षौमसूत्राभ्यां स्नाय्वा वालेन वा पुनः ।
मूर्वागुडूचीतानैर्वा सीव्येद्वेल्लितकं शनै ः ॥२१॥
सीव्येद्रोफणिकां वाऽपि सीव्येद्वा तुन्नसेवनीम् ॥।
ऋजुग्रन्थिमथो वाऽपि  यथायोगमथपि वा॥२२॥
देशेऽल्पमांसे सन्धौच सूची वृत्ताऽङ्गलद्वयम् ।
आयता त्र्यङ्गुला त्र्यस्रा मांसले चाऽपि पूचिता ॥२३॥
धनुर्वक्रा हिता मर्मफलकोशोदरोपरि।
इत्येतास्त्रिविधाः सूचीस्तीक्ष्णाग्राः सुसमाहिताः ॥२४॥
कारयेन्मालतीपुष्पवृन्ताग्रपरिमण्डलाः ।
नातिदूर्व् निकृष्टे वा सूचीं कर्मणि पातयेत् ॥२५॥
दूराद्रुजो व्रणौष्ठस्य  सन्निकृष्टेऽवलुञ्चनम ॥२६॥

Next, the wounds should be elevated (raised up slightly), placed in the usual (normal) position and then sutured, with one or the other among the below mentioned things –

–        thin thread of bark of Asmantaka, flax, jute, linen,
–        ligaments,
–        hairs,
–        fiber of Murva or of Guduci

The type of suture may be Vellitaka, Gophanika, tunnasevani, Rujugranthi, or any kind as suitable or appropriate to the place.

Round needles (cylindrical and straight) of two angula in length should be used for suturing the places of the body which have less of muscles and also for suturing over the bony joints.

In the fleshy regions of the body i.e. body parts having more muscles, triangular (having three borders and straight) needles of four angulas in length are considered to be the best (ideal).

For suturing on vital points, scrotum and abdomen the needle should be curved like the bow.

In this way, suturing needles are of three kinds. The needles should have sharp point, manufactured in a precise way, and their hind tip should be rounded, resembling the stalk of malati flower.

While using the needle (for suturing the edges of the wound), punctures should neither be made either very far or very near (from one hole to the other). If the punctures are far apart, that will give rise to pain in the edges of the wound and if very near, the edges will get torn.

अथ क्षौमपिचुच्छत्रं सुस्यूतं प्रतिसारयेत् ।
प्रियङ्ग्वञ्जनयष्टयाह्वरोध्रचीर्णौः समन्ततः ॥२७॥
शल्लकीफलचुर्णौर्वा क्षौमध्यामेन वा पुनः ।
ततो व्रणं यथायोगं बद्ध् वाऽऽचारिकमादिशेत् ॥२८॥

After suturing has been done properly, the wound should be covered with linen and cotton and sprinkled with the powder priyangu, anjana (sauviranjana), yasti and rodha or of fruit or Sallaki or ash of linen cloth; then the wound should be bandaged appropriately, and the patient advised the regimen (of food activities) to be adhered.

एतदष्टविधं कर्म समासेन प्रकीर्तितम् ।
चिकित्सितेषु कार्त्स्येन विस्तरस्तस्य वक्ष्यते॥२९॥

Thus, the eight kinds of surgical operations were described in brief; these will be described in detail in chikitsa sthana (section IV).

Shastra Karma Vyapat: Complications of surgery

हीनातिरिक्तं तिर्यक् च गात्रच्छेदनमात्मनः ।
एताश्चतस्रोऽष्टविधे कर्मणि व्यापदः स्मृताः ॥३०॥

In these eight kinds of operations, four kinds of complications might occur. They are –

–        hina cheda (inadequate cutting)
–        atirikta cheda (excess cutting),
–        tiryak cheda (oblique / improper cutting) and
–        atmana cheda (cutting of own body, fingers etc. of the physician himself, accidentally)

अज्ञानलोभाहितवाक्ययोगभयप्रमोहैरपहैश्च भावैः ।
यदा प्रयुञ्जीत भिषक् कुशस्रं तदा स शेषन् कुरुते विकारान् ॥३१॥

When the physician performs surgical operations improperly (using improper or bad instruments), due to either ignorance, greed, inciting words of others, fear, delusion (confusion) or any other factors, then he creates many other diseases.

Physicians to be avoided

तं क्षारशस्त्राग्रिभिरौषधैश्च भूयोऽभियुञ्जानमयुक्तियुक्तम् ।
जिजीविषुर्दूरत एव वैद्यंविवर्जयेदुग्रविषाहितुल्यम् ॥३२॥

Just like one would avoid an immensely poisonous snake, the person who wishes to live should keep distance (reject or avoid) from the physician who administers the below mentioned in an improper way –

–        Ksara – alkali for cauterization
–        Shastra – surgical instruments / sharp instruments used for surgery
–        Agni – fire for cauterization / branding and
–        Aushadha – medicines

तदेव युक्तं त्वति मर्मसन्धिन् हिंस्यात् सिराः स्नायुमथास्थि चैव ।
 मूर्खप्रयुक्तं पुरुषं  क्षणेन प्राणैर्वियुञ्ज्यादथवा कदाचित्  ॥३३॥

When the same sharp instrument is used in a wrong way by a foolish physician it would cause the below mentioned effects –

–        Severe pain in marma – vital points, joints, veins, ligaments and bones,
–        Loss of life – sometimes

Shastrakarma Vyapat Lakshana: Symptoms of complications of surgery

भ्रमः प्रलापः  पतनं प्रमोहो विचेष्टनं संलयनोष्णते च ।
स्रस्ताङ्गता मूर्छनमूर्ध्ववातस्तीव्रा रुजो वातकृताश्च  तास्ताः ॥३४॥
मांसोदकाभं रुधिरं च  गच्छेत् सर्वेन्द्रियार्थोपरमस्तथैव ।
दशार्धसंख्येष्वपि विक्षतेषु सामान्यतो मर्मसु लिङ्गमुक्तम् ॥३५॥

When the above said five structures of the body i.e. vital spots, bony joints, veins, tendons and bones, especially the marmas are injured by the knife, the below mentioned symptoms appear –

–        giddiness,
–        delirium,
–        fainting,
–        delusion,
–        loss of activity of the body parts,
–        semi-consciousness,
–        increase of body temperature,
–        weakness of body parts,
–        fainting,
–        vata abnormally moving upwards / increased expirations,
–        severe pain caused by vata,
–        discharge of blood resembling mutton wash,
–        cessation of activity of all the sense organs

सुरेन्द्रगोपप्रतिमं प्रभूतं रक्तं  स्रवेद्वै क्षततश्च  वायुः ।
करोति रोगान् विविधान् यथोक्तां श्छिन्नासु भिन्नास्वथवा सिरासु॥३६॥
कौब्ज्यं शरीरावयवावसादः क्रियास्वशक्तिस्तुमुला रुजश्च॥
 चिराद्व्रणो रोहति यस्य चापि तं स्नायुविद्धं मनुजं व्यवस्येत् ॥३७॥
शोफातिवृद्धिस्तुमुला रुजश्च बलक्षयः पर्वसु भेदशोफौ ॥
 क्षतेषु सन्धिष्वचलाचलेषु  सर्वास्ववस्थासु न शान्तिरस्तित ॥
तृष्णाऽङ्गसादौ श्वयथुश्च रुक च तमस्थिविद्धं मनुजम् व्यवस्येत् ॥३९॥
यथास्वमेतानि विभावयेच्च लिङ्गानि मर्मस्वभिताडितेषु॥
स्पर्श न जानाति विपण्डुवर्णों यो मांसमर्मण्यभिताडितः स्यात् ॥४०॥

 Profuse bleeding would occur from the wound when the blood vessels (veins) are cut open or torn. The blood would resemble Indragopa i.e. bright red in color (cochineal insect). Vata gets aggravated due to this bleeding and causes many kinds of diseases.

Symptoms of cut or injury to the ligaments include –

–        shortening (of the body),
–        debility of body parts,
–        inability to perform their actions,|
–        severe (excruciating) pain,
–        wound (of the knife) healing after a long time

 Symptoms of injury to the movable or immovable joints include –

–        great increase of swelling,
–        very severe pain,
–        loss of strength of the joints;
–        blasting / splitting pain and edema in the small joints of fingers and toes and
–        loss of function of the joints

Symptoms of cut or injury in the bones include –

–        severe pain day and night (constantly), 
–        finds no comfort in any position (postures),
–        thirst,
–        weakness of the body,
–        edema and
–        dryness

Symptoms of injury of vital spots (related to veins, ligaments, bones and joints) include the above symptoms also should be included (along with others concerned to the particular vital spots).

Symptoms of injury of vital spots related to muscles include –

–        loss of sensation of touch,
–        profound yellowish white color of the body

आत्मानमेवाथ जघन्यकारी शस्त्रेण यो हन्ति हि कर्म कुर्वन् ।
तमात्मवानात्महनं कुवैद्यं विवर्जयेदायुरभिप्समानः ॥४२॥

The physician / surgeon who causes injuries while conducting surgery, using sharp instruments should be considered as jaghanyakari i.e. mean fellow or inferior. Such a Kuvaidya – quack can kill the patient. Therefore, an intelligent person desirous of longevity shall avoid such type of quack physicians.

तिर्यक् प्रणिहिते शस्रे दोषाः पुर्वमुदाहृताः ।
तस्मात् परिहरत् दोषान् कुर्याच्छस्त्रनिपातनम् ॥॥ ४२॥

In the earlier context i.e. in chapter 5 itself, the hazards which might occur due to improper use of surgical instruments have been described. The surgeon therefore, should avoid those possible hazards and perform the instrumentation – surgical operations.

Aturva vishvasa: Faith of the patient

मातरं पित्तरं पुत्रान् बान्धवानपि चातुरः ।
अप्येतानभिशङ्केत वैद्ये विश्वासमेति च॥४३॥
विसृज त्यात्मनाऽऽत्मानं न चैनं परिशङ्कते॥
तस्मात् पुत्रवदेवैनं  पालयेदातुरं भिषक् ।४४॥

Acharya says that the physician should always take care and protect the patient like his own son. This is because there are chances that the patient might suspect his own mother or father, sons or relatives, but he will always invest his trust and faith in the physician and unconditionally submit himself to the physician. So, it is the responsibility of the physician to reciprocate the faith and take care of him as his own son.

धर्मार्थौ कीर्तिमित्यर्थं सतां ग्रहणमुत्तमम् ॥
प्राप्रृयात् सर्गवासं च हितमारभ्य कर्मणा ॥४५॥

The physician by his efficacious actions (surgery) earns –

–        righteousness (merits),
–        wealth, and
–        reputation,
–        great respect from the wise and
–        even life in heaven

कर्मणा कश्चिदेकेन द्वाभ्यां कश्चित्त्रिभिस्तथा।
विकारः साध्यते कश्चिच्चतुर्भिरपि कर्मभिः ||46||

There are some diseases that get cured by any one kind of treatment only. The other diseases may get cured by two kinds of treatments, some by three kinds of treatments and some others by administration of four kinds of treatments.

इति  श्रीसुश्रुतसंहितायां सूत्रस्थानेऽष्टविधशस्त्रकर्मीयो  नाम पञ्जविंशोऽध्यायः ॥२५॥\

Thus ends  the Twenty-fifth chapter  by name Astavidha Sastra Karmiya in Sutra Sthana of Susruta Samhita.