Sushruta Samhita Chapter 27 Shalya Apanayaniya Adhyaya (Removal of Foreign Bodies)

The 27th chapter of Sutrasthana of Sushruta Samhita is named as Shalya Apanayaniya Adhyaya. This chapter deals with the information on Removal of Foreign Bodies.

अथातः  शल्यापनयनीयमध्यायं व्याख्यास्यामः॥१॥
यथोवाचभगवान् धन्वन्तरिः॥२॥

We will now expound the chapter known as shalyapanayaniya- removal of foreign bodies; as revealed by the venerable Dhanvantari.

Dvida shalya: Two kinds of foreign bodies

शल्यं द्विविधमवबद्धमनवबद्धं च ॥३॥

The shalyas i.e. foreign bodies are of two types. They are –

1.   Avabaddha – fixed / stuck up and
2.   Anavabaddha – not fixed / free / loose

Shalya Aharanopaya: Methods of removal of foreign bodies

 तत्र समासेनानवबद्धशल्पोद्धरणार्थंपञ्चदशहेतून वक्ष्यामः । तद्यथा- स्वभावः, पाचनं, भेदनं, दारणम् पीडनंं, प्रमार्जनं, निर्ध्मपनं, वमनं, विरेचनं, प्रक्षालनं, प्रतिमर्शः, प्रवाहणम्, आचूषणम्, अयस्कान्तो, हर्षश्चेति॥४॥

Below mentioned are fifteen different methods of removal of shalyas – foreign bodies which are not fixed –

तत्राश्रुक्षवथूद्रारकासनूत्रपुरीषानीलैः  स्वभावबलप्रवृत्तैर्नयनादिभ्यः पतति । मांसावगाढं  शल्यमविदह्यमानं पाचयित्वा प्रकोथात्तस्य पूयशोणितवेगाद्रौरवाद्वा पतति। पक्वमभिद्यमानंं भेदयेद्दारयेद्वा। भिन्नमनिरस्यमानं पीडनीयैः पीडयेत् पाणिभिर्वा। अणून्यक्षशल्यानि

परिषेचनाध्मापनैर्वालवस्त्रपाणिभिः प्रमार्जयेत् । आहारशोषश्लेष्महीनाणुशल्यानि श्वसनोत्कासनप्रधमनैर्निर्धमेत् । अन्नशल्यानि वमनाङ्गुलिप्रतिमर्शप्रभृतिभिः । विरेचनैः पक्वाशयगतानि । प्रणदोषाशयगतानि प्रक्षामनैः । वातमूत्रपुरीषगर्भसङ्गेषु प्रवाहणमुक्तम् । मारुतोदकसविषरुधिरदुष्टस्तन्येष्वाचूषणमास्येन विषाणैर्ण । अनुलोममनवबद्धमकर्णमनल्पव्रणमुखमयस्कान्तेन । हृद्यवस्थितमनेककारणोत्पन्नं शोकशल्यं हर्षेणेति। ॥५॥

Foreign bodies come out of the body during natural acts also. They come out from eyes and other organs during the below mentioned acts –

–       Crying / flow of tears,
–       Sneezing
–       Coughing,
–       Urination
–       Defecation
–       Discharging fart / flatus

The foreign body stuck inside the muscle if not suppurating naturally should be made to suppurate by applying medicinal pastes (which would cause suppuration). Following suppuration, the foreign body will come out due to the force of (out-flowing) pus and blood or due to its own heaviness.

In spite of initiating suppuration also if the foreign body is not coming out, medicinal pastes having hot potency should be applied on it and made to burst (cut open or tear) and then facilitated to come out.

If the foreign body or pus is not coming out after cutting or bursting it should be squeezed by application of medicinal pastes (which would squeeze the site) or with the hands and made to come out. (Alternatively, the site should be hit or given a blow with appliances such as a wooden plank, stick, small hammer etc or with the hand).

Minute foreign bodies located in the sense organs should be carefully removed or cleared by –

–       Pouring water,
–       Blowing of air,
–       Wiping,
–       Sweeping with brushes made of hairs,
–       Edge of a clean cloth or
–       Cleaned finger tips

Foreign body such as particles of food which have wrongly entered the nose or respiratory passages due to speaking or laughing (while taking food) or kapha (which is thick and adhering) which is not expelled from the respiratory passages in spite of coughing and small and minute foreign bodies should be removed by inducing deep and forceful breathing, coughing and blowing air (into that site).

When the foreign bodies are food particles, one needs to insert fingers etc. into the mouth, throat deep, induce vomiting and remove them.

Purgation is the best treatment to remove the foreign body present in pakvashaya – colon / large intestine.

Foreign bodies present in the vrana (wound) and seats of doshas should be removed by washing with liquids.

Obstruction of flatus, urine, faeces and foetus (these acting as foreign bodies) should be removed by straining.

Direct sucking from the mouth or by using the horn is the best method for removing the foreign bodies if they are in the below mentioned forms –

–       accumulation of gas or air
–       accumulation of water or any fluids
–       accumulation of poisons,
–       accumulation of blood
–       accumulation of breast milk etc.

Magnets shall be used to remove the below mentioned kinds of foreign bodies –

–       facing downwards,
–       not fixed,
–       not having ear like appendages,
–       wide orifice of the wound,

Grief is also a foreign body and is produced by many causes. When such grief is present engulfing the heart and mind, it should be removed by administration of its opposite attribute i.e. creating joy in and around the patient.

Shalya aharana Marga: Routes of pulling out the foreign body

सर्वशल्यानां तु महतामणूनां वा द्वावेवाहरणहेत् भवत्:- प्रतिलोमोऽनुलोमश्च ॥६॥
तत्र प्रतिलोममर्वाचीनमानयेत्, अनुलोमं पराचीनम् ॥७॥

The modes of extraction of shalya – foreign bodies, immaterial of they being big or minute, are only of two kinds, they are –

Pratiloma Aharana – in this, the

–       shalya is pulled out in backward direction,
–       pulled out in the same direction of its entry
–       adopted when the foreign body has entered superficially, and only the first half of the body,

Anuloma Aharana – in this, the

–       shalya is pulled out in forward direction,
–       in the opposite direction of its entry
–       be adopted when the foreign body has entered deep inside the body i.e. into the other half of the body as well

When the shalya is pulled in the opposite direction of its entry, it damages a larger area of the body, thus leading to several complications and even death.

Yuddha Bhoomi chikitsa: Battlefield surgery

उत्तुण्डीतं छित्त्वा निर्घातयेच्छेदनीयमुखम् ॥८॥

When the front portion or tip (face of the shalya) of the foreign body is visible protruding out of the body, it should be cut at the other end. Later it should be pulled out either in Anuloma or pratiloma direction after shaking it i.e. moving it to and fro.

According to Master Dalhana, the region around the protruding foreign body should be cut. This would make the orifice wider facilitating its removal. Now it should be gently pulled in the opposite direction of its entry. Materials like thorn, leaf of date palm tree etc should be used for cutting the area around the shalya.

Method of removing the foreign body impacted in abdomen etc regions of the body

छेदनीयमुखान्यपि कुक्षिवक्षःवंक्षणपर्शुकान्तरपतितानि च हस्तशक्यं यथामार्गेण हस्तेनैवापहंर्तुं प्रयतेत॥९॥
हस्तेनैवापहर्तुमशक्यं विशस्य शस्त्रेण यन्त्रेणाहरेत् ॥१०॥

The surgeon should make all attempts to pull out the shalya by his hand itself in the direction of its entry when –

–       the foreign body is protruding out from the abdomen, chest, axilla, groin and space between ribs,
–       if the shalya can be held by hands

On the other hand, the shalya should be cut with the help of a sharp instrument and pulled out using yantras i.e. blunt instruments like forceps, if it is not possible to pull it out by hand.

Paschat Karma: Post-operative procedures

भवति चात्र:-
शीतलेन जलेनैनं मूर्च्छन्तमवसेचयेत् ।
 संरक्षेदस्य मर्मणि मुहुराश्वासयेच्च तम् ॥११॥

One verse here:-

Below mentioned measures should be done if the patient has fainted,

–       cold water should be sprinkled on him,
–       his marmas – vital organs / spots shall be preserved and protected
–       he should be assured and given courage

 ततः श्ल्यमुद्धृत्य निर्लोहितं व्रणं कृत्वा स्वेदार्हमग्रिघृतप्रभृतिभिः संस्वेद्यावदह्यप्रदिह्य सर्पिर्मधुभ्यां बद्धवाऽऽचारिकमुपदिशेत् ॥ (सिरास्नायुविलग्रंशलाकादिभिर्विमोच्यापनयेत्; श्वयथुग्रस्तवारङ्ग समवपीश्च श्वयथुं ; दुर्बलवारङ्ग कुशादिभिर्बद्ध्वा।)॥१२॥

Below mentioned procedures should be done after removing the foreign body –

–       nirlohitam – wound should be thoroughly cleansed and be made free of blood,
–       svedana – if the person is eligible for sudation, sudation should be given by burning the area / wound with fire (cauterization) or with warm ghee etc.
–       pradeha – now, the wound needs to be smeared with a mixture of ghee and honey
–       bandhana – now bandaging is done and
–       acharika – regimens related to food and activities is advised

हृदयमभितो वर्तमानं शल्यं शीतजलादिभिरुद्वेजितस्यापहरेद्यथामार्गं ; दुरुपहरमन्यतोऽपबाध्यमानं पाटयित्वोद्धरेत् ॥१३॥

अस्थिविवरप्रविष्टमस्थिविदष्टं वाऽवगृह्य पादाभ्यां यन्त्रेणापहरेत्, अशक्यमेवं वा बलवद्भिः सुपरिगृहीतस्य यत्रेण ग्रहयित्वा शल्यवारङ्ग प्रविभुज्य धनुर्गुणैर्बद्धवैकतश्चास्य पञ्चाङ्ग्चामुपसंयतस्याश्वस्य वक्त्रकविके बध्नीयात्, अथैनं कशया ताडयेद्यथोन्नामयन् शिरो वेगेन  शल्यमुद्धरति; दृढां वावृक्षशाखामवनम्य तस्यां पूर्ववद्वद्धवोद्धरेत् ॥१४॥

Below mentioned is the method of removing the foreign body (mainly arrow) that has entered into the bone cavity or is stuck tightly in the bone –

–       the physician should hold the position of the foreign body intact using both his legs (restraining any movements)
–       after fixing it, the physician using a yantra – blunt instrument such as forceps should pull the arrow out

The shalya (arrow) impacted in the cavity of the bone or in the bone itself shall be removed by using the below mentioned method if it is not possible to remove it by the above said methods –

–       strong persons / attendants should hold the patient tightly
–       with the help of an instrument, the shaft of the arrow should be bent
–       after bending the shaft, it should be fastened with five tailed bandages to the string of a bow at one end and to the reins of a horse at the other end,
–       the horse should now be whipped so that it would lift its head suddenly with force,
–       with this the arrow is pulled out

Doing it in the other method, the shaft of the arrow is tied to a strong branch of a tree which is bent down and then the branch is released. The force imparted by the released branch of the tree when released, pulls out the arrow. Thus, the arrow is pulled out.

अदेशोत्तुण्डितमष्टीलाश्ममुद्रराणमन्यतमस्य प्रहारेण विचाल्य यथामार्गमेव यन्त्रेण ॥१५॥

The shalya – arrow should be hit by a stone hammer or something similar to that, loosened and pulled out in the same way of its entry, especially so if it is stuck up in wrong places of the body wherein cutting is contraindicated i.e. abdomen, chest etc. and is seen protruding out.

विमृदितकर्णानि कर्णवन्त्यनाबाधकरादेकरदेशोत्तुण्डितानि पुरस्तादेव ॥।१६॥

The foreign body, mainly arrow, should be pulled out from the front only in the below mentioned conditions –

–       the arrow has ear like attachments which are not troublesome, and
–       not protruding out, then
–       its ear like attachments should be bent or constricted, following which,
–       the arrow should be pulled out from the front only

Kantha shalya: Foreign body in the throat

जातुषे कण्ठासक्ते कण्टे नाडीं प्रवेश्याग्रियप्तां च शलकं, तयाऽवगृह्य शीताभिरद्भिः परिषिच्य स्थिरीभूतं शल्यमुद्धरेत् ॥१७॥

Below mentioned are the steps of removing the foreign body made up of shell-lac is stuck up in the throat –

–       a hollow tube is inserted first into the throat and
–       a heated metal rod should be inserted through the tube until it touches the foreign body
–       when the hot rod touches it, the foreign body i.e. lac melts and adheres to the heated rod, now
–       the foreign body sticking to the hot rod is bathed with cold water, and
–       once the foreign body becomes stable by adhering to the rod, it should be gently pulled out

अजातुषं तु जतुमधूच्छिष्टप्रलिप्तया शलाकया पूर्वकल्पेनेत्येके ॥१८॥

On the other hand, according to the opinion of the other physicians, the foreign body which is not made up of shell-lac and is adhering in the throat etc should be pulled in the same manner described earlier – by using a rod which is smeared with lac of beeswax. When the foreign body sticks to the lac or wax, the rod shall be gently pulled out.

अस्थिशल्यमन्यद्वा तिर्यक्कण्ठासक्तमवेक्ष्य केशोण्डुकं द्दढैकदीर्घसूत्रबद्धं द्रवभक्तोपहितं पाययेदाकण्ठात् पूर्वाकोष्ठं च वामयेत्,  वमतशच शल्यैकदेशसक्तं ज्ञात्वा  सूत्रं सहासा त्वाक्षिपेत्, मृदुना  वा दन्तधावनकूर्चकेनापहरेत्  प्रणुदेद्वाऽन्तः । क्षतकण्ठाय च मधुसर्पिषीलेढुं प्रयच्छेत्रिफलाचूर्णों वा मधुशर्कराविमिश्रम् ॥१९॥

Below mentioned is the method of removing a piece of bone or similar such foreign body when it is stuck up horizontally inside the throat –

–       the patient should be made to swallow a ball of hairs, which has been
–       tied to a strong and long thread, along with
–       liquid foods which make swallowing the ball easier, later,
–       more liquid food should be consumed,
–       until the stomach is filled, following this,
–       the patient is made to vomit by tickling / stimulating his throat,
–       while the vomitus is coming out, the physician should make sure that the foreign body has stuck to
the hair ball and
–       suddenly pull the thread to which the ball was fastened hanging out from the mouth, alternatively,
–       the ball of hair shall be pulled out using a soft toothbrush made from twigs of plants

In spite of all these acts, if the shalya does not come out, it should be further pushed deep into the food pipe. While doing this, if any injury occurs to the throat, a mixture of honey and ghee should be given to the patient for licking. Alternatively, Triphala powder added with honey and sugar shall be given.

Udaka Nirharana: Removing water

उदकपुर्णोदरमवाक्शिरसमवपीडयेद्धुनीयाद्वामयेद्वा भस्मराशौव निखनेदामुखात् ॥२०॥

Below mentioned are the methods which need to be done to remove the water, when forcible immersion or accidental / intentional drowning causes filling of water in the abdomen of the patient,

–       the patient should be held with his head down, and
–       his abdomen shall be pressed and
–       his body should be shaken and
–       the patient made to vomit or alternatively,
–       the patient should be buried in a heap of ash, up to his face

Annagrasa Shalya: Bolus of food acting as foreign body:-

ग्रासशल्ये तु कण्ठासक्ते निशःङ्कमनवबुद्धं स्कन्धे मुष्टिनाऽभिहन्यात्, स्नेहं मद्यं पानीयं वा पाययेत् ॥।२१॥

The below mentioned steps should be followed to remove the bolus of food which has been blocked and choking in the throat and acting as a foreign body –

–       make the patient bend forward and
–       give a hard hit over his neck with the fist, without intimating the patient, with this,
–       the foreign body will come out or alternatively,
–       the patient is given oil or ghee for drinking of wine or water and push the foreign body towards the stomach

Kantha rodha: Strangulation

बाहुरज्जुलतापशैः कण्ठपीडनाद्वायुः प्रकृपितः श्लेष्माणं कोपयित्वा स्त्रोतो निरुणाद्धि,  लालास्त्रावं फेनागमनं संज्ञानाशं चापादयति, तमभ्यज्य  संस्वेद्य शिरोविरेचनं तस्मै तीक्ष्णं विदध्याद्रसं च वातघ्नं दद्यादिति ॥ २२॥

When the throat  is held tight (with force) by the arms, rope or creepers, then Vata gets aggravated. The aggravated vata would aggravate the slesma (kapha). Both these doshas (vata and kapha) would cause blockage of the passages of the throat.

Due to this, salivation, froth coming out of the mouth and loss of consciousness are caused.

The below mentioned should be given to such a person to mitigate Vata –

–       anointment or herbal oil massage
–       sudation
–       strong errhines to purge the head
–       meat soup

भवन्ति चात्र:-
शल्यकृतिविशेषांश्च स्थानान्यावेक्ष्य  बुद्धिमान् ॥
तथा यन्त्रपृथक्त्वं च सम्यक् शल्यमथाहरेत् ॥२३॥
कर्णवन्ति तु शल्यानि दुःखाहार्याणि यानि च ॥
आददीत भिषक् तस्मात्तानि युक्त्या समाहितः ॥२४॥

 एतैरुपायैः शल्यं तु नैव निर्यात्यते यादि।

 मत्या निपुणया   वैद्यो यन्त्रयोगैश्च निर्हरेत् ॥२५॥

 शोथापाकौ रुजश्चैग्राः कुर्याच्छल्यमनाहृतम् ॥

वैकल्यं मरणं चापि तस्मद्यत्नाद्विनिर्हरेत् ॥२६॥

Some verse here:-

The intelligent physician should pull out the foreign body after carefully observing –

–       the shape of the foreign body
–       the place of lodgement of foreign body and after deciding
–       the instruments which need to be used to remove the foreign body

The foreign bodies shall be carefully removed with appropriate methods when –

–       they have ears attached and
–       are difficult to pull out

If the foreign body cannot be extracted or removed by the above mentioned methods, the physician should remove them using his skill or using blunt instruments.

If the foreign body is not removed it would produce swelling, suppuration (formation of pus), severe types of pains, deformities and even death.

Therefore, these foreign bodies should be carefully removed effortfully.

इति  श्रीसुश्रुतसंहितायां सूत्रस्थाने शल्यापनयनीयो नाम सप्ताविंशतितमोऽध्यायः ॥२७॥

Thus ends the Twenty seventh Chapter by name shalyapanayaniya in Sutra Sthana of Susruta Samhita.