Now the chapter on the eight kinds of surgical procedure will be explained, as taught by Bhagavan Dhanvantari. Conditions designated for excision include bhagandara, granthi, a kapha-origin tilakalaka, wound margins, arbuda, arshas, carmakila involving bone or flesh, a foreign body, jatumanimamsasanghata, galashundika, putrefaction of ligaments, flesh or vessels, valmika, shataponaka, adhrusha, upadamsha, mamsakandi and adhimamsaka.
Because excision was previously introduced, its particular indications are listed first. The kapha granthi intended here is unripe, not already suppurated. Tilakalaka is the condition listed among minor diseases, not the condition bearing that name among disorders of the penis, which is considered incurable. Vranavartman means a moist wound lip or margin. All varieties of arbuda are included. The arshas intended are the vata and kapha types. Carmakila is a fleshy projection beside the anus. Kotha, meaning putrefaction, applies separately to ligament, flesh and vessel. Shataponaka is listed among disorders of the penis. Others say it is named again despite already being included under bhagandara to prescribe complete excision, since no other remedy applies.
Key terms
chedya
A condition designated for excision, the first of the eight operative categories.
भेद्या विद्रधयोऽन्यत्र सर्वजाद्ग्रन्थयस्त्रयः ||५||
आदितो ये विसर्पाश्च वृद्धयः सविदारिकाः |
प्रमेहपिडकाः शोफः स्तनरोगोऽवमन्थकाः ||६||
कुम्भीकानुशयी नाड्यो वृन्दौ पुष्करिकाऽलजी |
प्रायशः क्षुद्ररोगाश्च पुप्पुटौ तालुदन्तजौ ||७||
तुण्डिकेरी गिलायुश्च पूर्वं ये च प्रपाकिणः |
बस्तिस्तथाऽश्मरीहेतोर्मेदोजा ये च केचन ||८||
Meaning of the śloka
Conditions designated for incision include vidradhi except the type arising from all doshas, the three dosha-specific granthis, the first three types of visarpa, vriddhi together with vidarika, prameha pidaka, shopha, breast disease, avamanthaka, kumbhika, anushayi, nadi, ekavrinda and vrinda, pushkarika, alaji, most minor diseases, palatal and dental pupputa, tundikeri, gilayu, conditions previously said to suppurate, the urinary bladder specifically because of a stone, and disorders arising from medas.
The three granthis are those from vata, pitta and kapha. The first three visarpa types are likewise vata, pitta and kapha. Vidarika belongs to the minor diseases, avamanthaka and pushkarika to disorders of the penis, and ekavrinda and vrinda to throat diseases. Palatal pupputa and dental pupputa are both included. The earlier suppurating disorders include bhagandara and others. The bladder is incised only when a urinary stone is the cause, not for another cause; the source reasons that non-incision then brings certain death while incision has an uncertain result.
Conditions designated for scraping include the four treatable rohini types, kilasa, upajihvika, medas-origin disease, dantavaidarbha, granthi, wound and eyelid margins, adhijihvika, arshas, mandala lesions, mamsakandi and raised flesh.
The four rohini types are those arising from vata, pitta, kapha and their combination. The blood-origin type is omitted because it is considered invariably incurable. Vartman includes both the margin of a wound and the eyelid. Mandala refers to circular lesions of itching skin disease and related conditions. Mamsakandi is a small fleshy sprout.
Key terms
lekhya
A condition designated for scraping.
Adhikarana ൪ (൧൦) · Śloka ൧൦
വേധ്യാഃ സിരാ ബഹുവിധാ മൂത്രവൃദ്ധിര്ദകോദരമ് ||൧൦||
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वेध्याः सिरा बहुविधा मूत्रवृद्धिर्दकोदरम् ||१०||
Meaning of the śloka
The many vessels, urinary retention, and dakodara are designated for puncturing.
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വേധ്യവിഷയം ദര്ശയന്നാഹ- വേധ്യാ ഇത്യാദി||൧൦||
Meaning of the commentary
This is the list of subjects for vedhya, the puncturing procedure.
Key terms
vedhya
A condition or structure designated for puncturing.
Adhikarana ൫ (൧൧) · Śloka ൧൧
ഏഷ്യാ നാഡ്യഃ സശല്യാശ്ച വ്രണാ ഉന്മാര്ഗിണശ്ച യേ |൧൧|
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एष्या नाड्यः सशल्याश्च व्रणा उन्मार्गिणश्च ये |११|
Meaning of the śloka
Nadi tracts, wounds containing a foreign body, and tracts that follow an abnormal course are designated for probing.
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ഏഷ്യവിഷയം ദര്ശയന്നാഹ- ഏഷ്യാ ഇത്യാദി| ഏഷ്യാ ഇതി ലോഹാദിശലാകയാऽന്തരന്വേഷണീയാ ഇത്യര്ഥഃ, ശല്യസ്ഥിതിജ്ഞാനാര്ഥം, സുഖേനാപകര്ഷണായ ച| ഉന്മാര്ഗീ തിര്യഗ്ഗതിഃ|൧൧|-
Meaning of the commentary
Eshya means that the interior is to be explored with a metal or similar probe in order to locate a foreign body and facilitate its removal. Unmargi means following a transverse or otherwise abnormal course.
Key terms
eShya (eshya)
Designated for internal exploration with a probe.
unmArgin (unmargin)
A tract running in an abnormal or transverse direction.
Conditions or objects designated for extraction include the three kinds of sharkara, tooth and ear deposits, urinary stone, foreign bodies, an obstructed fetus, and feces accumulated in the rectum.
Conditions designated for drainage include the five vidradhis other than the type arising from all doshas; kushtha; painful vata; localized swelling; diseases of the ear lobe; shlipada; blood affected by poison; arbuda; the first three types of visarpa and granthi; three types each of upadamsha; breast diseases; vidarika; sushira according to one transmitted reading; galashaluka; kantaka; krimidantaka; dantaveshta with upakusha; shitada; dental pupputa; lip diseases arising from pitta, blood or kapha; and most minor diseases.
Conditions designated for suturing include divided disorders arising from medas after they have been completely scraped, fresh traumatic wounds, and wounds especially situated at movable joints.
Medas-origin conditions includes any disorders produced from medas. Bhinna means split open. Completely scraped means scraped without leaving a remainder. Vyapashrita indicates being especially or closely situated at a movable joint. Some read sadhya, treatable, in this passage.
Key terms
sIvya (sivya)
A wound or condition designated for suturing.
Adhikarana ൯ (൧൭) · Śloka ൧൮
ന ക്ഷാരാഗ്നിവിഷൈര്ജുഷ്ടാ ന ച മാരുതവാഹിനഃ ||൧൭||
നാന്തര്ലോഹിതശല്യാശ്ച... |൧൮|
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न क्षाराग्निविषैर्जुष्टा न च मारुतवाहिनः ||१७||
नान्तर्लोहितशल्याश्च... |१८|
Meaning of the śloka
Wounds affected by alkali, fire or poison, wounds carrying air, and wounds containing blood or a foreign body internally are not to be sutured.
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അഥ കേ ന സീവ്യാ ഇത്യാഹ- ന ക്ഷാരേത്യാദി||൧൭||
Meaning of the commentary
This passage identifies exceptions to the preceding list of wounds designated for suturing.
Adhikarana ൧൦ (൧൮) · Śloka ൧൮
... തേഷു സമ്യഗ്വിശോധനമ് |൧൮|
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... तेषु सम्यग्विशोधनम् |१८|
Meaning of the śloka
In those cases, proper cleansing should be performed.
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തേഷു കിം കര്തവ്യമിത്യാഹ- തേഷ്വിത്യാദി|൧൮|-
Meaning of the commentary
The instruction answers what should be done for the wounds excluded from suturing: they should receive appropriate cleansing.
Key terms
samyagvishodhana
Proper cleansing or purification prescribed in place of suturing for the preceding wounds.
Dust, hair, nails, fragments such as these, and any loose piece of bone should be removed from a wound. If left in place, they cause severe suppuration and many kinds of pain; therefore, the wound should be cleared of them.
The passage identifies what must be removed in cleansing the wound. Some witnesses read grass and similar foreign material instead of dust, hair and nails. The following line explains why removal is required.
Key terms
vishodhayet
Should cleanse the wound by removing the listed foreign material and loose bone.
The wound should then be raised and restored to its proper position and sutured gently with fine thread, bark fiber of ashmantaka, thread of hemp or flax, ligament-like material, hair, or fibers of murva, guduci or tana. According to the site, the suture may be vellitaka, gophanika, tunnasevani or rjugranthi. In a region with little flesh and at a joint, a round needle two finger-breadths long is used; in a fleshy region, a three-edged needle three finger-breadths long is preferred. A bow-curved needle is suitable over a vital point, scrotum or abdomen. These three needle types should have sharp points, be well made and rounded like the stalk-tip of a malati flower. During suturing, the needle should be placed neither too far from nor too close to the wound edge: distant placement causes pain, while placement too near causes tearing of the margin.
Of the eight procedures beginning with excision, the placement of seven is described elsewhere, while suturing is detailed here. Samunnamya means raising the tissue. Ashmantaka is a tree resembling amlalotaka. Kshauma is flax fiber. The ligament-like material is a bowstring-tying secondary tissue shaped like hemp. Murva is identified as caurasnayu, used in eastern regions to make bowstrings; others identify it as a paired-leaf vine resembling kovidara. Tana means fibers. Vellitaka is curved, gophanika resembles a sling, tunnasevani joins tissue as weavers join torn cloth, and rjugranthi has a fastening resembling a straight knot. Tryasra means three-edged. Phalakosha is the scrotum. Susamahita is glossed as well fashioned or fit for the hand, and parimandala as rounded. Avaluncana means tearing.
Key terms
sIvyet (sivyet)
Should suture after restoring the wound margins to their proper position.
vellitakam
A curved form of suture.
tunnasevanIm (tunnasevanim)
A suture likened to the way a weaver joins torn cloth.
अथ क्षौमपिचुच्छन्नं सुस्यूतं प्रतिसारयेत् |
प्रियङ्ग्वञ्जनयष्ट्याह्वरोध्रचूर्णैः समन्ततः ||२७||
शल्लकीफलचूर्णैर्वा क्षौमध्यामेन वा पुनः |
ततो व्रणं यथायोगं बद्ध्वाऽऽचारिकमादिशेत् ||२८||
Meaning of the śloka
After a wound has been properly sutured, it should be covered with flax cloth and cotton and dusted all around with powders of priyangu, anjana, yashtyahva and rodhra, or with powder of shallaki fruit, or with ash of flax cloth. The wound should then be bandaged as appropriate and the rules of conduct prescribed.
This is the care described after suturing. Kshauma is flax cloth and picu is cotton; the wound is covered with both. Pratisarayet means to dust with powder, and anjana here is sauviranjana. Samantatah means on every side. Kshaumadhyama is ash from flax cloth. The prescribed conduct is that taught in the chapter on attendance upon a wounded patient. Some witnesses present the procedures beginning with excision entirely in prose up to the instruction to bandage and prescribe conduct.
Key terms
pratisArayet (pratisarayet)
Should dust the covered, sutured wound with the stated powder.
AcArikam (acarikam)
The prescribed regimen of conduct for a wounded patient.
The present account is concise and a fuller account is promised later. The number eight is repeated specifically to reject Charaka's enumeration of six procedures.
Key terms
aShTavidhaM karma (ashtavidham karma)
The eightfold set of surgical procedures summarized in the chapter.
हीनातिरिक्तं तिर्यक् च गात्रच्छेदनमात्मनः |
एताश्चतस्रोऽष्टविधे कर्मणि व्यापदः स्मृताः ||३०||
Meaning of the śloka
The four complications recognized in the eight procedures are an insufficient operation, an excessive operation, an oblique operation, and cutting one's own limb while operating.
The verse states complications common to all eight procedures. Cutting one's own limb means the operator injuring the operator's own body during the procedure. Others read that there are three complications, but the commentator calls this an erroneous reading.
Key terms
vyApadaH (vyapadah)
Complications or operative errors associated with the eight procedures.
When a physician applies an inadequate instrument or procedure through ignorance, greed, following harmful counsel, fear, confusion or other such causes, the physician produces further disorders.
The passage lists causes of operative complications. Harmful counsel means acting on an enemy's advice. Pramoha means mental confusion, and other causes include distraction by competing purposes. Kushastra is interpreted as an instrument or operation that is deficient or insufficient. The physician thereby causes additional disorders.
Key terms
kushastram
An inadequate or insufficient instrument or operative application.
A person wishing to live should avoid from a distance a physician who repeatedly applies alkali, instruments, fire and medicines without sound reasoning, regarding that physician as comparable to a powerful poison or an enemy.
The verse tells the patient how to respond to a physician corrupted by the faults of ignorance and the other causes just listed. Such a person merely moves under the guise of a physician and acts without appropriate reasoning. Avoiding the physician from afar is explained as not even presenting oneself for examination.
Key terms
ayuktiyuktam
Acting without appropriate reasoning or proper method.
That same instrument, when applied excessively, may injure vital points, joints, vessels, ligaments and bone. When used by a fool, it may separate a person from life in an instant or at another time.
After the complication of insufficient use, the verse describes excessive instrumental action. 'That same' refers to the instrument; applied means put into use, and excessive emphasizes that it is used beyond the proper measure. Separation from life means causing death.
General signs when a vital point, joint, vessel, ligament or bone is pierced include dizziness, delirious speech, falling, confusion, loss of movement, stupor, bodily heat, looseness of the limbs, fainting, upward-moving breath, severe pains attributed to vata, blood resembling meat-washing water, and cessation of all sensory functions.
Having stated five forms of injury from excessive instrument use through cutting vital points, joints, vessels, ligaments and bones, the passage gives their shared signs. Dizziness is likened to the feeling of riding something that spins. Pralapa is incoherent speech, falling is inability to remain upright, and pramoha is impaired awareness rather than complete loss of mind. Vicestana is absence of bodily movement, samlayana is mental inactivity resembling deep sleep, and heat is generalized burning of the body. Looseness of the limbs is bodily flaccidity; fainting is loss of consciousness. Urdhvavata here means difficult or upward breathing, not the separately named disease. The blood resembles water used to wash meat. Cessation means withdrawal of the functions of all senses. The expression 'numbered as half of ten' refers to the five injured structures named in the earlier verse.
Key terms
saMlayanam (samlayanam)
Mental inactivity or stupor resembling the state of deep sleep.
UrdhvavAtaH (urdhvavatah)
Upward or difficult breathing in this context, not the separately named disease.
When vessels are cut or pierced, abundant blood resembling the indragopa insect flows from the injury, and vata produces the various disorders previously described. Injury to a ligament is recognized by two forms of bending deformity, loss of function in a body part, inability to perform movements, intense pain and delayed wound healing. Injury to a movable or immovable joint produces extreme swelling, severe pain, loss of strength, splitting pain and swelling at the joint, and cessation of joint function. Bone injury is recognized when terrible pain has no relief by night or day or in any position, together with thirst, weakness of the limbs, swelling and pain.
These are signs of injury to non-vital vessels, ligaments, joints and bones. Vessel blood is compared to the indragopa insect. The various vata disorders include conditions previously described in the account of blood, such as head disease and adhimantha. Kaubjya comprises two kinds of abnormal bending, inward and outward. Loss of function in a body part means inability to perform its own action. General inability of the body concerns movements such as raising, lowering, extending and flexing. Tumula pain means deep or intense pain; others define it as pains generated by vata, pitta and kapha becoming confused together in one site. Bheda at a joint is a sensation like splitting. Movable joints include those of the limbs, jaw, hands and neck.
Key terms
snAyuviddham (snayuviddham)
Injury involving a ligament, recognized by deformity, functional loss, severe pain and delayed healing.
tumulA rujaH (tumula rujah)
Deep or intense pains; alternatively, pains of all three doshas confused together at one site.
After describing injury signs in vessels and other structures away from marmas, the verse extends the corresponding signs to injured vessel-based and other marmas. By construing 'and' with 'these,' the commentary includes both the previously stated signs such as confusion and delirium and the appropriate signs of injured vessels and other structures within the marma.
Adhikarana ൨൨ (൪൦) · Śloka ൪൦
സ്പര്ശം ന ജാനാതി വിപാണ്ഡുവര്ണോ യോ മാംസമര്മണ്യഭിതാഡിതഃ സ്യാത് ||൪൦||
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स्पर्शं न जानाति विपाण्डुवर्णो यो मांसमर्मण्यभिताडितः स्यात् ||४०||
Meaning of the śloka
A person whose muscular marma has been struck does not perceive touch and becomes markedly pale.
This supplies the previously unstated signs of injury to a muscle-based marma. Injury to muscle alone was not listed earlier because its effects are not widely distributed. Some teachers assign the earlier confusion, delirium and related signs to the five prognostic classes of marma. They also apply the previously stated vessel and other structural injury signs specifically to corresponding marmas rather than to those structures outside marmas, and incorporate the preceding 'according to each' line into that series without giving an independent force to 'and.'
Key terms
mAMsamarma (mamsamarma)
A vital point constituted predominantly by muscle.
आत्मानमेवाथ जघन्यकारी शस्त्रेण यो हन्ति हि कर्म कुर्वन् |
तमात्मवानात्महनं कुवैद्यं विवर्जयेदायुरभीप्समानः ||४१||
Meaning of the śloka
An inferior operator who, while performing a procedure, injures his own body with the instrument harms himself. A discerning patient who desires life should avoid such an incompetent physician who cuts himself.
This describes the mishap of a physician cutting his own limb because he lacks skill in grasping, holding and using the instrument. Jaghanyakari means one who performs extremely deficient work. Atmavan is the intelligent patient understood in the sentence. Atmahan means one who cuts himself; some read atmatuda, one who pierces himself.
The faults caused by placing an instrument obliquely were stated earlier. Therefore the operator should make the instrument's incision while avoiding those faults.
The earlier Agropaharaniya chapter lists faults such as cutting vessels and ligaments. This verse cautions against complications from oblique placement of the surgical instrument.
मातरं पितरं पुत्रान् बान्धवानपि चातुरः |
अप्येतानभिशङ्केत वैद्ये विश्वासमेति च ||४३||
विसृजत्यात्मनाऽऽत्मानं न चैनं परिशङ्कते |४४|
Meaning of the śloka
A patient may distrust mother, father, sons and relatives, yet places trust in the physician. Of his own will he entrusts his body to the physician and does not suspect him.
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ഇദാനീം വൈദ്യം പ്രത്യാതുരേണ കിം കര്തവ്യമിത്യാഹ- മാതരമിത്യാദി| അത്ര ശ്ലോകേ പ്രഥമോऽപിശബ്ദഃ സമുച്ചയേ, ദ്വിതീയസ്തു സമ്ഭാവനായാമ്| വിസൃജതി ദദാതി| ആത്മനാ സ്വയമേവ| ആത്മാനം ശരീരമ്| ഏനം വൈദ്യമ്||൪൩||-
Meaning of the commentary
The first 'even' adds the relatives to the list, while the second expresses possibility. Visrijati means gives or entrusts; atmana means voluntarily, atman means the body, and enam refers to the physician.
Adhikarana ൨൬ (൪൪) · Śloka ൪൪
തസ്മാത് പുത്രവദേവൈനം പാലയേദാതുരം ഭിഷക് ||൪൪||
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तस्मात् पुत्रवदेवैनं पालयेदातुरं भिषक् ||४४||
Meaning of the śloka
Therefore the physician should protect and care for that patient as for a son.
By undertaking beneficial work, the physician obtains dharma, material benefit, fame, the highest esteem among good people, and residence in heaven.
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സമ്യക്പാലനേ മഹദേവ ഫലം ഭവതീതി ദര്ശയന്നാഹ- ധര്മാര്ഥാവിത്യാദി| സതാം ഗ്രഹണമുത്തമമിതി ശിഷ്ടാനാം മധ്യേ ഗ്രഹണമുപാദാനമുത്തമം ഭവതീത്യര്ഥഃ||൪൫||
Meaning of the commentary
The verse states the great reward of properly caring for the patient. 'Highest acceptance among the good' means being held in the highest regard among cultivated people.
Even a curable disease may require several procedures. Karma may refer to the surgical procedures beginning with excision or to measures beginning with oleation. The inclusive wording also allows five or more. Some place the preceding verse on dharma and fame at the end of the chapter.