अथातः शल्यापनयनीयमध्यायं व्याख्यास्यामः ||१||
यथोवाच भगवान् धन्वन्तरिः ||२||
शल्यं द्विविधमवबद्धमनवबद्धं च ||३||
Meaning of the śloka
Now the chapter concerning removal of foreign bodies will be explained, as taught by Bhagavan Dhanvantari. A foreign body is of two kinds: firmly lodged and not firmly lodged.
Avabaddha means especially or firmly attached. Others explain a foreign body that has entered bone or a similar structure as avabaddha and all other foreign bodies as anavabaddha.
Key terms
avabaddha shalya
A firmly lodged foreign body, alternatively one embedded in bone or a comparable structure.
Fifteen means for removing a foreign body that is not firmly lodged are stated in summary: natural action, maturation, incision, splitting, pressure, wiping, expulsion by blowing, emesis, purgation, washing, rubbing, bearing down, suction, a magnet, and joy.
Natural action means the body's own process. Maturation uses ripening substances for an unripe embedded object. Incision opens it with instruments such as the vriddhipatra, while splitting uses medicines such as cirabilva described in the Mishraka section. Pressure employs the specified slimy substances. Wiping is done with hair, cloth or similar material. Nirdhmapana is blowing medicinal powder such as pippali or katphala through a tube into the nose. Pratimarsha is rubbing with a finger or similar means. Pravahana is bearing down or straining, with a variant form of the term in the commentary. Suction is performed with the mouth or a horn. Ayaskanta here specifically means an attracting magnetic stone. Harsha means joy or delight.
Dust and similar small foreign matter may fall from the eyes and other sites through natural tears, sneezing, belching, coughing, urine, feces and flatus. A foreign body deeply lodged in flesh that is not maturing is first made to mature; when the flesh decomposes, it falls out through the force of pus and blood or through its own weight. A ripe collection that does not open is incised or split. After opening, if its contents do not come out, it is pressed with prescribed substances or with the hands. Minute foreign matter in the sense organs is removed by irrigation, blowing, hair, cloth or the hand. Small remnants of food or broken foreign matter lodged in the nose and related passages are expelled through breathing, forceful coughing or blowing. Food obstructions are removed by emesis or finger rubbing, those in pakvashaya by purgation, and pus or other matter in a wound cavity by washing. Bearing down is prescribed for obstruction of flatus, urine, feces or fetus. Air, water, poisoned blood and corrupted breast milk are removed by suction with the mouth or horns. A smooth, unbarbed iron foreign body aligned with its course and having an adequately large wound opening may be removed with a magnet. A grief lodged in the heart and arising from many causes is removed through joy.
The passage assigns a subject to each of the fifteen means. Natural power is the inherent force by which tears and the other discharges expel dust-like matter. Deeply lodged means situated internally, and flesh decomposition supplies the pus and blood that drive the object outward. Aksha means the sense organs; irrigation is pouring in a stream and adhmApana here includes directing air from the mouth toward the eye. Food residue can mean food remaining in a nasal or similar passage, while hina-anu-shalya means a small fragment of a foreign body that has fallen or broken away. Nirdhamana means expelling it. Finger pratimarsha is rubbing with a finger. In washing, wound dosha means pus, itself treated as shalya, along with other foreign matter in the wound cavity. Sanga means non-progression or obstruction. Some authorities exclude incision, splitting, pressure, emesis, purgation and washing from the means for anavabaddha shalya. They assign incision and splitting to firmly lodged foreign bodies and subsume the other four under methods already stated, as appropriate.
Key terms
pravAhaNa (pravahana)
Bearing down or straining to overcome obstruction of flatus, urine, feces or fetus.
AcUShaNa (acushana)
Suction with the mouth or a horn in the situations listed by the source.
Adhikarana ௪ (௬) · Śloka ௬
ஸர்வஶல்யாநாஂ து மஹதாமணூநாஂ வா த்வாவேவாஹரணஹேதூ பவதஃ- ப்ரதிலோமோऽநுலோமஶ்ச ||௬||
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सर्वशल्यानां तु महतामणूनां वा द्वावेवाहरणहेतू भवतः- प्रतिलोमोऽनुलोमश्च ||६||
Meaning of the śloka
For all foreign bodies, whether large or minute, there are only two general directions of removal: against their course and along their course.
The five possible trajectories are reduced to two removal approaches according to whether removal follows the entry path. Pratiloma removes the object back through its path of entry, while anuloma removes it in the opposite direction, continuing onward.
Key terms
pratiloma AharaNa (pratiloma aharana)
Removal back through the route by which the foreign body entered.
anuloma AharaNa (anuloma aharana)
Removal onward in the direction opposite to withdrawal through the entry route.
A foreign body that remains on the nearer side should be brought out against its course through the entry path. One that has passed to the farther side should be brought out along its course.
Arvacin is an object that has not entered far and remains in the nearer half of the body relative to its entry wound. It is withdrawn through that same path. Continuing such an object forward could injure a much larger uninjured region and lead to death or complications. Paracin is an object that has entered deeply and emerged into the farther half; it is carried onward toward that farther region.
Key terms
arvAcIna shalya (arvacina shalya)
A foreign body lodged relatively near its point of entry and selected for withdrawal through that path.
parAcIna shalya (paracina shalya)
A foreign body that has passed deeply toward or into the far side and is selected for onward removal.
Adhikarana ௬ (௮) · Śloka ௮
உத்துண்டிதஂ சித்த்வா நிர்காதயேச்சேதநீயமுகம் ||௮||
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उत्तुण्डितं छित्त्वा निर्घातयेच्छेदनीयमुखम् ||८||
Meaning of the śloka
When a foreign body with a head that must be cut projects outward, cut the projecting part and then loosen or dislodge it for removal.
This concerns an object that, because it entered with limited force, has emerged on the far side with its head projecting, while its cuttable portion remains caught in the tissues. Uttundita means projecting upward like a protruding mouth. Nirghatayet means moving it from side to side by hand or with a mallet-like implement, after which it is removed onward. Heads like a thorn or date-palm leaf are examples. Thus an object with a cuttable projecting head on the far side and a portion caught in the cut tissue is assigned to forward, anuloma removal.
Key terms
uttuNDita (uttundita)
Projecting outward or upward at the far-side opening.
chedanIyamukha (chedaniyamukha)
A foreign-body head whose projecting or caught portion is described as requiring cutting.
छेदनीयमुखान्यपि कुक्षिवक्षःकक्षावङ्क्षणपर्शुकान्तरपतितानि च हस्तशक्यं यथामार्गेण हस्तेनैवापहर्तुं प्रयतेत ||९||
Meaning of the śloka
Foreign bodies with heads that would otherwise be cut, when lodged in the abdomen, chest or heart region, armpit, groin or between the ribs, should be removed by hand through their entry path whenever manual removal is possible.
Vakshas is interpreted here as the heart region. Hastashakya means a foreign body that can be removed by hand, and yathamarga means through its entry path. It should be extracted manually and not shaken with a mallet or similar means. An alternative reading begins with foreign bodies whose heads are not to be cut. On that view, both non-projecting objects and those with non-dislodgeable heads in the listed regions are withdrawn without cutting or shaking. Even a deeply directed object otherwise eligible for forward removal should be drawn back through its entry route there, because forward removal would require a large additional incision. Some append a verse from the Bhoja Samhita saying that non-projecting objects and cuttable heads should not be dislodged because of the extensive incision that would result, but the commentator rejects this as an erroneous addition absent from the authoritative commentaries.
In the main reading, vishasya means cutting or opening the tissues with a surgical instrument before extraction with a device. Some instead read that when it cannot be removed by hand, it should be removed with an instrument without cutting. In that interpretation, the conjunction implies that if extraction with the device is also impossible, the object is first cut free.
Key terms
yantra
An extracting instrument or device used when manual removal is not possible.
If the patient faints during removal of a foreign body, the patient should be sprinkled with cold water. The vital points should be protected, and the patient should repeatedly be reassured and revived.
The verse gives care for a complication during foreign-body extraction. 'This person' means the patient with the foreign body, and avasecayet means to sprinkle. Reassurance or revival may include giving milk-based nourishment and similar support. Many witnesses omit this passage, but Gayadasa reads and explains it at this point. The commentator regards it as appropriate and says it should be retained.
Key terms
AshvAsayet (ashvasayet)
Should reassure or revive the patient, including through the supportive measures mentioned by the commentary.
After removing the foreign body, bleeding should be stopped. If the wound is suitable for fomentation, it should be warmed with fire, warm ghee or related means, cauterized where indicated, covered with an application, anointed with ghee and honey, bandaged, and followed by prescribed conduct. A parenthetical passage adds that an object attached to a vessel or ligament should be freed with a probe or similar instrument before removal; a swollen instrument shaft should be released by compressing the swelling, and a weak shaft should be bound with kusha or similar support before removal.
The passage describes care after extraction. Nirlohita means made free of bleeding. A wound with excessive blood loss and no pain is warmed with comfortably warm ghee, while other suitable wounds are warmed with fire. Avadahya means cauterizing wounds for which fire treatment is indicated. Pradihya means applying a paste and applies especially to a wound not suitable for fomentation or one with excessive bleeding. Some witnesses omit cauterization and read 'nourishing' in place of 'applying a paste.' The parenthetical instructions are traced to Bhoja: varanga means the shaft of an instrument, the swelling is compressed to permit its removal, and a weak shaft is tied to a rod of bamboo, cane or similar material before being withdrawn. The commentator says this method belongs to another treatise, was inserted here by readers unwilling to consult that source, and should not be accepted as part of the Sushruta text.
Key terms
nirlohitam
Made free from active bleeding after removal of the foreign body.
vAra~ggam (varangam)
The shaft of the instrument in the parenthetical procedure attributed to another treatise.
A foreign body lying near the heart should be displaced by cold water and similar means and then removed along the path by which it entered. If it is difficult to remove that way and presses upon a vital point from another location, an opening should be made there and the object extracted.
This is a special method for an object that has fallen into the chest and lies near the heart. Cold water is used to startle or shift the heart and relieve fatigue. Yathamarga means removal through the same track by which the object entered. If that is impossible, the difficult object pressing on a vital point may be approached at another location by splitting or opening the tissue.
Key terms
yathAmArgam (yathamargam)
Along the original path by which the foreign body entered.
durupaharam
A foreign body that can be removed only with difficulty.
An object lodged in a bone cavity or tightly gripped by bone should be held with the feet and removed with an instrument. If that fails, strong attendants should hold the patient securely; the shaft of the object should be grasped with an instrument, bent, and tied with bowstrings. One end is then attached to the ring at the mouth-bridle of a horse restrained with a pancangi binding. The horse is struck so that, raising its head forcefully, it pulls out the object. Alternatively, a strong tree branch is bent down, the object is tied to it in the same manner, and it is extracted as the branch rebounds.
This historical passage describes extraction when an impacted object cannot be removed by hand. A bone-cavity object lies within a hole in bone, while asthividashta means firmly stuck. The patient is held securely, the shaft is bent, and bowstrings made of murva or arka fiber are used. Pancangi is a type of binding. The horse's kavika is a ring at its mouth or bridle. An alternative uses a strong branch bent downward. Some read pancangi instead of 'strong branch' and interpret it as a branch with five subsidiary branches. Others identify pancangi collectively with plaksha, ashvattha, udumbara, nyagrodha and vetasa. A further variant rearranges the horse and branch instructions, describing attachment directly to the horse's bridle ring or to a bent pancangi or other tree branch.
Key terms
asthividaShTam (asthividashtam)
A foreign body tightly gripped or firmly impacted in bone.
pa~jcA~ggyAm (pancangyam)
A particular five-part binding; in variant explanations, a five-branched limb or a group of five named trees.
An object protruding at an unsuitable site should be loosened by a blow from an ashthila, stone or mallet, then removed with an instrument along its original path.
The method concerns an object tightly held by bone and protruding at a site such as the flank where making an incision is unsuitable. The omitted verb is 'should remove.' Some witnesses read 'protruding at the bone site' rather than 'protruding at an unsuitable site.'
Key terms
adeshottuNDitam (adeshottunditam)
Protruding at a site considered unsuitable for a new incision.
A barbed foreign body protruding at a site where it will not cause injury should first have its barbs crushed or folded inward and should then be drawn out forward through that site.
The passage explains extraction of a barbed object. Vimrditakarna means making its barbs contracted or folded inward. Purastat means through the region in front of the object; the omitted action is that it should be drawn out there.
Key terms
karNavanti (karnavanti)
Foreign bodies furnished with barbs or ear-like projections.
vimRuditakarNAni (vimrditakarnani)
Having the barbs crushed, contracted or folded inward before extraction.
When a lac-made foreign body is lodged in the throat, a tube is inserted into the throat and a fire-heated probe passed through it. The object is grasped by the heated probe, sprinkled with cold water until it becomes firm, and then removed.
Jatusha means made of lac, and throat-lodged means caught in the gullet. The tube is made of copper or another suitable material. Cooling makes the lac object adhere firmly. The commentary explains that children play with lac objects and may accidentally swallow them, for which this method is stated. Others think the reference is to lac material lodged or attached specifically in vessels and similar structures.
Key terms
jAtuShe (jatushe)
A foreign body made of lac.
sthirIbhUtam (sthiribhutam)
Made firm after cooling so that the object adheres for extraction.
अस्थिशल्यमन्यद्वा तिर्यक्कण्ठासक्तमवेक्ष्य केशोण्डुकं दृढैकदीर्घसूत्रबद्धं द्रवभक्तोपहितं पाययेदाकण्ठात् पूर्णकोष्ठं च वामयेत्, वमतश्च शल्यैकदेशसक्तं ज्ञात्वा सूत्रं सहसा त्वाक्षिपेत्; मृदुना वा दन्तधावनकूर्चकेनापहरेत् प्रणुदेद्वाऽन्तः |
क्षतकण्ठाय च मधुसर्पिषी लेढुं प्रयच्छेत्त्रिफलाचूर्णं वा मधुशर्करामिश्रम् ||१९||
Meaning of the śloka
On observing a bone or other foreign body lodged transversely deep in the throat, the text directs giving liquid food containing a hair-ball firmly tied to a single long thread until the stomach is full, then inducing vomiting. When the foreign body catches in the ball during vomiting, the thread is pulled suddenly. Alternatively, it may be removed with the soft brush-like end of a tooth-cleaning twig or pushed inward. After throat injury, honey and ghee, or triphala powder mixed with honey and sugar, are given for licking.
Keshondaka is a small ball made of hair. Sudden pulling is intended to bring out the caught foreign body. The brush is the pounded end of a tooth-cleaning twig such as karanja. If the object will not come outward, pranudeta means push it inward. Some read the hair-ball passage differently. The final instruction is aftercare following extraction of a throat foreign body.
Key terms
keshoNDukam (keshondukam)
A small ball made of hair and tied to a long thread in the historical procedure.
Adhikarana ௧௮ (௨௦) · Śloka ௨௦
உதகபூர்ணோதரமவாக்ஶிரஸமவபீடயேத்துநீயாத்வாமயேத்வா பஸ்மராஶௌ வா நிகநேதாமுகாத் ||௨௦||
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उदकपूर्णोदरमवाक्शिरसमवपीडयेद्धुनीयाद्वामयेद्वा भस्मराशौ वा निखनेदामुखात् ||२०||
Meaning of the śloka
For a person whose abdomen is filled with water, the text directs placing the head downward, pressing the abdomen, shaking the person, inducing vomiting in that position, or burying the body in a heap of ashes up to the mouth.
The procedure is stated for water retained in the abdomen of a person taken from water. Avakshiras means positioned face or head downward; the abdomen is pressed, the body shaken, and friction used to provoke vomiting. Nikhanet means place within the ash heap up to the mouth.
For a food bolus lodged in the throat, the text directs unexpectedly striking the unafraid patient on the shoulder with the fist, or giving oil, alcohol or water to drink.
When constriction of the throat by an arm, rope, creeper or noose aggravates vayu, which then aggravates kapha and obstructs the channel, salivation, frothing and loss of consciousness result. The text prescribes anointing, fomentation, strong shirovirechana and a vata-reducing liquid preparation.
A discerning physician should examine the particular shape and location of a foreign body and the distinct instruments, then remove it properly. Barbed and otherwise difficult objects must be grasped and removed attentively with a suitable method. If the stated methods fail, the physician should use skilled judgment, combinations of instruments and other suitable measures. A retained foreign body causes swelling, suppuration, severe pain, disability and death; therefore the text urges careful removal.
Because foreign-body shapes are limitless, the verse covers methods not explicitly stated. Locations include the head, eye, ear, nose and heart. Yukti means appropriate application, avoiding deficient, excessive or wrong use. If removal is obligatory but established methods fail, a physician skilled in the work devises combinations of instruments; 'and' includes unstated measures such as binding according to relevant qualities. Some omit the final verse on harms of retention, but the commentary accepts it because it is read in Nyayachandrika.
Key terms
yuktyA (yuktya)
By an appropriately reasoned method, avoiding deficient, excessive or incorrect application.