Sushruta Samhita Chapter 27 Shalyapanayaniya Adhyaya

This article explains Sushruta Samhita Sutrasthana Chapter 27 “Shalyapanayaniya Adhyaya” – Removal of foreign bodies.

Shalyapanayaniya

Removal of foreign bodies

We will now expound the chapter known as Shalyapanayaniya- removal of foreign bodies; as revealed by the venerable Dhanvantari.
Read – Methods Of Surgical Training Elaborated In Ayurveda

Dvidha shalya

Two kinds of foreign bodies

शल्यं द्विविधमवबद्धमनवबद्धं च ||३||

Shalya (foreign bodies) are of two kinds-

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

 Shalya Aharanopaya

Methods of removal of foreign bodies

तत्र समासेनानवबद्धशल्योद्धरणार्थं पञ्चदश हेतून् वक्ष्यामः |
तद्यथा- स्वभावः, पाचनं, भेदनं, दारणं, पीडनं, प्रमार्जनं, निर्ध्मापनं, वमनं, विरेचनं, प्रक्षालनं, प्रतिमर्शः, प्रवाहणम्, आचूषणम्, अयस्कान्तो, हर्षश्चेति ||४||

Methods of removal of foreign bodies which are not fixed (free), are fifteen in brief which shall be enumerated here –

1. Svabhava – by nature (on its own accord)
2. Pachana – ripening / suppuration / creating formation of pus
3. Bhedana – cutting / breaking.
4. Darana – bursting / causing bursting
5. Pidana – squeezing / kneading
6. Pramarjana – sweeping / clearing
7. Nirdhmapana – blowing / insufflations
8. Vamana – causing vomiting / emesis therapy
9. Virecana- causing purgation /purgation therapy
10. Praksalana – washing with water / draining
11. Pratimarsha – instilling liquids into the nose (and such other cavities)
12. Pravahana – straining / making effort to expel out
13. Achushana – sucking
14. Ayaskanta – use of a magnet to pull out and
15. Harsha – creating joy
Read – Sushruta’s 8 Types Of Surgical Procedures – Astavidha Shastra Karma

तत्राश्रुक्षवथूद्गारकासमूत्रपुरीषानिलैः स्वभावबलप्रवृत्तैर्नयनादिभ्यः पतति |
मांसावगाढं शल्यमविदह्यमानं पाचयित्वा प्रकोथात्तस्य पूयशोणितवेगाद्गौरवाद्वा पतति |
पक्वमभिद्यमानं भेदयेद्दारयेद्वा |
भिन्नमनिरस्यमानं पीडनीयैः पीडयेत् पाणिभिर्वा |
अणून्यक्षशल्यानि परिषेचनाध्मापनैर्बालवस्त्रपाणिभिः प्रमार्जयेत् |
आहारशेषश्लेष्महीनाणुशल्यानि श्वसनोत्कासनप्रधमनैर्निर्धमेत् |
अन्नशल्यानि वमनाङ्गुलिप्रतिमर्शप्रभृतिभिः |
विरेचनैः पक्वाशयगतानि |
व्रणदोषाशयगतानि प्रक्षालनैः |
वातमूत्रपुरीषगर्भसङ्गेषु प्रवाहणमुक्तम् |
मारुतोदकसविषरुधिरदुष्टस्तन्येष्वाचूषणमास्येन विषाणैर्वा |
अनुलोममनवबद्धमकर्णमनल्पव्रणमुखमयस्कान्तेन |
हृद्यवस्थितमनेककारणोत्पन्नं शोकशल्यं हर्षेणेति ||५||

• Foreign bodies present in the eyes etc. come out naturally during the acts such as flow of tears, sneezing, belching, coughing, expulsion of urine, faeces, and 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.
• If it (foreign body) is not coming out (in spite of causing suppuration), it should be cut / torn or made to burst (by applying medicinal pastes having hot potency) and then made 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 in the sense organs should be removed / cleared by pouring water, blowing air, wiping, sweeping with hairs (made as brush), cloth (edge of cloth) of hand (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).
• Foreign bodies in the form of particles of food may be removed by inducing vomiting by inserting fingers etc. (into the mouth).
• Foreign bodies present in the Pakvasaya (large intestine) should be removed by inducing purgation.
• 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.
• In case of accumulation of air (gas), water (serous fluids), poison, blood and vitiated breast milk etc. (acting like foreign bodies), it should be removed by sucking by mouth (directly) or by using the sucking horn.
• Foreign  body which is facing downwards, not fixed, not having ears (earlike appendages) and the orifice of the wound if wide, that should be removed by using a magnet.
•  Grief produced by many causes which itself is a foreign body present in engulfing the heart (mind) should be removed by creating joy.
  Read – Shastra – Surgical Instruments Of Ayurveda: Astang Hriday Sutrasthana 26

Shalya aharana Marga

Routes of pulling out the foreign body

 सर्वशल्यानां तु महतामणूनां वा द्वावेवाहरणहेतू भवतः- प्रतिलोमोऽनुलोमश्च ||६||
तत्र प्रतिलोममर्वाचीनमानयेत्, अनुलोमं पराचीनम् ||७||

For all kinds of foreign bodies whether big or minute, modes of extraction are only two, viz pratiloma and anuloma.
In pratiloma- pulling out is in backward direction and in anuloma pulling out is in forward direction.

Notes:- Dalhana clarifies the meaning of these two methods of extraction as follows: Pratiloma is pulling  out the foreign body in the same direction of its entry and Anuloma as pulling out in the opposite direction of entry. Pratiloma (pulling in the same direction) is to be adopted  when the foreign body has entered only the first half of the body (superficial) and anuloma (pulling in the opposite direction of entry) be adopted when the foreign body has entered into the other half of the body also (deep inside). Pulling in the opposite direction of entry causes damage to a large area, gives rise to complications and even death.
Read – Siravyadha Method Of Bloodletting: Procedure, Precautions, Benefits

Yuddha Bhoomi chikitsa

Battlefield surgery

उत्तुण्डितं छित्त्वा निर्घातयेच्छेदनीयमुखम् ||८||

When the face (tip or front part) of the foreign body is seen protruding out, then it should be cut at the other end, shaken (moved to and fro) and pulled out in anuloma or pratiloma direction.  
Notes:- Dalhana clarifies that the area of the body around  the foreign body  should be  cut  to make the orifice wider to facilitate pulling it in the direction opposite of its entry. For cutting the area, materials such as thorn, leaf of Kharjura (date palm tree) etc may be used.

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

 छेदनीयमुखान्यपि कुक्षिवक्षःकक्षावङ्क्षणपर्शुकान्तरपतितानि च हस्तशक्यं यथामार्गेण हस्तेनैवापहर्तुं प्रयतेत ||९||
हस्तेनैवापहर्तुमशक्यं विशस्य शस्त्रेण यन्त्रेणापहरेत् ||१०||
In places such as abdomen, chest, axilla, groin and space in between two ribs, if the foreign body is seen protruding out and if possible, to hold by the hand, attempt should be made to pull out by the hand itself, in the same route (direction of entry). If it is not possible to pull it out by hand, then it should be cut with a sharp instrument and pulled out using blunt instruments (forceps etc).
Read – Yantra Instruments used in Ayurveda: Ashtanga Hrudayam Sutrasthana 25

Pascat Karma

Post-operative procedures

भवति चात्र-
शीतलेन जलेनैनं मूर्च्छन्तमवसेचयेत् |
संरक्षेदस्य मर्माणि मुहुराश्वासयेच्च तम् ||११||
The patient who had fainted should be sprinkled with cold water. His vital spots (organs) should be protected and he should be assured (given courage).

ततः शल्यमुद्धृत्य निर्लोहितं व्रणं कृत्वा स्वेदार्हमग्निघृतप्रभृतिभिः  संस्वेद्यावदह्य प्रदिह्य सर्पिर्मधुभ्यां बद्ध्वाऽऽचारिकमुपदिशेत् |
(सिरास्नायुविलग्नं शलाकादिभिर्विमोच्यापनयेत्; श्वयथुग्रस्तवारङ्गं समवपीड्य श्वयथुं; दुर्बलवारङ्गं कुशादिभिर्बद्ध्वा|) ||१२||

Next, the foreign body having been removed, the wound should be made free of blood (cleaned), if the person is suitable  for sudation, then the area (wound) should be burnt (cauterized) by fire or ghee (warmed) etc. smeared with mixture of ghee and honey, bandaged and regimen of food and activities advised.

हृदयमभितो वर्तमानं शल्यं शीतजलादिभिरुद्वेजितस्यापहरेद्यथामार्गं; दुरुपहरमन्यतोऽपबाध्यमानं पाटयित्वोद्धरेत् ||१३||
Foreign bodies which are stuck up in veins and ligaments should be freed by using metal rods etc. and then pulled out.
If the handle (shaft) of the foreign body is embedded in the swelling then it should be pulled out by squeezing (kneading) the swelling.
If the handle (shaft) is weak, it should be tied (fastened) to Kusa (splint) etc. and pulled out.
When the foreign body (arrow) is near the heart, then it should be pulled out in the same direction of its entry; after having comforted (assured) the patient who is agitated (in mind / afraid of the consequences) by the use of (sprinkling of) cold water.

The foreign body which is at other places (or in other ways) should be pulled out by cutting it.
अस्थिविवरप्रविष्टमस्थिविदष्टं वाऽवगृह्य पादाभ्यां यन्त्रेणापहरेत्, अशक्यमेवं वा बलवद्भिः सुपरिगृहीतस्य यन्त्रेण ग्राहयित्वा शल्यवारङ्गं  प्रविभुज्य धनुर्गुणैर्बद्ध्वैकतश्चास्य पञ्चाङ्ग्यामुपसंयतस्याश्वस्यवक्त्रकविके बध्नीयात्, अथैनं कशया ताडयेद्यथोन्नामयञ् शिरो वेगेन शल्यमुद्धरति; दृढां वा वृक्षशाखामवनम्य तस्यां पूर्ववद्बद्ध्वोद्धरेत् ||१४||

When the foreign body (arrow) has entered into the cavity of the bone or stuck up tightly in the bone, then the physician should hold the position of the foreign body intact using both his legs (restraining any movements) and pull out the arrow using a blunt instrument (such as a forceps etc). If by these methods  it is possible to remove it, then the patient should be held tightly by strong persons, the bundle (shaft) of the arrow should be bent with the help of an instrument, and then fastened with five tailed bandages to the string of a bow at one end and reins of the horse at the other end. Then the horse should be whipped so that it lifts its head suddenly with force, resulting in pulling the arrow out. Alternatively, a strong branch of a tree bent down and the arrow pulled out as before i.e., shaft of the arrow is tied to the branch and released. The resulting pulling force imparted by the released branch pulls out the arrow.

अदेशोत्तुण्डितमष्ठीलाश्ममुद्गराणामन्यतमस्य प्रहारेण विचाल्य यथामार्गमेव यन्त्रेण ||१५||
 Foreign body (arrow), if stuck up in wrong places (places forbidden for cutting such as abdomen, chest etc. mentioned in para 9) and seen protruding out, it should be stroked by a stone hammer or any such thing, made loose and then pulled out in the same way of its entry.

विमृदितकर्णानि कर्णवन्त्यनाबाधकरदेशोत्तुण्डितानि पुरस्तादेव ||१६||
Foreign body (arrow) having  ears (ear- like attachments), which are not troublesome and  seen protruding out, then its ear-like  attachments  should be bent (or constricted) and the arrow pulled out from the front only.
Read – Sushruta Samhita Chapter 5 Agropaharaniya Adhyaya

Kantha Shalya

Foreign body in the throat

जातुषे कण्ठासक्ते कण्ठे नाडीं प्रवेश्याग्नितप्तां च शलाकां, तयाऽवगृह्य शीताभिरद्भिः परिषिच्य स्थिरीभूतं शल्यमुद्धरेत् ||१७||
When a foreign body made of shell-lac is found stuck up in the throat, then a hollow tube should be introduced first and a heated metal rod inserted through it till it touches the foreign body. When the foreign body adheres to the heated rod (because of lac melting), it should be bathed with cold water, and after it becomes stable (adhering fast) it should be pulled out.
अजातुषं तु जतुमधूच्छिष्टप्रलिप्तया शलाकया पूर्वकल्पेनेत्येके ||१८||
Foreign body which is not made of shell- lac should be pulled out by using a rod smeared with lac or beeswax in the same manner as described earlier; say some others (physician).
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||
A piece of bone or any similar foreign body, if found stuck up in the throat horizontally, then the patient is made to swallow  a ball of hairs, fastened to a strong and lengthy thread, along with liquid food, followed by consuming more liquid food, till his stomach becomes full. Then he is made to vomit (by tickling his throat). During vomiting, after determining that the foreign body has stuck to the ball of hair, the thread (hanging out from the mouth) should be pulled suddenly or a soft toothbrush (made from twigs of plants) may be used (to pull out the ball of hair). If by these acts, if it (foreign body) does not come out, then it should be pushed deep inside (into the oesophagus). During this, if any injury occurs to the throat, then the patient should be given a mixture of honey and ghee or powder of triphala added with honey and sugar, to lick.

Udaka Nirharana

Removing water

उदकपूर्णोदरमवाक्शिरसमवपीडयेद्धुनीयाद्वामयेद्वा भस्मराशौ वा निखनेदामुखात् ||२०||
When any person had his abdomen filled with water (due to forcible immersion, drowning accidentally or intentionally) he should be held with his head down and his abdomen should be pressed, his body shaken, made to vomit or buried in a heap of ash up to his face.

Annagrasa Shalya

Bolus of food acting as foreign body

ग्रासशल्ये तु कण्ठासक्ते निःशङ्कमनवबुद्धं स्कन्धे मुष्टिनाऽभिहन्यात्, स्नेहं मद्यं पानीयं वा पाययेत् ||२१||
When a bolus of food is present (choked or blocked) in the throat acting as a foreign body, then the person should be made to bend (forward) and given a hard hit with the fist over his neck without his knowledge (by this  the foreign body comes out) or  he may be made to drink fats (oil or ghee) wine or water (thus making it enter the stomach).

Kantha rodha

Strangulation

बाहुरज्जुलतापाशैः कण्ठपीडनाद्वायुः प्रकुपितः श्लेष्माणं कोपयित्वा स्रोतो निरुणद्धि, लालास्रावं फेनागमनं सञ्ज्ञानाशं 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.
This causes flow of saliva, froth in the mouth and loss of consciousness. Such a person should be anointed with oil (given with herbal oil massage), given sudation (fomentation, administered strong purgative therapy to the head (head purging errhines), and given soup of meat mitigating Vata.
Read – How To Balance Vata Dosha? Line Of Treatment And Reasoning

भवन्ति चात्र-
शल्याकृतिविशेषांश्च 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 यदि |
मत्या निपुणया वैद्यो यन्त्रयोगैश्च निर्हरेत् ||२५||
शोथपाकौ रुजश्चोग्राः कुर्याच्छल्यमनाहृतम् |
वैकल्यं मरणं चापि तस्माद्यत्नाद्विनिर्हरेत् ||२६||
Some verse here:-
The intelligent physician, after carefully observing the shape of the foreign body, the place of its lodging and deciding the particular instruments to be used, should pull out the foreign body.
The foreign body which has ears attached and which are difficult to pull out should be carefully removed with appropriate methods.
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.
Hence these should be removed carefully by all efforts.

इति  श्रीसुश्रुतसंहितायां सूत्रस्थाने शल्यापनयनीयो नाम सप्ताविंशतितमोऽध्यायः ॥२७॥
 Thus ends the Twenty seventh Chapter by name Shalyapanayaniya in Sutra Sthana of Sushruta Samhita.