Select Ashtanga Hrudaya Sutra Sthana Chapter 29: Shastra Karma Vidhim Adhyayam (Surgical Procedures and the Way of Conducting Them)

Ama Shopha (Unripe swelling)

शोफोऽल्पोऽल्पोष्मरुक् सामः सवर्णः कठिनः स्थिरः ॥ २ ॥
The unripe swelling is mild (less swollen) with mild heat and pain, has the same color of the skin, hard in consistency and immovable.

Pachyamana Shopha (A swelling in the process of ripening)

पच्यमानो विवर्णस्तु रागी बस्तिरिवाततः ।
स्फुटतीव सनिस्तोदः साङ्गमर्दविजृम्भिकः ॥ ३ ॥
संरम्भारुचिदाहोषातृड्ज्वरानिद्रतान्वितः ।
स्त्यानं विष्यन्दयत्याज्यं व्रणवत् स्पर्शनासहः ॥ ४ ॥
The swelling which is in the process of ripening is discolored, usually red colored, distended like a urinary bladder, feels as if the swelling is going to burst open, has pricking pain aches all over the body, excessive yawning, agitation or irritation in the swelling, tastelessness / anorexia, burning sensation, increased temperature, thirst, fever, loss of sleep, quick melting of solid ghee placed on the swelling (due to high temperature), tenderness (intolerance on touching) just as in an ulcer.

Pakwa Shopha (Swelling which has ripened)

पक्वेऽल्पवेगता म्लानिः पाण्डुता वलिसम्भवः ।
नामोऽन्तेषून्नतिर्मध्ये कण्डूशोफादिमार्दवम् ॥ ५ ॥
स्पृष्टे पूयस्य सञ्चारो भवेद्बस्ताविवाम्भसः ।
In pakwa shopha, the swelling / symptoms are less severe, swelling is reduced in size with pale color, appearance of wrinkles on it (swelling). The swelling is depressed all around the periphery and is elevated at the center. Itching, swelling etc. symptoms are mild in nature. On touch of the swelling, the movement of pus can be known, resembling the movement of water within the bladder.

Symptoms of involvement of doshas in swelling and suppuration

शूलं नर्तेऽनिलाद्दाहः पित्ताच्छोफः कफोदयात् ॥ ६ ॥
रागो रक्ताच्च पाकः स्यादतो दोषैः सशोणितैः ।
In swelling, pain doesn’t occur without the involvement of vata, burning sensation doesn’t occur without the involvement of pitta, swelling doesn’t occur without the involvement of kapha, redness doesn’t occur without the involvement of rakta. The suppuration of swelling occurs due to the involvement of all the three doshas along with the blood.

Symptoms of ati paka (excessive suppuration in the swelling)

पाकेऽतिवृत्तेऽतिसुषिरस्तनुत्वग्दोषभक्षितः ॥ ७ ॥
वलीभिराचितः श्यावः शीर्यमाणतनूरुहः ।
When there is excessive suppuration (formation of pus) in the swelling, cavity forms inside the swelling (hollowed inwards). The skin over the swelling becomes thin and gets destroyed by the vitiated doshas. It gets covered with wrinkles, becomes dark / black in color and there is fall of body hairs (in the region of the suppurated swelling).

Raktapaka (Suppuration of blood in swelling caused by kapha)

कफजेषु तु शोफेषु गम्भीरं पाकमेत्यसृक् ॥ ८ ॥
पक्वलिङ्गं ततोऽस्पष्टं यत्र स्याच्छीतशोफता ।
त्वक्सावर्ण्यं रुजोऽल्पत्वं घनस्पर्शत्वमश्मवत् ॥ ९ ॥
रक्तपाकमिति ब्रूयात्तं प्राज्ञो मुक्तसंशयः ।
In the swelling caused by predominance of kapha dosha, the blood gets suppurated / ripened deep inside the swelling, in a concealed way. Therefore, the signs of ripening / suppuration are not clearly seen. Such conditions can be made out by the presence of cold swelling (swelling which is cold on touch), is of the same color as that of surrounding skin, has mild pain, is hard to touch, just like a stone (stony hardness). The wise without any doubt, call this condition as rakta paka i.e. suppuration of blood.

Darana – Tearing (bursting, splitting) and Patana – Cutting (incise) of swelling

अल्पसत्त्वेऽबले बाले पाकाद्वात्यर्थमुद्धते ॥ १० ॥
दारणं मर्मसन्ध्यादिस्थिते चान्यत्र पाटनम् ।
Bursting / tearing the swelling (abscess – pus filled swelling) should be done (by application of alkalis etc.) in persons having weak mind, who are debilitated, in children or when the swelling is elevated due to excessive accumulation of pus and when the swelling is located in the vital spots of the body and on the joints of the body. In other cases (apart from the above said conditions), the swelling should be cut open by using sharp instruments.

Dos and don’ts in ulcers

वालोशीरैश्च वीज्येत न चैनं परिघट्टयेत् ॥ ४१ ॥
न तुदेन्न च कण्डूयेच्चेष्टमानश्च पालयेत् ।
स्निग्धवृद्धद्विजातीनां कथाः शृण्वन्मनःप्रियाः ॥ ४२ ॥
आशावान् व्याधिमोक्षाय क्षिप्रं व्रणमपोहति ।
The site of ulcer should be fanned with either tuft of hairs of animals or with that of Vetivaria zizanioides (vetiver grass). It should not be beaten, poked or scratched with nails. It should be protected from injury while doing other activities
The person who engages himself in hearing pleasant stories, about (from) virtuous elders and Brahmins, he who is hopeful of getting cured from the disease, gets cured of the ulcer quickly.

Care of ulcer on the third day, following surgery

तृतीयेऽह्नि पुनः कुर्याद्व्रणकर्म च पूर्ववत् ॥ ४३ ॥
प्रक्षालनादि दिवसे द्वितीये नाचरेत्तथा ।
तीव्रव्यथो विग्रथितश्चिरात्संरोहति व्रणः ॥ ४४ ॥
On the third day (after surgery), the same treatment of the ulcers such as washing the ulcers etc. should be done again as explained earlier. These should not be done on the second day as that will give rise to severe pain, formation of tumors and delayed healing of the ulcers.

Nature and quality of wick and medicinal paste applied over the ulcer

स्निग्धां रूक्षां श्लथां गाढां दुर्न्यस्तां च विकेशिकाम् ।
व्रणे न दद्यात् कल्कं वा स्नेहात् क्लेदो विवर्द्धते॥ ४५ ॥
मांसच्छेदोऽतिरुग्रौक्ष्याद्दरणं शोणितागमः ।
श्लथातिगाढदुर्न्यासैर् व्रणवर्त्मावघर्षणम् ॥ ४६ ॥
In the ulcers, the wick of cotton threads smeared with paste of herbs and also the paste of herbs should neither be too unctuous nor very dry, neither flabby (loose and thin) nor very thick (hard) and should not be improperly placed (over the ulcer). Because unctuousness (excessively oily or fatty) increases moistness, dryness causes tears in the muscles, severe pain, lacerations and bleeding, flabby, hard and improperly placed wicks produces friction of the edges of the ulcers.

Management of ulcer inside which the wick remains for long duration

सपूतिमांसं सोत्सङ्गं सगति पूयगर्भिणम् ।
व्रणं विशोधयेच्छीघ्रं स्थिता ह्यन्तर्विकेशिका ॥ ४७ ॥
When the medicinal wick remains for a long duration inside the ulcer, it produces putrefaction of the muscles, elevated surface, loss of tissues and accumulation of pus inside (the ulcer). Then the ulcer should be cleared (cleaned) of its contents quickly.

Management of ignorantly cut unripe swelling

व्यम्लं तु पाटितं शोफं पाचनैः समुपाचरेत् ।
भोजनैरुपनाहैश्च नातिव्रणविरोधिभिः ॥ ४८ ॥
When an unripe swelling has been cut open by ignorance, it should be treated with foods and poultices which bring about ripening of swelling. But which are, at the same time, not very much harmful to the ulcer.

Sadyovrana Chikitsa (Management of traumatic wounds)

सद्यः सद्योव्रणान् सीव्येद्विवृतान् अभिघातजान् ।
मेदोजाल्लिखितान् ग्रन्थीन् ह्रस्वाः पालीश्च कर्णयोः ॥ ४९ ॥
शिरोऽक्षिकूटनासौष्ठगण्डकर्णोरुबाहुषु ।
ग्रीवाललाटमुष्कस्फिङ्मेढ्रपायूदरादिषु ॥ ५० ॥
गम्भीरेषु प्रदेशेषु मांसलेष्वचलेषु च ।
Traumatic wounds which are caused due to recent injury (recently occurred) and those which are wide, should be sutured immediately.
So also the ulcers which are made by scraping fatty tumors, pinna of the ears which are very thin, ulcers located on the head, eye-sockets, nose, lips, cheeks, ears, thighs, arms, neck, forehead, scrotum, buttocks, penis, rectum, abdomen etc. which are situated on important and deep, fleshy and immovable parts should be sutured.

Wounds that should not be sutured immediately

न तु वङ्क्षणकक्षादावल्पमांसे चले व्रणान् ॥ ५१ ॥
वायुनिर्वाहिणः शल्यगर्भान् क्षारविषाग्निजान् ।
The ulcers / wounds which are located on groins, axilla etc. which are less muscular and movable, ulcers which emit air (gas), which have foreign bodies inside them, which are produced by alkalis, poisons and fire should not be sutured.

Method of proper suturing of wounds and materials used therein

सीव्येच्चलास्थिशुष्कास्रतृणरोमापनीय तु ॥ ५२ ॥
प्रलम्बि मांसं विच्छिन्नं निवेश्य स्वनिवेशने ।
सन्ध्यस्थि च स्थिते रक्ते स्नाय्वा सूत्रेण वल्कलैः ॥ ५३ ॥
सीव्येन् न दूरे नासन्ने गृह्णन्नाल्पं न वा बहु ।
Suturing should be done only after removing loose pieces of bones, dried blood clots, grass, hairs, etc. by placing the torn and hanging pieces of muscles in their proper places and also by keeping the joints of the bones and bones fractured in their normal positions and after the stoppage of bleeding,
by making use of tendons of animals, threads (of cotton, silk, flax etc) or inner fibers of bark of trees, suturing being done neither very far apart nor very close, holding neither very much of the tissues nor very little.

Measures to be taken after suturing the wounds

सान्त्वयित्वा ततश्चार्त व्रणे मधुघृतद्रुतैः ॥ ५४ ॥
अञ्जनक्षौमजमषीफलिनीशल्लकीफलैः ।
सलोध्रमधुकैर्दिग्धे युञ्ज्याद्बन्धादि पूर्ववत् ॥ ५५ ॥
After suturing, having comforted the patient (with encouraging words, cold water, fanning etc.), the ulcer should be covered with cotton swab soaked in a mixture of honey, melted ghee, collyrium, ash of flax, Callicarpa macrophylla, fruits of Boswellia serrata, Symplocos racemosa, Madhuka longifolia. Then bandaging and other measures should be done as described previously.

Suturing the non bleeding ulcers

व्रणो निःशोणितौष्ठो यः किञ्चिदेवावलिख्य तम् ।
सञ्जातरुधिरं सीव्येत् सन्धानं ह्यस्य शोणितम् ॥ ५६ ॥
The edges of the ulcer which are not bleeding should be scraped a little to induce bleeding and it should be sutured when the blood is flowing. Because the blood is the cause (agent) for healing of ulcers.

Bandhana (Bandages)

बन्धनानि तु देशादीन् वीक्ष्य युञ्जीत तेषु च ।
आविकाजिनकौशेयमुष्णं क्षौमं तु शीतलम् ॥ ५७ ॥
शीतोष्णं तुलासन्तानकार्पासस्नायुवल्कजम् ।
ताम्रायस्त्रपुसीसानि व्रणे मेदःकफाधिके ॥ ५८ ॥
भङ्गे च युञ्ज्यात् फलकं चर्मवल्ककुशादि च ।
After having analyzed the site of the ulcer, bandages suitable to the site of the ulcer / organs of the body should be made use of therein. Among them, the bandages prepared from skin of sheep and silk are hot, bandages made out of flax is cold, the bandages made from silk-cotton, cotton, tendons of the animals, sheaths, thin layers of tendons etc. and bark of trees is both hot and cold.
Wounds which have more of fat and kapha (caused by predominance of fat and kapha) should be covered with sheets of copper, iron, zinc or lead (also in fractures)
In case of fractures, bandaging should be done by using leather, barks of trees and splints, hard and flat pieces of bamboo, wood, metal etc.

Bandhana Prakara (Types of Bandages)

स्वनामानुगताकारा बन्धास्तु दश पञ्च च ॥ ५९ ॥
कोशस्वस्तिकमुत्तोलीचीनदामानुवेल्लितम् ।
खट्वाविबन्धस्थगिकावितानोत्सङ्गगोष्फणाः ॥ ६० ॥
यमकं मण्डलाख्यं च पञ्चाङ्गी चेति योजयेत् ।
यो यत्र सुनिविष्टः स्यात् तं तेषां तत्र बुद्धिमान् ॥ ६१ ॥
विदध्यात् तेषु तेष्वेव कोशमङ्गुलिपर्वसु ।
स्वस्तिकं कर्णकक्षादिस्तनेषूक्तं च सन्धिषु ॥ ६११+(१) ॥
खट्वां गण्डे हनौ शङ्खे विबन्धं पृष्ठकोदरे ।
अङ्गुष्ठाङ्गुलिमेढ्राग्रे स्थगिकामन्त्रवृद्धिषु ॥ ६११+(३) ॥
वितानं पृथुलाङ्गादौ तथा शिरसि चेरयेत् ।
विलम्बिनि तथोत्सङ्गं नासौष्ठचिबुकादिषु ॥ ६११+(४) ॥
गोष्फणं सन्धिषु तथा यमकं यमिके व्रणे ।
वृत्तेऽङ्गे मण्डलाख्यं च पञ्चाङ्गीं चोर्ध्वजत्रुषु ॥ ६११+(५) ॥
यो यत्र सुनिविष्टः स्यात्तं तेषां तत्र बुद्धिमान्॥६१॥
Bandages are of the same shapes implied in their very names and are fifteen in number.
They are sheath, cross shaped, winding, ribbon like, long roll shaped, spiral shaped, four tailed, noose like, betel box type, canopy shaped, loosely knotted, cow horn shaped, two tailed, ring shaped, and five tailed bandages – should be considered and administered in the relative sites of their usage (as mentioned below).
Sheath bandage should be used for the joints of the fingers,
cross shaped bandage should be used for ears, axilla etc., for breasts and bony joints, winding type of bandages should be used for the penis, neck etc. sites and ribbon like bandage should be used for the outer canthus of the eyes,
a long roll shaped bandage shall be used at the junction of body parts such as groins etc., and spiral shaped bandage for the extremities.
Four tailed bandage should be used over the cheeks, lower jaws and temples, noose like bandage is used for the back and abdomen, betel box shaped bandage should be used for the thumb, fingers, tip of penis, and in hernia, canopy type of bandage should be used for organs which are thick and also for the head, loosely knotted bandage is used for hanging parts of the body, cow horn shaped bandage should be used for the nose, lips, chin, joints etc.
Two tailed bandages are used for places having two adjacent ulcers, ring shaped bandage should be used for parts of the body which are round,
Five tailed bandages are used for parts of the body above the shoulders, the brilliant physician should administer those types of bandages which are most suitable for particular parts of the body.

Tight, moderate and loose bandages

बध्नीयाद्गाढमूरुस्फिक्कक्षावङ्क्षणमूर्धसु ।
शाखावदनकर्णोरःपृष्ठपार्श्वगलोदरे ॥ ६२ ॥
समं मेहनमुष्के च नेत्रे सन्धिषु च श्लथम् ।
बध्नीयाच्छिथिलस्थाने वातश्लेष्मोद्भवे समम् ॥ ६३ ॥
गाढमेव समस्थाने भृशं गाढं तदाशये ।
शीते वसन्तेऽपि च तौ मोक्षणीयौ त्र्यहात् त्र्यहात् ॥ ६४ ॥
पित्तरक्तोत्थयोर्बन्धो गाढस्थाने समो मतः ।
समस्थाने श्लथो नैव शिथिलस्याशये तथा ॥ ६५ ॥
सायं प्रातस्तयोर्मोक्षो ग्रीष्मे शरदि चेष्यते ।
Bandages should be tied tight over the thighs, buttocks, axillae, groins, and head,
it should be moderately tight, over the extremities, face, ears, chest, back, flanks, neck, abdomen, penis and scrotum, over the eyes and joints, the bandage should be tied loose, so also on places which are flabby, on (flabby) places wherein the ulcers have been produced by vata and kapha, the bandage should be moderate, on places which are even neither hard nor flabby, it should be tight.
It should be very tight if the wound / ulcer is situated on the seats / organs belonging to vata and kapha.
Bandage should be removed once in three days during cold and spring seasons.
Bandage should be tied moderately tight on hard parts, if the ulcers / wounds on them are produced by pitta and kapha and on even parts, it should be loose.
In places where loose bandaging is prescribed, it should not be tied at all. During summer and autumn seasons, the bandage should be removed in the evening and morning.

Consequences of not bandaging the ulcers

अबद्धो दंशमशकशीतवातादिपीडितः ॥ ६६ ॥
दुष्टीभवेच्चिरं चात्र न तिष्ठेत् स्नेहभेषजम् ।
कृच्छ्रेण शुद्धि रूढि वा याति रूढो विवर्णताम् ॥ ६७ ॥
If the ulcer is not bandaged, it gets contaminated by the bite of mosquitoes, cold breeze etc. The fats and medicines applied to the ulcer do not stay on for long. The ulcer gets clean with difficulty (requires longer time to become clean, without pus etc. contaminants) and also gets healed with difficulty. And even after healing, it will be discolored (the skin over the area around the wound / ulcer does not get back the normal color.

Benefits of bandaging the ulcers / wounds

बद्धस्तु चूर्णितो भग्नो विश्लिष्टः पाटितोऽपि वा ।
छिन्नस्नायुसिरोऽप्याशु सुखं संरोहति व्रणः ॥ ६८ ॥
उत्थानशयनाद्यासु सर्वेहासु न पीड्यते ।
उद्धृतौष्ठः समुत्सन्नो विषमः कठिनो ऽतिरुक् ॥ ६९ ॥
समो मृदुररुक् शीघ्रं व्रणः शुध्यति रोहति ।
Bandaging helps easy and quick healing of wounds, in which the bones are found crushed or fractured, joints are dislocated, which are cut up by the physician, in which tendons / ligaments and veins are severed.
By bandaging there will be no pain during getting up, lying down and such other acts. The ulcers which are uneven, elevated, having elevated edges, hard and very painful, even, soft, and painless, all become clean and also heal quickly.

Managing long standing and stubborn ulcers / wounds

स्थिराणां अल्पमांसानां रौक्ष्यादनुपरोहताम् ॥ ७० ॥
प्रच्छाद्यमौषधं पत्रैर्यथादोषं यथर्तु च ।
अजीर्णतरुणाच्छिद्रैः समन्तात् सुनिवेशितैः ॥ ७१ ॥
धौतैरकर्कशैः क्षीरिभूर्जार्जुनकदम्बजैः ।
Ulcers which are persisting for long duration, which have very little muscular tissue, which do not heal to dryness (due to absence of moisture) should be applied with medicines which are wrapped in leaves of trees, appropriate to the doshas involved and the seasons. The leaves should not be ripened, should be young (tender), should not have holes, should be good in all respects, those washed well and not rough, should belong to the trees which have milky sap (latex yielding), Bhurja (Betula utilis), Arjuna or Kadamba.

Contraindication of bandaging

कुष्ठिनां अग्निदग्धानां पिटिका मधुमेहिनाम् ॥ ७२ ॥
कर्णिकाश्चोन्दुरुविषे क्षारदग्धा विषान्विताः ।
बन्धनीया न मांस्पाके गुदपाके च दारुणे ॥ ७३ ॥
शीर्यमाणाः सरुग्दाहाः शोफावस्थाविसर्पिणः ।
Bandaging should not be done for ulcers occurring in those suffering from leprosy / skin diseases, caused due to fire burns, in ulcers having eruptions, those occurring in patients of diabetes mellitus, swelling which has occurred due to the rat bite, ulcers caused by burns caused by alkalis, caused by poison, having putrefaction of muscles, severe ulcerations of rectum, which are degenerating with loss of tissues, which are associated with pain and burning sensation, which retains the swelling over long period and ulcers which spread to other parts of the body.

Measures to manage infected ulcers

अरक्षया व्रणे यस्मिन् मक्षिका निक्षिपेत् कृमीन् ॥ ७४ ॥
ते भक्षयन्तः कुर्वन्ति रुजाशोफास्रसंस्रवान् ।
सुरसादिं प्रयुञ्जीत तत्र धावनपूरणे ॥ ७५ ॥
सप्तपर्णकरञ्जार्कनिम्बराजादनत्वचः ।
गोमूत्रकल्कितो लेपः सेकः क्षाराम्बुना हितः ॥ ७६ ॥
प्रच्छाद्य मांसपेश्या वा व्रणं तानाशु निर्हरेत् ।
The flies deposit bacteria (worms) inside the ulcers which are not protected by bandaging, the bacteria by eating (destroying) the tissues cause pain, swelling and bleeding
For washing and filling of such infected ulcers, the herbs of Surasadi Gana group of herbs should be used, the paste of barks of Alstonia scholaris, Pongamia pinnata, Calotropis gigantean, Azadirachta indica and Vigna unguiculata made in (ground and made paste in) urine of cow should be pasted.
Bathing the ulcer with the solution of alkalis (alkaline water) is beneficial or scarification of the muscle tissue, by these measures, the worms should be removed from the ulcers, quickly.

Effects of Hasty healing of ulcers

न चैनं त्वरमाणोऽन्तः सदोषमुपरोहयेत् ॥ ७७ ॥
सोऽल्पेनाप्यपचारेण भूयो विकुरुते यतः ।
Hasty healing of the ulcers having residue doshas inside, should not be attempted, because it will flare up greatly even with slight improper regimen.

Restrictions to be followed even after healing of ulcers

रूढेऽप्यजीर्णव्यायामव्यवायादीन् विवर्जयेत् ॥ ७८ ॥
हर्षं क्रोधं भयं चापि यावदास्थैर्यसम्भवात् ।
आदरेणानुवर्त्योऽयं मासान् षट् सप्त वा विधिः ॥ ७९ ॥
Even after the ulcer has healed, the patient should avoid indigestion (foods and activities which cause indigestion), physical activities, copulation etc., rejoicing, anger, fear etc., till he attains his full strength.
He should follow these principles and regulations (lead a disciplined life) with sincere efforts, for at least six or seven months.

Management of similar conditions

उत्पद्यमानासु च तासु तासु वार्तासु दोषादिबलानुसारी ।
तैस्तैरुपायैः प्रयतश्चिकित्सेदालोचयन् विस्तरमुत्तरोक्तम् ॥ ८० ॥
Similar other conditions which manifest should be treated with great efforts, using methods appropriate to the strength of the doshas etc., in the light of details furnished in the uttara tantra, the last section of this treatise (chapters 25-27).

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायां अष्टाङ्गहृदयसंहितायां सूत्रस्थाने शस्त्रकर्मविधिर्नाम एकोनत्रिंशोऽध्यायः॥२९॥
Thus ends the 29th chapter of Ashtangahridaya Samhita Sutrasthana, named Shastra Karma Vidhim Adhyayam, written by Shrimad Vagbhata, son of Shri Vaidyapati Simhagupta.