An English Translation of the Sushruta Samhita (Bhishagratna ed.)

A physician should have recourse to the following measures (surgical operations) in cases where the above-mentioned decoctions, medicated milk, alkalies, clarified butter and Uttara-vasti (urethral syringe) of the aforesaid drugs, etc., would prove ineffective. Surgical operations in these cases do not prove successful even in the hands of a skilful and experienced surgeon ; so a surgical (Lithotomic) operation should be considered a remedy that has little to recommend itself. The death of the patient is almost certain without a surgical opera- tion and the result to be derived from it is also uncertain. Hence a skilled surgeon should perform such operations only with the permission of the king. 11-12.

IVIodes of Surgical Operations :— The

patient should be soothed (Snigdha) by the application of oleaginous substances, his system should be cleansed with emetics and purgatives and be slightly reduced thereby ; he should then be fomented after being anointed with oily unguents ; and be made to pertake of a meal. Prayers, offerings and prophylactic charms should be offered and the instruments and surgical accessories required in the case should be arranged in the order laid down in the Agropaharaniya chapter] of the present work (Sutra-sthanam, ch. V.). Thej

* Dallana recommends the use of Triphala boiled with milk in] cases of pain accompanying Plttaja As'mari, while that boiled with] Varshabhu is advised to be given for the alleviation of pain in a case of! Vdtaja or Kaphaja As'mari. The drugs of Vira-taradi group should be] used with milk, clarified butter, a decoction, Yavagu (gruel), food, etc.,j and also for bath, immersion, etc.

Chap. VII.] CHIKITSA STHANAM. 333

surgeon should use his best endeavours to encourage the patient and infuse hope and confidence in the patient's mind. A person of strong physique and un- agitated mind should be first made to sit on a level board or table as high as the knee-joint. The patient should then be made to lie on his back on the table placing the upper part of his body in the attendant's lap, with his waist resting on an elevated cloth cushion. Then the elbows and knee-joints (of the patient) should be contracted and bound up with fastenings (S'ataka) or with linen. After that the umbclical region (abdomen) of the patient should be well rubbed with oil or with clarified butter and the left side of the umbelical region should be pressed down with a closed fist so that the stone comes within the reach of the operator. The surgeon should then introduce into the rectum, the second and third fingers of his left hand, duly anointed and with the nails well pared. Then the fingers should be carried upward towards the rope of the perineum i.e , in the middle line so as to bring the stone between the rectum and the penis, when it should be so firmly and strongly pressed as to look like an elevated Granthi (tumour), taking care that the bladder remains con- tracted but at the same time even.

PrOg^nosiS-M. Text :— An operation should not be proceeded with nor an attempt made to extract the stone (Salya) in a case where, the stone on being handled, the patient would be found to drop down motionless (/.^., faint) with his head bent down, and eyes fixed in a vacant stare like that of a dead man, as an extraction in such a case is sure to be followed by death. The operation should only be continued in the absence of such an occurrence.

An incision should then be made on the left side

334 TiiK SUSHRUTA SAMHitA. tChap. Vn.

of the raphe of the perineum at the distance of a barley- corn and of a sufficient width to allow the free egress of the stone. Several authorities recommend the opening to be on the right side of the raphe of the perineum for the convenience of the operation. Special care should be taken in extracting the stone from its cavity so that it may not break into pieces nor leave any broken particles behind (i.e., inside the bladder), however small, as they would, in such a case, be sure to grow larger again. Hence the entire stone should be extracted with the help of an Agravaktra Yantra (a kind of forceps the points of which are not too sharp). 13.

Lithotomic Operation in a female : —

In a woman, the uterus (Garbhds'aya) is adjacent to the
urinary bladder, hence the stone should be removed
by making an oblique and upward incision, otherwise
a urine-exuding ulcer might result from the deep
incision in that locality. Any hurt to the urethra
during the operation would be attended with the
same result even in a male patient. An incision
made only on one side of the organ in a disease other
than that of stone, baffles all attempts at healing ;
while an ulcer incidental to an incision made on both
its sides, should be deemed incurable. An ulcer
incidental to an incision made on either side of the
bladder in extracting a stone might be healed up, in-
asmuch as medicinal potions and fomentations, etc.,
employed for the healing of a surgical wound, lead
to the healing of the wound in the bladder ; secondly
because the surgical opening is only made large enough
for the extraction of the stone as recommended in the
authoritative books ; and thirdly because an increase
in the quantity of urine contributes to an increase in
the size of the stone and hence a slight secretion of that

Chap. VII.] CHIKITSA STHANAM. 335

fluid or employment of diuretic Peyas, etc., are not attended with any injurious effects.

Post-Surgical IVleaSUreS ".—After the ex- traction of a stone, the patient should be made to sit in a Droni (cauldron) full of warm water and be fomented thereby. In doing so the possibility of an accumula- tion of blood in the bladder will be prevented ; however if blood be accumulated therein, a decoction of the Kshira- trees should be injected into the bladder with the help of a Pushpa-netra (urethral Syringe). 14-15-

Memorable Verse : — Stones and the accu-
mulated blood in the bladder would be speedily expelled
by means of injecting a decoction of the Kshira-trees
into it with the help of a Pushpa-netra (urethral
Syringe). 16.

For the clearance of the urinary passage, a treacle
solution should be given to the patient ; and after tak-
ing him out of the Droni, the incidental ulcer should be
lubricated with honey and clarified butter. A Yavagu,
boiled with the drugs* possessed of the virtue of cleans-
ing or purifying the urine, and mixed with clarified
butter, should be given to the patient in a warm state
every morning and evening for three consecutive days.

After that period a diet (meal) of rice well boiled and mixed with milk and a large quantity of treacle, should be given (to the patient) in small quan- tities for ten days for the purification of the blood and the secretion of urine as well as for the purpose of esta- blishing secretion in the ulcer. The patient should be made to partake of a diet (of rice) with the soup of the flesh of Jangala animals and the expressed juice of acid fruits after the lapse of these ten days. 17.

• The urine-purifying drugs are the Trina-Panchamulas, Gokshura, Kasamarda, Pashanabheda, etc.

336 THE SUSHRUTA SAMHITA. [Chap. VII.

After that period, the body of the patient should be
carefully fomented for ten successive days by applying
any warm oleaginous substance or with any warm
medicinal fluid (Drava-Sveda). As an alternative, the
ulcer should be washed with the decoction of (the
bark of) the Kshira-Vrikshas, A paste of Rodhra,
Madhuka, Manjishtha and Prapaundarika (pounded to-
gether), should be applied then to the ulcer. A medicated
oil or Ghrita cooked with turmeric and the preceding
drugs should be applied to the ulcer. The accumulated
blood in the affected part should be removed with the
help of a Uttara-vasti (urethral Syringe). The ulcer
should be cauterized with fire in the manner described
before in the event of the urine not flowing through
its natural passage after the lapse of seven days.
After the urine takes its natural course, Uttara-vasti,
Asthdpana and Anuvasana measures should be employed
with the decoction of the drugs belonging to the
Madhura- Varga.

A seminial stone or gravel (S'arkard) spontaneously
brought down into the urinary passage should be re-
moved through the same passage. The urethra should be
cut open and the stone should be extracted with a hook
(Vadis'a) or any other instrument in the case of its not
being expelled out by the passage. The patient should
refrain from sexual intercourse, riding on horse back or
on the back of an elephant, swimming, climbing on
trees and up mountains and partaking of indigestible
substances for a year even after the healing of the
ulcer. i8.

Parts to be guarded in Lithotomic

Operations: —The Mutra-vaha (urine-carry ingi and
the S'ukra-vaha (semen-carrying) ducts or channels, the
Mushka-srotas (cords of the testes), the Mutra-praseka

Chap. Vll.j CHIKITSA STHANAM. 337

[urinary) channels, the Sevani (the raphe of the perineum), the Yoni (uterus, vagina, etc.), the Guda (rectum j and the Vasti (bladder) should be carefully guarded at the time of performing a lithotomic operation. Death results in the event of the urine-carrying channels being in any way hurt during the operation owing to an accumulation of urine in the bladder. Similarly, any hurt or injury to the semen-carrying ducts at the time, results in death or in impotency of the patient ; a hurt to the cords of the testes begets an incapacity of fecundation ; a hurt to the urinary ducts leads to a frequent dribbling of urine ; while a hurt to the Yoni (uterus, vagina, etc.), or to the raphe of the perineum gives rise to extreme pain. The symptoms which characterise a hurt to the rectum or to the bladder have been described before. 19.

Memorable Verses:— The surgeon who is

not well cognisant of the nature and positions of the
Marmas or vulnerable parts seated in the eight Srotas
(ducts) of the body such as, the raphe of the perineum,
the spermatic cords, the cords of the testes and the
corresponding ones in females (Yoni), the anal region,
the urinary ducts, the urine-carrying ducts, and the
urinary bladder and is not practiced in the art of
surgery brings about the death of many an innocent
victim. 20.

Thus ends the seventh Chapter of the Chikitsita Sthanam in the Sus'ruta Samhita which deals with the treatment of Urinary calculus.

Now we shall discourse on the medical treatment of Fistula-in-ano, etc., (Bhagandara). r.

The disease admits of being divided into five different
groups, of which the two, known as S'ambukavarta and
S'alyaja (traumatic), should be regarded as incurable,
and th^ rest as extremely difficult to cure. 2.

The General Treatment :— The eleven*

kinds of remedial measures commencing with Apatar-
pana up to purgatives (as described under the treatment
of Dvi-vrana) should be employed as long as any
fistular ulcer would remain in an insuppurated stage.
The patient should be soothed by the application of
medicated oil, etc., and his body should be fomented by
immersing him in a receptacle of warm water, etc. as
soon as suppuration would set in (and even after the
ulcer had burst). Then having laid him on a bed
and bound his hands and thighs with straps as des-
cribed under the treatment of Haemorrhoid, the surgeon
should examine closely as to where the mouth of the
fistula is directed, outward or inward, and whether
the ulcer itself is situated, upward or downward. Then
the whole cavity or receptacle of pus (sinus) should
be raised up and scraped out with an Eshani (indicator
or probe). In a case of inter-mouthed fistula, the patient
should be secured with straps (as before described)
and asked to strain down. An incision should then
be made by first directing the indicator when its mouth
would become visible from the outside. Cauterization

* Apatarpana, Alepa, Parisheka, Abhyanga, Sveda, Vimldpana, Upandha, Pachana, Visrdvana, Sneha, and Vamana.

Chap. VIII.] CHIKITSA STHANAM. 339

with fire or an alkali is a general remedial measure which may be resorted to in all the types of this disease. 3-4.

Specific IWeasurcs— IVI. Texts :- Incases

of the ^ataponaka type all the small Vranas about
the anus should be first incisioned and the principal sinus
in the locality should not be looked after until these
small ones had been healed up. The connected abscesses
should be respectively incisioned on the external side,
while the unconnected ones should not be opened at
the same time in order that they may not run into
one another and be thus converted into a wide-mouthed
ulcer. The urine and the faecal matter are found in each
case to flow out of the cavity of such a wide-mouthed
ulcer ; and aching pains in the rectum and a rumbling
sound in the abdomen, due to the action of the aggrav-
ated Vdyu, are experienced. Such a case is enough
to confound even a well-read and experienced physician.
Hence the mouth of a fistula of the Sataponaka type
should not be opened with a broad incision.