Chapter V - Preliminary measures

Now we shall discuss the Chapter which treats of Preliminary measures (in connection with the curative remedies of a disease).^[1] (Agropaharaniya-adhyaya).

The entire course of medical treatment in connection with a disease may be grouped under three subheads, as the Preliminary measures (Purva-karma); the Principal therapeutical or surgical appliances (Pradhana-karma); and the After-measures (Paschat-karma). These measures will be discussed under the head of each disease as we shall have occasion to deal with them. As the present treatise principally  treats of surgical acts or operations, we shall discourse on them and their accessories at the outset.

Surgical acts or operations are divided into eight different kinds such as Incising (Chedya), Excising (Bhedya), Scraping (Lekhya) Puncturing (Vedhya), Searching or probing (Eshya), Extracting (Abarya), Secreting fluids (Visravya) and Suturing (Sīvya). A surgeon (Vaidya) called upon to perform any (of the eight preceding kinds) of operations, must first equip himself with such accessories as surgical appliances and instruments, alkali, fire, probe or director (Shalaka), horns, leeches, gourd (Alavu), Jamvavaushtha (a kind of pencil shaped rod made of slate with its top-end cut into the shape of a Jamboline fruit), cotton, lint, thread, leaves, tow (Patta), honey, clarified butter, lard, milk, oil, Tarpana (powdered wheat soaked in water), decoctions Kashaya, medicated plasters, paste (Kalka), fan, cold water, hot water, and cauldrons, etc., and moreover he shall secure the services of devoted and strong-nerved attendants.

Then under the auspices of blissful astral combinations, etc., and having propitiated the Brahmanas and the physicians, with gifts of curd, sun-dried rice, cordials and gems, etc., and having made offerings to the gods and uttered benediction, etc., the surgeon should commence his work. The patient should be given light food (before the act), and made to sit with his face turned towards the east. His limbs should be carefully fastened (so as to guard against their least movement during the continuance of the operation). Then the surgeon, sitting with his face towards the west, and carefully avoiding the vital parts (Mannas), Veins, nerves (Snayus), joints, bones and arteries of the patient, should insert the knife into the affected part along the proper direction till the suppurated part would be reached and swiftly draw it out. In case of extended suppuration, the part opened (length of incision) should be made to measure two or three finger’s widths in length. An incision (Vrana) which is wide, extended, equally and evenly divided, should be deemed the best.

Authoritative verses on the subject:—

An incision which is wide, extended, well divided, does not involve any vital part, etc. of the patient, and is well-matured as regards time, is the best of its kind^[2]. Courage, light handedness, non-shaking, non-sweating, sharp instruments, self confidence and self command are what should be possessed by a surgeon engaged in opening a boil or an abscess.

Two or three incisions should be made if a single opening does not seem large enough for the purpose.

Authoritative verse on the subject:—

The knife (lancet) should be freely used wherever a fissure, sinus, or a cavity would appear in a boil, so as to ensure a complete flowing out of the pus accumulated in it.

Lateral (tirjak) incisions should be made in regions of the eye-brows, temple, forehead, cheeks, eyelids, lower lip, gums, armpits, loins, belly and the groins.

An incision made in the region of the hand or root should be made to resemble the disc of the moon, while those about the anus and the penis should be made semi-circular (half-moon) in shape.

Authoritative verse on the subject:—

An incision in any of the abovesaid regions not made as directed, may give rise to extreme pain, prolonged granulation (healing) and condylomatous growths in and about the ulcer, owing to an inadvertent cutting of the local veins, or nerves. In a case of artificial or instrumental parturition, in ascites, in piles, in stone in the bladder, in fistula in ano, and in diseases affecting the cavity of the mouth, the patient operated on should be kept on an empty stomach (before the act).

Then sprays of cold water should be dashed over the face and the eyes of the patient to relieve the pain and the sense of exhaustion incidental to the operation. The sides of the incision should be firmly pressed (so as to ensure a good outflow of the accumulated pus) and the margins of the wound should be rubbed with the fingers (so that they may have a level surface and be of uniform structure throughout. Then the wound should be washed with an astringent decoction (of Nimba, Triphala, etc.) which should be wiped and made thoroughly dry with a piece of clean linen. Then a lint plug (Varti) plastered over with the (paste) Kalka of sesamum, honey and clarified butter, and soaked in disinfectant (lit:—purifying medicines such as Ajagandha, etc.) should be inserted deep into the cavity of the wound. After that, a poultice made of officinal substances should be applied over it and the whole should be bound up with thick layers of tow (Kavalikas—such as the leaves and bark of the Indian figtree etc.) which are neither too irritant nor too cooling in their effect; and finally scraps of clean linen should be wound round them. The limb, [or the affected part] should be subsequently fumigated with the fumes of pain-killing (anodyne) substances and also with those of drugs which are supposed to ward off all malignant spirits (from the bedside of the patient.)^[3]

Then it should be fumigated with the drugs, known as Guggulu, Vaca, white mustard, Saindhava and the leaves of the Nimva tree, soaked in clarified butter. The residue of the clarified butter [dripped down and collected from the fumigating compound described above], should be rubbed over the region of the heart and other vital parts of the patient, and the floor of the chamber should be washed and sprinkled over with drops of water previously kept in a (new) pitcher for the purpose. The rites of protection from the influences of baneful spirits, should then be performed by reciting the Mantra which runs as follows:—

“I am about to practise the prophylactic incantation for guarding thy person against the malignant influences of Rakshas and conjured demonesses, and may the god Brahma be graciously pleased to approve of its performance.

May the Gods and deities and ministers of grace disperse and confound the hosts of wrathful Nagas (celestial serpents), Pishachas, Gandharvas and Pitris that might be maliciously disposed to strike thee in thy sickly confinement.

May the spirits, which stir abroad in the night and roam about in the sky and on earth, defend thy person in recognition of thy fervent devotion to them.

May the concourse of Brahma-begotten sages (such as, Sanaka, etc.), the saintly and canonised kings (Rajarshis) in heaven and the sacred mounts, streams and oceans of the earth protect thee from evil.

May the fire-god guard thy tongue; the wind-god protect thy breath; and the Moon-god, Parjanya, Vidyut (lightning) and the spirit of the clouds preserve the healthy coursings of those vital winds in thy organism which are respectively known as Vyana, Apana; Udana and Samana.

May Indra, the presiding deity of all physical energies, keep thy bodily strength immaculate.

May Manu defend the two side tendons at the nape of thy neck, as well as thy faculty of intellect; the Gandharvas, thy faculty of desire; Indra, thy fortitude; Vanina, thy faculty of cognition; the Ocean, thy region of umbilicus; the Sun-god, thy eyes; the Quarters of the Heaven, thy ears; the Moon-god, thy mind; the Stars, thy complexion; the Night, thy shadow; the Water, thy vigour; the Oshadhis, thy hair; Infinite Ether, the space which is imprisoned in thy body; Vasundhara, thy body; Vaishvanara, thy head; Vishnu, thy moral courage; Purushottama (the foremost of beings), thy energy of action (dynamical action of purposes); Brahma, thy self; and Dhruva (immutable being), thy eyebrows.

May these divinities, which perpetually reside in thy body, ensure thy safe continuance in being and may thou enjoy a long life through their grace.

May the gods such as, Brahma, etc., confer blessings on thy head.

May the Sun, the Moon, the twin sages Narada and Parvata, the fire-god, the wind, and the other celestial helpmates of Indra, bring thee good.

May the prophylaxis devised by Brahma keep thee from evil.

May thou be spared to witness the return of many a long and happy year on earth.

May such abnormal physical phenomena as, drought, deluge, excessive downpour of rain, and excessive germination (or wholesale extinction of such vermin as) rats, mosquitoes, flies which invariably portend evil and mortality in a community, as well as bloody feuds among kings, abate and cease.

May thou be relieved of all pain and misery. ”

We close the prayer with a “Svaha” (obeisance). The present Vedic mantra exercises an occult power in relieving ailments which are due to the malignant influences of conjured up she-devils. May thou acquire a long life through the protective energy of the prophylactic prayer (lit:—incantation now read by me.

Then having protected the body of the patient with the recitation of the above Vedic Mantra, the surgeon shall see his patient taken to his own chamber, and prescribe the proper course of medicine and diet according to the exigencies of each case. The old bandage should be loosened on the third day of the operation, when the wound or the ulcer should be washed, and a fresh bandage should be wound round as before. The bandage should not be loosened on the day following the lancing of a boil, as such a measure might give rise to a sort of excruciating pain and formation of knots in the wound and retard the process of granulation (healing). On the third day, the surgeon (Vaidya) should prescribe the proper medicated plaster, diet, etc. after fully considering the strength of the patient, the nature of the disease, and the then prevailing season of the year. A wound should not be tried to be healed up, as long as the least morbid matter, or pus remains in its inside, as it would lead to the formation of fresh cavities in the surrounding healthy tissues, and ultimately to a recrudescence of the disease.

The authoritative verses on the subject:—

Accordingly a wound or an ulcer should be made to heal up after the perfect purification of both of its inside and exterior has been fully brought about. Even after the healing of the wound the patient should studiously avoid all sexual connections, indigestive viands, fatiguing physical exercises and indulgence in emotions of grief or fright, or in ecstasies of joy, until the cicatrix has acquired enough toughness. The dressings and bandages should be untied and changed every third day in winter, in spring and in the season of Hemanta, and on each alternate day in summer and in the rains. But a physician (surgeon) should not be guided by these rules in cases where there would be reasons to apprehend imminent danger, and in such cases the wound or the ulcer, like a house in flames, should be checked as speedily as possible.

Clarified butter boiled with Yashtimadhu, and applied tepid to a wound, incidental to a surgical operation, is sure to alleviate the excruciating pain that is usually experienced in such an affected part.

 

Thus ends the fifth chapter, of the Sutrasthana in the Sushruta Samhita which treats of Preliminary measures.

Footnotes and references:

[1]:

Several authorities hold that acts such as fasting, administration of purgatives, etc. should be included within the preliminary measures; application of absorbent (Pacana) or healing medicinal agents, within the second or the principal measures; and the administration of tonics or restoratives within the third or the after-measure group. Others, on the contrary, lay down that measures adopted for the absorption, lubrication (pacification by the application of oily substances) or elimination of the deranged bodily humours by sweating should be grouped under the first subhead (Purva-karma), the administration of active purgatives, emetics etc., under the second (Pradhana-karma) and the giving of rice meal, etc. to the patient under the (Paschat-karma) last; while according to others the active medicinal agents employed to cope with the deranged humours in the incubative stage of a bodily disease till the appearance of its first characteristic symptoms, should be denominated as the Preliminary measure; measures employed for the subjugation of a disease in its patent or fully developed stage as the Pradhana-karma, and measures employed to guard against the recrudescence of a disease and for the restoration of health in a patient is the sequel treatment or the Paschat-karma.

[2]:

Certain commentators interpret the couplet as follows: A boil or an abscess which is wide, extended, well defined in its shape, equally suppurated in all its parts and does not involve any vital part of the body is the fittest thing for a surgeon’s knife—Tr.

[3]:

Even the bedsheets, etc. of the patient should be fumigated as above. This foreshadows the germ theory of the modern days—Tr.