Sushruta Samhita, volume 1: Sutrasthana
Chapter XVIII - Poulticing and bandaging of wounds
A medicinal plaster should be regarded as the general and most important remedy in all cases of (inflammatory) swelling. We shall presently discuss the nature of plasters to be used in each specific form of disease. A bandage plays a more important part (than a medicinal plaster) as regards its healing and curative efficacy, inasmuch as it materially contributes to the purification and healing of an ulcer and keeps the joints steady. A medicinal plaster should be applied from down upward or in a direction contrary to that of the local hair (Pratiloma). It should never be applied (so as to run down with the local hair), since a plaster, applied as directed above, would firmly stick to the surface of the affected part, and naturally percolate through the follicles of the hair and the external orifices of the vehicles of perspiration (Sudoriferous ducts), thus permeating the organism with its own native potency and virtue.
A medicinal plaster should be removed or replaced by a fresh one as soon as it has become dry, except in cases where the purpose of its application would be found to be the drawing of pus to a definite head (Pidayitavya Vrana).
A dried medicinal plaster will prove useless or abortive, and may act as a caustic or corrosive agent. A medicinal plaster admits of being grouped under any of the three subheads of Pralepa, Pradeha and Alepana (according to its thickness or consistency) etc.
A medicinal plaster of the Pralepa class is applied thin and cold, and is made to be endued with an absorbing (Vishoshi) or non-absorbing (Avishoshi) property according to the nature of the effect desired.
On the other hand, a medicinal plaster of the Pradeha class is applied either thick or thin, warm or cold, and acts as a non-absorbent.
A medicinal plaster of the Alepana class stands midway between a Pralepa and a Pradeha.
Of these, a plaster of the Pralepana class is possessed of the efficacy of pacifying or restoring the deranged blood and Pitta to their normal condition. A plaster of the Pradeha class pacifies the deranged Vayu and Kapha and tends to bring about the union, purification, and healing (of an ulcer), causing the subsidence of pain and swelling. Hence it should be used in all types of swelling whether ulcerated or otherwise.
A medicinal plaster (Alepana) applied over an ulcer is called by the changed epithet of Kalka or Niruddha-Alepana (arrestive or astringent plaster). The function of such an Alepana consists in arresting a local hemorrhage, in softening the ulcer, in withdrawing sloughing or putrifying flesh from its cavity, in checking the formation of pus in its inside, and in correcting the morbid matter or deranged humours (that retard its union and healing).
A medicinal plaster of the Alepana class would prove beneficial in a swelling marked by the absence of suppuration, inasmuch as it subdues the characteristic symptoms of each of the deranged bodily humours viz, the burning sensation (peculiar to the deranged Pitta), itching (incidental to the deranged state of Kapha) and the aching pain (which marks the disorder of the bodily Vayu). Its action lies principally in cleansing the skin, the flesh and the blood of all morbiferous diatheses, in removing the burning sensation, and in alleviating the piercing pain and itching.
A physician (surgeon) should use an Alepana in (ulcerous) diseases appearing about the anus, or about any other vital part (Marmas) of the body, with a view to bring about the purification of the (local deranged humours). In diseases caused by a deranged condition of the Vayu, Pitta or Kapha, medicinal plasters should be respectively mixed with a quantity of clarified butter, measuring a sixth, quarter, and an eighth part of their respective quantities.
It has been said that the thickness of an Alepana should not be made to exceed that of the newly-flayed skin of a buffalo. Under no condition, should a medicinal plaster be applied at night, inasmuch as such a measure would arrest the escape or radiation of heat from the swelling in virtue of its own inherent humidity, and thus bring on an aggravation.
In diseases, which are amenable to the application of medicinal plasters of the Pradeha type, as well as in swellings resulting from the vitiated condition of blood and the Pitta, or in those which are of extrinsic origin, or are due to the effect of a poison or blow, the plaster should be applied cold, by day. A plaster should not be applied without removing the previous one, nor over the one applied on the day before, as this would increase the local heat and aggravate the pain and the burning sensation on account of its greater or increased thickness. A medicinal plaster, previously used, should not be moistened and applied again; it should be held as absolutely ineffective owing to its virtue having been previously used or soaked in.
Articles of bandaging Now we shall enumerate the names of articles which are required in bandaging ulcers. They are as follows:—
Kshauma (cloth woven with the fibres of Atasi plant), avika (blankets made of sheeps’ wool), Dukulum (loom-silk), Kausheya (silk), the Patrorna (a kind of cloth made of the fibres of Naga trees, which grow in the provinces of Paundra and Magadha), the Chinapatta (Chinese cloth), Antarvalkala (the inner bark or fibres of a tree), Charma (skin), the Alavu Shakala 'the skin of a gourd), the Lata-Vidala (half thrashed Shyama creepers), string or cord, the cream of milk, Tula-phala (cotton seeds) and iron. These accessories should be used in consideration of the exigencies of each case and the time or the season of the year in which it occurs.
The fourteen different forms of bandage are named as the Kosha (a sheath or scabbard), the Dama (a cord or chaplet.), the Svastika (cross), the Anuvellita (a twist), the Pratoli (a winding street or road), the Mandala (ring), the Sthagika (a betel-box), the Yamaka (double or twin), the Khatta (a bedstead), the China (a streamer), the Vivandha (noose), the Vitana (canopy) the Gophana (cow-horn), the Panchangi (five limbed). Their shapes can be easity inferred from the meanings of their names.
Out of these, the Kosha or the sheath-shaped bandage should be tied round the thumb and the phalanges of the fingers; the Dama or chaplet-shaped bandage, round the narrow or unbent parts of the body; the Svastika or cross shaped, round the joints, round the articulations or the Marmas known as the Kurchakas (Navicular ligaments) round the eye-brows, round the ears and round the region of the breast. Similarly, the bandage, known as the Anuvellita, should be used when the seat of the affection would be found to be situated at the extremities (hands and legs). A bandage of the Protoli class should be tied round the neck or the penis; the Mandala (ring-shaped), round the circular parts of the body; the Sthagika (betel-box), round the glans-penis and the tips of the fingers; the Yamaka, round the confluent or contiguous ulcers; the Khatta (bedstead-shaped), over and around the cheeks, cheek-bones, and the parts between the ears and the eye-brows; the Vitana over the skull, the Gophana (horn-shaped), round the region of the chin; and the Panchangi, round the part lying above the clavicles.
In short, a bandage of any particular shape should be tied round the part of the body to which it would be found to be most suited. Now we shall deal with the Yantranas (fastenings of bandages) which admit of being divided into three different classes according as they are fastened above, below, or obliquely round an ulcer.
Any soft stuffing or tow (such as the leaves or the bark of trees of medicinal virtues) between the medicine applied over an ulcer and the bandaging linen is called the Kavalika (medicated tow). The tow or the Kavalika should be placed thickly (on the seat of affection); and then the physician (surgeon) having pressed it with his left hand should place a piece of straight, soft, untwisted, and unfolded or unshrivelled linen over it, and then firmly tie up the bandage in a manner so as not to leave any knot over the seat of the ulcer, or to cause any discomfort to the patient.
Introduction of lint:—
A Visheshika (lint) saturated with honey, clarified butter, and a medicinal paste should be inserted into the ulcer. Care should be taken not to introduce the lint extremely dry, or oily (oversoaked in a lubricating or oily medicinal preparation), inasmuch as an over-lubricated lint would give rise to an excessive formation of slimy mucus in the ulcer, whereas, its parched substitute would bring about the friction and the consequent breaking of the edges of the ulcer, like one misplaced or wrongly inserted.
A bandage should be tied in any of the three ways of Gadha, Sama and Shithila fastenings according to the shape and seat of the ulcer. A tight bandage (Gadha-Vandha) should be tied round the buttocks, round the sides, round the arm-pits, round the inguinal regions, round the breast or round the head. A bandage of the Sama pattern should be fastened round the ears, round the extremities (hands and legs), round the face, round the throat, round the lips, round the penis, round the scrotum, round the back, round the belly and the chest. A loose bandaging (Shithila-Vandha) should be the rule in the region of the eyes and locations of important joints or unions.
An ulcer, brought about or characterised by the symptoms of the deranged Pitta and occurring at a place where a tight bandaging is indicated, should be fastened with one of the Sama-Vandha class, and with a Shithila bandage where one of the Sama type would be indicated; whereas it should not be bandaged at all in the event of a loose bandage (Shithila-Vandha) being indicated. The same rule should be observed in the case of an ulcer caused through a diseased or contaminated state of the blood. Similarly, in the case of an ulcer produced through a deranged condition of the Kapha, a loose bandaging, otherwise enjoined to be adopted, should be substituted for one of the same pattern. A tight bandage should give place to a lighter one under the same circumstances, and such a procedure should be deemed as holding good even in the case of an ulcer caused by the action of the deranged Vayu.
In summer and autumn, the bandage of an ulcer, due to the vitiated blood or Pitta, should be changed twice a day; while the one tied round an ulcer of the deranged Vayu or Kapha, should be changed on each third day in spring and Hemanta. Similarly, an ulcer, marked by the action of the deranged Vayu, should be bandaged twice a day. “Thou shalt exercise thy own discretion, and vary or adopt the preceding rules of bandaging according to the exigencies of each case.”
A medicated lint fails to have any efficacy but rather tends to augment the local pain and swelling where a bandage, enjoined to be loosely bound, or bound up with moderate and uniform steadiness (Sama-Vandha), is replaced by a tight or deep fastened one (Gadha-Vandha. A loose bandage, injudiciously used in a case where a tight or a moderately firm bandage should have been used, would cause the medicine to fall off from the lint and give rise to the consequent friction and laceration of the edges of the ulcer. Similarly, a moderately firm and steady bandage (Sama-Vandha) fastened in a case where a light or loose bandage should have been used, would fail to produce any effect. A proper bandage would lead to the subsidence of pain, and the softening of the edges of the ulcer, thus bringing about a purification of the local blood.
Evils of non-bandaging:—
An ulcer, left uncovered and untied with a suitable bandage, is soon assailed by gnats and flies. It is moistened by sweat and cold wind, etc. and stands in danger of being irritated by deposits of many foreign matters such as, the particles of bone, dust, weeds, etc. Moreover, a constant exposure to heat or cold brings on varied pains, the ulcer develops into one of a malignant type, and the applied medicinal plasters are dried, encrusted and speedily fall off.
A smashed, lacerated, fractured, dislocated, displaced bone, or a vein or a ligament similarly jeopardised, may be soon healed or set right with the help of a surgical bandage. The patient is enabled by such a means to lie down, or stand up or move about with ease. And an increased facility of rest or movement leads to speedy healing.
Cases where bandaging is prohibited:—
Ulcers should not be bandaged at all that are due to the deranged condition of blood or Pitta, or to the effects of a blow or of any imbibed poison, and characterised by a sucking, burning pain, redness, or suppuration, as well as those which are incidental to burns, or to the applications of actual or potential cauteries marked by a sloughing or phagedenic character.
An ulcer due to a scald in a leper or a carbuncle in a diabetic patient (Pidaka) as well as a fleshy condylomata due to a bite from a venomous rat, or any other poisonous ulcer should not be bandaged at all. The same rule should be observed in the case of a dreadful suppuration about the anus, or in that of a sloughing ulcer. An intelligent physician, familiar with the specific features of ulcers, should observe the shape of the one under treatment, and prognosticate the result from its seat or locality and the nature of the deranged bodily humours involved in the case. The season of the year in which an ulcer is first seen to appear also determines the nature of the prognosis.
Bandages may be tied up either from above, below, or from the sides of a diseased locality. Now I shall fully describe the process of bandaging an ulcer. First the Kavalika or tow should be thickly laid over the seat of the ulcer and after that a piece of soft and unshrivelled linen should be placed upon it, and the bandage should be loosely or tightly tied up according to the directions laid down before.
The lint and the (inserted) medicine should not be over-lubricated and must not be inordinately oily in as-much as such a lint or medicine would give rise to the formation of excessive and abnormal slimy mucous in the ulcer. On the other hand, an extremely dry lint would set up friction and laceration of the edges of the ulcer, like the one wrongly or improperly inserted into its cavity, causing numbness, excessive exudation and unevenness of its surface. A lint, properly saturated with a medicinal plaster and rightly inserted into the cavity of an ulcer, leads to its speedy healing. All secreting measures in connection with an ulcer should be continued or stopped according to its condition, whereby the nature and shape of the bandage should be determined as well. An ulcer, due either to the deranged condition of blood or the Pitta, should be dressed and bandaged once a day which may be extended to a number of times in the case of an ulcer brought about by the deranged Kapha and Vayu. The pus or the local morbid matter should be secreted by pressing the base or the bottom of an ulcer and by gently moving the hand along it in a contrary direction (down, upward; and all bandages around joints and Gudasandhis) should be duly tied up.
The rules laid down under the head of adhesioning the parts of a bifurcated ear-lobe would hold good in a case of severed lips as well. The measures amply discussed in the present Chapter should be extended by means of inference, analogy and judgment to apply mutatis mutandis to the bandaging of a fractured or dislocated bone.
An ulcer, properly bandaged, has a greater chance of not being affected by lying down, sitting up, or any other movement of the patient, nor by the joltings of a conveyance he may ride or be carried in. An ulcer affecting a vein or a ligament or the skin (superficial) or the flesh or the bones cannot be healed without bandaging it. An ulcer situated in any of the internal chambers (cavities) of the body, or occurring at any junction of the limbs or organs, etc. or having its seat in a bone and whether of a deep, superficial, malignant, or corrosive character, cannot be brought to a successful termination without the help of a bandage.
Thus ends the eighteenth Chapter of the Sutrasthana in the Sushruta Samhita which treats of the dressing and bandaging of ulcers.
Footnotes / commentary:
As in the case of a Pidayitavya ulcer, described before, where the withdrawing or gathering of pus to a definite head is desired.
This portion of the text has been omitted by Chakrapani in his commentary entitled the Bhanumuti.
In a swelling or ulcer caused by the deranged Vayu and Kapha, the bandage should consist of a piece of thick cloth; whereas in summer it should consist of thin linen. Similarly, a bandage, tied round any deep or hollow part of the body, should consist of a piece of thick cloth. The contrary rule should be observed, when the seat of the bandage would be at any flexible part of the body.
Similarly, in the case of a snake-bite, a ligature should be firmly tied above the punctured wound with a string or twisted cord of cotton, while a fractured bone should be set right by twisting bunches of half-thrashed shyama creeper (Latavidala) round the seat of fracture. A local hemorrhage should be arrested by binding the part with milk-cream, while the affected part in a case of Ardita (facial paralysis) as well as a broken tooth should be bound with strings of iron, gold or silver. Warts, etc. should be bandaged with Ela (cardamom skins), while dried gourd-skins should be used in bandaging ulcers on the head (scalp).
Carefully examining whether the applied remedy had been uniformly distributed over the diseased surface and whether the contemplated pattern of bandage would be actually suited to the case.
Additional text:—A bandage, tightly tied round an ulcerated or affected part of the body without causing any pain or discomfort to the patient, is called a Gadha-Vandha, while the one which is loosely bound is called Shithila, the one neither too tight nor too loose being called a Sama-Vandha.
Several authorities such as Gayadasa, Brahmadeva, etc. hold this portion of the text to be an interpolation. Both Dallana and Chakrapani have included it within their commentaries with nearly the same remark.
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