Chapter VIII - The method of Venesection

Now we shall discourse on the Sharira which treats of the method of Venesection etc. (Sira-Vyadha-Vidhi-Sharira). 1.

Persons unfit for Venesection:—

The vessel or vessels (Sira) of an infant, an old man, a perched man, one fatigued and emaciated with endocarditis (Kshata-kshina), a person of timid or coward disposition, a person used up with excessive drinking or sexual enjoyments or tired with the troubles of long journey, an intoxicated person, a patient who has been treated with purgatives, emetics or with Anubasana and Asthapana measures (enemas), a man who has passed a sleepless night, an impotent (Kliva) or emaciated person, an enceinte, or one afflicted with cough, asthma, high fever, phthisis convulsions, paralysis, thirst, epilepsy, or effects of fasting, should not be pierced or opened. Incisions should not be made into those veins (Siras) which are not fit for opening, or into the fit ones, if invisible; it should be the same with those which cannot be properly ligatured or even if ligatured cannot be raised up. 2.

Diseases which are amenable to acts of venesection have been described before (Shonita-Varnaniya-Adhyaya). Venesection may be performed in the said diseases as well as in those which have not been enumerated in connection with them and also in other cases whether suppurated or unsuppurated, if such a proceeding is deemed necessary and after the application of Sneha and Sveda. Venesection should be made even in the cases declared unfit for it (such as in an infant etc.) in cases of blood-poisoning (such as snake-bite etc.) and in fatal diseases (Vidradhi etc.). 3–4.

Preliminary rules:—

The patient should be duly fomented (Sveda) and anointed (Sneha) with oily preparations, A liquid^[1] food or diet consisting of articles which are antidotal to the bodily principles (Doshas) which engendered the disease or Yavagu (gruel) should be given to him at first. Then at the proper season (i.e., not in the rainy or winter season etc.) the patient should be brought near the surgeon and made to sit or lie down and the part to be incised upon should be bound, neither too loosely (e.g., in the extremities etc.) nor too tightly (e.g., in the head etc.), with any of the accessories, such as cloth, linen, skin, the inner fibres of a bark, creepers etc., so as not to create any pain or agitation in his mind. Then the vein should be duly opened with proper instrument (and with a careful regard to the situation of any local Marma). 5

Metrical text:—

Venesection should not be performed in an extremely cold or hot, cloudy or windy day. It is forbidden to open a vein without necessity or in a healthy person, or in a disease in which such as a proceeding is absolutely prohibited. 6.

The Yantra-Vidhi:—

The patient whose vein is to be operated upon should be seated on a stool to the height of an Aratni (distance of the elbow from the tip of the small finger) with his face turned towards the sun. He should keep his legs in a drawn up or contracted posture resting his elbows (Kurpara) on his knee-joints and the hands with his two thumbs closed in his fists placed on (the upper ends of) his Manyas (sterno mastoid muscles), Then having cast the binding linen on the two closed fists thus placed on the neck, the surgeon should ask another man from the back side of the patient to take hold of the two ends of the cloth with his left hand having the palm turned upward, and then ask him to tie up with his right hand the bandage round the part, neither too diffusely nor too tightly nor too loosely, so as to raise the vein and to press the bandage round the back for a good out-flow of blood. Then he (surgeon) should perform the operation in the desired spot, the patient having been previously asked to sit with his mouth full of air (i.e., he should confine his breathing till the surgical operation is completed). This proceeding should be adopted in opening any vein of the head, save those which are situated in the cavity of the mouth. 7.

In the case of opening a vein (Sira) in the leg, the affected leg should be placed on a level ground, while the other leg should be held in a somewhat contracted posture, at a little higher place. The affected leg should be bound with a piece of linen below its knee-joint and pressed with the hands down to the ankle. A ligature of the above kind should then be tied four fingers above the region to be incised upon, after which the vein should be opened. 8.

In the case of opening a vein (Sira) in the arms, the patient should be caused to sit easily and fixedly with his two thumbs closed in his fists (as above). A ligature of the above-mentioned kind (rope etc.,) should be tied (four fingers above the part to be incised upon and the vein opened in the aforesaid manner. The knee-joint and the elbow should be held in a contracted or drawn up posture at the time of opening a vein in a case of Gridhrasi (Sciatica) and Vishvaci, respectively. The patient should hold his back raised up and expanded and his head (and shoulders) bent down at the time of opening a vein in the back, shoulders and the Sroni (hips). He should hold his head thrust back and his chest and body expanded at the time of opening a vein in the chest or in the abdomen. 9–12.

He shall embrace his own body with his arms at the time of opening a vein in his sides. The penis should be drawn downward (i.e., in an flaccid state) on a similar occasion in that region. The tongue should be raised up to the roof of the mouth and its fore-part supported by the teeth at the time of opening a vein in its under-surface. The patient should be told to keep his mouth fully open at the time of opening a vein in the gums or in the palate. Similarly a Surgeon should devise proper and adequate means for the purpose of raising up (distinct appearance of) a Sira (vein) and determine the nature of the bandage to be used therein according to the exigencies (i.e., the health and the kind of diseases of the patient), of each case. 13–17,

An incision to the depth of a barley-corn should be made with a Vrihimukha instrument (into a vein situated) in the muscular parts of the body, whereas the instrument should be thrust only half that depth or to the depth of a Vrihi seed in other places (Vrihi here signifies Shukadkanya as well as Rakta-shali) An incision over a bone should be made with the Kutharika (small surgical axe) to the half depth of a barleycorn. 18–19.

Memorable Verses:—

An opening should be effected in such a day in the rainy season as would be devoid of the rumblings of a thunder-cloud, during the cold (i.e., in the fourth) part of the day in summer, and at noon in the winter season (Hemanta). These are the only three times of opening a vein. A well and successfully pierced vein bleeds in streams (almost simultaneously with the thrusting of the knife) and spontaneously stops after a Muhurta (a little while). The vitiated blood is seen first to flow out of an opened vein, like the drop of yellow pigment first coming out of a Kusumbha flower. Blood does not flow out from an incision made into a vein of an unconscious (Murccita), much frightened, or a thirsty patient. An incision of a vein without proper bandaging and raising up is attended with a similar result. 20-23.

A weak person, or one affected with the unusual derangement of the bodily Doshas etc., or one fainted (under operation), should not be subjected to a measure of continuous blood-letting at a time; instead of that, the vein should be opened afresh in the same afternoon or on the following day, or on the third day (as the exigency requires). An intelligent surgeon should not allow the flow of blood to an excess but should stop the flow even with a remnant of the diseased blood in the system and administer soothing internal remedies (Samshamana) for the purification of the diseased remnant. Bleeding to the quantity of a Prastha^[2] measure should be deemed sufficient for a strong and adult patient, stuffed with a large quantity of the deranged Doshas (in the body). 24-26.

The vein should be incised with a Vrihimukha instrument at a distance of two fingers above the seat of the Kshipra-marma in such diseases as Padadaha, Pada-harsha, Ava-vahuka, Chippa, Visarpa, Vata-rakta, Vata-kantaka, Vicharchika, Padadari etc. The mode of opening a vein in the case of Shlipada (Elephantiasis) would be described under the treatment of that disease. In Vata-rogas, such as Kroshtuka-shirah (Synovites), maimedness (Pangu) and lameness (Khanja), the Sira (vein) of the Jangha (lower leg-calf), four fingers above the Gulpha, should be opened. In cases of Apachi (scrofula), the vein should be opened simultaneously with the appearance of the disease two fingers below the Indravasti-marma. In a case of Gridhrasi (sciatica), the vein should be opened four fingers above or below the Janu (knee-joint). In a case of goitre, the veins attached to the roots of the Uru (thighs) should be opened. The instructions regarding the opening of a vein in one leg shall hold good in the case of that in the other, as well as in cases of those situated in the two upper extremities (hands), but the speciality is that in a case of enlarged spleen, the vein near the Kurpara- sandhi (elbow-joint) of the left hand or that inside the fourth and the fifth fingers should be opened. Similarly in a case of Yakriddalyodara or Kaphodara, the corresponding vein in the right hand should be opened. Several authorities advise the opening of the same vein in cases of cough and asthma^[3] due to the action of the deranged Kapha. 27–35.

In a case of Vishvaci, the same argument holds good (four fingers above or below the Kurpara-sandhi) as in a case of Gridhrasi. In a case of Pravahika (diarrhea) attended with Shula (colic), the vein within two fingers width around of the Pelvis (Shroni) should be opened. The vein of the penis should be opened in a case of Parikartika (D.R.-Parivartika), Upadansha, Shuka-dosha and seminal disorders. The vein on either side of the scrotum should be opened in a case of hydrocele (Mutra-Vriddhi). 36-39.

The vein four fingers below the navel and on the left side of the Sevani (suture) should be opened in a case of Dakodara (ascites). In a case of internal abscess and colic in the sides (Pleurodynia), the vein in the region between the breast and the left armpit should be opened. Several authorities assert that in a case of Avavahuka and Vahushosha (atrophy of the hand), the vein between the Amsas (shoulders) should be opened. In a case of Tritiyaka (Tertian) fever, the vein inside the Trika-Sandhi should be opened. In a case of Caturthaka fever, a vein joined with either side of and below the shoulder-joint should be opened. In a case of Apasmara, the middle vein adjacent to the joint of the jaw-bones (Hanu-Sandhi) should be opened. In a case of insanity and hysteria (Apasmara)^[4], the vein between the temple and the edge of the sculp or those in the Apanga (tips of the eyes), the forehead or the chest should be opened. In cases of the diseases of the tongue and the teeth, the veins on the under-surface (Adho-Jihva) of the tongue should be opened. In the case of a disease of the palate, the local vein should be opened. In diseases of the ears and specially in a case of inflammatory ear-ache (Karna-Shula), the vein along the region above the ears should be opened. In diseases of the nose and specially in a case of the loss of the smelling faculty, the vein at the tip of the nose should be opened. In cases of eye-diseases, such as Timira (blindness), Akshipaka (ophthalmia) etc., as well as in diseases of the head and in Adhimantha, the veins about the nose, the forehead and the Apanga (the outer canthus of the eyes), should be opened. 40–51.

Defective Venesection:—

Now we shall describe the twenty kinds of defects relating to an opened vein (Dushta-vyadhana). They are as follows:—Durviddha, Atividdha, Kuncita, Piccita, Kuttita, Aprasruta, Atyudirna, Ante-abhihata, Parishushka, Kunita, Vepita, Anutthita-viddha, Shastrahata, Tiryag-viddha, Apaviddha, Avyadhya, Vidruta, Dhenuka, Punhpunarviddha and Marmaviddha, i.e., incised about the Sira-marma, the Snayu-marma, the Asthi-marma and the Sandhi-marma. 52–53.

Their definitions:—

The vein in which an act of venesection is unattended with a satisfactory outflow of blood owing to its being incised with an extremely slender instrument and is marked by an extremely painful swelling in consequence thereof, is called Durviddha (badly incised).

The vein in which the incision becomes excessive and no blood comes out properly or enters an internal channel owing to the largeness of the incision, is called Atividdha (over-incised).

An opened vein in which the incision has been made in a curving manner and is attended with the foregoing results, is called Kuncita (crooked or contracted).

An incised vein presenting a flattened or thrashed appearance on account of its being opened with a blunt knife (Kantha-Shastra) is called Piccita (thrashed).

The vein at the sides of which incisions have been successively made, instead of in its body, is called Kuttita (lacerated).

An incised vein, unattended with any bleeding owing to the patient’s fright, coldness or loss of consciousness, is called Aprasruta (unbleeding).

A vein with a large incision in its body made with a sharp and flat-edged instrument, is called Atyudirna (improperly wide-incised).

An opened vein in which blood oozes out in small quantity is called Ante- abhihata (struck in the interior).

An opened vein in an anemic patient (marked by a total absence of bleeding and) stuffed with Vayu (lit., as if the flow has been dried up by the Vayu), is called Parishushka (dried up).

A vein opened but to a quarter part of the proper length and attended with a scanty outflow of blood, is called Kunita (partially incised).

A vein which trembles owing to its being bandaged at a wrong place and from which blood does not flow out in consequence, is called Vepita (quivering).

A vein incised without being previously properly raised up and attended with a similar result (i e., absence of blood), is called Anutthita-viddha.

A vein cut into two and attended with excessive bleeding and inoperativeness of the organ is called Shastrahata (knife-cut).

A vein incised with an instrument applied slantingly and (consequently) not fully opened, is called Tiryag-viddha (obliquely incised).

A vein incised several times and (every time) with an improper instrument, is called Apaviddha (wrongly incised)

A vein unfit for opening whose opening has been forbidden in the Shastras), is called Avyadhya (unfit for opening).

A vein opened carelessly and hastily is called Vidruta (erratic).

A vein bleeding continuously owing to its being repeatedly pressed and successively opened, is called Dhenuka.

A vein variously cut owing to its being pierced into the same part with an extremely slender-pointed instrument, is called Punah-punarvidaha (repeatedly incised).

If a vein in the Snayu-marmas, the Asthi-marmas, the Sira-marmas or the Sandhi-marmas be opened, it is called Marma-viddha and in such cases severe pain, emaciation (Sosha) deformity or (even) death may be the result. 54.

Memorable Verses:—

Practice (even) does not give the necessary skill in surgical operation of the veins etc., as they are naturally unsteady and changing like fishes. Hence a vein should be opened with the greatest care. An opening into the body, made by an ignorant and unskilful surgeon, is attended with the aforesaid dangers and many other distressing symptoms. An act of venesection, properly performed, gives more speedy relief than that derived from the application of medicated oil etc., or of plaster as well. Venesection (bleeding) properly performed is half of the treatment described in surgery like the application of Vasti- karmas (enematic measures) in therapeutics. 55.

A man medically anointed (Sneha-karma), diaphorised (Sveda), vomited (Vamana), purged (Virecana), or treated with both the Vasti-karmas (Anuvasana and Asthapana) or bled shall forego anger, physical labour, sexual intercourse, sleep in the day time, excessive talking, physical exercises, riding or driving etc., sitting on his haunches, frequent rambling.?, exposure to cold, winds and the sun, hardly digestible, uncongenial and incompatible food until the strength is perfectly restored or, according to some authorities, for a month. These subjects will be fully dealt with later on Aturopa- drava-chikitsa, ch.—39). 56.

Memorable Verses:—

The vitiated blood incarcerated in any part of the body should be abstracted therefrom by scarifying it, by cupping it with a Sira (pipe), a horn, a gourd, or leeches, or by the opening of a vein respectively, according to the density of the blood. (Others assert that) leeches should be applied in the case of the (vitiated) blood being confined deep into the body, scarification with a surgical instrument should be made in the case of clotted blood, with a pipe in the case of extensive vitiation of the blood throughout the body and with a horn or a gourd in the case of the deranged blood having been seated in the skin. 57-58.

 

Thus ends the eighth Chapter of the Sharira Sthana in the Sushruta Samhita which treats of venesection.

Footnotes and references:

[1]:

A liquid food is recommended for the purpose of liquefying the blood so as to bleed easily.

[2]:

In medicinal preparations, a Prastha measure is understood to be four seers in the case of liquids, but in cases of excreta due to emetic and purgative measures and of blood-letting, a Prastha is meant to be thirteen Palas and a half only.

[3]:

Gayi holds that in cases of asthma and cough venesection should be had recourse to only when they are in a mild form.

[4]:

Dallana, however, differs here from the text. He says, on the authority of Vagbhata, that the opening of a vein between the temple and the edge of the sculp or those in the Apanga, the forehead and the chest should be recommended in cases of insanity only, and not in the case of of Apasmara as well (as in the text).