Charaka Samhita and Sushruta Samhita
by Nayana Sharma | 2015 | 139,725 words
This page relates ‘perception of surgery’ of the study on the Charaka Samhita and the Sushruta Samhita, both important and authentic Sanskrit texts belonging to Ayurveda: the ancient Indian science of medicine and nature. The text anaylsis its medical and social aspects, and various topics such as diseases and health-care, the physician, their training and specialisation, interaction with society, educational training, etc.
The perception of surgery
The authors of the Suśruta Saṃhitā unequivocally uphold the therapeutic efficacy of surgery which is described as the foremost (adyaṃ [adya]) and best of all the subdivisions (aṅgavara [aṅgavaram])[1] of Āyurveda. Not only does surgery give swift results, it is applicable in all other branches of medical science.[2]
Surgery is a branch of medicine that is concerned with treating disease, disorder or injury by physical means, i.e., cutting into the patient‘s body to operate directly on or to remove the affected part.[3] The manual element is intrinsic to this branch of medicine as is evident from the etymology of the term ‘surgery’. It derives from the French word surgerie that is derived from Latin chirurgia. The corresponding Greek term kheirourgia is derived from two words: kheir meaning ‘hand’ and ergon meaning ‘work’.[4]
In Āyurveda the branch of Śalya-tantra is the equivalent of surgery dealing with the extraction of śalyas or foreign bodies such as straw, wood-pieces, stones, dust and metallic particles, pebbles, bone pieces, hairs or nails; extraction of pus, secretions, contaminated ulcers and obstructed labour; alkali treatment, cauterization, diagnosis and treatment of wounds, and cases requiring surgical intervention.[5] Thus, the surgeon of the Dhanvantari school worked not just with surgical instruments but also with a host of other materials to perform blood-letting as well as alkali and thermal cauterization. Interestingly, Suśruta designates the hand as the most important of all instruments that makes possible the use of any instrument[6] highlighting the manual aspect of surgery. Śalya-tantra makes use of eight kinds of procedures: excision (chedana), incision (bhedana), scraping (lekhana), probing (vedhana), extraction (eṣaṇa), drainage (visravaṇa)[7] and suturing (sivya).[8] A large number of instruments are described by Suśruta: 101 blunt instruments (yantras)[9] and 20 sharp ones (śastras).[10] Scraping may be done by the application of caustic alkalis (kṣāras)[11] and drainage by means of leeches, horn or gourd.[12]
Caustic alkalis (kṣāras) perform the tasks of excision, incision and scraping; they are capable of alleviating all the doṣas and they can be used to carry out special procedures.[13] They are capable of destroying lesions[14] and can be used as collyrium in eye diseases.[15] Alkalis can be used as an alternative to sharp instruments in diseases of the oral cavity; hence, cauterisation with alkalis is considered superior to the use of sharp instruments.[16] Superior to the caustics is thermal cauterization (agnikarma) as there is little chance of relapse of the disease after treatment and it is capable of curing those conditions that do not yield to medicines, surgery and caustic alkali treatment.[17] Thermal cauterization is useful in surgical cases to induce haemostatis.[18]
There are, nonetheless, some limitations to treatment by both alkali and fire cautery for they cannot be applied to all patients and in all clinical conditions. Neither of these procedures is suitable for persons who are weak, very young, elderly, timid or suffering from haemorrhagic diseases.[19] Alkali treatment is also not recommended for pregnant and menstruating women and for the patients suffering from generalised oedema, abdominal diseases, hyperpyrexia, urinary abnormalities, dehydration, loss of weight and muscle mass due to chest lesions, tendency of fainting, impotency and displacement of the ovaries and the uterus.[20] Cautery is also contraindicated for patients of paittika constitution, or those suffering from ruptured viscera, unextracted foreign body, multiple lesions, and for those who have been disallowed from undergoing fomentation.[21] If at all it is necessary to apply alkalis or fire cautery to children and the elderly, they should be by given in mild doses very gradually.[22]
Further, caustics are not applicable to all parts of the body. The vulnerable areas, such as, blood vessels, ligaments, joints, cartilages, sutures, arteries, the throat, the umbilicus, the nail bed, etc., are not suitable for such treatment.[23] However, cauterisation (by fire cautery) has a wider applicability; it safe for the skin, muscle, the vessels, the ligaments, the joints and the bones[24] but not suitable in all seasons. It is avoidable in autumn and summer.[25] Suśruta warns that alkali treatment should be done cautiously by a physician with good knowledge of caustics which may otherwise have fatal repercussions; but its judicious application by a wise clinician gives excellent results as even serious diseases are cured quickly.[26]
A fourth specialised procedure of the surgeons is blood-letting (visrāvaṇa) that is particularly useful in the treatment of diseases caused by the vitiation of blood. It is recommended as a preventive measure in skin diseases, lymph node enlargements, oedema and blood diseases.[27] It helps to reduce pain and suppuration in inflammations,[28] gout,[29] erysipelas (visarpa),[30] alleviation of vitiated vāta in skin, muscles, blood and veins,[31] Blood-letting by application of leeches is considered the most gentle and safe for use in all areas including the eye region.[32]
Surgical intervention is, however, not always the first step in therapeutics for a surgeon. Suśruta clearly lays down that surgical procedures should not be attempted in diseases that are curable by non-surgical methods.[33] In the management of piles for instance, there are four methods of treatment depending on the stage of the disease. If the disease is of recent origin with minimal vitiation of doṣa, as in piles for instance, it is first treated with non-surgical measures, such as -medication.[34] In advanced cases physicians would resort to caustics, fire cautery or surgery.[35] Similar is the recommendation in case of urinary stone where surgery is understood to be the last resort when the condition is not amenable to treatment with oleation, alkalis, decoctions, milk based preparations and bladder washes.[36] As success in such cases is generally elusive, recourse to surgery is considered avoidable unless it is rendered inevitable by the circumstances.[37]
One would have thought that surgical procedures would be out of place in a treatise on internal medicine but the references to phlebotomy, cauterization and other surgical procedures in the Caraka Saṃhitā imply that the practitioners of this medical branch were not averse to them. In fact, they found it expedient to take recourse to surgical procedures in certain conditions either as an integral part of therapy or as the final recourse in the advanced conditions not amenable to medication alone. Blood-letting is accepted as a curative in conditions of blood vitiation,[38] such as kuṣṭha,[39] phantom tumour (gulma)[40] and herpes.[41] It is also prescribed in several other conditions: consumption (in particular clinical symptoms),[42] unmāda, irregular fever, epilepsy,[43] jālakagardabha (a type of swelling that spreads),[44] exogenous swelling,[45] enlargement of the spleen,[46] liver enlargement,[47] visarpa (herpes)[48] and vāta-rakta (gout).[49]
Caraka also acknowledges the inefficacy of medication in these diseases if vitiated blood is not eliminated first through blood-letting.[50] All the modes of blood-letting are mentioned-the application of śṛṅga (horn), alābu (gourd), jalaukas (leeches),[51] rough-surfaced instruments[52] and by venesection.[53]
Clinical conditions requiring application of surgical procedures or cauterization or both have also been indicated. Caraka recommends their application in miscellaneous types of swellings,[54] excision and cauterization of granthi (hard tumour),[55] removal of śalya (foreign object),[56] fistula-in ano,[57] raktaja type of piles,[58] granthi-visarpa (nodules in herpes),[59] vraṇa (ulcers),[60] and urinary calculi (aśmari).[61] In cases of poisoning, procedures like excision (utkartana), cauterization and blood-letting, are accepted as vital measures to draw out the venom and prevent its spread.[62] Caustic alkali treatment becomes imperative when the application of surgical instruments is contraindicated in kuṣṭha patches.[63] A particular variety of ulcers is classified as kṛtya, that is, relievable by surgery alone.[64] Interestingly, incision of the suppurated abscess is described as an excellent remedial measure (śastraṃ tu paramucyate).[65] Surgical cases are referred to the experts in this field as we have already noted.[66] However, Caraka cautions that the procedures must be carried out by a surgeon well versed in the technique[67] and in many cases they are advocated as the last resort when all other therapeutic measures are ineffectual. Thus, in case of gulma (phantom tumour), oral administration of fatty substances, dietary measures, massage and medicated enema constitute the first-line treatment.[68] If they prove inadequate, the physician can opt for blood-letting,[69] application of alkalis and cauterisation.[70] Surgical intervention is also advised as the last resort in urinary calculi.[71] The feasibility of surgical management depends much on the condition and constitution of the patient. Surgery is successful in those who are physically and mentally strong (kṛcchra).[72] Alternative formulations are mentioned for patients of tender nature (sukumāra).[73] Caraka also forbids agnikarma in infants, weak and elderly persons, pregnant women and those afflicted with certain diseases.[74] Blood-letting is forbidden if the patient suffers from emaciation and unctuousness.[75]
Though alkalis are held to be effective and safe (siddhā niratyayāḥ), it is advised that they should be used as a last resort when other therapies are not effective (dāhastvante praśasyate).[76] Caraka points out that though excision, alkali or thermal cauterizations are preferred by some physicians, they are fraught with risk as any lapse could lead to several serious complications.[77] Therefore, they should be administered only by one who is well versed in the subject (bhūritantreṇa), intelligent (dhīmatā) and experienced (dṛṣṭakarmaṇā).[78] The perception of risk and pain involved in surgical procedures compared to other therapies is very much evident.[79] Suśruta, too, admits the high risk factor in some procedures, such as, removal of urinary stone and cases of mal-presentation of foetus. The latter is regarded by Suśruta as the most difficult among all surgeries.[80] Yet another potentially fatal procedure is the surgical excision of the galaśuṇḍikā (uvula).[81] Suśruta enjoins that difficult surgeries should be attempted only by one who is well versed in surgery and has practical experience.[82]
Apart from professional dexterity, the surgeon is called upon to be sensitive to the needs of the patient. When conducting procedures on infants and those who fear the sight of surgical instruments, he is advised to use instead bamboo skin, quartz (sphatika), glass (kāca) and kuruvinda (corundum)[83] for the procedures.[84] Leaves of gojī, śephālikā and śākapatra are used as substitutes in drainage of lesions within the oral cavity and on the eyelids.[85] Leeches, fire cautery and alkalis can also be used as the substitutes for sharp instruments. Among the various methods of phlebotomy the most gentle is leech treatment which, we have noted earlier, is preferred by Suśruta for kings and affluent persons, children and the elderly, timid and weak persons, women and delicate persons.[86]
Footnotes and references:
[1]:
Suśruta Saṃhitā Sūtrasthāna 1.16.
[2]:
Suśruta Saṃhitā Sūtrasthāna 1.18.
[4]:
Chambers 21st Century Dictionary, p.1423.
[5]:
Suśruta Saṃhitā Sūtrasthāna 1.8(1).
[6]:
Suśruta Saṃhitā Sūtrasthāna 7.3.
[7]:
Blood-letting is included in drainage.
[8]:
Suśruta Saṃhitā Sūtrasthāna 5.5.
[9]:
Suśruta Saṃhitā Sūtrasthāna 7.3.
[10]:
Suśruta Saṃhitā Sūtrasthāna 8.3.
[11]:
Suśruta Saṃhitā Sūtrasthāna 11.18.
[12]:
Suśruta Saṃhitā Sūtrasthāna 13.4.
[13]:
Suśruta Saṃhitā Sūtrasthāna 11.3.
[14]:
Suśruta Saṃhitā Sūtrasthāna 11.4.
[15]:
Suśruta Saṃhitā Uttaratantra 11.10-12.
[16]:
Suśruta Saṃhitā Sūtrasthāna 11.3.
[17]:
Suśruta Saṃhitā Sūtrasthāna 12.3.
[18]:
Suśruta Saṃhitā Sūtrasthāna 12.10.
[19]:
Suśruta Saṃhitā Sūtrasthāna 11.28; 12.14.
[20]:
Suśruta Saṃhitā Sūtrasthāna 11.28.
[21]:
Suśruta Saṃhitā Sūtrasthāna 12.14.
[22]:
Suśruta Saṃhitā Sūtrasthāna 35.32.
[23]:
Suśruta Saṃhitā Sūtrasthāna 11.29.
[24]:
Suśruta Saṃhitā Sūtrasthāna 12.7.
[25]:
Suśruta Saṃhitā Sūtrasthāna 12.5.
[26]:
Suśruta Saṃhitā Sūtrasthāna 11.31.
[27]:
Suśruta Saṃhitā Sūtrasthāna 14.34.
[28]:
Suśruta Saṃhitā Cikitsāsthāna 1.27-29.
[29]:
Suśruta Saṃhitā Cikitsāsthāna 5.7.
[30]:
Suśruta Saṃhitā Cikitsāsthāna 17.16.
[31]:
Suśruta Saṃhitā Cikitsāsthāna 4.7.
[32]:
Suśruta Saṃhitā Uttaratantra 12.8.
[33]:
Suśruta Saṃhitā Sūtrasthāna 24.3.
[34]:
Suśruta Saṃhitā Cikitsāsthāna 6.3.
[35]:
Suśruta Saṃhitā Cikitsāsthāna 6.3.
[36]:
Suśruta Saṃhitā Cikitsāsthāna 3. 27.
[37]:
Suśruta Saṃhitā Cikitsāsthāna 7.28-29.
[38]:
Caraka Saṃhitā Cikitsāsthāna 5.32; 21.141.
[39]:
The hard skin patches in kuṣṭha are required to be scrapped with a hard brush (kūrca) or incised with a sharp scalpel prior to the application of medication; Caraka Saṃhitā Cikitsāsthāna 7.50-51.
[40]:
Caraka Saṃhitā Cikitsāsthāna 5.36-37.
[41]:
Caraka Saṃhitā Cikitsāsthāna 21.141.
[42]:
Caraka Saṃhitā Cikitsāsthāna 8.82.
[43]:
Caraka Saṃhitā Cikitsāsthāna 9.77.
[44]:
Caraka Saṃhitā Cikitsāsthāna 12.100.
[45]:
Caraka Saṃhitā Cikitsāsthāna 12.102.
[46]:
Caraka Saṃhitā Cikitsāsthāna 13.77.
[47]:
Caraka Saṃhitā Cikitsāsthāna 13.88.
[48]:
Caraka Saṃhitā Cikitsāsthāna 21.68.
[49]:
Caraka Saṃhitā Cikitsāsthāna 29.35-36.
[50]:
Caraka Saṃhitā Cikitsāsthāna 7.53.
[51]:
Caraka Saṃhitā Cikitsāsthāna 7.52
[52]:
Caraka Saṃhitā Cikitsāsthāna 23.39.
[53]:
Caraka Saṃhitā Cikitsāsthāna 8.82.
[54]:
Caraka Saṃhitā Cikitsāsthāna 12.101.
[55]:
Caraka Saṃhitā Cikitsāsthāna 12.82.
[56]:
Caraka Saṃhitā Cikitsāsthāna 13.184-188.
[57]:
Caraka Saṃhitā Cikitsāsthāna 12.97.
[58]:
Caraka Saṃhitā Cikitsāsthāna 14.61.
[59]:
Caraka Saṃhitā Cikitsāsthāna 21.132-136.
[60]:
Caraka Saṃhitā Cikitsāsthāna 25.40, 101-104.
[61]:
Caraka Saṃhitā Cikitsāsthāna 26.68.
[62]:
Caraka Saṃhitā Cikitsāsthāna 23.35.
[63]:
Caraka Saṃhitā Cikitsāsthāna 7.54.
[64]:
Caraka Saṃhitā Cikitsāsthāna 25.20.
[65]:
Caraka Saṃhitā Cikitsāsthāna 25.54.
[66]:
Caraka Saṃhitā Cikitsāsthāna 5.44.
[67]:
Caraka Saṃhitā Cikitsāsthāna 5.139.
[68]:
Caraka Saṃhitā Cikitsāsthāna 5.20-26.
[69]:
Caraka Saṃhitā Cikitsāsthāna 5.32.
[70]:
Caraka Saṃhitā Cikitsāsthāna 5.56.
[71]:
Caraka Saṃhitā Cikitsāsthāna 26.68.
[72]:
Caraka Saṃhitā Cikitsāsthāna 25.54.
[73]:
Caraka Saṃhitā Cikitsāsthāna 25.54.
[74]:
Caraka Saṃhitā Cikitsāsthāna 25.101.
[75]:
Caraka Saṃhitā Cikitsāsthāna 29.38.
[76]:
Caraka Saṃhitā Cikitsāsthāna 5.163.
[77]:
Caraka Saṃhitā Cikitsāsthāna 14.35-36.
[78]:
Caraka Saṃhitā Cikitsāsthāna 14.34.
[79]:
Caraka Saṃhitā Cikitsāsthāna 14.37.
[80]:
Suśruta Saṃhitā Cikitsāsthāna 15.3.
[81]:
Suśruta Saṃhitā Cikitsāsthāna 22.51.
[82]:
Suśruta Saṃhitā Cikitsāsthāna 22.52.
[83]:
Corundum is a mineral that is second only in hardness to diamond among natural substances. L. Grande and A. Augustine, Gems and Gemstones: Timeless Natural Beauty of the Mineral World, Chicago, 2009, p. 55.
[84]:
Suśruta Saṃhitā Sūtrasthāna 8.16.
[85]:
Suśruta Saṃhitā Sūtrasthāna 8.18.
[86]:
Suśruta Saṃhitā Sūtrasthāna 13.3.