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.
* Several authorities hold that acts such as fasting, administration of purgatives, etc. should be included within the preliminary measures; application of absorbent (Pachana) 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.
Surgical acts or operations are divided into eight different kinds such as Incising (Chhedya), Excising (Bhedya), Scraping (Lekhya) Puncturing (Vedhya), Searching or probing (Eshya), Extracting (Abarya), Secreting fluids (Visravya) and Suturing (Seevya). 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), Jamvavoushtha (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, Tarpanam (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 combina-tions, 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 (Marmas), 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.
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 *. 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.
* 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 bod) is the fittest thing for a surgeon's knife - Tr.
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.
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.) *