The vessel or vessels (Sirá) 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 Anubásana and Asthápana 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 (Sirás) 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 (Sonita-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.
The patient should be duly fomented (Sveda) and anointed (Sneha) with oily preparations. A liquid * food or diet consisting of articles which are antidotal to the bodily principles (Doshas) which engendered the disease or Yavágu (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 (eg , 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
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 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.
* A liquid food is recommended for the purpose of liquefying the blood so as to bleed easily.
In the case of opening a vein (Sirá.) 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 (Sirá) 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 Vis'vachi, 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 Sirá (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