The exact middle point of the external ear should be pierced (with a knife) and the severed parts should be pulled down and elongated in the case where both the parts of a bifurcated ear-lobe would be found to have been entirely lost or eaten away. In the case where the posterior one of the two bifurcated parts would be found to be longer or more elongated, the adhesion should be effected on the anterior side; whereas the contrary should be the case where the anterior one would appear to be more elongated. Only the remaining one of the two bifurcated parts of an ear-lobe would be pierced, cut in two and adhesioned on the top, in the case where the other part would be found to be gone. A surgeon well-versed in the knowledge of surgery (Shastras) should slice off a patch of living flesh from the cheek of a person devoid of ear-lobes in a manner so as to have one of its ends attached to its former seat (cheek). Then the part, where the artificial ear-lobe is to be made, should be slightly scarified (with a knife), and the living flesh, full of blood and sliced off as previously directed, should be adhesioned to it (so as to resemble a natural ear-lobe in shape).
A surgeon, wishing to effect any sort of adhesion other than those described before, should first collect the articles enumerated in the chapter on Preliminary Measures to Surgical Operations, together with milk, water, Dhanyamla fermented rice boilings), Suramanda (transparent surface-part of wine) and powders of earthen vessel. Then the hair of the patient, whether male or female, should be gathered and tied up in a knot, and the patient should be given a light food (so as to keep up his strength without hampering his digestion); after which his friends and relations should be asked to hold him firm. Then having ascertained the particular nature of adhesion to be effected in the case, the surgeon should examine the local blood by incising, excising, scarifying or puncturing the affected lobes as found necessary, and determine whether the same is pure or vitiated. Then having washed the blood with Dhanyamla and tepid water, if found vitiated through the action of the deranged (Vayu), or with milk and cold water in the event of the same being contaminated by the deranged Pittam, or with Suramanda and warm water in the case of its being vitiated by the action of the disordered Kapham, the surgeon shall bring about the adhesion by again scarifying the affected parts of the ear, so as not to leave the adhesioned parts elevated (raised), unequal and short. Of course the adhesion should be effected with the blood being still left in the parts that had been scraped. Then having anointed them with honey and clarified butter, they should be covered with cotton and linen, and tied with strings of thread, neither too loose nor too tight, and dusted over with powders of baked clay. Then directions should be given as regards the diet and nursing of the patient, who may be as well treated with the regimen laid down in the chapter on Dvi-vraniyam.
The patient should be careful not to disturb the bandage and avoid physical exercise, over-eating, sexual intercourse, exposure to, or basking in, the glare of fire, fatiguing talk, and sleep by day. For three consecutive days the ulcer should be anointed with unboiled oil; and cotton soaked in the same substance should be placed over it, which is to be altered, each third day, till healing.
The incidental ulcer should not be tried to be healed up as long as the local blood (blood in the ulcer) is not fully purified; or so long as there is haemorrhage from the seat of the affection or the local blood continues feeble. An ulcer, adhesion-ed with the least of the Vayu-vitiated blood continuing in its inside, will spontaneously burst or break open afresh. It will be again attended with pain, turning, redness and suppuration in the event of its being closed with a little quantity of Pitta-deranged blood incarcerated in its inside. Adhesioned even with a little quantity of Kapha fouled blood in its cavity an ulcer is marked by itching and numbness. An ulcer adhesioned with the continuance of an active haemorrhage from its inside is marked by a brown or blackish yellow swelling. An ulcer, adhesioned at a time when the local blood, though otherwise good or pure, has been thinned or weakened through excessive bleeding, is followed by a corresponding emaciation (thinness) of the adhesioned part. The lobule of the ear thus adhesioned should be gradually pulled down and elongated after the complete healing of the local ulcer and the subsidence of its concomitant symptoms, and after the cicatrix has assumed the colour of the skin of the surrounding part. Otherwise the adhesioned part may be characterised by pain, swelling, inflammation, burning and suppuration, or the adhesion may again fall off. An adhesioned ear-lobe, unaccompanied by any of the distressing or unfavourable symptoms, should be gradually elongated by rubbing it with an unguent composed of the milk, fat, and marrow of any such animals and birds as the Godha, the Pratudas, the Vishkiras, the Anupas, or the Audakas as would be available, and clarified butter and the oil expressed out of the seeds of white mustard, boiled with the decoction or Kvatha of Arka, Alarka, Vala, Ativala, Ananta, Apamarga, Ashvagandha, Vidari-gandha, Kshira-Shukla, Jalashuka and the drugs forming the group known as the Madhura, which should be previously prepared and carefully stowed in a covered receptacle.
Then the above medicinal unguent should be applied or rubbed over the lobe of the affected ear, whereby all the disturbing or unfavourable symptoms would be subsided, thus favouring its firm and steady growth. Similarly a plaster composed of Yava, Ashvagandha, Yashtyahva, and Tila, pasted together might be rubbed over the affected ear-lobe with advantage. Oil prepared and boiled with the essence of Shatavari, and Ashvagandha, or Payasya, Eranda, Jivana and milk increases the growth of an ear-lobe. The lobe of an ear, which refuses to grow in size in spite of being fomented and lubricated as above indicated, should be scarified with slight longitudinal incisions on its anterior side (that is on the side nearest to the cheeks) and not on the posterior one, as such a procedure might be attended with dreadful results.
An ear-lobe should not be tried to be elongated just after the adhesion of its two severed parts, inasmuch as the centre of the adhesion, still being raw, might cause them to fall off again. Thus an ear-lobe under the circumstance should be gradually elongated, only when it would be found to be marked by the growth of hair on its surface, and the hole or the perforation has assumed a circular look, and the adhesion has become firmly effected, well-dried, painless, even and level in its entire length.
The modes of bringing about an adhesion of the two severed parts of an era -lobe are innumerable; and a skilled and experienced surgeon should determine the shape and nature of each according to the exigencies of a particular case. *
O Sushrula, again I shall deal with diseases which affect the lobule of an ear under the circumstance described above The deranged bodily Vayu, Pittam and Kapham, either jointly or severally, give rise to several types of diseases which affect the lobule of an ear. The deranged Vayu produces numbness and an erysipelatous swelling and ulcer about the affected ear-lobe, while an erysipelatous ulcer in the locality accompanied by swelling, burning, suppuration, etc., should be ascribed to the action of the deranged Pittam. Heaviness, numbness and swelling of the ear-lobe accompanied by constant itching in the affected locality mark the action of the deranged Kapham. The medical treatment in these cases consists in effecting a subsidence of the particular deranged humour by means of diaphoresis, lubrication, Parishekas (medicated plasters) or blood-letting as the case may be. These measures should be moderately applied and a nutritive and invigorating food should be prescribed for the patient. The physician who is well familiar with the actions of the deranged bodily humours as described above, should be looked upon as alone entitled to take in hand a case, which falls under the head of one of the preceding types.
Now I shall deal with the process of affixing an artificial nose.
Now I shall enumerate the names of the several diseases which affect a severed lobe of the ear and describe the symptoms which each of them develops in succession. They are known as Utpataka, Utputuka, Shyava, Bhrisam-kandujata, Avamantha, Sakanduka, Akundaka, Granthika, Jam-vala, Sravi and Dahavana. Now hear me discourse on the nature of medicinal treatment to be adopted in each of them.