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Susruthasamhitha -The first Surgical Pathology Text of the world Dr Suvarna Nalapat http://drsuvarnanalapattrust.org

What distinguishes Susruthasamhitha from other Ayurveda texts is its Surgical Pathology knowledge.The most important part of the treatise is this. The comparison to Modern Surgical Pathology is interesting. General rules and procedures in surgery:There are three stages in salyachikitsa of any type whether minor or major .    1 Poorvakarma ( To be done before the main procedure) –Pre-operative 2.Pradhanakarma ( The surgery proper ) – Operative surgery 3.Paschaath karma ( Procedure after surgery) – Post-operative

Thrividham karma: poorvakarma,pradhaanakarma,paschaathkarma ( sooth: 5;3) All these are equally important for success of treatment .  Poorvakarma: Decide the best time for procedure consulting the cosmic powers , and meditate upon the ancestral teachers and divine powers for success in the procedure. Musical sthothra are recited by teh Vaidya ( Music Therapy ) at this stage . Examines the client thoroughly and decide whether surgery should be done immeadiately or not. If needed , the patient is prepared and taken to the place for that .He may be put in a sitting or lying down posture depending upon surgery. The hands and legs were tightly gripped by disciples. If the surgery is removing a dead foetus from womb, piles,ulcers in anus or rectum,asmari ( stones) surgery in nose,mouth or throat , the client should fast before surgery. For minor surgery on other organs he/she can take light, nutrient kanji water. Susrutha does not describe Anaesthesia in detail.But in Chikitsaasthaanam he mentions about a gas which produce sleep showing that he knew about it . Supthivaathe thaw sringmoksham kuryartthu bahuso bhishak” (chi:4;12).Supthi is sleep and vaatham is gas/air and a doctor using this must be for Anaesthesia.

At a hands length all the instruments should be kept and surgeon should inspect himself whether allare kept ready. Sasthra , yanthra, tools etc , fire to boil and make them red hot , salaaka,

2 srimgha,jalougha for blood letting, alaabu ( dry pumpkins the inner flesh removed as a pot for collecting body fluids and other surgical material) Jambovoushtam ( serrated needlelike instrument long as a pencil made of sila or stone ) cotton thread and cotton, plotham ( clean cloths) soothra made of different materials in different thickness, pathra (leaves) ,patta ( bandages of chana) milk,vegetable oils, wheat powder in water, alkaline fluids, sour medicines for Sthambana ( anaesthesia), different types of plasters,gums,ointments,fans,cold water,hot water, pots and instruments which are red hot , several disciples and parichaaraka ( nurses ) who are trained in the art of surgery should be there.Only after making sure that these are kept ready one should start surgery.Before surgery all materials used must be purified ( soo:5;2-4-12)  Pradhaanakarma: This differs depending upon what the disease is . Chedana ( Excision), bhedana ( incision), lekhana ( scraping and curettage), eshanam ( probing), vedhanam ( puncturing),aaharanam ( extraction), visraavanam ( letting out body fluids which also includes tapping and blood letting) and seevana ( suturing) are th e8 functions which a surgeon should get training to do quickly and without any doubt . Only after getting practical training in this one is allowed to do surgery. The surgeon should have complete knowledge of his science and prolonged practical experience in it , courage,confidence , strength and hands which donot sweat .

Souryamaasu kriyaasasthrathaikshanyamaswedavepathu Asammohascha vaidyasya sasthrakarmaani sasyathe ( soo:5-10) When one does excision ( chedana) it should be deep and wide as far as possible ( wide excision). Special care is taken not to injure veins , arteries, nerves ,bones,joints, origin of muscles (tendons) .Bhedanam ( incision) is done in straight line, in angular way, or as ardhachandra ( half moon ) circular and after that through the incision excise the tissue/swelling to be removed. The incision depends on which part is subjected to surgery , whether it is a ulcer,swelling etc. To remove an organ or a foreign body and to let out excess pus, sometimes the first incision will have to be deepened or smaller incisions ( multiple) made. The operated site is made free of all dead tissue and washed with sour astringents , pressed with hands and dried with clean cotton cloth. In the medicine for healing, dip cotton and cover that cotton in honey,gum,fats, and keep it in the hole made by the procedure. The sutured area is covered with medicinal ointments. Soft,cool, smoothening medicines applied and then tied . To prevent external organisms to attack the wound, at the site of the bandage dhoopa like saampraani is shown,and when the dhooma is given a second time, the medicines mixed and its dhooma also applied ( Guggulu, vacha, white katuku,nimbi leaf, saindhava,dry ghee are mixed and smoked for this). The balance after dhooma is let out has medicinal powers and this bhasma is collected and applied on the marma points of patient (bhasmadhaarana) like chest /heart etc. To reduce tiredness sprinkle water on his face. The room of surgery should be washed clean before and after each surgical procedure .After surgery Vedic manthra are chanted musically to prevent bad forces to attack client ( Mental problems prevented by soothening music ). The patient is transferred to a special room after surgery and special care given till teh wound heals completely ( Soo:5;3-15)  Paschaathkarma:-Quick and complete surgical wound healing depends upon postoperative care . After surgery 48 hours the bandage is kept as such without disturbing. ( closed wound healing ). The part is not moved to prevent pain . If moved , the upper part of wound will dry

3 up and crust formed before the lower part of wound heals . It is always better that the wound heals from below upwards .Third day the bandage is removed slowly and carefully. Exmine wound and see whether pus or dead tissues are there. If there are dead tissues they will affect the normal tissues around also . Therefore pus and dead tissues are removed, wound slowly cleaned and a new bandage applied. If it is summer or rainy season , daily change bandage. In snowly season third day only change is needed ( alternate days). Around,inside and outside wound is seen without pus and dead tissue, and there is no pain means wound has healed. If doctor thinks the wound is healed , but the patient say there is pain, apply clarified ghee and yashtimadhu mixture as a gummy paste on wound and it will cure pain. The medicines for wound healing , their uses, the food schedule of patient are explained by Susrutha.These are determined by the status of patient, of the wound, and immunity of patient , complications after surgery ,seasons .Wound should heal from inside outwards. The dry scar when it is soft , patient should avoid excess food intake,excess exercise, sexual contact, excess fear and sorrow and pleasure ( emotions).Doctor should be available at a safe distance so that he can reach patient in case of any emergency after surgery. If change isseen in patient’s condition paricharika ( nurse) or caretaker ( bystander) should inform doctor ( soo:5;16-21)  Salyayanthra and yanthrakarma:-

Yanthrakarmaani thu – nirghaathana,poorana,bandhana,vyoohana,varthana,chaalana,vivarthana,vivarana,peedana,ma arggavisodhana,vikarshnaa,haranaa,njanonnamana,vinamana,bhanjano,nmathanaachooshanou, shana,daarana,rjjukarana,prakshaalana,pradhoomana,pramaarjannai chathurvimsathi. Swabudhyaa chaapi vibhajedhyathra karmaani budhimaanAsamkhyeyavikalpathwaachalyanaamithi nibadha: ( soo: 7:17-18)

There are too many diseases. Therefore there are numerous types of surgery also for each of these. Which is to be accepted is the choice of an intelligent surgeon depending upon his knowledge, expertise and abilities. Usually there are 24 yanthrakarma ( instrumentational procedures ) used in surgery . They are : 1.Nirghaathana: With a probe move forward and backwards and then take out 2.Pooranam: Injecting something and filling a cavity 3.Bandhanam: applying a bandage 4.vyoohana:Positioning the part to be operated in a correct position suitable for surgery 5.Varthanam : A cyclical movement/rotating or swirling movement 6.Chaalanam : Transfering from one place to another 7.Vivarthanam : An object is changed upside down

4 8.Vivaranam:Expose and make it visible 9.Peedanam : pressure application 10.Margavisodhanam: Removing blood ,pus etc and make the way for surgery, or the body canals and ducts clean 11. Vikarshanam : Taking out 12.Aaharanam : Extraction 13.Aanjanam : Raising from internal plane to external plane and then bring back to its original position 14.Unnamanam: bending upwards 15.Unmathanam: Probing with a probe ( churning movement) 16.Vinamanam: Bending downwards 17. Banjanam : pressing around 18.Aachooshanam : sucking action 19.Eshanam: exploration – usually using a probe 20. Daaranam: cutting into 2 21 .Rijukaranam: making straight 22. Prakshaalanam : washing clean 23. Pradhoomam: allowing smoke or thin dust of medicine into a cavitylike space 24.Pramaarjanam: scrubbing clean .  Practical Training for surgeons :-

The student might have read lots of books, heard from teachers a lot, and understood several things from teachers watching them perform surgery . Yet these are not enough.He/she should get practical hands on experience .Both theoretical and practical knowledge are essential for a professional. The practical training is called Yogyaasoothreeyam ( Soo: 9-2) Chedana is first tried infruits of Pushpaphala ( Benincasa cerifera) Alabu ( Lageneria vulgaris),kaalindakam( cetrullis melo)karkaaru( Benincasa sativus)urvaarukam( cucumis melo) Thrapusa ( cucumis sativus ) . To learn Bhedana either dead animals , their urinary bladder or stomach are used by students. Or they are given a skinbag filled with water or dirt to learn incision. To learn vedhana , the vein of a animal which is recently dead , ( vein puncture is siravedhanam) or if not available start learning it first on teh lotus stems . The branches of trees made porous by worms (eating the central part )is useful for learning probing. Bilwam ( Aegle marmelos) Bimbi( Coccinia indica) and seeds of jackfruit tree is used to practice bhedana and aaharana ( incision+

5 extraction).The extraction of teeth was practiced on dead animals.The branches of salmali tree are covered with wax. The fluids oozing out of teh branch will collect inside this wax cover.This branch of salmali is used for learning Visravanam or tapping of fluids by a student of surgery.Suturing is learned on tick cloths,skins,or on dead animals .Bandhana( bandage) is learned on earthen idols made in real size of man .On skin and flesh of dead animal cauterisation learned. In a sprout of pot filled with water , practice use of catheter and speculum and on certain gourds of special shapes try compression,and such practices were necessary before a student was allowed to touch a human patient . To learn anatomy one has to do dissection. We find that students were practicing dissection on dead animals .It was also done on dead human body .After learning Anatomy from texts, and teachers and understanding the functioning of body one has to dissect and compare , observe whatever is theoretically learned and make sure that it is correct .The dead body used for this should be that of a mature adult, not very old, not very young, without any congenital diseases , with no sign of poisoning ,and without any chronic disorders.If such a person dies suddenly, that body is first cleaned after removing the internal organs and studying them ( post Mortem). Then the body is covered in medicinal grass, tied with rope,and kept in a cage and the cage is immersed in a cool, calm freshwater lake in a lonely forest or any other lonely place . After 7 days take it out. Each covering of body , skin and tissues are removed one by one .For this needles with bamboo, thick hairs, sharp roots of grass are used . One has to carefully learn all the internal and external structures and their relationships. (sar: 5;49-51) The use of the primitive instruments mentioned by Susrutha for dissection indicate that the practice originated in India in a very distant past , probably during the oldest Veda( Atharvaveda) period and dropped later on.  Instruments :-

There are four classes of instruments generally used in surgery.(soo:8;2-3) 1Sasthra : very sharp ones used for cutting 2.Yanthra :- They are not sharp 3.anusasthra ( minor sasthra) 4. Upayanthra ( Minor yanthra) Use of these are varied.Some special instruments with names : 1.Kankamukham: Shape of beak of crane. To do surgery of internal organs. This instruments make it easy for surgeon to reach all important internal organs including major blood vessels , effortlessly. 2.Mandalaagram: One end is circular and flat and used for Lekhana . Other uses given in tabular form . 3.Karapathram (saw).To cut bones

6 4.Vridhipathram( Razor blades) ,Ardhadhaaram (scalpel),mudrikam, nakhasasthram ( a instrument that resembles a nailcutter),ulpalapathram( in shape of lotus leaf), are needed for bhedana and chedana 5.Kusapathra ( shape of kusa grass leafblade),Aadimukham( shape of birds beak),saraarimukham(like beak of sarari bird),thrikoorchakam(shape of half circle with three pointed ends-thrisoola),soochi ( needles of different sizes) are used to let out fluids , for tapping . 6.Kutaarika ( knife),vreeheemukham ( resembles a paddy seed with thorns )Aara (awls),vethasapathram( a lancet or ardhapathra with shape of Rattancane grass) and needles are for vedhana 7 Vadisha ( sharp hook) is for taking out objects accidentally entered in body ( removal of foreign body) 8 Danthasankhu ( dental forceps) 9 Eshani ( surgical probes) The ends are slightly swollen like the head of a earthworm .This can probe into internal part where pus is originating . 10 soochi with nethra ( needles with eyes ) For suturing About 100 instruments , the most important instrument according to Susrutha is the hands of surgeon itself. Without that no other external instruments can function . Yanthra are classified as 6 main groups ( Soo:7;3-12). There is an internal bend at end of Swasthikayanthra. It is like a Ankusa in the hands of a mahout. The end that is in the hands of surgeon is shaped as head of a animal or bird. According to this there are 24 types swasthikayanthra. They are used for removing foreign bodies, cancerous growths, swellings in bones etc Sandamsayanthra are for surgery on skin,muscles,veins,nerves and ligaments Thaalayanthra are for ENT surgery and have a small handle and a bend end like the fin of a fish.7 to 9 inch is the length Nadeeyanthra have an inner opening and are tubular. Depending on shape,size and the size of the internal opening 20 types are there. To probe the natural openings of body, for treatment of swellings,cancers,ulcers,cavities,fistula and sinuses in perineum,piles,ascites,oedema of testis these are used. In some naadeeyanthra the opening exists from end to end.In others it is partial on one side only. To tap fluids, let out fluids and pus, remove obstacles in natural passages , especially of urethra,anal opening , and introducing smoke from medical preparations into them are functions. Salaakaayanthra depending on shape and size are used in pairs .One is dakshina and the other vaama ( clockwise ,anticlockwise).Main end is like a earthworm, body like an arrow,or hood of cobra or fishbone,or an opened bean’s shell/cover. Arow shape for Eshana (probing), for vyuhana ( cobrahood),for chaalana fishbone, and for aaharana the beancover shape )To purify and remove pus, cover the end with cotton and use. Some have triangular ends with a small depression like a spoon and these are used for applying medicinal fluids in the diseased parts easily. The ones with

7 serrated ends (like a jackfruit surface) and with sheroidal ends ( like pumpkin) are used for Kshaaravidya ( Cauterisation).The ones used to remove swellings, growths from nasal cavity are having sharp triangular ends .One mm thick, and shaped like a flowerbud is for surgery within the eye and for application of medicines in eye. Salaka which is elongated like a stem of a flower is for probing urethral orifices.  Making instruments :

The scientific advices given in the Medical textbooks of ancestors has to be strictly followed in making instruments. Or the oral traditions of ancestral doctors has to be followed. The already existing models of instruments were used during Susrutha’s time .Usually metals are employed in making of surgical instruments. A doctor has freedom to make slight differences and to invent/discover new modifications of old instruments depending upon need and utility. All instruments made should be strong, with a strong handle . The length should not increase or decrease than which is needed. The ratio of materials should be correct. The workers who make them should be careful , not to make surgical instruments with lower metals,without proper handles, which bends when pressure is applied, which is loose in joints,nuts or axial planes, that which does not move or function etc .If rust is seen the metal used is not good and a doctor should not accept it.( soo:7;3-5;8-15).All instruments have to be put in alkaline liquids, oils and pure water depending on type of metal used and this is called Paayanam .To sharpen instruments special stones are used (Honing), and when not in use all instruments should be kept within proper covers ( soo:8-9) All upayanthra also should be ready before the surgery starts .In the listof upayanthra come Rajju ( coir),hard thread,thread from chana , skins,pith of trees and plants,cotton cloths,dress,big stones,small stones,hammers,ayaskaantham (magnets),kshaara( alkaline salts),horsehair,human hair,fire,medicines, hands and legs of Vaidya and his assistants, their fingers,nails,teeth,tongue and lips (soo:7-11). Anusasthra (soo:8-15)are pieces of bamboo,crystals ,lenses,lotus,leeches,nails,leaves , sprouts of grains,wheat,rings ( which we wear on fingers). In some special situations if the correct instrument is not available these anusasthra can be used , and also in very small infants,in very anxious people ( soo:8-16).  Instruments and Appliances in detail :Any receptacle for carrying out a chemical Reaction Surgical lock/Forceps with bend end .Extract baby,bladder stones Cupping instrument for collection of blood ,body fluids during surgery Minor instruments Bambooskin for excision/incision if infant ,for dissections (sar:8,12; 5-10) Same as above For sucking blood during surgery/bloodletting

1.Adhikaranam 2 Agravakthrayanthram (chi 7-13) 3 Alaabu

4. 14 types anusasthra Twakksaara Sphatika (crystal),kaacha (lens) kuruvinda (Ruby) Jalouka (leeches )

8 Agni (fire) : pippali,goatdroppings,teeth of cow ,sara grass Eshani for skin diseases, jaambavoushtam,different metals for muscle cautery, honey,ghee,oils for blood vessels,joints,ligaments are used for agnikarma . Kshaaram (alkali) Nakham (nail) Pathram (leaves ) soo:8-11;chi:1;49-50 of gochi,sephalika ,saakha and Padma Cautery

Cauterization with alkali For excision,incision,extraction Collect ,evaculate pus/phlegm during surgery of eye,oral cavity; handles eyeball and intestines,replace intestines to proper position when prolapsed For probing or searching.Surgery of sinuses, on eyelids,around anus

Kareeram ( tender sprouts of corn ) Vaala (horsemane/horsehair),anguli (fingers of surgeon) Roma ( hairs ) are upayanthra in special situations 5. Darvvi (chi 6,6) wooden spoons/spatula 6.Dhoumanethram ( tube elongated and thin made of ivory or metal .1/2 inch at End is sharp ,tapering .length 12to 25 inch.One end diameter of thumb and the other less than the end of small finger. Through the internal opening a small bean can pass. 7 dwimukhanaali, dwidwaaranaadi or ubhayathomukhanaali: Canula open at both ends 8 Gudayanthram (chi: 6,8-9)Speculum to cauterise inside rectum Made of metal,ivory,animal horns in shape of cow’s hoof .length 4 inch. Diameter 1 inch.This is for men. For women a bigger gudayanthra used .On the lower end there is a balllike protruberance with 2 openings and through one doctor see /observe and through the other he does agnikarma ( cautery) 9 Jaambavoushta (soo:5,3) surgical probe ,pencilshaped rod ,serrated knob at one end 10 kapatasayanam (chi:3;39) A splint like a door plate on which with 2 sticks limb is fixed 11.Krithaaha (Ghata) is a cauldron 12 Kuntha ( sa:8-54) Pointed spearlike instrument 13 Koorcham ( sa:5-10;ch:6-6) sharp grassroot,hair,ends of kusa grass, bamboo split at end 14. Mukuni (Uth:15-2)

Application of cautery/medicines Inhalation or fumigation syringes

Draw fluids in ascites,hydrocoele,mechanical dilatation in urethral or rectal strictures Piles,fistula,and also as a proctoscope

Probing Immobilisation of fractured limbs Boiling,compounding,evaporating liquids Venesection Scraping decomposed skin,dissection of cadaver

Small forceps to remove pterygium

9 15.Mudgaram (soo:27-7) Hammer Loosen an arrow firmly fixed to a bone

16.Phalakam ( soo8-9;chi 7-13) Operation Tble and Instrument holders made of salmali tree 17.Prathudam: Uth 62-11. Knife 18. Pushpanethram ( ch:7;15-16)Urethral syringes/catheter pipes 19.samku (ch:15-7) Hook 20.sasthram ( soo 1;4-8) cutting instruments made of metal are of 20 types Mandalagra

Essential for surgery and holding of instruments during surgery Special knife used in lunatic patients Quick expulsion of stones and blood in bladder

Raising up a filmy growth in eye surgery

Excision ,scraping,tonsil surgery,piercing skull of dead foetus in utero,scraping pterygium,eye surgery Bone surgery Incision,excision, removal of scrotal tumours Excision,incision Blade shaped in obtuse angle Scalpel with curved blade like lotus leaf Straight narrow blade with handle 8inch long ( 6 inch is that of handle) Puncturing and suturing Vrithanguladwaya –straight- stich loose fleshy part,around joints Thrymgulam stich fleshy parts ,thighs ,is a 3 ribbed needle.Dhanurvakthra is curved needle sutures intestines,stomach,scrotum,vital parts

Karapathra Vridhipathra Nakhasasthra nail-parer Mudrika Ulpalapathra Ardhadhaara lancet/scalpel

Soochi 3 types (Vrithanguladwaya,thryamgulam,dhanurvakthra )

Kusapathra Aathimukha Sarareemukha(karthareemukham) Amtharmukha

To draw fluids To draw fluids Scisssors to evacuate abscess Scissors with straight cutting edge within curved claws Trocar . 3 needles fixed on round wooden handle to evacuate abscess

Thrikoorchaka

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Kutarika Vreehimukha

Tapering cutting instrument Trocar.sharp end pointed like a grain of paddy.Paracentesis of dropsy ,hydrocoele Handle with long sharp needle for puncturing & perforation of bone in diseases of medulla ( like an L P Needle ) Puncturing

Aara or paanimantha (soo:8-3) ( chi:4-9)awls

Vethasapathraka

Vadisha

Sharp hook to extract solid bodies,stones,fixing and dragging Uvula and tonsil before surgery of these parts Extraction of sordes, tartar Probe course of fistula,raising ridge of skin covering sinuses

Danthasanku -tooth scalar Eshani -sharp probe

Gandupadaakaramukhi eshani has end shaped like earthworm .Soocheevakthra eshani has ends like needle These are the 20 sasthra made of metals 21 sringayanthra :Horn implements 22 Utharavasthi is made by joining the urinary bladder of a small animal into Pushpanethra. For women the pushpanethra should have 10 finger length for men 14 finger length .The front is thin like a jasmine flowerstem, and with a small orifice through which only a sesame seed can pass.In middle two swollen bulbs are there (chiki: 1;22-97,7-16,37-8) 23 vamsavidalam bamboo forceps or tongs 24 Vasthiyanthram similar to 22 .there are 3 parts to this ,Vasthi ( the bag), nethram( the pipe) and karnika ( bulb ofpipe).Bladder of ox,buffalo and sheep used for vasthi. The skin has to be purified. If not available another animal’s bladder used .Or a bag is sewn in the shape of urinary bladder .Nethra is straight , thin at ends.Nethra made of gold,silver,brass,copper,iron,ivory,wood,animal horns,jewels were used.

Pierce tissues through blind end of sinus by means of caustic thread passed through eye of probe

Surgical bleeding,probing into body orifices,extraction of insects ,cerumen For urinary tract diseases of of men and women

Extraction of parasites Thridoshasamana,getting ojus,veerya,eyesight,rejuvenation’ Nairoohikavasthi for removing dosha and purify. Snaihikavasthi for rejuvenation Vasthi used to suck out poison in snakebite etc is called Prathipooryamukha.

11 There are 25 yanthra or Blunt instruments made Of metals Swasthikayanthra –Forceps –hinged instruments. Two ½ s joined by pivot handle end turn inwards ,working end resemble animal/birds of prey ( simhamukha,vyaghramukha,vrikamukha, tharakshumukha,rikshamukha,dweepimukha, marjaramukha,srugalamukha,kaakamukha, airbbaarukamukha,kankamukha,koormamukha, chaasamukha,bhaasamukha,sasaghaathimukha ulookamukha,chillimukha,gridhramukha, syenamukha,krounchamukha,bringarajamukha anjaleekarnamukha,avabhanjanamukha nandeemukha ) samdamsayanthra : surgical pincers –gripping instruments 9-12 inch length ,2 types ( sanigraham , anigraham) thaalayanthra: picklocklike instruments ,curved blade single or double with a handle (ekathaala and dwithaala ) nadeeyanthra :- Metal tubes with the internal opening having different size depending upon organ used .Some open at both and others only at one end salaakaayanthra:- Surgical probes with ends shaped differently 2 types gandapadamukha,2 types sarapumkhamukha,2 sarpaphanamukha, 2 vadisaamukha,2 masooladaalamukha,6 types swabs called pramarjjana, 3 types spoons called khallamukha,3 types amkusavadana,one kolasthidalamukha,one mukulaagra,one maalatheepushpavrndaagra.

Extraction of splinters,foreignmatter,bones, infant

Sanigraha are tongs soldered together with bolts, anigraha without bolts

ENT surgery

Rhinoplasty,fracture nasal bone,draining fluid after tapping ascites, removing urethral and rectal contents ,inspection of orifices of body

Probes

26 Upayanthra (accesoory appliances ) 25 types Rajju (vegetable fibres,threads) Venika (twine for ligature after snakebite) Patta (tow/bandage) Charma(leather ) bandage,ligature, lithotomy strap,abdominal binder,bands for sirovasthi Antharvalkkalam inner bark of trees as splinters for fracture and dislocation ,to arrest circulation as ligature in snakebite Latha –tendril,creeper for ligature Vasthra –cloth as bandage Asthilaasmam –bone,stone,pebbles for

12 loosening arrow embedded in bone Mudgara –hammer same purpose Paanipaadathalam -palm and sole of surgeon for many actions – palpation,percussion,compression,do surgery ,to fix a part etc Tongue Teeth to extract foreign body Nails –same Face to suck fluids ,blood Horse and human hair to remove foreign body (salyam) in brain , fishbone in throat , to suture wounds Aswakathakam is ring of horse bridle for Extraction of arrow fixed to bones Saakha or branch of tree –same purpose Stheevanam is spittle Pravaahanam –an object for fluxing patient for emesis,purgation,lacrimal secretion,for extracting foreign body Harsham: any object for exciting happiness and driving away shaft of grief Ayaskaantham for extracting metals ,metallic arrows from wounds Kshaaram 3 types mridu,theeshna and Madhya Bheshaja (medicines) Yavavakram or needle with yava shaped end for removing filmy growth from eyes

Importance of Marmma :-

Marmma are important poits as far as surgery is concerned . The places where the veins, arteries, joints, ligaments, muscles and nerves meet as a plexus is a marmma. A wound/injury to such sites are dangerous. There are 11 Maamsamarma, 41 siraamarmma,27 snaayumarmma,8 asthimarmma,20 sandhimarmma,and atotal of 107 marmma are there in body according to Susrutha.These are present all over our body. In each upper and lower limbs 11 each, in abdomen and chest 12, in back 14 and above clavicle 37 marma are important. The plexuses which modern medicine describe are included in this , but susrutha knows more marmma than modern medicine recognises. If an injury happen to certain marma death occur within seconds.Heart,vein that descends from head (Jugular vein) naabhi, urinary bladder,perineum and anus are among them. There are marma which cause death a few days after injury. In certain marma if an arrow or spear or any other foreign body is plucked forcefully death happen immeadiately .Ceratin other marma after injury cause nonhealing wounds, severe pain and even anomalies of that body part causing permanaent disfunction and disfigurement (sa: 6;1-4;15-16).A good surgeon should know these positions and avoid injury to them during surgery .He should not go naywhere near such places with his surgical instruments. Suppose one has to remove a limb containing many marma, this has to be done without touching the marma, and the complications can then be safely avoided.Human body

13 has the strength to withstand loss of an organ containing several marmma. But it cannot withstand an injury to a single marmma. Avoiding marma, a good surgeon removes a limb and it cause only a little amount of blood from patients body . A tree lives even after a branch is cut off. Like that man survives after removal of an organ or limb. But if a severe blow is there in the main root of tree, it die eventually.Similarly if a marmma is cut man suffers excessive blood loss, severe pain,vaayukopa and become very tired and die eventually ( sa: 6-81-82).Even if bones are fractured,a blow happened on head, and internal parts are seen projecting out of wounds, and limbs are severed by weapons – still a good surgeon can treat and cure human beings provided marmma are intact . To diagnose and prevent marmmaaghaatha ( injury to marmma) doctor needs deep knowledge of his subject and lot of experience .( expertise and experience ) Because in such patients it is not mandatory that special symptoms are obvious. Since marma are special places where vaayu ( air/oxygen) somam ,thejas,sathwa,rajas,thamas function together in same place only with an extraordinary ability of doctor death can be avoided in such injuries and even then the body suffers complications . Some marmma if injured leads to unconsciousness. ( sa: 6;82-86). There are small arteries in body about 700 of them are listed and 98 of them are important in surgery. They should never be opened up,pierced,injured by surgeon’s knife or his procedures. Susrutha gives names of all these 98 arteries and their positions showing how accurate and comprehensive his knowledge was ( sa:7;14-31).  Kshaarakarma and Agnikarma :-

Kshaara is alkali and agni is fire and cauterisation using alkali and fire is described.By agnikarma total cure and stopping of blood loss is possible and it is better than cautery by alkali. There are two ways of cauterising with fire. On skin and on internal organs . Metalic instruments of silver, brass and copper are used ( exclude iron) or the teeth of cow or ox .These are made red hot in fire for cautery. Depending on severity of disease, position of disease , agnikarma is done and the place show a valaya ( circle/vritha) prathisaarana ( extensive cautery ) Bindu ( just a point) . (Soo: 12;1;2-9) Khsaarakarma is external or internal. On external skin surface alkali causes vilayanam ( corrosion),sodhanam ( removing skin and purification),ropanam ( forming granulations and healing of ulcers),soshanam( drying)lekhanam ,sthambanam ( haemostasis).If alkali is dense and strong it will destroy skin and tisssues. Internally they produce sour,heat, and digestion. If only a little is ingested it digest worms in intestine and destroy organisms ,remove poisons and toxins and secrete more mucous , and it destroy skin disease and excess fat .If taken in excess it destroy ability for sexual intercourse . When patient is unable to withstand major surgery and when even a small intervention is needed to cure a disease alkali is preferred. Mridu is very weak, theekshna is very strong and Madhya is having a strength in between these. The alkali is prepared in these 3 ways and kept ready after filtering. For geriatric people,infants,tired people,feverish , internal bleeding ,bilious,unconscious people alkali is used only externally and never internally ( soo:11;5-6).The 3 strengths of alkali are prepared from powders obtained by burned branches,roots,fruits and leaves of some medical plants .The trees and plants for this are 24 in number .They are :-

14 Sanskrit name Kutajam Palasam Aswakarnam Paaribhadrakam Vibheethakam Aaragbhadam Thilwakam Arkkam Snuhi Apaamaarga Paathaala Nakthamaala Vrisha Kadali Chithrakam Poothika Indravriksha Aasphota Aswamaaraka Sapthaschada Agnimanda Gunja 2 varieties of Kosaathaki Botanical name ( Modern ) Holarrhena antidysenterica Butea frondosa Erythrena indica Terminalia bilerica Cassia fistula Simplocos racemosa Calotropis giantea Euphorbia nerrifolia Achyranthes aspira Sterospermium suarcoleus Pongaamia glaabra Justicia adhatoda Musa sapiontum Plumbago zeylanica Basella rubra Holarrhena antidysenterica ( a variety of kutaja) Salvadora persica Nerium odollum Alastonia scholaris Premna integrifolia Abrus precatorius Luffa amara

Select these trees which are mature, with no disease and their branches are cut into fuel. Make a pit bound with stones/ishtika and burn them .To light the fuel use the stem of Thila ( sesamum).Collect the bhasma (ashes) and the pieces left unburned separately . To the ashes 6 times water or cows urine is added (1/6 ratio) and filter through cloths continuously .In a open iron pot keep it and stir continuously while boiling .When the solution is red ,pure with a strong smell and formsa foam on your finger stop heating .The pure part above is taken into iron jars .That in lower part is discarded. The jar is kept airtight .This is Mridukshaaralayani . 8 palam ( 1/4th of a Ser) dhal of Bandhooka and the pieces left unburned ( in previous procedure) ,ground conch powder, shell of fresh water mollusc are dried in a iron pot till it is red. 3/4th of a ser of mriduksheeralaayani is used to wet this mixture and then powdered nicely. In 64 ser mriduksheeralaayani this is put and boiled , stirring continuously and when it is in a syryp form pot is taken out of the oven , cooled slightly and then liquid transferred to iron pot upto its neck. Keep airtight .This is Madhyaksheeralaayani . What is said for madhyaksheeralayani + powdered plants and solid elements are needed for theeshnakshaaralaayani . 50 gm each of dried powdered plants , and powdered calcium and salts , sand containing alkali are added before boiling . Danthi ( Baliospermum montanum) dravanthi( Anthericum tuberosum)chithrakam ( Plumbago zeylonica) laangalaki ( Gloriosa superb)Thaalapathri ( cureuligo orcheoides) poothika (Basella rubra) hingu( Ferula asafoetida),knakaksheeri( Cleome feline) Vacha ( Acorus calamus) Athivisha ( Aconitum heterophyllum) are the dried powdered plants added ( Soo: 11;6-10)

15  Sonithaavasechanam (Blood letting )

For blood poisonings , snakebites , putrefying unhealing complicated ulcers, other special diseases etc needs removal of blood from system . The Bhishak ( doctor) decides when and how and from where blood should be removed. Siraavedham means cutting a vein to let out blood ( venesection). There are three other methods of venesection apart from this . One is using a leech ( for pitharoga), another is using a alaabuyanthra (kapharoga),and third is using sringhayanthra where horns are made into a tube ( naadeeyanthra ) in vaayuroga . In an area of excess mucous make 2 to 3 Prachitha ( superficial incisions). Fix an alaabuyanthra in them .Mucous, pus and blood flow out into the alaabu .Susrutha says a light (lamp) is kept inside the alaabu ( probably to assess the nature of fluid from the light it emits out ). The wide mouth of a sringa is fixed in patients body and the narrow end in doctors lips and doctor slowly sucks out through the tube . A thin cloth is kept between the lips and end of sringa so that the infected material does not enter doctors mouth while sucking .(soo: 13;5-7) When leeches does not bite , doctor resort to siraavedha .When a drop of milk or blood is dropped at site usually the leech will bite . Poisonless leech are kept in a mixture containing mustard and manjal and washed in fresh pure water . The leeches are taken with wet soft cloth piece. When the leech’s neck is bend like a arch it is a sign to understand bloodletting is complete.Bloodletting is done until patient feels itching and pain. These signs show blood letting of impure blood is over .When bad blood is let out patient feels comfort . To remove leech use powdered salt .Some leeches come off by themselves when the are satisfied with blood. Apply honey in the site and wash with clean freshwater and wet with theeshna mixtures and take care till blood flow stops. Apply cool ointments and apply a bandage over. ( soo:13;17-20)There are 2 types of leeches (Jalougha). Poisonous and non-poisonous.Do not use poisonous variety for blood letting .To distinguish these varieties Susrutha gives following hints : Poisonous jalougha: 1 They are of colour of powdered kitchen carbon and have a thick head –krishnam 2. Long flat body , fatty middle and round body with separated joints –karvuram 3.Fat,round with rounded ends and very hairy , black mouths and body – Alagardham 4.Colours of rainbow in body ,have severe poison, with one bite kills prey – Indraayudham 5.Yellowish black with white spots and different shapes =Saamudrikam 6.Narrow mouth, lower end has a depression in middle giving shape of testicles of ox, and grow in dirtywater , in faecal matter containing water which does not flow , and in places where poisonous fishes and wooden frogs are seen. Itching at bite site, swelling, burning,fever,nausea, speaking incoherently, unconsciousness occur ( soo:13;8-10) Non-poisonous Jalougha :1 Back is blueish green , sides colour of Manayola ( green) –Kapilam

16 2. Red , round and moves fast . Pingalam 3. Colour of liver. Samkhamukhi 4.Colour of a rat , and smell of faecal matter .Moosheeka 5. Yellow colour and face like a fully blown lotus flower. Pundareekamukham 6. Color of lotus leaf. Long about 18 finger . Cool to touch and drinks lot of blood and therefore used for treating domestic animals rather than humans . Saavarikam . Non-poisonous leeches grow and increase in fresh pure water .seen on Degenerated plant parts, stems of water plants , leaf of flowering water plants .Catch them by making a wet leather bag . Keep them in a pot containing the dirt of lakes and water .If we want to keep for long time dried powdered flesh ,leaf of water plants and tubers has to be put in pot. After use sprinkle powdered rice on the leech and apply a mixture composed of salt and oil on them. Then keep them upside down, and from behind to the head end ( mouth) slowly press and make it vomit all the blood ingested. Then after changing water in pot keep them again for next use ( soo:13-17)  Siraavedham (venesection):-

It is the easiect method for bloodletting . Yet, since it is a procedure where a vein is cut , only if all other methods fail one should resort to it.Usually bloodletting is not done unless in an emergency situation. Never use bloodletting for infants,geriatric,tired,thin, anxious ,drunkards,sexually mad, and with weakened sexual powers( sa:8;1-4) Before venesection the surface of skin is massaged with oily medicines and warmed. Patient is given liquid diet with nutrients like kanji water etc in plenty. This reduce thridoshakopa. Patient can either sit or lie down while doing procedure. Tie a ligature above the vein so that the vein is more visible and prominent . With a sharp instrument , without touching the nearby marma, open the vein.For an external vein the instrument can have size of ½ yavam ( about 2-3 mm) length so that it goes only upto that depth. If for veins under a muscle or fats more depth is needed . If a vein pass over a bony prominence a Kutarika is used . ( sa: 8;5-19).How much blood can be taken out is decided depending upon the condition .From a healthy young mature adult man 13 ½ palam blood can be taken , says Susrutha . (This is about 250cc ). Now , at rate of 8cc/1 Kg body weight from a 45 Kg weighing healthy man 360 cc is taken out . The decision is based on condition of patient, disease , the vein from which blood is taken and by which method according to Susrutha. For an experienced and expert person venesection is easy and quick .Veins are moving and like fishes in water move position and when the site is in wrong position it is not comfortable for patient and it can even cause complications. Rest, nutritious food are given after procedure till he gets back previous state and make lost blood . (Sa: 8;20-56)  Salyasaasthram :

Removal of external bodies ( foreign bodies) and obstructions is called salyasaasthram.This is a subbranch of salyathanthra ( surgery). Salya are foreign objects which entered body and are stuck there . They create swellings and pus around them. And sometimes obstruct the flow of fluids of body. Salya need not be always from outside. They could be internal too. They are formed from our own body and therefore called saareerasalya. Hairs,nails,bloodclots,excreta , concentrated

17 vayu,pitha and kapha are all internal salya .The external foreign bodies are called Aaganthukasalya . Metal piece, metal powder,bone piece,grass, thorn,bamboo,woodpiece,horn etc are external salya. Arrows and spears in war are common salya to be removed by Vaidya .This shows the hunting/ warlike situations in which Susrutha lived and practiced his art . These weapons enter and pierce tissues and veins,arteries, internal organs , orifices, bones are destroyed and pain , dark bluish swellings are produced.These swellings are soft to touch and periphery show dark discolouration, and if slightly pressed pus and blood will ooze out .( Soo: 26.2-8). Woodpiece,grassstems,thorns,bamboo makes flesh and blood to putrify and they have to be removed immeadiately . Hair,bone , stone piece, carbon piece can remain in body for long period without causing symptoms .Metals are most dangerous and have to be removed immeadiately . They react with body tissues , and liquefied by biles that can heat and cool, and thus absorbed into the body (soo:26;12-15).In modern medicine we teach about Foreign body granulomas .The thorn stuck into a starfish reacting with body of the starfish , liquefied and taken up by macrophages and absorbed to other parts was observed first by a Biologist Metnikoff watching starfish on Mesina beach. Onlythen the reaction to foreign body was discovered by modern medicine . There was no microscope during Susrutha’s time , we assume . Though he did not see macrophages, he has described that the toxin is absorbed by body cells and then taken to a distant site in body which is scientific. Salya are Badha (fixed) and anabadham( loose) . Methods to remove salya are : 1 depend on nature of body : In eye by increasing flow of tears, in nose making sneeze powerfully,in throat by making cough and in urethra and rectum by increasing urine flow, virechana, vaayu, and from stomach by making vomit ( vamana), from trachea and bronchi by Utkaas . Utkaasa is powerfully breathing up through nose. To make vamana , do prathimarsa .Introduce one finger into throat is prathimarsa. 2. Paachana:- Near the place where salya sits, pus collects .This is called paachanam. The nearby tissue is made soft by paachana. This makes iteasy to take out salya 3.Bhedana: Incision and drainage 4.daaranam :- open and press it out 5.Peedanam: compression 6.Pramaaarjanam : scrubbing strongly 7. Nirddmaapanam : by air or water (cold) sprinkled to take out 8 Prakshaalanam: wash out with water 9. Prathimarsam : with one finger 10. Pravaahanam : contract muscle and expel 11.Aachooshanam : sucking out

18 12. Ayaskantham attract metal piece out 13. Anulomam .Pierce with sharp instrument and take out instrument through the other end , taking out salya through this opening made 14 Prathiloma : Take out through opposite way of the instrument .For this sasthra,eshani,threads,bow,high branch of trees bend as bow , horses on straddle wee used . 15. Excise wround the salya 16 .Using stones , and hammers 17. Make opening larger with tubes of metal ( dilatation) and introduce eshani ( curettage ) 18. One end of eshani or probe is dipped in liquefied wax and with other end remove salya ( soo:27)

Karnavyaadhabandhavidhi:-

Either by birth or by acquired accidentally ears may be lost or disfigured and in such cases Susrutha removes the damaged ear and do plastic surgery or a primitive Transplantation recorded in history for the first time in a scientific book .Ears split into 2 or cut as a punishment were replaced by him. Congenitally small ears and disfigured or no ears, are subjected to this and beautiful ears are given to them. For swellings on ear,contracted ear, change in size and shape of right and left ears etc are all treated with this. This is a cosmetic surgery as well as a curative one . About 15 surgical procedures are described for this. The most important one Susrutha describes is to graft a portion of skin from near the ear itself and is the modern plastic surgery itself. The skin from cheek is detached at one end and the other end attached to the original part ( hanging from it) and only after the graft has joined nicely that connection is cut .Methods and medicines for quick growth of skin and tissues are also discussed. Before surgery Vaidya takes out a small amount of blood from patient’s body and make sure that it is pure and without diseases. Then the area is cleaned with alcoholic solution (arishta) and warm water . Nurses (Paricharaka) hold the patient . A piece of skin and flesh is cut in the desired shape and size ( of the ear ). The stump of the cut or disfigured ear is scraped until blood comes out and the cut piece from cheek is fixed to the stump in desired shape and size. For this cutting skin and making desired form have to be known. On the area , clarified ghee and honey are applied and covered with cotton and cotton cloth and without much pressure a bandage is tied. Powdered and burned clay is applied over it to keep the bandage dry .Lot of rest , diet prescribed by doctor, and care is needed for patient. Without hard work,or accidental exposures, and contacts with external world ( which might cause infections) without moving the bandage patient has to take rest. Alternate days , doctor opens the bandage , removes pus, black swellings ( echymoses ?) and ulcers if any and find out whether the wound is healing properly. Black swelling is sign of blood clot inside and it will prevent healing and hence it could be hematoma. If such signs are seen the graft will have to be changed soon. If wound heals satisfactorily and new skin appears , that part is cleaned and vegetable oils of medicinal herbs applied and every two days new bandage put. If skin is well taken ,

19 new skin will have dry surface, without pain,and show very tiny hairs which are new and soft. If this sign is observed apply the medicine as follows and slowly massaging make it in desired shape . Milk, marrow or fat of Godaa( iguana) or animal belonging to lizard family , (or prathunda,vishkeera ,aanoopa, oudraka birds and animals fat from their marrow) is boiled in ,oil of white mustard ( sinapsis alba)arkka( calotropis gigantea) alarkka ( calotropis gigantean white variety) bala ( sida cordifolia) athibala ( sida rhombifolia) apaamarga( achyranthus aspera)aswagandha ( Withania somnifera) Vidarigandha ( Desmodium gangeticum) Ksheerasukla ( Ipomoea digitata) jalasooka( commelina salicifolia) which are sweet plants as kashaaya and it is this which is massaged on to teh site . This help repair and growth of the tissues . To make desired shape by flattening, making big or by making longer etc if needed oil of white mustard is boiled with sathavari ( Asparagus racemosa), Payasya ( Ipomoea digitata) Erantha ( Ricimus communis) and jayanthi and also milk can be used .(soo:16;1-18)  Visleshithanaasikaasandhaanam :-

Deformed or cut nose is made and shaped as desired by plastic surgery .The name of that surgery is Visleshithanaasikaasandhaanam . Cutting nose and ears was apunishment of olden times ( as we see in Ramayana period ) and Susrutha being son of Viswamithra of that period knew this punishment and its treatment as well. The cut nose is covered in a big leaf from a special climbing plant. The leaf is first cut in shape of nose before this. On this model, from skin on cheek from either side of nose a piece is cut. This is not totally detached from cheek. The skin is covered over two small tubes inserted into nose and made into desired shapes. The free end of this skin is bend and folded to the back , and as it becomes the naasaagra ( tip of nose) suture . Take care to apply bandage in correct shape, measurement and this needs lot of experience .Use cotton dipped in pure sesame oil for the purpose. To keep the bandage dry apply anjana, yashtimadhu,pattaanga( caesalpenia sappan) powdered . Care of skin is as before ( said for plastic surgery of ear). Care , observation, and alternate day change of bandage is done. If new skin develop at site surgery is successful. If one side is satisfactory and other side not, the unsatisfactory part is removed and new transplant done. If nose is small the same medicine said for ear can be applied for massage and making shape. (soo:16;27-32) .For congenitally split ( cleft lip) lips, acquired injuries of lip etc also plastic surgery was done . Bhagnavislishtachikitsa :Bhagna means fracture of bone. Vislishta means the displacement of bone or dislocation. Treatment for fracture dislocation is bhagnavislishtachikitsa.The position, nature of bones fractured and displaced determines method of treatment. Generally speaking the treatment is done in three periods. 1 Praathamikasusrooshaakaalam ( primary care) 2.Chikitsaanantharakaalam ( After treatment) 3. When patient gets well ( convalescence ) In primary care 4 types of care is given.

20 1 aanjanam: The bones fractured are brought back to their original position ( Replacement) 2.Peedanam : Compress the fracture displacement by surgeon’s hands and make them united an din position 3.Samkshepam : The parts thus brought together are kept in taht position itself (Splintering) 4.Bandanam . Apply a bandage .These procedures reduce movement of teh parts ( immobilisation) so that repair is quickened. Cover with a cloth dipped in clarified ghee and above it a chana cloth is tied and splint applied .The tie should not be much tight or much loose .If too tight pain,swelling ,putrifaction can happen.If too loose, it is not properly immobilised. Therefore good repair is delayed or never happen. Depending on weather after 4-7 days change bandage. To apply and take in and thereby hasten repair certain medicines were given. Food without Salt, acid,alkaline and sour tastes is prescribed. Excess exercise and sun’s heat is avoided ( chi:3;3-7-9)In sisira season, in a healthy young body repair of bone is quick. Extreme summer and heat, old age, unhealthy body are causes for prolonged periods of healing and faulty repair. Usually one month to 3 months is taken for complete repair ( chi: 3;13-14).In patients with vaathakopa, rheumatism and in people who do not follow a orderly life style repair is prolonged. For such people fever,constipation,urinary obstruction and a whizzing sound from ears are experienced. Toes,feet,anklebones,leg,knee,bone of thigh, pelvis, spine , ribs,clavicle, elbow,finger bones, hand bones, neck bones , bones of face and head can be fractured and susrutha says each can be treated with proper care . In limbs some times complications can occur ( complicated fracture). In Nirggatha the bone is projecting outside skin. In sphutitha bone is fractured into several pieces. In pichitha the partially broken bone piece get fixed to the neighbouring piece .These are cared for , make them into original position and then treat as before. If there is internal bleeding that blood is withdrawn by a tubular instrument and after evacuating hematoma, bone is put in normal position and put bandage. If neck is turned,or bend in an angle, put hands firmly in the place where neck and lower jaw meet and slowly move neck and bring to normal position. Then a wooden slab is used to support neck and around it the head and neck bandaged together and make the patient lie down flat .Minimum for one week he has to be in that position ( Ch: 3;20-37) Without moving limbs, tied to a bamboo stick and nails is advocated for people who have broken pelvis,spine,ribs,clavicle,femur (ch:3;40)If proper treatment is not available in time, bones grow and unite unnaturally ( non-union and disunion-malunion) and Vaidya has to separate this union forcefully and then proceed as if for a ordinary fracture. Nirgatha without treatment cause a nonhealing ulcer and the dead bone will have to be removed using a bone saw. (ch: 3;41-42). To have good union apply gandhathaila (ch:3.41-45).To say the treatment is successful the organ has to be painless, functionally and structurally perfect as before .(ch: 3;48).  Piles, and Ulcers of anus :-

Internal and external medicines, cautery ,surgery are described for them.Those which are sudden, and with less of dosha can be cured by medicines. For mridu (soft) kshaarakarma, for severe and hard ones Agnikarma; and for complete cure surgery are prescribed.

21 Atha oordwham yanthrapramaanaamupadekshyaama:-Thathra yanthram louham daantham saamkhayaaksham vaa gosthanaakaaram chathurangulaayatham panchaamgulaparinaaham pumsaam ,shadangulaparinaaham naarenaam thalaayanam. Thad dwichidram darsanaartham ,ekachidram thu karmani. Ekadware hi sasthrakshaaraagninaamathikramo na bhavathi. Chidrapramaanam thu thryamgulaayathamamgushtodaraparinaaham yadamgulamavasishtam thasyaardhaamgulaadasyasthaadardhaamgulocchitho parivrithakarnikam .Esha yanthraakruthi samaasa (ch ;6-11) The sloka describes an instrument similar to speculum , also is a type of instrument for observation or scopy (which is a comparatively new equipment in modern medical practice ).The examination and treatment is done in bright sunlight and patient is lying on his side . Some types of reddish elevated growths, and putrefying pus filled growths , and some which are connected to bowel wall by a thin stem or stalk are described by Susrutha in rectum. These growths are removed surgically , visualising them through scope. If there is an ulcer or fistula extending out from the anal opening a special speculum with a half moon shape and no opening is used . Decide how many fistula and ulcers are there with abscess formation. Their direction, amount of pus and blood and faecal contamination are assessed .Clean and make it warm, remove pus and impurities, and apply alkaline solutions and then apply medicines for cooling and destroying infective agents and worms. Fead tissue (necrotic) are removed carefully ( ch: 8;3-4;21); There are 7 types of anal ulcers. They are saanthaponakam,ushtagreevam,parisraavi, aaganthuka,thridoshaja,sambookaavartha,salyaja . For saathaponaka, keeping the main opening intact the small openings around are opened and cut and removed. After they heal, the abcesses which are interconnected are opened from outside , one by one, and those which are not interconnected are left as such. This is for keeping them separate and preventing their union to form a big ulcer. Each is thus treated separately and one or two pathways ( fistulous tracts) only remains. Since each is treated separately and one by one this treatment takes time. The remaining tracts and the main tract are opened only last. This method though time consuming has an advantage . There will not be obstruction to pathways of feces, urine or pus .( Ch: 8;5). Cauterisation can be done for all types ( ch: 8-10). The incision for surgical procedure near the anus is different from other incisions .They are not straight incisions.

1 Langalakam .The angle i less than 90 degree and both arms are equal .

V

2 ardhalangalakam . Angle is less than 90 degree but the two arms are not equal . 3.sarvathobhadram in shape of swasthika . 4.Gotheerthakam . A straight incision made parallel to anal orifice near it .

If bleeding is seen outside do cauterisation and stop it immeadiately .During the postoperative period a special oil (syandanathaila) is for improving and quickening repair, and to keep scar soft and of same colour as surrounding skin .In vegetable oils 12 medicinal plants are added with mild heat to manufacture this . (ch: 8;1-20). In usual surgical procedures care for a few weeks is needed but for anal surgery care for minimum one year is needed. Hard labour, horse riding, sexual union

22 are prohibited. Light and easily digestible food alone should be taken. Excess anger and other emotions are not good (ch:8-22). Even after all these precautions patients getting complete cure are only very few . Sambookaavartham ( tracts with angular openings having serrated walls ) salyajam ( due to foreign body) are temporarily cured but recur again. Others can be cured though with difficulty ( Ch: 82).vidrathy ( outside and inside ) anus nadeevrana ( sinus ulcers ) are first probed by needles to assess depth .Then by chedana, bhedana, remove pus and necrotic debris. For internal pus tubular surgical needles introduced or the opening is allowed to open into anal opening . After letting out pus in this way , apply medicines for healing and postoperative care . (ch 16).Varthi (plug-sticks) are for cleaning sinus (ch: 17;17-20).  Other sites :-

When abscess in breast , and swellings are treated the pathways for milk and tissues below the nipple should not be injured .In this part a tight bandage should not be put (ch:17;29-31). Chikitsasthaanam 17th chapter Visarppa and breast diseases are discussed .In 33rd sloka susruta mentions breast cancer (Sthanaarbudha) . Arbudaadishu chotkshipyamoole soothram nidhaapayeth .Glands, swellings and cancers ,galakandam ( thyroid swellings) vridhi( testicular tumours) certain upadamsa ( lesions in male genital system ) have only surgical treatment .(ch:18;19) In skin and just beneath the skin , if we see swellings and they have not spread to any other organs Susrutha calls them Sopha .They can appear in any part of body . Round or oval and easy to remove surgically .Surgery planned according to site,nature and origin of sopham. Susrutha describes 6 types of sopha 1 Due to vaathakopa 2. Pithakopa 3 Kaphakopa 4.Thridoshakopa 5.Rakthakopa 6. By accident from exterior –Trauma Certain sopha pass through 3 stages : Aama ( immature), vipachyamaana( suppuration-mature) and samyakapaakam ( fully mature and suppurated ).Signs of each sopha and its symptoms are different. Amma and vipachyamana can be treated with medicines , applications, and blood letting. In Aama using surgical knife is dangerous. Only after aama has become vipachyamana one can think of using a knife . This description indicates inflammatory swellings and cysts . Before surgery for such conditions patient takes simple light food. A little alcoholic drink is given to reduce pain and anxiety . There are 7 steps in treatment of a sopham. 1 Vimlaapanam .Cleaning the part 2.Blood letting or rakthaavasechana

23 3.Upanaahakam ( hot fomentation) 4.Paathanam ( opening with a knife/incision) 5.Sodhanam (removal of pus and impurities inside) 6.Ropanam ( healing by medicines) 7. Vaikruthaapaham ( giving natural colour to healing scar tissue ) If putrefying swellings are left untreated the pus spread to neighbouring tissue and sinuses, fistule are formed .Then treatment become difficult ( soo: 17;13-20)  Treatment of eye diseases :-

There are 76 types of eye diseases known . Of these 9 affect joints, 21 affect eyelashes,11 affect the white part (swethamandala/sclera),4 affect the black part( krishnamandala/pupil) and 17 affect whole eye, 14 affect Drishti ( eyesight) ,says Susrutha (U:1;7).For 40 of them there is surgical treatment .36 of them are cured by medicines. Of these 36 , seventeen are not completely cured. 2 of the external injuries are belonging to this class . The only possible method then is to reduce pain and temporarily stop the symptoms.(U 8;2). For certain eye disorders bloodletting can be done (U:9;12). In eye surgery most important are the functions of Lekhanam,Bhedanam and Chedanam. As preoperative procedure medicines are applied or dropped in to the organ. Lekhana and bhedana are for diseases of eyelashes and for carbuncles ,abscesses. The patient is purified with vamana and virechana, and then put in a room away from heavy winds and sunlight. Eyes are softly mopped with cloth dipped in warm water. The eyelashes are turned inside out and kept in that position.Pupils are covered with wet clean cloth. If any pus or impurity seen mop carefully softly. By a sharp instrument or with a rough clean leaf do lekhana until blood is seen .Then the part is cleaned of blood with a cloth dipped in warm water and apply medicinal gums.When bleeding stops completely wash with light warm water. Then apply clarified butter. Care should be taken not to cause putrefaction or infection.Every third day remove pus if any softly and carefull.Usually a bandage is not needed. If it is a very big carbuncle a bandage can be applied. Such carbuncles should be opened up by scalpel first and pus let out before starting treatment. For small ones medicinal application alone will suffice.They will open up naturally without surgical intervention. Lekhanam should not be very deep. It should not be too superficial either. The first has many complications and the second will not give desired effect.(U 13-14).For swellings outside eye only bhedanam is needed. If lekhanam become necessary , only after removing pus and cleaning it should be done. First mop with cloth dipped in warm water,and powdered minerals and plant products are dusted. Then oily medicines ,clarified butter,honey applied. Sasthra is used according to nature of disease and a list of instruments are given in Utharasthaana ( U:14;2-6). Chedanam is for swellings on eyelashes and outside eyes. The patient is prepared for this giving lot of fats and oils. Rocksalts,soft alkalies are powdered and dusted in eye and vaidya slowly massages them .Make it warm with cloths dipped in warm water. Ask the patient to look in a direction so that doctor can visualise the diseased part clearly .The instrument and chedana procedure depend upon the disease and type of swelling.For soft growths (polyps) with a vadisam (hook) catch hold of it .With Mndalaagra cut it away. If cut deeply bleeding and pain will be there. That will cause ulcers in

24 eye and affect eyesight permanently. If a part of polyp is kept there, by a superficial cut, then a new growth arise from stump; Thus cut should bean optimum one. Touch the lower end of growth with a needle and remove the entire growth.Care taken to preserve eyesight.Swellings, abscesses,loose networks of hardened vessels , fleshy hard growths,growths of nerves etc are removed after catching hold of them with a vadisam. The stumps if remains, are removed by continuous application of mixture of powdered metals,salts,jewels,horns,teeth,eggshells,painkilling and tranquillising medicines,garlic ,thriphala, Elam, and seed of Karanja . Paarvanika is a coppercoloured swelling ( Pigmented neoplasm of eye )seen in the krishnamandala ( black part/pupil) and it has to be removed very carefully and slowly. First remove 3/4th of it . Then ½ of the remaining part, its ½ and so on slowly and steadily proceed and remove completely . This prevents bleeding ,ulceration and pain. In certain circumstances instead of chedana, lekhana and rocksalt,honey application to remove the fleshy growth is resorted to. Salt and honey mixed is scrubbed slowly to remove growths in eye. Inside eyelashes if we do surgery, cauterise with a hot needle and then the remaining part of growth removed with soft alkaline fluids . After surgery to get back functional and structural abilities as before is the sign of a successful surgery .Use medicines for healing wound after surgery.The medicine and its component are determined based on which thridosha is imbalanced causing the disease , the season , time ( morning/evening etc) and immune status of patient . After chedana patient needs complete rest and bandaging over eye. In postoperative care vamana and virechana for balancing thridosha are mentioned. Third day teh bandage is removed and doctor warms his hand and keeps it on patient’s eye. If pain is felt apply medicine which is made of fruit of Amlaki, yashtimadhu and seed of karanja in honey . Again after 3 days observe as before .Food and rest for one month according to this schedule is necessary . Pakshmakopa is a dangerous disease . The dosha concentrate at the root of eyelashes. The eyelashes become hard and straight in pakshmakopa. A bhedana (incision) of ½ inch long is made in the eyelash parallel to a imaginary line from pupil to angle of eye .Remove al impurities and pus and suture with horse mane. One end of horse hair is tied to a cloth which is tied on forehead. When fully healed the mane can be removed. If this does not cure , each eyelash has to be removed one by one and their roots subjected to cautery .At that time with 3 small vidisa the eye has to be kept open through out procedure (U :16). Partial or complete loss of vision needs medical treatment . For Linganaaasa ( seeing white and red colours through black pupil , and lack of vision) surgery is needed. (In linganaasa cataract, corneal opacity and white and yellow reflex are included. Diseases like Coat’s disease and Retinoblastoma belong to this category ).Even then complete cure is not possible. If linganasa is due to kapha and if the colour seen through pupil is soft , circular and equal in density and colour ( Thimiram /cataract) it can be cured by surgery. Cold , and rainless weather is best for surgery of cataract. Give alcoholic drinks and tie limbs and open up eye widely and keep in that position until surgery is over.Patient is asked to look atown nosetip. Carefully introduce Yavavakthram ( a needle) through the natural orifice at the medial end of eye (Lacrimal duct). Blood vessels and sclera should notbe injured . For left eye use right hand and for right eye use left hand . To know whether the needle has entered the correct duct there are 3 signs.

25 1. No pain 2. No bleeding 3. A soft sound followed by a drop of water/tear come out of the needle entry point Inside of eye is wetted with breastmilk. Keeping the needle in situ foment with medicines which reduce vaathakopa. With sharp eshani remove the object seen through pupil. Then eye get usual light rays. The pupil become nonopaque. Close the nostril on the opposite side of the eye on which surgery was done and breath through the other forcibly so that mucous etc are removed from it. When patient is able to see as before slowly remove the yavavakthra . Drop clarified butter and close eyes and put bandage. In a soft comfortable bed , without dust,sunlight and smoke patient has to take rest . Strong cough,sneezing ,spitting , sexual movements and ejaculation,sudden movements are prohibited . Daily remove bandage to reduce vaayukopa and apply medicines and rebandage. Doctor examines eye everyday . Only easily digestible light food should be given. The surgery for linganaasa can be done only by a very experienced expert surgeon. He is a specialist surgeon .Even a small flaw in procedure can cause the eye to be permanently useless ( U : 17:34-38)  Dentistry :Teeth, gum,and root of teeth and their surgery is described.Foreign matter lodged between teeth are taken out with vidisa,eshani and danthasanku. Danthapupputa are excised by sharp knives or by sharp edged leaves (if knife is unavailable). Soo: 812;25.3).Danthavestham is a swelling with pus .It and danthapupputa are first subjected to sraavyam ( drainage) . For this small needles or sharp small instruments can be used. (soo:8.3;25-7). The growths on the roots of teeth , loose teeth are cleaned of pus and blood by mandalagra and washed with alkaline solutions (ch”:22-15).Adhimaamsa are excised with knife and medicines applied and gargled ( Ch 22-7).Danthasarkkara (tartar) is scraped with mandalagra and karapathra and then covered with powdered medicines and paste of lax in honey. (ch:22,23). Painful and very badly injured teeth are removed . Krimidantham ( cavity due to organisms –caries) is cleaned with needle and eshani and closed with suitable medicines or one can remove them. Adhikadantha ( extra teeth,impacted teeth) have to be removed. If bleeding is excessive control by cauterisation. ( soo:12-8;ch:22;16-25) Danthanaadi (sinus) is treated just as sinuses in other sites. If it is in lower jaw teeth the teeth can be removed. It should not be allowed to enter deep upto the bone below. After removing teeth, remove all impurities and necrotic debris and cauterise.Even in sinuses with extreme pain the teeth could be fixed and not loose .Inthat case do not try to remove it. That will lead to excess bleeding, facial palsy and even convulsions (apasmaram) and loss of vision. This danger is especially there in the upper jaw teeth. Removal of teeth of upper jaw is done only if it is absolutely essential and if the teeth is very loose.( ch:22;18-20) Paschaathkarma ( postoperative):Seevanam (suturing) is the first function among paschaathkarma.Suturing near the main joints which are needed for movements of organs suturing should be extremely carefully

26 done. This is applicable to suturing of surgical wounds as well as other wounds. Suturing should not be done before cleaning the wound of pus,blood and other oozed fluids.Otherwise fever and abscess will happen. The needles are of gold,silver,copper,iron and their shape and size vary depending upon teh position of wound .In joints and in skin not covered with flesh, needles with circular cross section , and 2 finger (1 ½ inch) length needles are taken. For fleshy parts Thraaya ( cross section triangular) and 3 finger length needles are suitable. For abdomen,scrotum,and marma positions thin , slightly curved and sharp needles called Dhanuvakra is suitable. The threads for suturing are made of cotton, chana, asmanthakam ( Bauhinia racemosa) moorvam( Sanseviera zeylanica) gudoochi ( Tinospora cordifolia) skin, horsemane , ligaments of animals .If a need for thick strong thread arises the thin threads were combined and made into a thick one. When seevana is done the two ends of the wound to be sutured are kept together .The sutures should not be too far or too near. Powdered priyangu( Agalia roxburghiana) rodhra(Symphocos racemosa)rasanjana,yashtimadhu as a mixture is dusted in the sutured site. Instead of this silk,chana were burned and the ashes also used by some .( Soo:25;9-12). Bandhanam : The bandage helps to heal the wound .Cotton,silk,chana, china silk,kambili ( wool),skin,inside of valkala, inside of barks,lathaavidaalam ( tendrils made into a cloth ) alaabusakala( outside skin of cucumber fruits) were all used for bandhana depending on availability . 14 types of bandages are described . 1 Kosa For fingers like a cover /scabbard of a sword 2 Dhaama Around long thin limbs as a garland 3 Swasthika Joints,eyebrow,eye,chest . 4.Anuvellitham On limbs encircling and bend going up like a tendril 5.Pratholi On neck and penis ,encircling bandage 6.Mandalam Around round organs like a ring 7.Snaagika At end of finger like a thimble 8.Yamakam A double bandage for two ulcers nearby 9.Khatwam Cheek,joint of cheek and forehead. Long bandage with 4 tails on 4 corners 10.Cheenam Bandage of eye using Chinese silk 11.Vibandham Shape of nose .on back and abdomen 12 Vithaanam As a cover over the skull 13. Gophanam Nose and cheek.shape of cow’s horn 14 Panchaamghi On face,head.Has 5 parts Before fixing the bandage a Visheshika (Lint) is dipped in honey or clarified butter and kept in ulcer. After application of proper medicines , green leaves kept above it .Put clean soft thin cloth over this and above this is the application of bandage .On mouth,sides,head,shoulders,tightly and on ears,arms,face,throat,penis and scrotum ,back,abdomen,chest not very tight and not very loose , and on eyes ,joints loose one has to tie bandage .If not pain,compression,skin injury,hardening of tissue can happen. An expert doctors bandage are able to give comfort not only to surgical wounds but also to fractures and rupture of internal organs .Needed rest and relaxation to the organ is ensured. By bandaging dust,flies and infections are prevented. Outside trauma also is prevented.

27 Sometimes it is needed to give contact with air .In such cases bandage is not applied and open healing is allowed .For example in wounds with contusions,and colour changes ,burns, cauterisation wounds, ulcers in Hansen’s disease ,and diabetes ,swellings acaused due to rats and bandicoots ( Bubonic plagues) ,pus in anus and rectum ,kledakam ( gangrene) are given an open healing without bandage . Bandages have to be removed periodically and changed. The nature of ulcer ,thridosha,seasons etc are taken into consideration by doctors to decide the interval and time of change of bandage. (soo:18;10-28) Aalepanam: A medicine which is like a gum and dries immeadiately after application is an alepana.The best example is sandalwood (chandana).The application of such medicines also is called alepanam.After surgery and before surgery ( on swellings etc) alepanam is done.There are two types of alepanam .Vishoshi is absorbent and avisoshi is non-absorbent. Apply the aalepa half soaked , flatly , and against the direction of hair growth .The medicines are absorbed through pores in skin and hair follicles. All alepa except the ones used to concentrate pus to a single point, should be changed and new one applied, if it is seen dried and cracked. Depending upon heat and thickness of alepa are the classifications of pralepa,pradeha and kaalaka. Pralepa is for vayuand pithakopa, pradeha for vayu and kapha. Pradeha decreas size of swelling and pain. Kalaka is for prevention,and prevents accumulation of pus and necrotic debris ,and it softens the ulcer and takes out the degenerated cells . When used for vayukopa aalepa is mixed with ¼ of its weight clarified butter .For pitha, 1/6 and for kapha 1/8 is the ratio.The thickness is decided depending upon the nature of disease. Generally the thickness should never exceed the newly prepared skin of a buffalo>(soo”18.1-9) For healing :Put the patient in a big clean room where excess winds and heat does not enter. This is also the case for people convalescing from any disease including psychological problems. The bed should be soft big and comfortable. Head is towards east.Relatives and friends should visit frequently and speak about happy things and give confidence that disease will be cured soon.Excess sleep,sudden movements,loud noises,standing or sitting for prolonged time, are to be avoided. Lying down for long periods also is not good and will increase vaatha and pain.Sexual contacts , and arousals,excess talk with opposite sex are avoided. Pure white dress should be worn. Cut nails and hairs. Thinking about good scriptures and Athman, satisfied and happy the patient self heals . Vaidya and Brahmana come and bless for early recovery . Even when sleeping fanning and caring for good bystanders are needed. New rice,green leaves,tamarind and salt , things which are sweet and sour, different types of Appam, dried fish and flesh , other condiments , flesh of goat,sheep,other aquatic and terrestrial animals, fats, cold water ,milk,curds,whey, alcohols are avoided. Boiled and nicely cooked old rice, green vegetables,rocksalt,clarified butter,juice of anar and amalaki,soup of mudga(groundnut) ,barley water are recommended. For nice healing excess heat,winds,dust,smoke,cold ,excess food, unhappy sights and sounds, uneasy way of sitting and lying down, fasting,excess talk,movements , bad food,and insect bites are avoided. All these obstruct healing. The room and surroundings are cleaned morning and evening and samrani is smoked ( soo:19)

28  Educational qualifications for doctors and nurses :Those youngsters who wants to enter the noble profession of caring for the sick should be born in the high class of society, healthy , enthusiastic and involved in work,desirous of acquiring knowledge by learning and discussions, patient and happy in words, deeds and mind. To be like this each person should cultivate certain qualities. These are mental control, courage,kindness,pure character,observation power,memory power, compassion and love,purity of body,mind and intellect. A person who has developed such qualities should approach a good Guru, as disciple. Guru should be higher or equal to disciple in the said qualities and should be experienced and have expertise on subject. He should be matchless in art of teaching. Only then he gets full faith and co-operation from disciple. Before accepting a disciple Guru makes the disciple take a oath. Arrogance,envy ,violence,untruthfulness,low character,laziness and showy nature are bad for profession and the oath is that he will avoid such bad qualities.Once disciple takes this oath Guru gives him Upanayana ( admission) to his school. Thathognim thri:parineeyaagnisaakshikam sishyam brooyaath Kaamakrodhalobhamohamaanaahamkaarershyo paarushya paisoonnyaanruthaalasyayasasyaanihithwaa neechanakharomanaa suchinaa kashaayavaasasaa satyavratha brahmacharyaabhivaadana Thathparenaavasyam bhavithavyam madanumathasthaaanaanagamanasayanaasanabhojanaadhyayanaparenabhoothwaa mathpriyahitheshuvarthithavyam athonyathaa the varthamaanasaaadharmo bahvathi Aphalaa cha vidyaa na cha praakaasyam praapnothi (soo:2-6) Only such students were entering profession .Therefore number of doctors were less. But those present were noble . The different aspects of life sciences, branches and philosophy of it as well theory and practice were subjects to be taught . The integration of Vedic sciences also was done by the Guru. However intelligent the student is, without help of an expert in subject these are not cognised. Years of careful study,observation,experimentation and practicing with teh expert teacher makes disciple also proficient in profession. Each word and each sloka ( guru utters, and learned from text) is carefully understood and experimented and cognised by disciple through years of learning . This learning is not restricted to Ayurveda alone. All other sciences and philosophy should be known to understand health science thoroughly and completely . The learning obtained from gurukula has to be widened by own experiments and observations and experience ( soo:4;3-8) Educational period is over when the Guru is satisfied with student’s performance. The new doctor who wants to practice vaidya in the public, has to get permission from the royal court ( Licensing ).He hs to prove his knowledge, free observational ability and practical expertise in the durbar of scholars ( External examination) . Soo:10.2. But these are only his minimum qualifications. Years of experience , and careful work,and observations, experimentation has to give him real ability . Only then he becomes qualified as a doctor . The plan of improving oneself day by day should be lifelong .Then only the public opinion that he is a good doctor is obtained. (soo:4;6-7) It is duty of doctor to treat all deserving. It should not be due to desire for money. A doctor should not treat perpetual criminals who is menace to society, and those who kill animals and men . They do not deserve treatment .Once the patient is in the care of a doctor, entire

29 expertise and experience should be utilised for healing him. Patients are entrusting their most valuable life , in total faith to a physician and the doctor should never forget that. Even those who doest trust relatives, sons ,parents do trust doctors .The patient is like a son to the doctor. Because of that noble professional compassion he is auspicious for all living beings and get due respect and praise in this birth itself and gets good worlds ( heaven) after death ( soo:25;24-25). The royal physician of the palace has some special duties apart from treating the royal family. He has equal role in the good of King as the Royal Guru. He should have collected all the medicines, instruments and books on his science and very adept in his discipline and should live in the royal palace itself. When king goes out for a war or hunting he accompanies and lives near Royal sibira.Water (well,tanks,and other water bodies) , grains which king uses and all other articles are inspected by him to protect king from poisoning. Examiningfor poisons, purifying toxic things or destroying them are his duties. Poisoning and its treatment, surgery for war accidents and plastic surgery for such loss of organs are all his special duties. (soo:34). He should be adept in diagnosing diseases due to planetary influences,and treat in auspicious time. To do japa on power divintities, and awaken them,in meditation, adhyathmavidya and rites of society he should be an expert.If a sign of danger is received he should be able to reach the king immeadiately so that he should be at hand or very near the royalty .(soo:5;14-15). Nursing attendants are called paricharaka,and they should be always with vaidya to take care near the bedside. The nurses should be healthy, satisfied and pleasing in form and behaviour and in whatever emergency they should not become emotional and should be friendly and communicative to patients .They should obey the doctor’s orders without any doubt .(soo:34;12) If the patient is male the nurse also should be male and vice versa. This means in the ashram of the Guru/Teacher both male and female attendents and disciples were present .These later on became the sanyasin/sanyasini orders .  Arbudham or Karkkarogam(Cancer ):In W AD Andersons Pathology it is said that the first mention about treating cancer with Arsenic and surgery is in Ramayana. Since Susrutha was son of Viswamithra of Ramayana times , this must be taken without wonder. Susrutha advocates a regime for prevention of cancer.( ch:18;29) 1.Avoid nonvegetarian diet 2.Eat food containing yavam and mudgam (groundnut) daily(yavamudgabhoji) 3.Do virechana and dhooma 4.Take oily baths 5.Use powdered seeds of “karkkaaruka, urvaaraka, naalikera, priyaala, panchaamgulabeejachoornam “ It is important that he includes coconut in this preparation. That shows coconut was known to Indians( keralites) even in ancient times and is not anew tree as some historians think it to be. The daily lifestyle of India was decided by doctors of yore and we have been following what is good for our geographical region and climate and seasons and it is even now possible for us to take up that daily lifestyle and reduce our cost of medicines and hospitalisation.

30 Here I quote some lines from Susruthasamhitha showing how much Susrutha was aware of cancer . 1.kurvanthi maamsopachayam thu sopham thamarbudham sasthravido vadanthi Vathena pithena kaphena chaapi rakthena mamsena cha medasaa cha (Ni:11-14) 2.Saasraavamunnahyathi maamsapindam mamsamkurairaachithamaswivridhim Sravathyajasram rudhiram pradushtamasaadhyamethadrudhiraathmakam syaath Rakthakshayopadravapeedithanuaath( ni:11-16) 3.Paandurbhaveth sorbudhapeedithasthu ( Ni:11;17) 4. avedanam snigdhamananyavarnamapaakamasmopamamapravaachyam Pradushtamaamsasya narasya baadamethadbhavenmaamsaparaayanaasya (ni:11;18) 5.Mamsarbudham thwethamasadhyamuktham (ni:11;19) 6.Dwirarbudham thascha bhavedasadhyam (Ni:11;20) 7 Yajjayathenyath khalupoorvajaathe gneyam thadadhyarbudha,amrbudhajna (ibid) 8. Na paakamaayaanthi kaphaadhikathwaanmedorbahuthwacha viseshathasthu Doshasthirathwadwayanaascha theshaam Sarvaarbudhaanyeva nisargathasthu ( ni:11;21) 9. Vaathaarbudham ksheeraghrithaambusidhairushnai:sa thailairupanaahayaithu Kuryaascha mukhyaanyupanahayaani sidhaischa mamsairathavesavaarai(ch:18;30) 10 swedam vidadhyaath kusalasthu naadyaa srumgena raktham bahuso harena Vaathagniryoohapayomlabhaagai:sidham sathaakhyam thrivritham pibedhwaa(ch:18:31) 11. Swedopanaaha mudavasthu kaaryaa:pitharbudhe kaayavirechanam cha(ch:18;32) 12.ghritham pibeth kleethakasamprasidham pithaarbudhithajjadaree cha janthu(Ch :18;34) 13.Sudhasya jantho:kaphajorbudham thu rakthevasikthe thu thathorbudham thath ( ch:18;35) 14. Medorbudham khinnamayo vidaarya visosya seevyedratha rakthamaasu(ch:18;41) 15.Karnaarbudham sapthavidham sophaschaapi chathurvidha: (U:20;5) 16.Salaakyasidhanthamavekshya chaaapi sarvaathmakam sapthamam arbudham thu Roga prathisyaaya ihopadishta:sa vakshyathe panchavidha:purasthaath Naasaasthrotho gathaa rogaasthrimsaadekascha keerthithaa:

31 Srotha:pathe yadvipulam kosavachaarbudham bhaveth Sophosthu sophavijnaanaa naasaasrothovyavasthithaa: Nidaanesaamsi nirdhishtaanyevam thaani vibhavayeth (U:22;19-21) 17. Medorbudhavidhaane na saadhayescharkkaraadbudham ( ch:20;17) 18. Varmaanthasthyam visham granthi bhoothamavedanam Vigneyamarbudam pumsaam sa rakthamavalambanam ( U : 3;24) These are only a few quotes from Nidanasthaanam ( Pathology) ,chikitsasthanam ( Treatment) and utharasthanam (The appendix ). The growth of a fleshy growth, absence or reduction of blood leading to pallor, painless swelling which is stony hard, lack of fixity and mobility , one of the causes as excessive nonvegetarianism, knowledge that cancer is a disease which is difficult to treat , and classification of cancer depending upon sites ( Systemic pathology of cancer )and treatment depending on system involvement , and spread to a second site as dangerous are all seen in these 18 slokas .

Sanskrit is no longer the educational language of India . Therefore, Indians like me, who have learned science in English language , are unaware of the treasure of knowledge in ancient Educational language of India. Learning Astrophysics and Medicine in original Sanskrit helped me to bridge that gap and understand my own tradition. And I could compare that to my educational language , English which is the current global language of communication. When I compare and find such treasures I felt that I should share with other members of our society and hence creation of these books. It will be easier for us to look at the Anatomical,Physiological ,Pathological terms Susrutha used in Tabular forms . We will see that in the 3rd part .