SHALYATANTRA - A PEDAGOGY OF AYURVEDIC SURGICAL PRINCIPLES — Dr Shyam Mohan

SHALYATANTRA - A PEDAGOGY OF AYURVEDIC SURGICAL PRINCIPLES

Imagine a time when there are no doctors and the world is suffering from a lot of diseases. A group of noble thinkers decides to meet up and find a solution for the same. They travel to Kashi, a place that is the abode of King Dhanwantari. They have heard about the King who has been doing miracles and helping people in need. His abilities were said to be nothing short of Godly.

This group of people approach the great King and request him to teach them this noble art of healing. It would have been approximately 5000 years and above since that event conspired and the legacy of Lord Dhanwantari still carries on through generation to generation of Shalyatantra practitioners until today. The science of Ayurveda is a supreme one since its ultimate aim is to eradicate diseases rather than to treat them alone.

In Ayurveda, there are two main schools of thought. The Bharadwaja and Dhanwantari school of thought. Bharadwaja school, has been mainly inspired from Kayachikitsa (conventional medicine) as their treatment methodology and the Dhanwantari school holds Shalyatantra supreme.

Ayurveda was divided into eight branches. This was to facilitate the study of Ayurveda as well as to make it easier to practice. The eight branches thus divided were Shalyatantra, Shalakyatantra, Kayachikitsa, Kaumarabhritya, Bhootavidhya, Agadatantra, Rasayanatantra and Vajeekarana.

Diseases of each branch and its particulars are described in the Sushruta Samhita, which is a part of the Brihatrayi (Charaka Samhita, Sushruta Samhita and Ashtanga Hridaya) in Ayurveda.

Acharya Sushrutha explains the branches and the diseases that come in their respective preview in the first chapter of the sutrastana itself because a student can choose his line of expertise and study accordingly.

It is interesting to note that the basic principles of Sushruth samhitha consists of all the details the student needs to assist in the procedures that the OPD of Acharya Sushrutha might have dealt with at the time. This would have been an orientation course for the student to swiftly get acquainted with the procedures, instruments and other aspects of the Shalyatantra.

Shalyatantra is one of the branches which deal with surgery, marma chikitsa (vital points related protocols), orthopaedics etc. The Sushruta Samhita opines that Shlayatantra is the most important treatment because of its many utilities. The application of its protocols and methods can be used in many diseases and conditions.

Even though there is a good deal of reference to Shalyatantra in the Charaka Samhita and Ashtanga Hrudaya, they seem to have given more importance to the Kayachikitsa division of Ayurveda.

In a very simple language, the word “Shalya” means something that is not needed in the body. For example, thorns, nails, arrow heads, metal bits, stone, pus, body waste etc. The treatment protocol for removing it from the body comes under Shalyatantra (Shalya nirharana vidhi). There are two kinds of shalya- that which affects the body and that which affects the mind. There are four main protocols for the same in Shalyatantra- Yantra, Shastra, Kshara and Agni.

Sushrutha samhita tells us that if you practice Shalyatantra, the practitioners will become prosperous, fame will come to him, it would become a worthy profession for livelihood and he will surely be in the good book of Chitraguptha.

Shouchyam (Cleanliness), Ashukriya (fast and efficient), Shastra Thaikshneeyam (Proper Instruments/ sharp instruments/ calibrated etc.), Asweda (unflinching under pressure), Vebhathu (Steady Hands), Asamoha (The surgeon who is mentally strong/ does not faint), Vaidyascha (Physician), Shastra Karmani Sashsyathe (is qualified for surgical procedure). These are the qualities required by the vaidya who is to take this branch as a speciality.

It is important to note here that Acharya used the word Vaidya here, which means the student after the completion of his first part of the study of Ayurveda, can choose this branch of Shalyatantra. This also means that this branch was the first Super speciality in the history of Medical science.

Another question that might arise in the mind of a student would be if Shalyatantra contains only surgery. A Shalyatantra practitioner should adopt the protocols in Shalyatantra only if the other treatment protocols fail to give any results to the patient, which clearly means that he or she should be an expert in Kayachikitsa also. Some experts do go straight to Shalyatantra procedures in certain cases. This is their experience and their reasoning (yukthi).

There are various other treatment protocols in Shalyatantra like Rakthamokshana, Agnikarma, Marma chikitsa which are used frequently in various diseases and conditions. They are very effective when used properly by a skilled practitioner.

In Raktamokshana, blood is drained using various methods. Here the concept of a fourth dosha is applied. This is a revolutionary idea if you think about it. It is sad to see that it is usually used as an insult in the western world. Any procedure if used improperly can fall out of favour. This procedure is a fascinating one which gives fast and sure results if used wisely. One of the methods in Rakthamokshana therapy known as Jalaukavacharana (Application of medical leeches) is catching on in the name of Hirudotherapy in the modern surgical field and it is used in plastic surgery. It is very common for the western scientific world to take ideas from our science, put a new name for it in Latin and baptise them “new”.

Ksharakarma is the method of removing the root of the disease using alkali preparations. This is a wonderful method that ensures results for the patient with ease. It is widely used in the proctological field which is one of the most valuable contributions that Shalyatantra is making nowadays. The procedures like Ksharakarma, Ksharsutra etc. are well practiced and are considered best in proctological practice in the world. It has inspired the modern practitioners to adopt similar medicated seat on methods and procedures that have given excellent results.

Shalyatantra Of these, Ksharasutra procedure is the most wellknown procedure. It is a medicated set on that gives the best results which have been duplicated by surgeons from other countries like Japan. The recurrence rate of Fistula in ano is tackled only by Kshar Sutra therapy.

Ksharasutra procedure is a method of ligating in cases such as a Fistula in ano, hemorrhoids etc. It is indeed a versatile method and is widely practiced and researched in our field. A multitude of papers have been published on it in universities at the top of our educational system.

Agnikarma is the procedure of cauterising and stimulating specific points on the body to get immediate relief from certain diseases. There are many aspects of this amazing therapy which a trained Shalyatantra practitioner can work magic with. This is the most important because the recurrence rate after this procedure is nil.

The diseases that come under the Shalyatantra speciality are fracture and dislocation Management, orthopaedic conditions, various surgical procedures, ulcer management and basically any disease that cannot be handled by conventional medical protocols alone.

When it comes to orthopaedics, fracture and dislocation management has long been practiced by doctors who practice Shalyatantra. The fracture and dislocation management in Ayurveda is what modern science follows in their treatment principles. The basics are the same but they have introduced many new innovative surgical methods for the same. Yet the Ayurvedic procedures manage the conditions without any surgery and complications. Only very complicated fractures and dislocations are advised to undergo surgery. Most of the time it is managed through closed reduction methods perfected with time. The three Rs which form the basis of fracture management are derived from Ayurveda. The chapters in Sushrutha samhitha on Bhagna chikitsa are a worthy read and are so thorough that till now nothing needs to be added to it and nothing could be discarded.

Another aspect of the Shalyatantra is marma chikitsa which is a branch that deals with vital points of the body and the management of injuries to those points. These vital points are also used to bring relief to certain conditions. Various marma manipulative techniques are also used in Shalyatantra for conditions like back pain, neck pain etc. which in turn have inspired the Chiropractic system in the western world.

The method of haemostasis (Raktha sthambana) is described in Sushrutha samhitha and it is the same that is being used nowadays in the most modern hospitals in the world using sophisticated machines. Suture materials that are absorbable and otherwise were first explained in Sushrutha samhitha. When the majority of people from our nation saw the movie “Apocalypto”, where ants were used as sutures, I am sure they did not know that it was the contribution of Ayurveda.

The management of ulcers is another very important treatment protocol. There are 60 methods that have been explained that can be used to manage even the most difficult of ulcers. Diabetic ulcers, varicose ulcers etc. can be cured without the need of any surgical intervention in most of the cases. Fascinatingly similar to the Jwara chikitsa in Charaka samhita, Vruna chikitsa in Sushrutha samhitha explains the basics of Ayurvedic management of almost all diseases.

All the tools we use in Shalyatantra can be divided into two- Yantra and Shastra. Yantras are simply instruments that are not sharp like forceps, probes, retractors etc. The shastras are sharp instruments that are used for the eight surgical procedures (Astavidha shastra karma). It is to be noted that the modern surgical instruments have their roots in Ayurveda and the instruments that we currently use are the updated versions of the same.

Today Shalyatantra practitioners mostly deal with anorectal conditions -hemorrhoids, fistula in ano, fissure in ano, rectal prolapse, pilonidal sinuses etc. Fracture and dislocation management, orthopaedic disorders, cancer and palliative care etc. are also practiced by some.

Outside Kerala, Ayurvedic doctors who practice Shalyatantra perform a variety of surgeries like

Gastric Surgery, Neuro Surgery, Laparoscopic procedures, etc. They are well trained and they keep up with excellent standards required.

Shalyatantra practitioners must be very active. If you look at the rest of the branches they can prescribe and treat with helpers. They do not have to be involved directly. But the Shalyatantra practitioner is actively involved in the procedures. My father Late Prof. Dr. P N Mohan Kumar who was also a Shalyatantra practitioner advised his students to be physically active and fit to perform these procedures themselves. He also advised his students that the method of reducing the pain of the patient is less important than the result.

There have been a number of setbacks in the field of surgery for Ayurveda. In western world, Barbers used to do these Shalyatantra procedures. It was done in a very unhygienic environment and there have been a lot of infections and deaths associated with such procedures. Those made the physicians of the time look down upon them and judge them barbaric. When the European influence came here, people began to look down on it too.

Buddhism is one of the reasons for its decline in India. In Buddhism, Ahimsa (non violence) was one of its core virtues. It is not my intention to blame it on Lord Budha who was a noble soul, but it is the frenzy of the followers to do one better that caused the downfall of this branch of ayurveda inside India. Shalyatantra Shalyatantra was demonised as an Asurika chikitsa and that stigma is still prevalent in the field. But you need a sharp weapon to take out a thorn.

For the better part of Independent India, the Government was not sure where Ayurvedic surgery should come in. The common public are yet not sure if Ayurveda has surgery. When a patient asks me if there is surgery in Ayurveda, I answer with a question. Who do you think invented surgery?

Even in the historical times, no student or Vaidya could step into the surgical theatre directly. They had vigorous training processes that may be considered old school but effective as mentioned in the Yogyasutreeya chapter. That shows the level of professionalism and ethics at the time. Once the teacher was sure the student was capable, then and only then they were allowed into the theatre. Standards were kept in the field of medical science and were according to the limitations of the time they lived in.

For a student who wants to see if taking up this branch as a speciality is advisable or not, I say go for it. It is my opinion that the student should choose a branch which gives satisfaction at the end of a busy day. As for me….. no where else I would rather be.

Dr. Shyam Mohan (M.S [Ayu])

Chief Physician, Vinayaka Ayurvedic Nursing Home, Thrissur