Ashmari Chikitsa in the Sushruta Samhita: Chikitsa Sthana 7, the King's Permission and the Eight Parts to Guard

📖 26 min read · Sushruta Samhita, Chikitsa Sthana 7, in Bhishagratna's English translation (Volume II, printed pages 329–337), read beside Nidana Sthana 3, Charaka's Chikitsa Sthana 26 and Celsus, De Medicina 7.26

Where Ashmari Chikitsa Sits in the Sushruta Samhita

We have been reading the Chikitsa Sthana of the Sushruta Samhita, its section on management (chikitsa), chapter by chapter in Bhishagratna's English. The fourth chapter, on vata-vyadhi, is read on our page on Vata-vyadhi Chikitsa. The sixth, on arsha (piles), finishes on the first pages of today's reading. Its subject has its own page, Arsha in the Sushruta Samhita, so we take only one line from those closing pages: their list of things to avoid, because chapter 7 ends with a list of the same kind.

Chapter 7 is Ashmari Chikitsa, the chapter on the stone. It fills printed pages 329 to 337 of Bhishagratna's second volume, in twenty numbered paragraphs. He prints each number at the end of its passage, and we cite them that way: Chikitsa Sthana 7.13 is the passage that ends with the number 13. The same stone is diagnosed in Nidana Sthana 3, which describes its four kinds and the bladder that holds it; we read that chapter on our page on Ashmari in the Nidana Sthana and do not repeat it here. That page stops where this one starts. It mentions the operation only to say that the Chikitsa Sthana describes it.

Charaka knows the same stone. In his Chikitsa Sthana 26, the chapter on the three vital organs, the stone comes inside the discussion of mutrakrichchhra, difficult urination, and the operation gets a single clause. In Gabriel Van Loon's English: Otherwise it should be extracted by surgeon. Sushruta's chapter is, in effect, that surgeon's chapter.

Twenty Paragraphs, Two Halves

The chapter divides cleanly. Paragraphs 1 to 10 open the chapter and give the medicines; paragraphs 11 to 20 are the operation and everything after it. The hinge is a single sentence near the start: A case of recent origin (acute) proves amenable to medicines, while an enlarged or chronic one requires surgical operations. (Chikitsa Sthana 7.2). The first half is for the young stone, the second for the stone that has grown.

Four passages carry Bhishagratna's labels for verse, "metrical text" or "memorable verse": the opening warning at 7.2, the stop-sign inside 7.13, a verse on the syringe at 7.16 and the closing verse at 7.20. They sit at the turning points. The first one says the stone is a dangerous disease and is as fatal as death itself. The last ends on the death of many an innocent victim, killed not by a stone but by a surgeon who does not know where the vulnerable parts are. The chapter begins with the danger of the stone and ends with the danger of the knife.

In between, the chapter follows one case from the young stone to the year after the operation, and we follow it in the same order.

The Medical Half: One Ghee for Each Dosha, and What We Leave Out

The first half has a plain architecture. Each of the three doshas gets the same package: one medicated ghee (for the vataja stone at 7.3, the pittaja at 7.4, the kaphaja at 7.5), followed by the same plants given in five everyday forms as food and drink: milk, a gruel (yavagu), a decoction, a soup and an alkali. The five forms are identical for all three doshas. Only their order changes from one paragraph to the next.

After the three doshas come potions for gravel (sharkara, 7.6-7), alkalis made from the ashes of the same plants (7.8-9), and a last group of potions with a milk for pain on passing urine (7.10). Then the medical half is over.

We stop there. The chapter names dozens of plants, animal products and preparations, many with quantities, and we leave every one of them out. A urinary stone is a matter for a doctor, and no page should send a reader to the kitchen with one. Indian law also lists stones among the conditions for which medicines may not be advertised, and a page on a shop's website should not read like an advertisement for one.

One structural point survives without the recipes. Paragraphs 11-12 begin by summing up what has been tried before anyone thinks of a knife: decoctions, medicated milk, alkalies, clarified butter and Uttara-vasti (urethral syringe). The uttara-vasti, a fine syringe passed up the urinary passage, belongs to the medical half, not the surgical one. The surgeon comes in only after the medicines have been given as food, as drink and by syringe, and have failed.

Nidana Sthana 3 Beside Chikitsa Sthana 7: Four Ashmari, Three Medicines

Open the diagnosis chapter first and the Chikitsa's list looks short. Nidana Sthana 3.2 names four kinds of ashmari: the vataja, the pittaja, the kaphaja and the shukraja, the seminal stone. Chikitsa Sthana 7 gives medicines for three. The fourth has no paragraph of its own in the medical half.

The order changes too. The Nidana lists the four as vata, pitta, kapha, shukra (3.2), and then describes them the other way round: the kapha stone first (3.7), the pitta stone (3.8), the vata stone (3.9), and the seminal stone last (3.11-12). It has its own logic for that. It has just said that kapha underlies every stone (3.2), so it describes the kapha stone first, and then the pitta and vata stones as kapha dried by pitta or hardened by vata. The Chikitsa goes back to the standard order, vata, pitta, kapha (7.3-5), the order in which the three doshas are usually named.

The seminal stone does turn up in Chikitsa 7, but only in the aftercare paragraph (7.18): a seminal stone or a piece of gravel that has come down into the urinary passage is to be taken out the same way, and if it will not come, the passage is opened and the stone is extracted with a hook (vadisha). That fits what the Nidana says about where the seminal stone forms: not in the bladder at all, but lower down, where it blocks the flow of urine (3.11-12). The operation of 7.13 is aimed at the bladder. The Nidana's seminal stone is not there, so the Chikitsa gives it a different exit. We claim the fit, not an intention.

One more difference. The Nidana says children are more liable to the first three kinds of stone, and that because In children the bladder is of diminished size and poor in muscular structure, their stones can be grasped and drawn out with the greatest ease (3.10). Chikitsa 7 gives no rule for children at all, and its operation never mentions age. Keep that in mind for Celsus.

The King's Permission: Chikitsa Sthana 7.11-12

A physician should have recourse to the following measures (surgical operations) in cases where the above-mentioned decoctions, medicated milk, alkalies, clarified butter and Uttara-vasti (urethral syringe) of the aforesaid drugs, etc., would prove ineffective. Surgical operations in these cases do not prove successful even in the hands of a skilful and experienced surgeon; so a surgical (Lithotomic) operation should be considered a remedy that has little to recommend itself. The death of the patient is almost certain without a surgical operation and the result to be derived from it is also uncertain. Hence a skilled surgeon should perform such operations only with the permission of the king.

Read it as an argument and it has three premises and a conclusion. The operation can fail, even for the skilled. Without it, death is almost certain. With it, the result is uncertain. Therefore, ask the king. The surgeon is not told to refuse the case, and he is not told to go ahead on his own judgment either. He is told to take the decision to someone outside the room.

What the permission was for, the text does not say. It may have protected the surgeon if the patient died, or protected the patient from a surgeon in a hurry, or both. The chapter gives only the reason, the uncertainty, and the word "hence".

The rule is not a one-off. In the same volume, the only other place where we found the king's permission is a footnote that Bhishagratna credits to the commentator Dallana, on a last-resort medicine in Chikitsa Sthana 14, the chapter on udara, the abdominal swellings. Without the medicine, the patient is sure to die; with it, it is not certain whether he would get any relief from this treatment; and so it should be used, as the last resort with the permission of the king. The same shape exactly: certain death without, uncertain relief with, and the decision goes up. We leave that medicine out as well.

Celsus, whose account we set beside Sushruta's below, also calls the operation this last resource and warns that it is most inadvisable to undertake it hastily, since it is very dangerous. But in his chapter, as far as we read it, nobody else has to agree. Sushruta adds a second judgment to the surgeon's own.

Before the Cut: Snigdha, Cleansed and Encouraged

The preparation at the start of 7.13 is brief, and part of it simply points back to the general rules for operations. The patient is first made snigdha, which Bhishagratna renders "soothed", by oiling; cleansed with emetics and purgatives so that he is slightly reduced thereby; fomented after a fresh anointing with oil; and then given a meal. Prayers, offerings and prophylactic charms should be offered, and the instruments are laid out in the order laid down in the Agropaharaniya chapter, the fifth chapter of Sushruta's Sutrasthana, on what must be got ready before an operation. Vagbhata's version of that preparation is read on our page on Sastrakarma Vidhi.

The meal is a puzzle. Vagbhata's Ashtanga Hridaya, Sutrasthana 29.14-16, gives the general rule, in Vidyanath's English: Food is to be given prior to surgery in all conditions except in four, and one of the four is urinary calculi. The Sanskrit line on the same page names it ashma, the stone. Vidyanath's note gives the reason for the meal: Due to the intake of food the patient cannot get fainted. Celsus, too, keeps his patient fasting from the day before. So either Bhishagratna's English, the text he translated, or the two Indian authors part company on this very operation, and from the English we cannot tell which. We leave the question open, and keep it out of the comparison with Celsus below.

The other detail is the chapter's only sentence about the patient's state of mind.

The surgeon should use his best endeavours to encourage the patient and infuse hope and confidence in the patient's mind.

It comes a few lines after the admission that the outcome is uncertain: honest with the king, encouraging with the patient, and the chapter sees no conflict between the two.

The Helper's Seat and the Raised Granthi

Then the position, which Bhishagratna's English leaves slightly open. A person of strong build and calm mind is first to sit on a level board or table as high as the knee-joint. Is that the patient or a helper? The next sentence decides it for us: the patient lies on his back, placing the upper part of his body in the attendant's lap, with his waist on a raised cloth cushion. The strong, calm person sitting first reads most naturally as that attendant, whose lap holds the patient. We take it so; the English alone does not rule out the other reading.

The patient's elbows and knees are contracted and bound up with fastenings (shataka) or with linen. His belly is rubbed with oil or ghee and pressed on the left side with a closed fist so that the stone comes within the reach of the operator. The surgeon then works from below, with the second and third fingers of his left hand, duly anointed and with the nails well pared, introduced into the rectum, and brings the stone forward in the midline until it is so firmly and strongly pressed as to look like an elevated Granthi, a raised knot under the skin. The bladder is to be kept contracted but even.

Two seats for one operation: Celsus seats the helper on a high stool, Sushruta on a board as high as the knee.

This is the part of the chapter that comes closest to Celsus. We give no more of the technique than the text's own outline: these were procedures for trained surgeons of their time, and the way a stone is managed now has nothing in common with them.

The Stop-Sign: When the Shalya Must Stay

An operation should not be proceeded with nor an attempt made to extract the stone (Salya) in a case where, the stone on being handled, the patient would be found to drop down motionless (i.e., faint) with his head bent down, and eyes fixed in a vacant stare like that of a dead man, as an extraction in such a case is sure to be followed by death. The operation should only be continued in the absence of such an occurrence.

Here the stone is called shalya, the surgical books' word for any foreign object lodged in the body and waiting to be removed. Vagbhata's chapter on removing such objects is read on our page on Shalyaharana Vidhi. Calling the stone a shalya puts it in that family: something the body made, handled by the surgeon as something that does not belong.

The verse is a stop rule written into the middle of the procedure. The fingers are in place and the stone is held, and now the surgeon is told to watch the patient's face. If he drops motionless, head bowed, eyes fixed like that of a dead man, the extraction is abandoned. Only in the absence of such an occurrence does the operation go on.

Two things make the verse unusual. It is a sign read after the operation has begun, not before, and it overrides everything that came before it, the king's permission included. The permission was a judgment about the case. The stop-sign is a judgment about the moment. We did not find a stop rule like it in Celsus's chapter.

At the Distance of a Yava: Left or Right of the Sevani

An incision should then be made on the left side of the raphe of the perineum at the distance of a barley-corn and of a sufficient width to allow the free egress of the stone. Several authorities recommend the opening to be on the right side of the raphe of the perineum for the convenience of the operation.

The cut is measured with a grain. A single grain of barley (yava) gives the distance from the midline: the incision begins on the left of the sevani, the seam that runs down the middle of the perineum, by the width of a grain, and it is made wide enough for the stone to come out freely.

At the distance of a barley-corn: the chapter measures where the cut goes with a single grain, yava.

The second sentence is a recorded disagreement. Several authorities put the opening on the right instead, for the convenience of the operation. The chapter does not settle the matter. It states its own side first and lets the other one stand, inside the text itself rather than in a commentator's note.

The operation that reaches the bladder through the perineum has a modern name, perineal lithotomy, and Sushruta's account is often cited in histories of surgery. We leave claims about who was earliest to the historians. The dates of the Sushruta Samhita's layers are argued over, and nothing on this page depends on them.

Whole, Not in Pieces: The Agravaktra Yantra

Special care should be taken in extracting the stone from its cavity so that it may not break into pieces nor leave any broken particles behind (i.e., inside the bladder), however small, as they would, in such a case, be sure to grow larger again. Hence the entire stone should be extracted with the help of an Agravaktra Yantra (a kind of forceps the points of which are not too sharp).

This is the chapter's most practical warning, and its reason is stated rather than assumed: fragments left behind would, in such a case, be sure to grow larger again. The choice of tool follows from the warning. The agravaktra yantra is, in Bhishagratna's gloss, a kind of forceps the points of which are not too sharp: an instrument chosen to grip without breaking. The family of blunt instruments it belongs to, the yantras, is set out in Vagbhata's chapter on them, read on our page on Yantra Vidhi.

Whole, not in pieces: fragments left behind, the chapter warns, would be sure to grow larger again.

Modern urology also takes fragments left behind seriously, because they can grow; the methods have nothing else in common.

Garbhashaya and Vasti: The Operation in a Woman, and the Wound That Can Close

Paragraphs 14-15 open with the operation in a woman. In a woman, the uterus ... is adjacent to the urinary bladder, so the stone is taken out through an oblique, upward incision; a deep cut in that place risks a urine-exuding ulcer, a wound that leaks urine. The same result, the text adds, follows any injury to the urinary passage in a man. The uterus here is garbhashaya and the bladder vasti, and the point is simply anatomical: in a woman the two lie close, and the cut must respect it.

Then comes a short argument about wounds of the bladder, in three cases. A wound on one side of the bladder, from any cause other than a stone, baffles all attempts at healing. A wound through both sides should be deemed incurable. But the one-sided opening of a stone operation might be healed up. Why the difference? The text gives three reasons.

• The potions and fomentations used for any surgical wound act on this one too. Sushruta's general chapter on wounds is read on our page on Dvivraniya.
• The opening is only made large enough for the extraction of the stone as recommended in the authoritative books.
• And an increase in the quantity of urine contributes to an increase in the size of the stone, so that a little urine through the wound, or the urine-increasing gruels, are not attended with any injurious effects.

The third reason is the hardest to follow in English, and we leave it there rather than force a meaning onto it. It is certainly not advice about how much to drink: anyone who has had a stone should follow their own doctor's advice on fluids.

Sushruta and Celsus: One Operation, Twelve Points

Aulus Cornelius Celsus wrote his De Medicina in Latin in the first century CE. Book 7, chapter 26, describes cutting for the stone, and read beside Sushruta's chapter the two accounts agree on more steps than one might expect. We read Celsus in W. G. Spencer's English translation. The twelve points and the labels in the last column are our own alignment.

Four points the same, three close, three different, and two that only one of the two has. Where they agree, it is mostly on what the problem itself dictates: the operation is a last resort and dangerous, the patient has to be held still with the limbs drawn up, the stone has to be fixed from below with two fingers of the left hand, and the opening has to be big enough for the stone. Where they differ, it is on the surgeon's choices: where to cut, what to grip with and how hard to press.

Each also has something the other lacks. Sushruta has the king. Celsus has an age limit and a season, and the age limit happens to fit what Sushruta's own Nidana says about children, that their stones are the easiest of all to take out. Sushruta's operation chapter, as we saw, says nothing about age.

We do not claim that either learned from the other, or which came first. Two surgical traditions facing the same stone in the same body could arrive at the same two fingers on their own. What the table shows is narrower and, we think, more interesting: on the steps the body decides, the two books agree, and on the steps the surgeon decides, they part.

After the Stone: The Droni, the Pushpa-Netra and a Clock From Three Days to a Year

The aftercare, from the second half of 7.14-15 to 7.18, runs on a clock.

After the extraction of a stone, the patient should be made to sit in a Droni (cauldron) full of warm water and be fomented thereby.

The droni is a large vessel, Bhishagratna's cauldron. The warm water is meant to keep blood from collecting in the bladder, and if blood does collect, a fine urethral syringe, the pushpa-netra, is used to clear it. A memorable verse (7.16) repeats the syringe step, the way the chapter's verses repeat the points it most wants remembered.

The droni: a wide vessel of warm water, the first thing after the stone is out.

Then the days. For three days, a warm gruel (yavagu) with ghee, morning and evening, boiled with plants we leave out. For the next ten, rice boiled with milk and plenty of treacle, in small amounts. After those ten days, rice with a meat soup of dry-land animals (jangala) and the juice of sour fruits. Then ten days of warm fomentation, with a warm oil or a warm liquid (drava-sveda). The wound is washed, dressed and oiled with preparations we also leave out.

And there is a check at seven days. If the urine is still not passing by its natural way, the wound is cauterized with fire (agnikarma) in the manner described before; Vagbhata's account of agnikarma is read on our page on Kshara Agnikarma Vidhi. Once the urine runs its natural course, basti procedures follow, with sweet-tasting (madhura) plants.

The last instruction is for a year. Apart from one item we leave out, the patient is to keep away from riding on horse back or on the back of an elephant, swimming, climbing on trees and up mountains and partaking of indigestible substances for a year even after the healing of the ulcer.

Three days, ten, ten more, a check at seven and a year: the operation itself takes a morning, and the chapter's attention to the patient lasts until a year after the wound has closed.

One Ride, Four Jobs: Charaka's Mutrakrichchhra and Sushruta's Ashmari

The ban on riding is not the only place the ride appears. Read across the two books, the same activity turns up four times in the story of the stone, and each time it does a different job.

• A cause. Charaka's Chikitsa Sthana 26.27, in Van Loon's English, lists the causes of mutrakrichchhra, the difficult urination under which his stone is discussed. One of them is riding on a fast-moving vehicle.
• A sign. Sushruta's Nidana Sthana 3.6: in a person with a stone, a pain is experienced in the bladder at the time of running or jumping or in swimming, or while riding on horseback, or after a long journey.
• A method. Charaka again, Chikitsa Sthana 26.60, under Van Loon's heading Method of extraction of the calculus: the first method is a fast ride, by chariot or on horseback, after a drink; the second is Otherwise it should be extracted by surgeon.
• A ban. Sushruta's Chikitsa Sthana 7.18: no riding on a horse or an elephant until a year after the wound has closed. And the chapter just before, on arsha, ends with the same ban among its things to avoid (Chikitsa Sthana 6.20-21: riding on horse-back, etc., sitting on the legs).

Cause, sign, method and ban: one ride does four different jobs in Charaka and Sushruta.

Put together, one jolting ride is a cause of the trouble, a sign of the stone, for Charaka a first attempt at moving gravel along, and, after the operation, something to avoid for a year. The four uses do not contradict each other; each fits its moment. We report Charaka's ride as a reading of an old book, not as a suggestion. A suspected stone needs a doctor, not a journey.

The Eight Srotas a Surgeon Must Guard

Paragraph 19 names the parts that should be carefully guarded at the time of performing a lithotomic operation. There are eight: the urine-carrying channels (mutra-vaha), two reproductive channels (shukra-vaha and the mushka-srotas), the urinary ducts (mutra-praseka), the seam of the perineum (sevani), the yoni, the rectum (guda) and the bladder (vasti).

For each, the paragraph says what an injury does, and as we read it the list runs from the worst outcome down. Injury to the urine-carrying channels kills: Death results in the event of the urine-carrying channels being in any way hurt during the operation owing to an accumulation of urine in the bladder. The two reproductive channels come next, with consequences we leave out. Then a hurt to the urinary ducts leads to a frequent dribbling of urine; an injury to the yoni or to the sevani gives rise to extreme pain; and for the last two, The symptoms which characterise a hurt to the rectum or to the bladder have been described before. Eight parts, six lines of consequence: the last two pairs share theirs.

Then the closing verse (7.20) names the same eight again, as the Marmas or vulnerable parts seated in the eight Srotas (ducts) of the body, but in a different order. It starts from the sevani, where the knife goes in, and ends with the bladder. The prose list starts from the injury that kills; the verse starts from the surface. And the verse ends on the surgeon, not the patient: one who does not know these parts and is not practiced in the art of surgery brings about the death of many an innocent victim.

Why the Chapter Ends on Marma: Vasti as a Seat of Prana

Why should a chapter on a stone end on vulnerable parts? Because the bladder is one. Sushruta's Nidana Sthana 3.14 calls it one of the primary seats of vital energy, and Bhishagratna notes that the Sanskrit word there is pranayatana, meaning that an injury to the urinary bladder may be attended with fatal result.

Charaka says the same in three places. His Sutrasthana 29.3 counts the bladder among the ten seats of life, the dasha pranayatana read on our page on Charaka Sutrasthana 29. His Siddhi Sthana 9.3, on the vital points, singles out three: Of them also the hrt (heart), basti (urinary bladder) and siras (head) are important ones because they are roots of the body. And the chapter in which his stone appears, Chikitsa Sthana 26, opens on the same three (26.3-4): Of the 107 vital parts mentioned under enumeration of body components, these 3 are regarded as important ones by the experts because they are seat of vital breath.

So Charaka files the stone under the bladder as one of three vital organs, and Sushruta closes his stone chapter on the parts around the bladder that a careless knife can destroy: two directions, one warning. The hundred and seven vital points that Charaka's line counts are set out on our page on Marma Sharira in the Bhavaprakasha.

Reading Ashmari Chikitsa Today

What does a modern reader take from Ashmari Chikitsa? Not a method. The medicines are not given here, and the operation belongs to the history of surgery. Urinary stones today are diagnosed with tests and scans and managed by doctors, usually urologists, in ways that have nothing to do with this chapter.

What the chapter does offer is a way of thinking about risk that has aged well. It says plainly that an operation can fail in skilled hands. It sets a condition for going ahead, that the medicines have been tried first. It names someone outside the room who must agree. It builds a stop-sign into the middle of the procedure. It writes down the parts that must not be harmed and what happens if they are. It gives as much attention to the year after the operation as to the morning of it. And it tells the surgeon to give the patient hope. None of that depends on believing anything about doshas.

What This Page Leaves Out

• Every medicine in the chapter (7.3-10): the plants, animal products, alkalis and quantities, and the plants named for the aftercare gruel and the wound.
• What is passed through the syringe after the operation, and the details of the basti procedures that follow.
• The consequences the chapter gives for injury to the two reproductive channels, and one item in each of the two lists of things to avoid.
• The medicines on the closing pages of the arsha chapter (6.13-19).
• The last-resort medicine in Dallana's note on Chikitsa Sthana 14, and the drink before Charaka's ride.

What We Could Not Settle

• Who the strong, calm person on the knee-high board is. We read the attendant; Bhishagratna's English allows the patient.
• What the king's permission involved in practice, and whether it covered other operations. In this volume we found it twice.
• The third reason a bladder wound can close (7.14-15), which links the amount of urine to the size of the stone. We cannot tell from the English what it means.
• Whether the patient ate before the operation. Bhishagratna's English says a meal; Vagbhata's rule withholds food in exactly this case, and Celsus fasts his patient too. The Sanskrit of 7.13 would show whether the translation or the authors differ.
• The Sanskrit of the chapter, which we read only in English; on the helper and the meal, the original might settle what the translation leaves open.
• Which came first, Sushruta's account or Celsus's, and whether either knew of the other. We do not know, and the table does not need us to.

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