Sushruta Samhita Chikitsa Sthana Chapter 1: Dvivraniya, the Sixty Upakramas and the Sixteenth Vrana

इस लेख को हिंदी में पढ़ें: सुश्रुत संहिता चिकित्सा स्थान अध्याय 1: द्विव्रणीय और व्रण के 60 उपक्रम

📖 25 min read · Classical text study · Sushruta Samhita, Chikitsa Sthana 1, paragraphs 1 to 120

Sushruta Samhita Chikitsa Sthana Chapter 1 at a Glance

The Sushruta Samhita is arranged in sections, each a sthana. The Sutrasthana lays down principles, the Nidana Sthana describes conditions, the Sharira Sthana describes the body, and the Chikitsa Sthana, which the 1911 translation subtitles "Section of Therapeutics", sets out what a physician does. That answers a question people often ask about the text: the section that deals with therapeutic principle is the Chikitsa Sthana, and its first chapter is the one read here.

Its Sanskrit title is Dvivraniya Chikitsitam. In Bhishagratna's edition it runs from printed page 239 to page 264, in 120 numbered paragraphs, and its colophon closes it as the first chapter of the Chikitsita-Sthanam, the one on the two kinds of vrana. The chapter immediately before it in the book is the last of the Sharira Sthana, which we read on 13 September in Garbhini Vyakarana, Sharira Sthana chapter 10. The Sharira Sthana's own first chapter is a different subject, covered in Karma Purusha, Sharira Sthana chapter 1.

The first quarter is classification, the middle a long formulary, the end a set of counts. This article reads the first and last parts, where the chapter's thinking shows; the formulary is not something a commercial website should reproduce.

Dvivraniya: Why the Chapter Is Named for Two Vranas

Paragraph 2 divides every vrana by where it came from. The first kind arises from within, "through the vitiated condition of the blood or the several deranged conditions of the Vayu, Pitta and Kapha, or ... their concerted action (Sannipata)". The second comes from outside, and the list is long: "the bites of men, beasts, birds, ferocious animals, reptiles or lizards, or ... a fall, pressure and blow, or ... fire, alkali, poison, or irritant drugs", and weapons from pointed wood to arrows and axes. A footnote gives the commentator Dalhana's reading of one item in that list as "fragments of broken pottery". The translation calls the two kinds "idiopathic" and "traumatic". The closing footnotes use the Sanskrit word agantu, the one that comes from outside, for the second.

The chapter admits at once that the two have "many features in common", and gives three reasons for keeping them apart anyway: a different origin, a different handling, and a difference in "strength and tenacity". "Hence the chapter is called Dvivraniya."

Paragraph 3 then shows how temporary the difference is. It gives the agantu vrana a handling of its own for the first days only. After that, "a week" in the translator's bracket, the outside kind is to be handled like the inside kind "to all intents and purposes", because by then it "is found to be associated with deranged Vayu, Pitta or Kapha". So the two kinds begin apart and converge within about a week. The division is as much about time as about cause: an injury from outside becomes, in this text's terms, an event inside the body once the doshas have joined it.

Vrana: A Word That Means a Break

Paragraph 5 explains the word itself: "A Vrana is so named from its etymology (the term being derived from the root Vrana, to break) and signifies a cracked or broken condition (of the skin and flesh of the afflicted part) of the body." The definition is about continuity. A vrana is the place where the body's covering has broken, whatever broke it.

The 1911 translation renders vrana throughout as "ulcer", which in modern English suggests something narrower. The Sanskrit covers a fresh cut and a long-standing sore alike. This article keeps the Sanskrit word.

Paragraphs 4 and 5 also divide the signs in two. The general sign is common to every vrana, and the translation names it as pain. The specific signs are the ones that follow "the virtue of the deranged Vayu, Pitta, etc." involved. That split, one shared sign and many distinguishing ones, is what makes the next section possible. The layers a vrana breaks through begin with the skin, which Sushruta's Sharira Sthana divides into seven; we read that division in Sapta Twacha, Sharira Sthana chapter 4.

Fifteen Vranas From Vata, Pitta, Kapha and Rakta

Paragraph 4 gives the number: vranas are "subdivided (particularly) into fifteen groups, according to the presence of the morbific diathesis (deranged Vayu, Pitta, Kapha and blood therein), either severally or in combinations as described (before) in the Chapter on Vrana-Prasna (Sutra Sthanam. Ch. XXI)". So the fifteen come from four agents: vata, pitta, kapha and rakta, the blood.

Fifteen is exactly the number of ways four things can be combined if at least one is present. Four agents alone give 4. Two at a time give 6. Three at a time give 4. All four together give 1. The sum is 4 + 6 + 4 + 1 = 15, which is 2 × 2 × 2 × 2 minus one. Paragraphs 6 to 20 then describe the fifteen in precisely that order of size: singles first, then pairs, then triples, then all four.

Two things stand out in the descriptions themselves. The first is that they are written almost entirely in comparisons that need nothing but the senses. The pittaja kind has a discharge "resembling the washings of Kimsuka flowers", the kimshuka being the flame-orange palash of the Indian dry forest. The raktaja kind "looks like a lump of red coral", pravala, and is said to "smell like a strong alkali". Colour, smell and texture carry the whole classification. No instrument is needed to apply it, which tells you who it was written for: a physician looking and smelling at the bedside.

Pravala, red coral: the comparison the chapter uses for the look of the raktaja kind.

The second is a small detail that matters later. The description of the raktaja kind ends by saying that "the specific symptoms of the Pittaja type are likewise found to supervene". Blood and pitta share their signs. Keep that in mind for the chapter's closing count.

Kimshuka, the palash or flame of the forest. The chapter borrows the colour of water in which its flowers have been washed.

A caution belongs here. This is a classification inside a text, written for physicians who were trained in it. It is not a way to sort a real wound, and no one should try. Any wound that is not closing needs a doctor, not a table.

Shuddha Vrana: The Sixteenth, the Colour of the Back of the Tongue

Paragraph 4 does not stop at fifteen. "Several authorities, by adding the simple uncomplicated ulcers (unassociated with any of the morbific principles of the deranged Vayu, Pitta, &c.) to the list, hold the number of types to be sixteen." The arithmetic explains the disagreement exactly. Four agents can be combined in 2 × 2 × 2 × 2 = 16 ways if the empty combination is allowed: the one in which none of the four is present. Fifteen counts only the combinations with something in them. Sixteen counts the empty one too.

The chapter never calls anything "the sixteenth". But the very next thing it describes after the fifteen, in paragraph 21, is that empty case: "An ulcer (Vrana) which is of the same colour with the back of the tongue, soft, glossy, smooth, painless, well-shaped and marked by the absence of any kind of secretion whatsoever, is called a clean ulcer (Suddha Vrana)." Reading the shuddha vrana as the sixteen-counters' extra kind is our reading, not the text's statement. It fits the chapter's order, and it fits the arithmetic.

The clean state is not defined as an absence, though that is what it is. It is described positively, by comparison with a healthy surface anyone can see in a mirror: the back of the tongue. The standard for the goal is the body's own healthy tissue.

Paragraph 4 ends with a bracket that keeps the whole scheme honest: "(Practically they are innumerable, according to the combinations made of the deranged Vayu, etc. and the different Dhatus of the system)." Fifteen is a working frame, not a claim that bodies come in fifteen kinds. Once the seven tissues (dhatus) are allowed into the combinations, the count runs away. The dhatus themselves are the subject of Saptadhatu: the seven tissues.

Shashti Upakrama: The Sixty Measures, Counted

Paragraph 22 divides the management of a vrana into sixty measures (upakrama) and names all of them in a single run of text, across printed pages 243 to 245. A footnote from the translator adds a remark that turns out to be the key to the whole chapter: "Authorities, however, differ in enumerating these factors, although every one of them sticks to the total number of sixty."

We counted the printed list against that total, reading the page images rather than the text layer (which garbles several names). It closes at exactly sixty. The glosses below are the translation's own, shortened where marked; the numbering is ours.

The list is not a sequence to be run from top to bottom. It mixes stages (a swelling not yet broken, an open vrana, a closed scar), routes (on the skin, by mouth, through the nose), and things done to the room and the day rather than to the body at all. And it spans almost every form a classical preparation can take: liquids, pastes, oils, clarified butter, powders, fumes, diet and rites. That breadth is one reason no product on this page is offered for any of the sixty.

The chapter's own imagery for these measures is fire and water. Explaining parisheka, paragraph 32 pictures the aggravated doshas as a fire (doshagni) and the poured liquid as water on it. It is the same picture the tradition uses for pitta itself.

Eleven or Twelve: Apatarpana and the Shopha Measures

Paragraph 24 turns from the vrana back one step, to the swelling (shopha) that can come before it: "There are six kinds of swellings (Sophas), as described before, and the following eleven measures, commencing with Apatarpana and ending in Virechana" belong to them. The same paragraph adds that these measures do not become unsuitable once a swelling has turned into a vrana, and it singles out apatarpana as "the first, general and principal" measure for every kind of swelling.

Count the printed list from apatarpana to virechana: apatarpana, alepa, parisheka, abhyanga, sveda, vimlapana, upanaha, pachana, visravana, sneha, vamana, virechana. That is twelve names, not eleven.

There are two ways to read this, and the edition does not choose between them. One: apatarpana, which the same paragraph calls first, general and principal, stands apart as the measure for every swelling, and the eleven are the particular measures that follow it, alepa to virechana. Eleven names fit that exactly. Two: one of the twelve, perhaps pachana, which ripens a swelling rather than dispersing it, is understood as belonging to a different stage. We have not found a note in this edition that settles it, and we have not settled it for the text. The discrepancy is small, but it is the first of several places where this chapter's numbers and its lists do not line up, and the pattern turns out to be the most interesting thing in it.

Nine Names, Eight Acts: Where Darana Falls Out

Paragraph 23 sorts the sixty into groups, and its second group is surgical: "The eight acts (from Chhedana to Sivana) are surgical operations." Counting again, the printed span from chhedana to sivana holds nine names: chhedana, bhedana, darana, lekhana, aharana, eshana, vyadhana, vidravana, sivana.

This time the translation resolves the count itself. Darana is glossed as "bursting by medicinal applications": it is the one act in the span done with a medicine rather than a blade. Take it out and nine becomes eight, the classical eightfold set of operative acts (ashtavidha shastra karma) that Sushruta's Sutrasthana sets out as the whole repertoire of operative work. Paragraph 47 confirms the reading: it reserves darana for those who cannot bear an operation, the young, the old, the timid and the weak.

So the count works as a check on the list. A student reciting nine names under the heading "eight" would know that one of them is different in kind, and the gloss says which. Here we name the eight acts and stop. How they are performed is withheld (see below). The instruments themselves are the subject of two earlier readings, Vagbhata's twenty-six sharp instruments and his 101 blunt ones.

Atikranta-vekshana and Anagata-vekshana: One Verse Points Both Ways

The rest of paragraph 23 does something no other passage in the chapter does. It tells the reader where in the whole Sushruta Samhita each measure is taught:

Seven measures point backwards, to the Sutrasthana. Ten point forwards, to later chapters. That leaves sixty minus seventeen, forty-three, for this chapter: 7 + 10 + 43 = 60. The forty-three is our subtraction; the chapter simply says "the remaining".

Now turn to the other end of the Samhita. Uttara Tantra 65 is Sushruta's chapter on the thirty-two tantra yukti, the technical devices by which a treatise is built, which we read in Tantra Yukti, Uttara Tantra chapter 65. Two of the thirty-two are defined like this in the same translation (Vol. III, paragraphs 26 and 27):

The textbook example of atikranta-vekshana is, almost word for word, the first sentence of paragraph 23: a line in the Chikitsa Sthana saying that something has already been said in the Sutrasthana. And the next sentence is anagata-vekshana, pointing forward. The first chapter of the Chikitsa Sthana uses both signposts in consecutive sentences, and the treatise defines them near its very end, in the sixty-fifth chapter of the Uttara Tantra.

A text that points at itself: paragraph 23 says what has already been taught and what is still to come.

The forward promise is kept, and the edition's own colophons show where. We read them to build this table; the chapter numbers below are the colophons', not ours.

The backward references are less precise. The edition's footnotes point to Sutrasthana 14 for the four ways of arresting the flow of blood, named there as sandhana, skandana, pachana and dahana, and to Sutrasthana 19 for the diet. For the other five, the chapter says only "in the Sutra-sthana", and we have not added chapter numbers it does not print.

Shodhana and Ropana: Seven Forms and a Fear of Prolixity

The first group paragraph 23 sets apart is seven measures: kashaya, varti, kalka, ghrita, taila, rasa-kriya and avachurnana. These are the measures for shodhana, making the vrana clean, and for ropana, knitting it closed; the translation's word for ropana is "granulation". They are also, read another way, the seven forms in which a drug can be put onto a vrana: a decoction, a plug or wick, a paste, clarified butter, oil, a thickened extract, and a powder.

Paragraph 70 makes that second reading explicit. A physician "should employ the drugs, mentioned before, in any of the seven forms", and paragraphs 71 to 74 turn the idea into a grid. The drug group is chosen by the dosha involved: the two pancha-mula groups and the vata-subduing drugs for vata, the Nyagrodhadi or Kakolyadi groups for pitta, the Aragvadhadi group for kapha, and two or three groups together when two or three doshas are involved. The form is then chosen from the seven. One axis is the dosha; the other is the form. The actual preparations, with their ingredients and quantities, are the formulary this article does not reproduce.

Then, near the very end, the author speaks in the first person about his own lists. Paragraph 115: "The comparatively smaller number of drugs which I have mentioned (under the heads of Ropana, Sodhana, etc., in the present chapter) from fear of prolixity, may be increased in combination with other drugs or substances of similar virtue". Paragraphs 116 and 117 give the editing rules: a recipe with rare or numerous ingredients is to be made up with as many as are available; a drug of a group that is described elsewhere as unsuited to a particular condition is to be left out; and a drug outside the group may be added where it is elsewhere described as suited.

The lists are short on purpose, and the text supplies the rules for lengthening them. A list here is a working set, and the rules for changing it are part of the text.

Ahara, Raksha-vidhana and Patradana: Measures That Are Not Medicines

Several of the sixty involve no drug at all, and the chapter gives them the same seriousness as the rest. Its word is upakrama, a measure or an undertaking, and the word is broad on purpose.

Ahara, diet. Paragraph 112 says the diet of a person with a vrana should be "light in quantity as well as in quality, demulcent, heat-making (in potency) and possessed of appetising properties", and a footnote sends the reader to Sutrasthana 19 for the detail.

Raksha-vidhana, protective rites. Paragraph 113 prescribes rites "for the safety of" the person "from the influences of malignant stars and spirits", with the major and minor duties, yama and niyama, observed on his behalf. We report this as part of the text's world, in which the care of a patient included the room, the household and the rites around the bed. We do not present it as having any effect.

Patradana, leaves. Paragraphs 99 to 102 choose leaves by dosha and by season, and then specify the leaf by what it must not be: "Only those leaves which are not rough, nor putrid, nor old and decomposed, nor worm-eaten and which are soft and tender" qualify. The text even gives its reason, a rare thing in a formulary: the leaves "serve to generate heat or cold and retain the liniment or medicated oil in their seat of application". The exclusions come first, then the positive qualities, then the reason. It is the same way Sushruta specifies an instrument.

Yantra, instruments. Paragraphs 109 to 111 reserve instruments for a foreign body (shalya) lodged deep behind a narrow opening, one that "could not be removed with the hand alone". All four of these are named here as the text names them. None of them is instruction.

The Closing Count: Six, Eight, Five, Sixty, Four

Paragraph 114 closes the chapter's argument with a verse made almost entirely of numbers: "The causes of ulcers are six; their seats in the body number eight in all; the features which characterise them are five. The medicinal measures ... are sixty in number." It ends with "the four necessary factors (the physician, the medicines, the nurse and the patient)". The translator's footnotes unpack each figure:

• Six causes: vayu, pitta, kapha, sannipata, shonita (blood) and agantu (from outside).
• Eight seats: tvak, mamsa, sira, snayu, sandhi, asthi, koshtha and marma.
• Five features: those of vata, pitta, kapha, sannipata and agantu. "The symptoms due to Sonita being identical with those due to Pitta, are not separately counted."
• Sixty measures: "those described before in the present chapter".
• Four factors: physician, medicines, nurse and patient.

Six causes but five sets of features: 6 − 1 = 5, because blood's signs fold into pitta's. That is exactly what paragraph 9 said about the raktaja vrana ninety paragraphs earlier, when its description ended by borrowing pitta's signs. The count at the end agrees with the description at the start.

The four factors are the classical chatushpada, the four legs of therapeutics. Charaka gives the same four as the pillars of treatment in his Sutrasthana 9, which we read in Charaka Samhita Sutrasthana 9: the four pillars. Sushruta puts them in a single line at the end of a chapter about wounds, and the placement says something: sixty measures are useless without the four people and things that carry them out.

Ashta Vrana-Vastu: The Eight Seats, and Where We Have Read Them

Each of the eight seats (vrana-vastu) is the subject of an anatomy chapter we have read over the past weeks, which makes this footnote a useful index to them.

Layers from the outside in: the seats begin at the skin, tvak, and run inward.

Skin, flesh, vessels, ligaments, joints and bone descend through the body's layers; the hollow organs follow, and the marmas, points where several tissues meet, come last. That looks like an order of increasing seriousness. The footnote does not say so; it is our reading.

Charaka's Chikitsa Sthana 25: Thirty-Six Measures and a Different Eighth Seat

Sushruta is not the only author with a chapter on the two kinds of wound. Charaka Samhita, Chikitsa Sthana 25, covers the same ground, and Gabriel Van Loon's English rendering lets the two be set side by side.

Charaka opens the same way, with two types, innate and exogenous (Ci 25.5-6). Then comes a passage that reads like a sheet of numbers (Ci 25.17-19): twenty types, three methods of examination, eight locations, fourteen kinds of discharge, sixteen complications, twenty-four defects, and thirty-six therapeutic measures. Van Loon's own aside on the passage is that "the above sort of list may have served as an aid to memorizing the text information".

Put the two chapters together and the same habit shows on both sides:

• Measures: Sushruta names sixty; Charaka names thirty-six (Ci 25.39-43). Charaka's thirty-six bundle several of Sushruta's measures together, and count some in pairs, such as two kinds of covering with leaves and two kinds of bandaging.
• Surgical acts: Sushruta has eight. Charaka counts six (Ci 25.55): incision, puncturing, excision, scraping, scarification and suturing.
• Seats: both say eight. Charaka's eight locations (Ci 25.26) are skin, blood vessels, flesh, fat, bone, ligaments, vital parts and viscera. Set that beside Sushruta's list and seven of the eight are shared. The difference is one member. Charaka has fat (medas) where Sushruta has joint (sandhi).

Same number, one member swapped. It is the pattern the translator described for the sixty, "every one of them sticks to the total", now visible across two different authors.

The Counts Hold, the Members Move

By now the pattern is plain enough to lay out in one table. In chapter after chapter of these texts, the number is the fixed point and the list is allowed to move.

Why would a tradition fix the number and let the members move? The likeliest answer is the one Van Loon hints at. These texts were learned by heart and recited. A number is a checksum on a recited list. A student who gets to the end of the list and has fifty-nine knows something has dropped out, even if the teacher down the road recites a slightly different sixty. The number travels intact from school to school; the members are where the schools differ.

Read that way, the discrepancies in this chapter are not mistakes to be tidied. They show how the text was built. The count tells you what the tradition agreed on. The places where the count and the list disagree tell you where it did not.

What This Article Withholds, and Why

This is a commercial website, the chapter is clinical, and several of its materials are toxic. So the following are described in outline above but not reproduced:

• The measures paragraph 3 gives for the first days of an agantu vrana. A dressing from a classical text is not first aid.
• Every pairing of a drug with a kind of vrana, and every preparation, ingredient and quantity in paragraphs 25 to 111: the formulary.
• How any of the eight surgical acts, probing, puncturing, cauterization or the use of caustics is carried out.
• The recipes for changing the colour of a scar and for bringing back or removing hair on it. Among other things they call for arsenic compounds (haritala, manahshila), copper sulphate and antimony.
• The indications for vasti and uttara-vasti.
• The symptom lists of the fifteen kinds, and the list of complications in paragraphs 118 to 120. Only the comparisons are quoted.

Nothing else in the chapter was left out of this account. The withholding is deliberate, and it is the same on every page of this series: this is a reading of a text, not instruction.

What the Chapter Does Not Say

• We did not find, anywhere in this edition, a statement of which name the "eleven" measures of paragraph 24 leave out.
• We did not find a chapter number for five of the seven measures paragraph 23 says were "already" covered in the Sutrasthana, and we have not supplied any.
• The chapter does not number the shuddha vrana as a sixteenth kind. That connection is our reading.
• It does not present the sixty as a sequence to be followed in order.
• It does not suggest that anyone but a trained physician should apply the classification. It speaks throughout of the physician and of the four factors.
• Nothing in it refers to any product sold today, and nothing on this page should be read as connecting one to it.

How We Read and Cite This Chapter

Edition. The Sushruta Samhita, English translation by Kaviraj Kunja Lal Bhishagratna, Vol. II, Chikitsita Sthanam, chapter I, printed pages 239 to 264, paragraphs 1 to 120 as printed. The key passages (the fifteen kinds, the sixty, paragraph 23 and paragraph 114 with its footnotes) were checked against page images, because the text layer of our scan garbles several names; "Sveda", for example, comes out as "^vejd'a".

Cross-texts. Uttara Tantra 65, paragraphs 26 and 27, in Vol. III of the same translation. Charaka Samhita, Chikitsa Sthana 25, in Gabriel Van Loon's English, cited by his verse markers. The chapter numbers for the Chikitsa Sthana chapters 24 and 31 to 40 were read from this edition's colophons.

Attribution. The "N.B." about the sixty and the footnotes to paragraph 114 are the translator's, and are attributed to the translator. This edition prints no Devanagari, so every Sanskrit word here is the translation's own transliteration, lightly normalised (Sodhana becomes shodhana). Where a reading is ours (the shuddha vrana as the sixteenth, the two readings of "eleven", the order of the eight seats) the page says so. None of this is instruction; for any health concern, the right person is a qualified practitioner.

From Ayurveda Hub: Two Everyday Things

Sushruta's own daily-routine chapter, the twenty-fourth of the same section, begins the healthy person's day with the teeth. Its tooth-brush (danta-kashtha) is a fresh twig, straight, not worm-eaten, with at most one knot, twelve finger-widths long and about as thick as the little finger. The two things below sit at that ordinary end of the day. What follows says only what they are.

A fresh green twig. Sushruta's daily-routine chapter begins the day with one.

More to Read on This Topic

Related reading on the classical texts: the Sushruta Samhita and its place in history, an overview of the Nidana Sthana, Vagbhata's chapter on leeches, horn and gourd, Charaka's six therapies and Vagbhata's Dvividhopakramaniya chapter. For the daily routine that the twenty-fourth chapter begins, see Dinacharya, the classical morning.

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