Prameha Pidaka in the Sushruta Samhita: A Saucer, a Tortoise, a Net and Four Steps of Waiting (Chikitsa Sthana 12)

इस लेख को हिंदी में पढ़ें: सुश्रुत संहिता में प्रमेह पिडका: सकोरा, कछुआ, जाल और देरी की चार सीढ़ियाँ

📖 26 min read · Sushruta Samhita, Chikitsa Sthana 12, read in Bhishagratna's translation (Volume II, printed pages 379 to 385) and in the Sanskrit

Prameha Pidaka: What Sushruta's Chapter 12 Is About

Prameha pidaka is two words. Prameha is the classical name for a family of twenty urinary disorders, set out by Sushruta in Nidana Sthana 6 and by Charaka in Nidana Sthana 4. Monier-Williams glosses pidaka as a small boil or a pustule. A prameha pidaka is a boil of the kind the old physicians watched for in someone with prameha, and the Sushruta Samhita gives these boils a chapter of their own: Chikitsa Sthana 12, the prameha-pidaka-chikitsitam.

Kunja Lal Bhishagratna's English opens the chapter with Now we shall discourse on the medical treatment of the abscesses or eruptions which mark the sequel of a case of Prameha. Sequel is the right word. In this chapter a pidaka is what comes after: after the early signs, after the sweetness, after the swelling. The chapter is short, seven printed pages, and much of it is the physician's formulary, which we leave in the book. What remains is a set of names, a set of counts, and one long sentence about time.

Twenty Lines, Twelve Numbers: How Chapter 12 Runs

The Sanskrit text on Wikisource numbers the chapter's lines 1 to 20. Line 1 is the title, and line 2 is the frame that opens every chapter of the Samhita:

Chikitsa Sthana 12.2
यथोवाच भगवान् धन्वन्तरिः
yathovacha bhagavan dhanvantarih "As the blessed Dhanvantari spoke."

Bhishagratna leaves that line out of his English, as he did in chapter 11, so his paragraph 1 is the title and his paragraph 2 is line 3. His numbers then run to 12, with one block numbered 4–6. Lines 1 to 11 are prose; lines 12 to 20 are verse.

So seven and a half of the twenty lines are read on this page, and twelve and a half stay in the book. The chapter before this one, on prameha itself, is read on our page on Sushruta Chikitsa Sthana 11.

Nava Pidakah: Nine in the Chikitsa, Ten in the Nidana

Chikitsa Sthana 12.3
शराविकाद्या नव पिडकाः प्रागुक्ताः
sharavikadya nava pidakah prag-uktah "The nine pidakas, beginning with sharavika, were described before."

Bhishagratna's English agrees: The nine kinds of abscesses (Pidakas), such as Saravika, etc., have been described before. But the place where they were described, Nidana Sthana 6, counts ten:

Nidana Sthana 6.14
प्रमेहिणो दश पिडका जायन्ते
pramehino dasha pidaka jayante "In the pramehi, ten pidakas arise."

The Nidana then names them: sharavika, sarshapika, kacchapika, jalini, vinata, putrini, masurika, alaji, vidarika and vidradhika. Bhishagratna's English of the Nidana says the same, The ten different types of Pidaka. So the Chikitsa says nine (nava) and points back to a list of ten (dasha).

Why nine? The chapter does not say, and we found no line that does. Our reading, flagged: the tenth name, vidradhika, is defined only by pointing elsewhere, An abscess of the Vidradhi type in Bhishagratna's English of Nidana Sthana 6.19, and vidradhi has chapters of its own in Sushruta, Nidana Sthana 9 and Chikitsa Sthana 16. A chapter that leaves the tenth to its own chapters would count nine. That is a guess about an editor's arithmetic, not a fact about the text. Nava can also mean new, fresh, recent, but "the new pidakas described before" makes no sense, and Bhishagratna reads the number.

Sharavika, Sarshapika, Kacchapika: Ten Names from the Kitchen and the Field

Read the ten definitions of Nidana Sthana 6.15–19 for their nouns and a pattern appears. Most of the names are similes. Each pidaka is named after a thing of ordinary life that it resembles in shape or size.

Nidana Sthana 6.15
शरावमात्रा तद्रूपा निम्नमध्या शराविका
sharava-matra tad-rupa nimna-madhya sharavika "The size of a sharava, of its shape, sunk in the middle: sharavika."

A sharava is, in Monier-Williams, a shallow cup, dish, plate, platter, earthenware vessel (also the flat cover or lid of any such vessel). Bhishagratna pictures it the same way, raised at the margin and dipped in its centre, so as to resemble an Indian saucer in its shape, and the CSRTSDC English of Charaka says As its shape is like that of an earthen saucer (sharavika), hence its name.

Nidana Sthana 6.15
गौरसर्षपसंस्थाना तत्प्रमाणा च सार्षपी
gaura-sarshapa-samsthana tat-pramana cha sarshapi "Shaped like a white mustard seed, and of its size: sarshapi."

The mustard seed (sarshapa) also served, Monier-Williams notes, as a mustard-seed used as a weight, any minute weight. Bhishagratna: of the shape and size of white mustard seeds.

White mustard seed and lentils on a bamboo winnowing tray. Two of the ten pidakas are named for these seeds: sarshapika and masurika.

Nidana Sthana 6.16
सदाहा कूर्मसंस्थाना ज्ञेया कच्छपिका बुधैः
sadaha kurma-samsthana jneya kacchapika budhaih "With burning, shaped like a tortoise: the wise know it as kacchapika."

Here the verse uses one word for tortoise, kurma, to explain a name built on another, kacchapa, which Monier-Williams glosses 'keeping or inhabiting a marsh', a turtle, tortoise. Bhishagratna adds the back: resembling (the back of) a tortoise in shape and attended with a burning sensation. Charaka's own line (Sutrasthana 17.85) calls this pidaka smooth and kacchapa-prishthabha, "like a tortoise's back", so the bracket is fair.

Nidana Sthana 6.16
जालिनी तीव्रदाहा तु मांसजालसमावृता
jalini tivra-daha tu mamsa-jala-samavrita "Jalini has sharp burning and is covered with a net of flesh."

Jala is a net, in Monier-Williams one for catching birds, fish and the like, and his entry for jalini itself reads N. of certain boils appearing in the Prameha disease. Bhishagratna turns the net into studded with slender vegetations of flesh and attended with an intolerable burning sensation.

Nidana Sthana 6.17
महत्यल्पाचिता ज्ञेया पिडका सा तु पुत्रिणी
mahaty alpachita jneya pidaka sa tu putrini "Large, and studded with small ones: that pidaka is putrini."

Putrini is the most human of the names. Monier-Williams gives having a son or sons, possessing children: a large boil with small ones around it, a mother among her children. Then the kitchen again:

Nidana Sthana 6.18
मसूरसमसंस्थाना ज्ञेया सा तु मसूरिका
masura-sama-samsthana jneya sa tu masurika "Shaped like a lentil: masurika."

Masura is a sort of lentil or pulse, and Bhishagratna writes to the size of lentil seeds. Seven of the ten names point at things: a saucer, a mustard seed, a tortoise, a net, children, a lentil, and the forest tuber of the next section. The other three describe. Vinata means "bent" or "sunk"; alaji is defined by colour and blisters, of a red and white colour, studded over with blisters or exuding vesicles; vidradhika is defined by another disease. Our reading, flagged: these names teach recognition by likeness, with objects every listener had handled.

Vidarika and Vinata: Two Lines That Changed in Translation

Nidana Sthana 6.19
विदारीकन्दवद्वृत्ता कठिना च विदारिका
vidari-kanda-vad vritta kathina cha vidarika "Round like the vidari tuber, and hard: vidarika."

Kanda is a bulbous or tuberous root, a bulb, and vidari is a forest creeper that Monier-Williams identifies as Batatas Paniculata, a plant with a large root. Bhishagratna's English reads: A hard and round abscess as large as a (full-grown) gourd. Two things changed. A tuber became a gourd, and a likeness of shape (-vat, "like") became a statement of size. It is the kind of small drift that only shows when the Sanskrit sits beside the English.

A large wild tuber, freshly dug. Sushruta compares vidarika to the vidari tuber; Bhishagratna's English turns it into a gourd.

The second change runs the other way. Sushruta's line for vinata is short:

Nidana Sthana 6.17
महती पिडका नीला पिडका विनता स्मृता
mahati pidaka nila pidaka vinata smrita "A large, blue pidaka is known as vinata."

Bhishagratna's English gives much more: A large blue-coloured abscess (carbuncle) appearing on the back or the abdomen, and exuding a slimy secretion and attended with a deep-seated pain is called Vinata. The back, the abdomen, the moisture and the deep pain are not in the Wikisource line. They are, almost word for word, in Charaka and Vagbhata:

Ashtanga Hridaya, Nidana Sthana 10.30
अवगाढ-रुजा-क्लेदा पृष्ठे वा जठरे ऽपि वा
avagadha-ruja-kleda prishthe va jathare 'pi va "With deep pain and moisture, on the back or on the abdomen."

Charaka's Sutrasthana 17.89 has the same half-line with udare for jathare, and the CSRTSDC English explains the name: It is known as vinata because it is depressed or deep. Monier-Williams agrees that vinata means bent, curved, bent down, bowed, stooping, inclined, sunk down, depressed, deepened. We cannot tell from two printed texts whether Bhishagratna's Sanskrit edition carried the longer couplet or whether he filled Sushruta's line from the other two. Either way, his "Sushruta" at this point is partly Charaka and Vagbhata.

Sapta and Dasha: Charaka's Seven, Vagbhata's Ten

Three classical authors list the prameha pidakas, and they do not count alike. Charaka names seven, and his opening line puts the cause in a single word:

Charaka Samhita, Sutrasthana 17.82
उपेक्षयाऽस्य जायन्ते पिडकाः सप्त दारुणाः
upekshaya 'sya jayante pidakah sapta darunah "From neglect of it, seven fierce pidakas arise."

Vagbhata's Ashtanga Hridaya (Nidana Sthana 10.25–26) names ten, the same ten as Sushruta's Nidana in a different order, and Sushruta's Chikitsa says nine. Set side by side:

A fishing net hung to dry by a river. Jalini, one of the ten, is the pidaka covered with a net of flesh.

Charaka's seven are all in the ten. The three he lacks are putrini, masurika and vidarika, the mother with children, the lentil and the tuber, and all three are similes. He also adds a caution that every reader of this page should keep (Sutrasthana 17.104):

Charaka Samhita, Sutrasthana 17.104
विना प्रमेहमप्येता जायन्ते दुष्टमेदसः
vina pramehamapy eta jayante dushta-medasah "These arise even without prameha, in one whose fat (medas) is disordered."

The CSRTSDC English: Pustules (pidika) can also occur due to vitiation of meda dhatu in a person who is not suffering from prameha. In other words, a boil is not a diagnosis. The old texts did not read one boil as proof of anything, and neither should anyone today. A boil that worries you is a question for a doctor.

Pranavato 'lpah: The Marks of a Sadhya Pidaka

Chikitsa Sthana 12.3
प्राणवतोऽल्पास्त्वङ्मांसप्राप्ता मृद्व्योऽल्परुजः क्षिप्रपाकभेदिन्यश्च साध्याः
pranavato 'lpas tvan-mamsa-praptah mridvyo 'lparujah kshipra-paka-bhedinyash cha sadhyah "In a strong person, small, reaching only skin and flesh, soft, of little pain, quick to ripen and break: these are sadhya."

The second half of line 3 gives six marks, one of the person and five of the pidaka. Pranavat is vigorous, strong, powerful; alpa is small; tvak and mamsa are skin and flesh; mridu is soft; alpa-ruja is little pain. Kshipra, quick, speedy, swift, governs the last compound: quick to ripen (paka) and to break (bheda). Bhishagratna's English: appearing in a strong person but small in size, affecting (only) the Tvak (skin) and the flesh, soft to the touch, slightly painful, easily suppurative and after a time bursting, are curable.

Sadhya is the text's word for a case it expects to manage. Notice what the five marks of the pidaka share: they are all about size, depth and speed. Small, shallow, soft, quick. The pidakas of the next section are their opposites.

Parivarjayet: The Nidana's Mirror Image

Nidana Sthana 6.20
गुदे हृदि शिरस्यंसे पृष्ठे मर्मणि चोत्थिताः सोपद्रवा दुर्बलाग्नेः पिडकाः परिवर्जयेत्
gude hridi shirasy amse prishthe marmani chotthitah sopadrava durbalagneh pidakah parivarjayet "Pidakas risen on the anus, the heart, the head, the shoulder, the back or a marma, with complications, in one whose agni is weak: let him decline them."

Line 3 of the Chikitsa and line 20 of the Nidana are mirror images. A strong person (pranavat) stands against weak digestive fire (durbalagni); skin and flesh against the anus, heart, head, shoulder, back and the vital points (marma); silence about trouble against sopadrava, "with complications". Bhishagratna: appearing about the region of the heart, anus, head, shoulder, back or at any of the vital joints (Marma) of the body, a pidaka that should be abandoned as incurable. Parivarjayet is the physician's verb for declining a case. Sushruta's Nidana writes the warning, and the Chikitsa writes its reverse.

Upadrava, the word behind "complications", is in Monier-Williams first that which attacks or occurs suddenly, any grievous accident, misfortune, calamity, and only then a medical term. A pidaka is itself an upadrava of prameha.

Evam Akurvatas Tasya: Four Times "If He Does Not"

Line 4 is the core of the chapter, a single run of prose built on a refrain. Four times it says:

Chikitsa Sthana 12.4, the refrain
एवमकुर्वतस्तस्य
evam akurvatas tasya "Of him, not doing so."

Each time, the trouble has moved one step further, and each time the text names the next response. The line opens with the early signs and ends with the word asadhya. Laid out as rungs:

The Sanskrit of the third and the fifth rungs:

Chikitsa Sthana 12.4
दोषाः प्रवृद्धा मांसशोणिते प्रदूष्य शोफं जनयन्त्युपद्रवान् वा कांश्चित्
doshah pravriddha mamsa-shonite pradushya shopham janayanty upadravan va kamshchit "The doshas, grown, spoil flesh and blood and bring a swelling, or some complications."

Chikitsa Sthana 12.4
पूयोऽभ्यन्तरमवदार्योत्सङ्गं महान्तमवकाशं कृत्वा प्रवृद्धो भवत्यसाध्यः
puyo 'bhyantaram avadaryotsangam mahantam avakasham kritva pravriddho bhavaty asadhyah "The pus, tearing inward and making a deep hollow, a large space, grows, and the case is asadhya."

Utsanga is one of Sushruta's surgical words. Monier-Williams gives the haunch or part above the hip, lap, and, from Sushruta, the bottom or deep part of an ulcer; avakasha is place, space. Bhishagratna keeps the picture: the pus eats into the deeper tissues of the locality, creates large cavities in its inside.

Stone steps going down into still water. Chikitsa 12.4 goes down the same way: four times "of him, not doing so", one step at a time.

His English keeps the steps but loses the refrain. Where the Sanskrit repeats one phrase four times, he varies it: if the aforesaid preliminary measures are not resorted to, then If the disease is not checked (even at this stage), then if the aforesaid remedies be not employed at this stage of the disease, then If these be not done (at this stage). It is good English, and it hides the drumbeat. Read in Sanskrit, the line goes down like a staircase, and each evam akurvatas tasya is one more step. No one should copy any rung of this ladder; the measures are the physician's, and on this page they are history.

Who Does Not? The Physician Advises, the Person Acts

The refrain hides a small piece of grammar. The first rung's verb is upadishet, "he should advise", and that is the physician. But the refrain is in the genitive, akurvatas tasya, "of him not doing", and the first time it appears the text says who he is:

Chikitsa Sthana 12.4
एवमकुर्वतस्तस्य मधुराहारस्य मूत्रं स्वेदः श्लेष्मा च मधुरीभवति
evam akurvatas tasya madhuraharasya mutram svedah shleshma cha madhuribhavati "Of him not doing so, one whose food is sweet, the urine, the sweat and the phlegm turn sweet."

Madhurahara, "one whose food is sweet", is the person under care. So the one who fails to act is the person, and the second rung's verb, aseveta, "he should resort to", reads most naturally as his as well. Bhishagratna makes the point plain: if the patient goes on using sweet articles of food in utter disregard of the instructions.

Our reading, flagged: the ladder is written about two people at once. The physician names the step, and the person keeps it or does not. The urgency is aimed at both.

Tasmad Adita Eva: From the Very Beginning

Chikitsa Sthana 12.4, the close
तस्मादादित एव प्रमेहिणमुपक्रमेत्
tasmad adita eva pramehinam upakramet "Therefore one should take up the pramehi from the very beginning."

This is the chapter's one general instruction, and it is about time. Monier-Williams gives aditas as from the beginning, from the first, at first, and eva sharpens it: from the very first. Bhishagratna: Hence a case of Prameha should be remedied at its very outset. The ladder above is the argument; this sentence is the conclusion it was built to reach.

The same thought closes the Nidana twin. Its last verse:

Nidana Sthana 6.27
सर्व एव प्रमेहास्तु कालेनाप्रतिकुर्वतः मधुमेहत्वमायान्ति तदाऽसाध्या भवन्ति हि
sarva eva pramehas tu kalenapratikurvatah madhumehatvam ayanti tada 'sadhya bhavanti hi "All pramehas, in time, of one who does not counteract them, come to be madhumeha, and then they are asadhya."

Bhishagratna's English: All types of Prameha, not properly treated and attended to at the outset, may ultimately develop into those of Madhumeha types, which are incurable. A-pratikurvatah, "of one not counteracting", is the Nidana's word; a-kurvatah, "of one not doing", is the Chikitsa's. The two halves of Sushruta's account of prameha end on the same negative. The modern meaning is plain enough: a boil that grows, hurts or will not settle is a reason to see a doctor early, not a reason to wait.

Kriyakala: Sushruta's Six Times for Action

In Sutrasthana 21, the chapter of questions about wounds, Sushruta divides the course of a disorder into six kriyakalas, "times for action": accumulation, aggravation, spread, settling in a place, manifestation, and the last stage, which 21.35 describes as the burst. Bhishagratna renders kriyakala as an occasion for medical treatment. Prameha is one of Sushruta's own examples of the fourth stage, the settling in a place: Lodged in the bladder, these humours usher in Prameha.

Sutrasthana 21.33
तत्र पूर्वरूपगतेषु चतुर्थः क्रियाकालः
tatra purvarupa-gateshu chaturthah kriyakalah "When they have reached the early signs: the fourth time for action."

The fifth is the disease made plain, which should be regarded as the fifth occasion for medical treatment, and the sixth is the burst:

Sutrasthana 21.35
अत ऊर्ध्वमेतेषामवदीर्णानां व्रणभावमापन्नानां षष्ठः क्रियाकालः ... तत्राप्रतिक्रियमाणेऽसाध्यतामुपयान्ति
ata urdhvam eteshamavadirnanam vrana-bhavam apannanam shashthah kriyakalah ... tatrapratikriyamane 'sadhyatam upayanti "After that, for these when they have burst and become wounds: the sixth time for action ... Not counteracted there, they go on to be asadhya."

Bhishagratna writes The sixth occasion for the calling in of medical aid for the moment a swelling would burst and exhibit the characteristic symptoms of an open ulcer, and he adds that a lingering case can turn for the worse if neglected or not sufficiently cared for at the outset.

A small copper bowl floating in a basin of water. Monier-Williams gives ghatika as both a water-jar and a period of time; kriyakala means the time for action.

Our reading, flagged: line 4 of chapter 12 walks the last three of these six times, in order. It starts in the early signs (purvarupeshu, the fourth), passes through the manifest prameha (the fifth), and ends with pus that bursts inward and a case called asadhya (the sixth). Even the verbs match. Sutrasthana 21.35 has avadirna, "burst", and Chikitsa 12.4 has avadarya, "tearing", both from the root dri, to split. Monier-Williams even derives the name vidradhi from the same root, said to be fr. vi + √ dṝ, though "said to be" is as far as he goes.

The principle behind the six times is one couplet:

Sutrasthana 21.37
संचयेऽपहृता दोषा लभन्ते नोत्तरा गतीः ते तूत्तरासु गतिषु भवन्ति बलवत्तराः
sanchaye 'pahrita dosha labhante nottara gatih; te tuttarasu gatishu bhavanti balavattarah "Doshas removed at accumulation do not reach the later stages; in the later stages they grow stronger."

Bhishagratna: if left unremedied, they gain in strength and intensity in the course of their further development. Chapter 12 is that couplet with a case attached.

Upeksha: Charaka and Vagbhata Name the Same Fault

Sushruta writes the fault as a negative verb. Charaka and Vagbhata give it a noun, upeksha, and Monier-Williams' gloss is worth reading to the end: overlooking, disregard, negligence, indifference, contempt, abandonment, and also endurance, patience. Neglect and patience share a word. Our reading, flagged: putting up with a thing is how it gets overlooked, but the double sense is the dictionary's, and none of the three authors plays on it.

Vagbhata's pair, from his Ashtanga Hridaya:

Ashtanga Hridaya, Nidana Sthana 10.20 and 10.26
कालेनोपेक्षिताः सर्वे यद् यान्ति मधु-मेह-ताम् ... विद्रधिश् चेति पिटिकाः प्रमेहोपेक्षया दश
kalenopekshitah sarve yad yanti madhu-meha-tam ... vidradhish cheti pitikah pramehopekshaya dasha "Since all of them, overlooked over time, come to be madhumeha ... and vidradhi: these are the ten pitikas, from neglect of prameha."

Charaka and Vagbhata name the neglect once; Sushruta walks it down four steps.

Vagbhata Keeps the Measures and Drops the Ladder

Vagbhata gives the same material twice, in the Ashtanga Sangraha (Chikitsa Sthana 14.21) and the Ashtanga Hridaya (Chikitsa Sthana 12.38–40). Both keep Sushruta's content: unripe pidakas handled like a swelling and ripe ones like a wound, the early measures, the remark that people with meha are hard to purge, and the early start:

Ashtanga Hridaya, Chikitsa Sthana 12.38–39
शराविकाद्याः पिटिकाः शोफवत्समुपाचरेत् अपक्वा व्रणवत्पक्वाः तासां प्राग्रूप एव च
sharavikadyah pitikah shophavat samupacharet; apakva, vranavat pakvah; tasam pragrupa eva cha "One should attend to the pitikas beginning with sharavika as a swelling when unripe, as a wound when ripe; and at their very first signs ..."

The Sangraha has the same turn, purvarupeshv eva tu tasam, "at their very first signs". What both versions drop is the ladder. Neither has evam akurvatas tasya, there is no step-by-step descent, and there is no closing tasmad adita eva; the early start survives as a phrase, not as an argument. Our reading, flagged: Vagbhata compressed for students who already knew Sushruta, and a compressor keeps the instructions and cuts the rhetoric.

Paribhashiki: Madhumeha as a Technical Name

Chikitsa Sthana 12.6
पिडकापीडिताः सोपद्रवाः सर्व एव प्रमेहा ... पारिभाषिकीं मधुमेहाख्यां लभन्ते
pidaka-piditah sopadravah sarva eva pramehah ... paribhashikim madhumehakhyam labhante "All pramehas, troubled by pidakas and with complications, ... take the technical name madhumeha."

The middle of the sentence, left out above, gives the reason: the sweetness of the urine and the rest, and the smell of honey (madhu). Bhishagratna: Hence they are technically known as Madhu-Meha. The key word is paribhashiki, which Monier-Williams glosses conventional, technical, citing Sushruta. Here Sushruta is telling his reader how to read one of his own words.

That matters, because Sushruta's list of twenty pramehas has no madhumeha in it. His four of vata are these:

Nidana Sthana 6.8
वातात् सर्पिर्वसाक्षौद्रहस्तिमेहाश्चत्वारोऽसाध्यतमाः
vatat sarpir-vasa-kshaudra-hasti-mehash chatvaro 'sadhyatamah "From vata, four: sarpir-meha, vasa-meha, kshaudra-meha and hasti-meha, the hardest of all."

Kshaudra is honey, species of honey, so a honey-meha is among the twenty, but under another name. In Sushruta, madhumeha is not one of the twenty kinds. It is the name any of the twenty takes when pidakas and complications arrive. The Nidana says the same: A Prameha patient afflicted with deep-seated abscesses and other distressing symptoms ... should be pronounced as suffering from Madhumeha and adjudged incurable (Nidana Sthana 6.24), and its last verse, read above, says that every prameha comes to madhumeha in time.

Charaka differs: his Nidana Sthana 4 makes madhumeha one of the four kinds of vata, as our page on Charaka's Prameha Nidana shows. Vagbhata keeps both senses: madhumeha is one of his four of vata (Nidana Sthana 10.18), and a few lines later he follows Sushruta's usage:

Ashtanga Hridaya, Nidana Sthana 10.21
सर्वे ऽपि मधु-मेहाख्या माधुर्याच् च तनोर् अतः
sarve 'pi madhu-mehakhya madhuryach cha tanor atah "All of them, too, are called madhumeha, from the sweetness, of the body as well."

So a reader who meets the word in this chapter should read a stage, not a type. Our reading, flagged: modern writing often equates madhumeha with one modern disease; in this chapter it is a technical label for a late stage of any prameha, and we do not map it onto anything modern.

Na Kathamchid Api Svedayet: The Chapter's Strongest "Never"

Chikitsa Sthana 12.7
न चैतान् कथंचिदपि स्वेदयेत् मेदोबहुत्वादेतेषां विशीर्यते देहः स्वेदेन
na chaitan kathamchid api svedayet; medo-bahutvad etesham vishiryate dehah svedena "And one should not sweat them in any way at all; because their fat is abundant, the body breaks down with sweating."

Most of the chapter says "should". This line says "not ... in any way at all" (na kathamchid api), the strongest negative in it. Sveda is the classical sweating procedure; Monier-Williams gives sweating, perspiring, sweat, perspiration and a sudorific. The reason given is fat (medas), and the verb, vishiryate, is vivid: Monier-Williams has to be broken or shattered or dissolved, crumble or fall to pieces, waste away, decay. Bhishagratna softens it into Fomentation (of any kind) is forbidden, since it might lead to the gradual emaciation of his frame by drying up the organic fat (Medas).

Charaka's list of those who should not be given sweating (Sutrasthana 14.16–19) includes them:

Charaka Samhita, Sutrasthana 14.16–17
रूक्षाणां मधुमेहिनाम् ... स्थूलानां पित्तमेहिनाम्
rukshanam madhumehinam ... sthulanam pittamehinam "the dry, those with madhumeha ... the stout, those with pittameha"

Vagbhata's list in Ashtanga Hridaya Sutrasthana 17.21–24 names the mehin (मेहिनः) among those not to be sweated, and closes with an allowance, mridu chatyayike gade (मृदु चात्ययिके गदे), "gently, in an urgent illness". Sushruta allows no exception. Our reading, flagged: of the three, his wording is the strictest. This is a classical rule about a classical procedure. It is not advice about saunas or steam rooms; anyone with a long-term condition should ask their own doctor before using heat. Vagbhata's procedure is described on our page on Vagbhata's four kinds of svedana.

Rasayani, Not Rasayana: Why the Pidakas Gather Below

Chikitsa Sthana 12.8
रसायनीनां च दौर्बल्यान्नोर्ध्वमुत्तिष्ठन्ति प्रमेहिणां दोषाः ततो मधुमेहिनामधः काये पिडकाः प्रादुर्भवन्ति
rasayaninam cha daurbalyan nordhvam uttishthanti pramehinam doshah; tato madhumehinam adhah kaye pidakah pradurbhavanti "Because the rasayanis are weak, the doshas of pramehis do not rise upward; so pidakas appear in the lower body of madhumehis."

The word to watch is rasayani, which is not rasayana. Monier-Williams keeps them apart: rasayana is an elixir, while the feminine rasayani is a canal or channel for the fluids (of the body), cited from Charaka and Sushruta. One letter at the end turns an elixir into a channel. The line says the channels are too weak to lift the doshas, so they settle low.

Bhishagratna's English expands the single word: owing to the weakness of the channels of chyle, blood, Kapha and Pitta (as well as for an exhausted condition of the nerves in his body). The Sanskrit has rasayaninam, "of the channels", and nothing more; the chyle, the blood, the kapha and pitta, and the nerves are his gloss. The doshas, in his words, confine themselves into the lower part of the body.

The Nidana twin pictures the same direction for the vata kind (Nidana Sthana 6.21), adhah prakramate vayuh (अधः प्रक्रमते), "vayu moves downward", which Bhishagratna renders as a Vayu that rages rampant in the lower part of the body. Line 8 says where pidakas usually appear; the warning list of 6.20, which names places high and low, says where they are dangerous. The text does not join the two lines, and neither do we.

Apakva and Pakva: A Swelling First, a Wound After

Chikitsa Sthana 12.9, first half
अपक्वानां तु पिडकानां शोफवत् प्रतीकारः पक्वानां व्रणवदिति
apakvanam tu pidakanam shophavat pratikarah, pakvanam vranavad iti "For unripe pidakas, the measures for a swelling; for ripe ones, those for a wound."

This half-line hands the pidaka over to two other parts of the Samhita. Before it ripens (apakva) it is a swelling (shopha), and Sushruta's Sutrasthana 17, the Amapakvaishaniya, is his chapter on telling an unripe swelling from a ripening and a ripe one. After it ripens (pakva) it is a wound (vrana), the subject of the first chapters of the Chikitsa Sthana. Bhishagratna: it should be treated as a swelling in its unsuppurated stage, and as soon as the process of suppuration would set in, with the measures described in connection with Vranas. Vagbhata's three stages of a swelling, unripe, ripening and ripe, are read on our page on Ashtanga Hridaya Sutrasthana 29. The rest of line 9 is preparations, and it stays in the book.

Dhanvantaram: The Verse Dallana Thought Was Added

Line 5 is a ghee preparation, and the line ends by naming it:

Chikitsa Sthana 12.5, last words
नाम्ना धान्वन्तरम्
namna dhanvantaram "By name, the Dhanvantara."

The name is a small irony. The chapter's frame makes Dhanvantari the speaker (line 2), and a preparation named after him sits in his own chapter. Bhishagratna's editor adds a footnote: According to Dallana, the introduction of this medicated Ghrita into the text is an interpolation. The evidence is a silence: Since Jejjata has not explained it in his commentary, Dallana does not explain it. Jejjata is an older commentator; a verse he passed over looked to Dallana like a later addition. The footnote ends: Chakradatta, however, mentions this Ghrita in his compilation, though with some additions and alterations under the treatment of Prameha.

There is a further witness that the footnote does not mention. Vagbhata's Ashtanga Hridaya closes a ghee recipe in its own prameha chapter (Chikitsa Sthana 12.24) with these words:

Ashtanga Hridaya, Chikitsa Sthana 12.24
धान्वन्तरमिदं घृतम्
dhanvantaram idam ghritam "This is the Dhanvantara ghee."

So a ghee of that name was known to Vagbhata, and his list for it is not the same as Sushruta's. Our reading, flagged: a name can travel between books while its contents change, which is the very thing Dallana's caution guards against; a verse can be old and still not be Sushruta's. A footnote on printed page 383 also records Dallana and Gayadasa disagreeing over one word and one quantity in a later preparation. We give no ingredient, amount, method or use for any of these.

What We Leave in the Book

Prameha is often equated with a modern disease that the schedule of India's Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 names, so a seller's website should not repeat a classical promise about it. Most of chapter 12 is the physician's formulary, and we have left all of that part where it is:

• line 4: the two preparations of the first rung;
• line 5: the ghee named dhanvantaram, its ingredients and the conditions it names;
• line 9, after its first half: the oil for the wound, the decoctions and the powder;
• line 10: a linctus;
• line 11: a second powder and the conditions it names;
• lines 12 to 19: one preparation in verse, how it is made and what it names;
• line 20: the signs by which the physician judged recovery;
• the footnotes' recipes, weights and readings of the preparations.

No quantity, ingredient or method from any of them appears on this page.

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