In this title, the term ama also implies the intermediate stage of ripening. The chapter contains examination and recognition of three conditions: ama, the stage undergoing maturation, and the fully ripe stage.
Key terms
Ama (ama)
The unripe or unresolved stage of a swelling; in the chapter title it also inclusively points to the stage undergoing maturation.
pakva
The ripe or fully suppurated stage examined in this chapter.
Diseases such as granthi, vidradhi and alaji have mostly been described as arising from swelling and can assume many forms. Distinct from those, a dosha aggregation arising in one region of the body, lodged in the skin and flesh, and appearing broad, knotted or elevated, and either regular or irregular in form, is called shopha.
Shophasamutthana may mean that these diseases have swelling as their cause; others explain it as their having the same mode of origin as swelling. The qualification mostly allows that they can sometimes have a different origin. Distinct from them can mean separate from granthi and the other named diseases; others interpret it as being made various in form by those diseases. Prithu means broad. Grathita can mean elevated like a nodule; others take it as having developed many nodules. Sama and vishama indicate regular and irregular configurations, showing that the form of a wound-related swelling is not fixed. Residence in skin and flesh applies mostly, because such swelling can also occur in the other structural constituents of a wound. A dosha aggregation may comprise one, two or several doshas, and sanghata here also conveys elevation. Arising in one body region distinguishes this swelling from a disorder spreading throughout the body.
Key terms
shopha
A localized swelling formed by an aggregation of one or more doshas, described here chiefly in skin and flesh.
doShasa~gghAta (doshasanghata)
An aggregation of one, two or several doshas; the commentary also relates the term to elevation.
This wound swelling is of six kinds, caused by vata, pitta, kapha, blood, combined doshas, or an external factor. Their signs are explained through the characteristic appearances and manifestations of the doshas. Vata swelling is black or reddish, rough, soft and unstable or mobile, with distinctive pains such as pricking. Pitta swelling is yellow, soft, or reddish, spreads quickly, and has sensations such as localized burning. Kapha swelling is pale, hard, unctuous, cold, slowly spreading, and has sensations such as itching. A swelling caused by all doshas displays all colours and pains. A blood-caused swelling resembles the pitta type but is very dark. An externally caused swelling has features of pitta and blood and a reddish appearance.
The sixfold subject is wound swelling. The dosha indicators are the forms and characteristic signs of vata and the others; an alternative explanation takes vyangjana as the signs through which the forms of the doshas become manifest. Anavasthita means mobile. The inclusive term after pricking pain also covers splitting, cutting and similar pains. The inclusive term after osha in pitta swelling covers sucking or drawing pain, widespread burning and a smoky sensation. The inclusive term after itching in kapha swelling covers heaviness, numbness and similar features. An externally caused swelling is one produced by falling, compression or comparable trauma.
Key terms
sannipAtashvayathu (sannipatashvayathu)
A swelling produced by the combined doshas and therefore displaying the range of colours and pains.
Agantu (agantu)
Arising from an external cause such as a fall, compression or similar trauma.
When swelling cannot be pacified by specific external and internal measures, because treatment has been applied in the contrary way or because the doshas are abundant, it turns toward suppuration. The signs of its unripe, ripening and ripe stages should then be observed. The unripe stage is marked by mild warmth, skin-coloured appearance, cold swelling, firmness, mild pain and slight swelling. During ripening, the person feels as if pierced by needles, bitten or crawled upon by ants, cut by a blade, split by spears, struck by a staff, pressed by a hand, moved by a finger, burned by fire or heated by alkali. There are localized burning, sucking pain and burning all around. Like one stung by a scorpion, the person finds no relief while standing, sitting or lying down. The swelling is stretched like an inflated bladder. Discolouration of skin, increasing swelling, fever, burning, thirst and loss of desire for food are further signs of ripening. The ripe stage is marked by subsiding pain, pallor, reduced swelling, appearance of wrinkles, lifting or separation of the skin, a depressed appearance, and rising back after finger pressure. When one edge is pressed, pus moves through the swelling like water in a bladder and reaches the opposite edge; when that opposite edge is pressed, it moves back. Repeated pricking, itching, elevation of the swelling, subsiding complications and renewed desire for food are also signs of ripeness. In kapha swellings, because the process is deep, and in some traumatic swellings, the signs of ripeness may not all appear. A physician may then mistakenly regard a ripe swelling as unripe. In such cases the surface can remain skin-coloured, cold, firm, only slightly painful and dense like stone; the physician should not be confused by these signs.
External measures include applications, while internal measures include drinking decoctions, emesis and purgation. One explanation takes failure to pacify as inability to achieve relief; another reads it as failure to reach the condition. Contrary treatment means deviation from measures such as depletion. A disorder with abundant doshas does not subside through bloodletting and related measures alone, as another cited line also states regarding properly used applications, drainage and cleansing. Firmness in the unripe stage means hardness. The particle in nistudyate intensifies the sense, indicating severe piercing pain. The comparisons describe sensations of being divided, torn, struck, compressed or shifted. Shakti is a particular weapon and danda a club. Burning by fire and cooking by alkali are paired respectively: fire seems to reduce the part to ash, while alkali seems to heat it like embers. Osha is burning confined to one area, chosha is a distinctive sucking sensation, and paridaha is burning on all sides. Atata means stretched without contraction of the skin. In the ripe stage, tvakpariputana is lifting or peeling of the skin, and pratyunnamana is upward return toward the examiner after pressure. The bladder comparison refers to movement of pus through the swelling when one side is pressed. Repeated pricking is associated with vata, itching with kapha, and pitta signs disappear after the burning process subsides. The complications that settle include localized and widespread burning. In a kapha swelling the suppuration may lie deep, leaving normal skin colour and external coldness while heat is present within. Slight pain and stone-like density are attributed to kapha and to the lack of superficial suppuration. In some traumatic swellings the cause may be a foreign body that has penetrated deeply. These apparently unripe external signs should not obscure recognition of actual ripeness. Another reading adds that elders call this raktapaka.
Key terms
pacyamAna (pacyamana)
The intermediate stage in which a swelling is undergoing maturation or suppuration.
tvakparipuTana (tvakpariputana)
Lifting, loosening or peeling of the skin over a ripe swelling.
pUyasa~jcaraNa (puyasancarana)
Movement of pus through a swelling when pressure is applied, compared with water moving in a bladder.
The verse states both the merit of knowing the signs of ama and the later stages and the fault of failing to know them. Those lacking this knowledge are compared to thieves because they take away life and wealth.
Key terms
taskaravRuttayaH (taskaravrittayah)
Behaving like thieves, explained as taking away patients' life and wealth through lack of diagnostic knowledge.
There is no pain without vata, no suppurative ripening without pitta, and no pus without kapha. Therefore, at the time a swelling ripens, all three doshas together bring about its suppuration. According to a second view held by other learned authorities, pitta rises after the preceding stages, forcibly brings vata and kapha under its control, and then cooks the blood; this cooking of the blood itself is regarded as suppuration.
The first verse explains that even a swelling initially produced by a single dosha becomes associated with all three doshas when it suppurates. The word meaning 'without' is to be understood with kapha as well as with vata and pitta. The second verse presents another doctrine, based on the teaching that the body is sustained by the three doshas together with blood as a fourth factor. 'After an interval' marks the limit represented by the stages of aggravation, spread and localization. Pitta then rises fully again and subdues the weakened vata and kapha by force; some explain this as enveloping or incorporating them. The resulting suppuration is accepted, in this view, as the cooking of blood itself.
Key terms
paripAkakAle (paripakakale)
At the stage when a swelling reaches suppurative ripening.
shoNitameva pAkaH (shonitameva pakah)
The alternative doctrine that suppuration is specifically the cooking or transformation of blood.
If an unripe swelling is incised, the flesh, vessels, ligaments, joints and bones may be injured; excessive bleeding, pain, tearing, many complications or a traumatic abscess may arise. Conversely, if a physician, through fear or confusion, mistakes even a ripe swelling for an unripe one and neglects the disease for a long time, the pus travels deeply. Unable to find an outlet, it tears its own site, creates a large cavity or pocket, forms a sinus tract, and the condition becomes difficult to cure or incurable.
The passage establishes that an unripe swelling should not be incised and a ripe one should not be neglected. Here the term for unripe also includes a swelling that is still ripening, since the same harms can occur in it. Injury means destruction, and avadarana means tearing. Kshatavidradhi is the traumatic abscess described in the chapter on the diagnosis of abscess. Moha means lack of understanding, a long time means an extended period, and deeply traveled means that the pus has penetrated far within. Utsanga is explained as a depressed internal pocket resembling a lap, produced when pus remains for a long time and tears into another internal region of the wound-bed. Others derive utsanga from pus becoming lodged upward. Avakasha means an intervening cavity or space.
Key terms
Amacchede (amacchede)
Incision of an unripe or still-ripening swelling.
utsa~ggam (utsangam)
An internal pocket or cavity formed by retained pus; an alternative explanation takes it as upward lodging of pus.
nADIm (nadim)
A sinus tract formed after pus penetrates and creates an internal cavity.
The person who ignorantly incises an unripe swelling and the person who neglects a ripe one should both be regarded like shvapacas, for they act without proper determination.
This verse censures the two errors just described. A ripe swelling is one suitable for an operative procedure. Shvapaca is glossed as chandala. The two practitioners are called indecisive or undiscriminating because one incises the unripe swelling and the other neglects the ripe swelling. Another explanation says that they are comparable to shvapacas because they harm the patient; they cause this harm because, as physicians acting without examination, they undertake procedures without first assessing the case.
Key terms
anishcitakAriNau (anishcitakarinau)
Two practitioners who act without proper determination or examination.
shvapacAviva (shvapacaviva)
A strongly condemnatory comparison, glossed by the commentator as 'like chandalas.'
Before an operative procedure, the physician should feed the patient suitable food. A person accustomed to alcohol who cannot tolerate pain should be given strong alcohol. Because food has been taken, the patient does not faint; when intoxicated, the patient does not perceive the instrument. Therefore, when an operation is required in the stated diseases, food must be taken. The internal prana of human beings, endowed with the qualities of external prana, sustains the body composed of the five elements without opposition.
This is the preliminary measure for a ripe swelling suitable for operation. Ishta primarily means wholesome or beneficial food; others interpret it as whatever the patient desires, even if normally unsuitable, to provide strength. Strong alcohol is limited to a patient accustomed to drinking who cannot bear pain. Not perceiving the instrument means not feeling the pain caused by it. The requirement to eat applies when surgery is indicated in the stated diseases, excluding conditions such as obstructed fetus, abdominal enlargement, piles and urinary calculus. The main explanation takes internal prana as strength arising from ojas and expressed as powers such as carrying a load. External prana is bodily nourishment or growth produced from five-element food; its qualities include bodily firmness. Internal strength, joined with those qualities, sustains the body. Another explanation treats the singular 'prana' as expressing a class: internal pranas comprise agni, soma, vayu, sattva, rajas, tamas, the five senses and bhutatman, while external pranas comprise fiery, cooling and airy substances, day, wind, night, and sound, touch, form, taste and smell. On that view, internal prana sustains the body by following the qualities of corresponding external pranas; the commentary gives internal agni supported by external agni's pungent, sour and salty qualities as an example but omits the full account. The Lakshmana note offers a further explanation: internal prana is the agni-soma complex and related factors by which a living being lives; external prana is food, whose nourishing and other qualities enable internal prana to sustain the body.
Key terms
iShTam (ishtam)
Primarily wholesome, beneficial food; alternatively, whatever food the patient desires, given for strength.
AbhyantaraH prANaH (abhyantarah pranah)
Internal sustaining power, interpreted variously as ojas-derived strength or as a class of internal life-supporting factors.
bAhyaprANaH (bahyapranah)
External nourishment or sustaining factors, interpreted chiefly as food-derived bodily development.
अल्पो महान् वा क्रियया विना यः समुच्छ्रितः पाकमुपैति शोफः |
विशालमूलो विषमं विदग्धः स कृच्छ्रतां यात्यवगाढदोषः ||१४||
Meaning of the śloka
A swelling, whether small or large, that has become raised and is allowed to ripen without treatment undergoes irregular suppuration, develops a broad base, and becomes difficult to treat because the dosha has penetrated deeply.
The verse describes the many harms that arise when either a large or a small swelling is left untreated. Vishamam vidagdha means irregular burning or, in this context, irregular suppuration. Avagadhadosha means that pus lies internally or deeply. Some read the opening as: 'A swelling that has arisen, whether small or large, and reaches suppuration without treatment.'
Key terms
viShamaM vidagdhaH (vishamam vidagdhah)
Irregularly affected by heat, explained in context as uneven or irregular suppuration.
avagADhadoShaH (avagadhadoshah)
Having the pathological process deeply situated, glossed as internal pus.
If a swelling does not subside even after the proper use of pastes, drainage and cleansing measures, it will mature quickly and uniformly. It will have a small base, become rounded and rise above the surrounding surface.
The commentary explains that this verse shows the effectiveness of the previously stated measures even when a swelling has proceeded to suppuration. 'It matures quickly and uniformly' indicates that suppuration occurs evenly. The swelling becomes pindita, meaning rounded.
Key terms
samapAkatvam (samapakatvam)
Uniform maturation or suppuration throughout the swelling.
कक्षं समासाद्य यथैव वह्निर्वाय्वीरितः सन्दहति प्रसह्य |
तथैव पूयोऽप्यविनिःसृतो हि मांसं सिराः स्नायु च खादतीह ||१६||
Meaning of the śloka
Just as fire, driven by wind after reaching a place thick with grass, forcibly burns through it, pus that is not released consumes the flesh, blood vessels and ligaments in the same way.
Using a comparison, the commentary reiterates the previously described harm of neglecting a swelling even after it has matured. Kaksha means an area abundant in grass and similar growth. Here refers to the mature swelling.
Key terms
aviniHsRutaH pUyaH (avinihsrutah puyah)
Pus that has not been released or drained from a mature swelling.
The first measure is vimlapana, the second avasecana, the third upanaha and the fourth incision. The fifth is cleansing, the sixth is healing, and the seventh removes deformity. These are the stated successive classes of treatment for a wound.
The verses introduce, in condensed form in the Sutrasthana, the sixty measures for wounds by naming seven principal stages. In the first explanation, vimlapana is dispersing a swelling by massage with the fingers or similar means; avasecana is bloodletting with leeches and related methods; upanaha is bandaging or applying a poultice to promote maturation; and removal of deformity includes restoring normal colour and promoting hair growth. The commentary also preserves another interpretation. According to it, the sixty measures are grouped under seven headings by another distinguishing scheme for easier understanding. Vimlapana then broadly denotes external measures that disperse swelling, including paste, irrigation, massage and fomentation, rather than only the massage with bamboo, reed, thumb or similar instruments prescribed elsewhere for a mildly painful, oleated and fomented swelling. Avasecana then means drainage or evacuation broadly, including emesis, purgation, bloodletting and other internal or external cleansing, rather than bloodletting alone. The remaining headings similarly include other measures that share the same function.
Key terms
vimlApanam (vimlapanam)
Dispersal of swelling; interpreted narrowly as massage or broadly as external dispersing measures such as pastes, irrigation, massage and fomentation.
avasecanam
Drainage or evacuation; interpreted as bloodletting in one explanation and as a broader class including emesis, purgation and bloodletting in another.
vaikRutApaham (vaikritapaham)
Measures that remove residual deformity, including restoration of normal colour and promotion of hair growth.