तृतीयोऽध्यायः । अथातोऽश्मरीणां निदानं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः ः।।१।।
Now we shall discourse on the Nidana of Ashmari (urinary calculi). 1
चतस्त्रोऽश्मर्यो भवन्ति, श्लेष्माधिष्ठानाः । तद्यथा – श्लेष्मणा, वातेन, पित्तेन, शुक्रेण चेति || २ ||
The disease admits of being divided into four several types, such as the Vataja, the Pittaja, the Kaphaja and the Sukraja (Seminal) concretions. An exuberance or preponderance of the deranged Kapha should be understood as the underlying cause of all invasions of this disease. 2
तत्रासंशोधनशीलस्यापथ्यकारिणः प्रकुपितः श्लेष्मा मूत्रसंपृक्तोऽनुप्रविश्य बस्तिमश्मरीं जनयति ।। ३ ।।
General aetiology: The Kapha of a man, who neglects to cleanse (Samsodhana) the internal channels of his organism, or is in the habit of taking unwholesome food, enraged and aggravated by its own exciting causes, is carried into the urinary bladder. Here it becomes saturated with the urine, and gives rise to the formation of concretions or gravels in its cavity. 3
Premonitory Symptoms of Renal Calculi
तासां पूर्वरूपाणि – बस्तिपीडारोचकौ मूत्रकृच्छ्रं बस्तिशिरोमुष्कशेफसां वेदना कृच्छ्राज्वरावसादौ बस्तगन्धित्वं मूत्रस्येति ।। ४ ।।
Premonitory Symptoms : An aching pain in the bladder, with a non-relish for food, difficulty in urination, an excruciating pain in the scrotum, penis, and the neck of the bladder, febrile symptoms, physical lassitude, and a goat-like smell in the urine are the symptoms, which indicate the formation of gravel in the bladder. 4
यथास्वं वेदनावर्णं दुष्टं सान्द्रमथाविलम् । पूर्वरूपेऽश्मनः कृच्छ्रान्मूत्रं सृजति मानवः ॥ ५॥
Metrical Text: The deranged Dosas involved in a particular case respectively impart their specific colour to the urine, and determine the character of the accompanying pain. The urine becomes thick, turbid, and vitiated with the action of the aggravated Dosas, and micturition becomes extremely painful. 5
Symptoms of Urinary Calculi
अथ जातासु नाभिबस्तिसेवनीमेहनेष्वन्यतमस्मिन् मेहतो वेदना मूत्रधारासङ्गः सरुधिरमूत्रता मूत्रविकिरणञ्च गोमेदकप्रकाशमत्याविलं ससिकतं विसृजति, धावनङ्घनप्लवनपृष्ठयानोष्णाध्वगमनैश्चास्य वेदना भवति ॥ ६ ॥
Leading Indications: A sort of excruciating pain is experienced either about the umbilicus, or in the bladder, or at the median rape of the perineum. or about the penis, during micturition when gravel is forming in the bladder. The urine is stopped at intervals in its out-flow, or becomes charged with blood, or flows out twisted and scattered like spray, leaving a sediment of clear, sandy, red or yellow particles of stone, which resembles a Gomeda gem in colour. Moreover 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. 6
Slesmashmari
तत्र श्लेष्माश्मरी श्लेष्मलमन्नमभ्यवहरतोऽत्यर्थमुपलिप्याधः परिवृद्धिं प्राप्य बस्तिमुखमधिष्ठाय स्रोतो निरुणद्धि, तस्य मूत्रप्रतिघाताद् दाल्यते भिद्यते निस्तुद्यत इव च बस्तिर्गुरुः शीतश्च भवति, अश्मरी चात्र श्वेता स्निग्धा महती कुक्कुटाण्डप्रतीकाशा मधूकपुष्पवर्णा वा भवति, तां श्लैष्मिकीमिति विद्यात् ।। ७ ।।
The Slesmashmari : Stone or gravel, originated through the action of the deranged Kapha, saturated with an excessive quantity of that Dosa by the constant ingestion of phlegm-generating (Slesmala) substances, increases in size at the lower orifice of the bladder and
ultimately obstructs the passage of the urine. The pressure and recoil of that incarcerated fluid on the walls of the urinary bladder gives rise to a kind of crushing, bursting, pricking pain in that organ, which becomes cold and heavy. A Kapha-origined stone or gravel is white and glossy, attains to a large size, to that of a hen’s egg, and has the colour of the madhuka flower. This type is called Slesmashmari. 7
Pittaja Ashmari
पित्तयुतस्तु श्लेष्मा संघातमुपगम्य यथोक्तां परिवृद्धि प्राप्य बस्तिमुखमधिष्ठाय स्रोतो निरुणद्धि, तस्य मूत्रप्रतीघातादूष्यते चूष्यते दह्यते पच्यत इव बस्तिरुष्णवातश्च भवति, अश्मरी चात्र सरक्ता पीतावभासा कृष्णा भल्लातकास्थिप्रतिमा मधुवर्णा वा भवति, तां पैत्तिकीमिति विद्यात् ।। ८ ।।
The Pittaja Ashmari: The Kapha charged (dried) with the deranged Pitta becomes hard (condensed) and large in the aforesaid ways, and lying at the mouth of the bladder obstructs the passage of the urine. The bladder, on account of the flowing back of the obstructed urine into its cavity, seems as if it has been exposed to the heat of an adjacent fire, boiling with the energy of an alkaline solution. A kind of sucking, drawing and burning pain is experienced in the organ. This type of Ashmari is further marked by symptoms which characterise Usna-vata (stricture ). The concretion is found to be of a reddish, yellowish black colour like the stone of the Bhallataka fruit, or it is coloured like honey. This type is called Pittaja Ashmari. 8
Vatashmari
वातयुतस्तु श्लेष्मा संघातमुपगम्य यथोक्तां परिवृद्धिं प्राप्य बस्तिमुखमधिष्ठाय स्रोतो निरुणद्धि । तस्य मूत्रप्रतीघातात् तीव्रा वेदना भवति, तदाऽत्यर्थं पीडयमानो दन्तान् खादति, नभि पीडयति, मेढूं प्रमृनाति, पांयु स्पृशति, विशर्धते, विदहति, वातमूत्रपुरीषाणि कृच्छ्रेण चास्य मेहतो निःसरन्ति; अश्मरी चात्र श्यावा पुरुषा विषमा खरा कदम्बपुष्पवत् कण्टकाचिता भवति, तां वातिकीमिति विद्यात् ।। ९ ।।
The Vatashmari: The deranged Kapha (mucus) inordinately saturated with the bodily Vayu, acquires hardness and gains in dimensions, and these lying at the mouth of the bladder obstructs the passage of the urine. The incarcerated fluid causes extreme pain in the organ. The patient constantly under severe pain gnashes his teeth or presses his umbilical region, or rubs his penis, or touches his anus (Payu) and loudly screams. A burning sensation is experienced in the penis, and urination, belching and defecation become difficult and painful. The concretions in this type of Ashmari are found to be of a dusky colour, rough, uneven in shape, hard, facetted and nodular like a Kadamba flower. This type is called Vatashmari.9
प्रायेणैतास्तिस्रोऽश्मर्यो दिवास्वप्नसमशनाध्यशनशीतस्निग्धगुरुमधुरा हारप्रियत्वाद् विशेषेण बालानां भवन्ति; तेषामेवाल्पबस्तिकायत्वादनुपचितमांसत्वाच्च बस्तेः सुखग्रहणाहरणा भवन्ति ।। १० । ।
Infants are more susceptible to an attack of any of the three preceding types of Ashmari, inasmuch as they are fond of day sleep or of food composed of both wholesome and unwholesome ingredients, and are in the habit of eating before the digestion of a previous meal, or of taking heavy, sweet, emollient and demulcent food. In children the bladder is of diminished size and poor in muscular structure. These facts contribute to the easy possibility of the organ being grappled (with a surgical instrument) and of the stone being extracted with the greatest ease in cases of infantile Ashmari. 10
Sukrashmari
महतान्तु शुक्राश्मरी शुक्रनिमित्ता भवति ।। ११ ।।
मैथुन (अभि) विघातादतिमैथुनाद् वा शुक्रं चलितमनिर्गच्छद् विमार्गगमनादनिलोऽभितः संगृह्य मेदूवृषणयोरन्तरे संहरति, संहृत्य चोपशोषयति; सा मूत्रमार्गमावृणोति, मूत्रकृच्छ्रं बस्तिवेदनां वृषणयोश्च श्वयथुमापादयति, पीडितमात्रे च तस्मिन्नेव प्रदेशे प्रविलयमापद्यते; तां शुक्राश्मरीमिति विद्यात् ।। १२ ।।
The Sukrashmari: Sukrashmaris or seminal concretions are usually formed in adults owing to the germination of semen in their organisms. A sudden or abrupt stoppage of a sexual act, or excessive coition tends to dislodge the semen from its natural receptacle in the body. The fluid thus disloged, but not emitted, finds a wrong passage. The Vayu gathers up the fluid (semen); thus led astray and deposits it (in a round or oval shape) at a place lying about the junction of the penis and the scrotum and dries up the humidity with which it is charged. The matter, thus formed, condensed, and hardened, is called the seminal stone (Sukrashmari), which then obstructs the passage of the urine, giving rise to pain in the bladder, painful micturition, and swelling of
1. Stool and urine can be voided only with the greatest straining.
the scrotum. The stone vanishes under pressure in its seat. 11-12 भवन्ति चात्र ।
शर्करा सिकता मेहो भस्माख्योऽश्मरिवैकृतम् । अश्मर्या शर्करा ज्ञेया तुल्यव्यञ्जनवेदना ।। १३ ।।
पवनेऽनुगुणे सा तु निरेत्यल्पा विशेषतः । सा भिन्नमूर्त्तिर्वातेन शकरेत्यभिधीयते ।। १४ ।।
हृत्पीडा सक्थिसदनं कुक्षिशूलं च वेपथुः । तृष्णोर्ध्वगोऽनिलः काष्र्ण्य दौर्बल्यं पाण्डुगात्रता ।। १५ ।।
अरोचकाविपाकौ तु शर्कर्ते भवन्ति च । कुर्यादुपद्रवान् ॥ १६ ॥
मूत्रमार्गप्रवृत्ता सा सक्ता दौर्बल्यं सदनं कार्यं कुक्षिशूलमरोचकम् । पाण्डुत्वमुष्णवातञ्च तृष्णां हृत्पीडनं वमिम् ।। १७ ।।
Authoritative verses on the subject : Concretions. sands and sediments found to be deposited in the urine in a case of Bhasma-meha are but the modifications, or attended with symptoms of a case of stone in the bladder (Ashmari). The same group of symptoms and the same kind of pain are exhibited and experienced in a case of gravel (Sarkara) as in a case of stone (Ashmari) in the bladder. The local Vayu coursing in its natural direction helps the discharge of calculi (Ashmari) with the urine in the event of they being extremely attenuated in structure. Particles of a stone broken by the Vayu are called urinary calculi (Sarkara). A pain about the cardiac region, a sense of weakness and lassitude in the thighs, a griping pain in the regions of the spleen and liver (Kuksi-sula), a shivering sensation, thirst hiccough or eructations, darkness or sallowness of complexion, weakness, emaciation with a non-relish for food and impaired digestion are the symptoms which are manifested in a gravel-patient. A gravel (Sarkara) obstructed at the mouth of the urinary channel is detected by the following indications : viz., weakness, lassitude, emaciation, cachectic condition of the body, pain over the hepatic region (Kuksi-sula), a non-relish for food,
1. We can not but contemplate with admiration the fact that Susruta was aware of the formation of seminal or spermatic concretions in the seminal vesicles through degenerative changes of spermatozoa and other secretions and their subsequent calcification as lately discovered by the savants of the West. sallowness of complexion, hot and high coloured urine, thirst, pressing pain at the cardiac region and vomiting. 13-17
( नाभिपृष्ठकुटीमुष्क – गुदवङ्क्षणशेफसाम् मध्ये बस्तिरधोमुखः ।। १८ ।। एकद्वारस्तनुत्वक्को
अलाब्वा इव रूपेण सिरास्नायुपरिग्रहः । बस्तिर्बस्तिशिरश्चैव पौरुषं वृषणौ गुदम् ।। १९ ।।
एकसम्बन्धिनो ह्येते गुदास्थिविवरस्थिताः । मूत्राशयो मलाधारः प्राणायतनमुत्तमम् ।। २० ।।
पक्वाशयगतास्तत्र नाडयो मूत्रवहास्तु याः । तर्पयन्ति सदा मूत्रं सरितः सागरं यथा ।। २१ । ।
सूक्ष्मत्वान्नोपलभ्यन्ते मुखान्यासां सहस्रशः । नाडीभिरुपनीतस्य मूत्रास्यामाशयान्तरात् ।
जाग्रतः स्वपतश्चैव स निःस्यन्देन पूर्यते ।। २२ ।।
आमुखात् सलिले न्यस्तः पाश्र्वेभ्यः पूर्यते नवः । घटो यथा तथा विद्धि बस्तिर्मूत्रेण पूर्यते ।। २३ ।।
The bladder is situated in the pelvic cavity, surrounded on its different sides by the back, loin ( Kati ), umbilicus, scrotum, rectum (Guda), groins and penis. This organ is provided with a single aperture or openingad lies with its mouth downward, Covered with nets of nerves (Sira) and ligaments (Snayu), in the shape of a gourd The organ is extremely thin in structure; and thus situated within the pelvic cavity, it is connected, through its mouth or external orifice with the rectum, the penis, and the testes. ft is also known by the name of Maladhara (the receptacle of impure matter) and forms (one of) the primary seats of vital energy (Prana) The urinary ducts (ureters) pass close by the large intestines (Pakvasaya) and constantly replenish the bladder and keep it moist with that waste product of the system in the same manner as rivers carry their contributions of water into the ocean! These passages or ducts (which are two) are found to take their origin from thousands of branches (or mouths tubuli uriniferi), which are not visible to the naked eyes, on account of their extremely_minute ajst structures and carry, whether in a state of sleep or wakening, the urine
1. The text has Pranayatana, which means that an injury to the urinary bladder may be attended with fatal result from below the region of the stomach¹ (Amasaya) into the bladder keeping it filled with this important fluid of the body, just as a new pitcher, immersed upto its neck in a vessel full of water, is filled by transudation through its lateral pores. 18-23
एवमेव प्रवेशेन वातः पित्तं कफोऽपि वा। मूत्रयुक्त उपस्नेहात् प्रविश्य कुरुतेऽश्मरीम् ॥ २४ ॥
अप्सु स्वच्छास्वपि यथा निषिक्तासु नवे घटे । कालान्तरेण पङ्कः स्यादश्मरीसम्भवस्तथा ॥ २५ ॥
संहन्त्यापो यथा दिव्या मारुतोऽग्निश्च वैद्युतः । तद्वद् बलासं बस्तिस्थमूष्मा संहन्ति सानिलः ॥ २६ ॥
In the same way the Vayu, Kapha and Pitta are carried into the bladder (through their respective ducts or channels), and in unison with the retained urine, give rise to the formation of stone, on account of the slimy character of the deposit produced. Stone is formed in the same way in the bladder as sediments are ultimately deposited from clear and transparent water at the bottom of a new pitcher which contains it. As the wind and lightning jointly condense the rainwater into hailstones, so the bodily Vayu and Pitta (heat) jointly contribute to the condensation of the Kapha in the bladder and transform it into stone. 24-26
मारुते प्रगुणे बस्तौ मूत्रं सम्यक् प्रवर्त्तते विकारा विविधाश्चापि प्रतिलोमे भवन्ति हि ॥ २७ ॥ मूत्राघाताः प्रमेहाश्च शुक्रदोषास्तथैव च। मूत्रदोषाश्च ये केचिद् बस्तावेव भवन्ति हि ॥ २८ ॥
The Vayu in the bladder, coursing in its natural downward direction, helps the full and complete emission of urine; while coursing in a contrary direction, it gives rise to various forms of maladies such as, Prameha, strangury, as well as seminal disorders; in short, it produces any urinary trouble to which the bladder may be subjected. 27-28
इति सुश्रुतसंहितायां निदानस्थानेश्मरीनिदानं नाम तृतीयोऽध्यायः || ३ ||
Thus ends the third Chapter of the Nidana Sthana in the Susruta Samhita which treats of the Nidana of urinary calculi..
