Sushruta Samhita Sutrasthana Chapter 17: Amapakvaishaniya Adhyaya (Knowledge of Unripe and Ripe Swelling)

The 17th chapter of Sutrasthana of Sushruta Samhita is named as Amapakvaishaniya Adhyaya. This chapter deals with the Knowledge of Unripe and Ripe Swelling.

अथात आमपक्वैषणीयमध्यायं व्याख्यास्यामः ।१॥
यथोवाच भगवान धन्वन्तरिः ॥२॥

 We will now expound the chapter by name Amapakvaisaniya- Knowledge of unripe and ripe(swellings) as revealed by the venerable Dhanvantari.

Shopha nirukti: Definition of Shopha

शोफसमुत्थाना ग्रन्धिविद्रध्यलजीप्रभृतयः प्रायोणव्याधयोऽभिहिता अनेकाकृतयः, तैर्विलक्षणः पृथुर्ग्रथितःसमो विषमो वा त्वङ्मांसस्थायीदोशसंघातः शरीरैकदेशोत्थित ः शोफ इत्युच्यते ॥३॥

Diseases of the likes of Granthi (cyst / tumor), Vidradhi (abscess), Alaji (a kind of skin disease) etc and many of similar kinds which manifest with different shapes and sizes usually arise with Shopha . Shopha means swelling or edema. This means to tell that these diseases are associated with swelling (the main presentation of these diseases is swelling).

Apart from these swellings, there is another kind of swelling which has spread out (isolated), knotted (cystic), even or uneven, occurring in skin and muscle etc tissues, which occurs in the form of accumulation of doshas in any one place of the body. Such swelling is called Shopha.

Shopha Bheda: Kinds of inflammatory oedema

स षडूविधो वातपित्तकफशोणितसन्निपातागन्तुनिमित्तः । तस्य दोषरुपव्यञ्जनैर्लक्षणानि व्याख्यास्यामः । तत्र, वातशोफः कृष्णोऽरुणो वा परुषो मृदुरनवस्थितास्तोदादयश्चात्र वेदनाविशोषा भवन्ति, पित्तशोफः पीतो मृदुः सरक्तो वा शीघ्रानुसार्योषादयश्चात्र वेदनाविशेषा भवन्ति, श्लेष्मश्वयथुः पाण्डुः कटिनःस्निग्धःशीतोस्निग्धो मन्दानुसारी कण्डूवादयश्चात्रवेदनाविशेषा, भवन्ति, सर्ववर्णवेदनः, सन्निपातश्वयथुः ।

पित्तवच्छोणितजोऽतिकृष्णश्चः पित्तरक्तक्ष्यणाअगन्तुर्लोहितावभासश्च ॥४॥

There are six kinds of Shopha.

Ekadoshaja Shopha – One Shopha is caused by each of the three doshas. That makes it three types. They are –

–        Vataja Shopha,
–        Pittaja Shopha and
–        Kaphaja Shopha 

Raktaja Shopha – One kind of Shopha is caused by vitiated Rakta i.e. blood and is called Raktaja Shopha . This is the fourth kind of Shopha.

Sannipataja Shopha – The fifth kind of Shopha is caused by simultaneous aggravation of all three doshas. It is called Sannipataja Shopha.

Agantu Shopha – The sixth type of Shopha  is caused due to external causes. It is called Agantu Shopha .

We will now describe these six kinds of Shopha , doshic features manifested in them and related symptoms. They are as below explained –

Ama-Pakva Lakshana: Signs of unripe and ripe swelling

स यदा बाद्याभ्यन्तरैः क्रियाविशेषैर्न संभावितः प्रशमयितुं क्रियाविपर्ययाद्वहुत्वाद्वादोषाणां तदा पाकाभिमुखो भवति ।

तस्यामस्य पच्यमानस्य पक्वस्य चा  लक्षनमुच्यमान मुपधारय।तत्र्,  मन्दोष्मता त्वक्सवर्णता सीतशोफता स्थैर्यं मन्दवेदनताऽल्पशोफता चामलक्षणमुद्दिष्टं; सूचीभिरिव निस्तुद्यते, दश्यत,इव पिपीलिकाभिः, ताभिश्च संसर्प्यत इव, चिद्यत इव शस्रेण, भिद्यत इव शक्तिभिः, ताड्चत इव द्ण्देन, पीड्चत इवपाणिना, घटघत इव चाङ्गुल्या, दद्यते पच्यत इव चाग्रिक्षराभ्यम्, ओषचोषपरीदाहाश्च भवन्ति,

वृश्चिकविद्ध इव च स्थानासनशयनेषु न शान्तिमुपैति, आध्मातबस्तिरिवाततश्च शोफो  भवति,  त्वग्वैवर्ण्यं शोफाभिवृद्धिर्ज्वरदाहपिपासा भक्तरूचिश्च पच्यमानलिङ्गं, वेदनोपशान्तिः पाण्डुताऽल्पशोफता वलीप्रादुर्भावस्त्वक्परिपुटनं निम्रदर्शनमङ्गुल्याऽवपीडिते प्रत्युन्नमनं, बस्ताविवोदकसंचरणं  पूयस्य प्रपीडयत्येकमन्तमन्ते चावपीडिते, मुहुर्मुहुस्तोदः कण्डूरून्नतता व्याधेरुपद्रवशान्तिर्भक्राभिकाङ्ग्क्षा च पक्वलिङ्ग्म् । कफजेषु तु रोगेषु गम्भीरगतित्वादभिघातजेषु वाकेषुचिदसमस्तंपक्वलक्षणं दृष्ट्वा पक्वमपक्वमिति मन्यमानो भिषङ् मोहमुपैति; तत्र हि त्वक्सवर्णता शीतशोफता स्थैर्यमल्परुजताऽश्मवच्च घनता, न तत्र मोहमुपेयादिति ॥५॥

Due to opposite or improper treatments being done or due to severe aggravation (and accumulation) of the doshas, if the swelling does not subside either by different kinds of external or internal treatments, then it should be considered that the swelling is going in for paka (ripening / pus) formation.

Now I am going to describe the symptoms of ama – unripe, pacyamana – ripening and pakva – ripened stages of Shopha. Listen to the same.

1. Ama Shopha Symptoms – Below mentioned are the symptoms of unripe swellings –

–        mild increase in temperature
–        color of the swelling will be same as the color of the surrounding skin
–        cold in touch,
–        immovable,
–        associated with mild pain
–        there will be slight swelling

2. Pachyamana Shopha Symptoms – Below mentioned are the symptoms of ripening swellings –

–        ‘needle prick’ pain
–        pain / sense of being bitten by ants
–        feeling of ants crawling in the region of swelling
–        pain as if the region of the swelling is being cut by sharp weapons or punctured by pointed sharp weapons
–        pain as if beaten by baton,
–        pain as if hit by hand,
–        pain as if burnt by agni – fire or ksara – alkali,
–        burning sensation – local or general,
–        discomfort in any position – sitting, lying down or sleeping and feeling as if stung by a poisonous scorpion,
–        swelling – appears like an ‘air distended bag’ on touch
–        change of skin color
–        increase in swelling size
–        association of – fever, burning sensation, thirst, loss of appetite etc

3. Pakva Shopha Symptoms – Below mentioned are the symptoms of ripened swellings –

–        pain gets subsided,
–        color of the body getting pale or white
–        swelling decreases,
–        appearance of wrinkles,
–        cracking of skin,
–        the swelling gets depressed when pressed with finger – pitting on pressure, which quickly elevates once the pressure of the finger is released,
–        the pus moves in the swelling just like the water moves in a bag from place to place (fluctuation) – this fluctuation is experienced at one end of the swelling when the swelling is tapped or pressed with finger of the other hand on the other side of the swelling,
–        pricking pain occurring again and again,
–        itching,
–        subsiding of the elevation of swelling,
–        complications of swelling subside,
–        desire for food

When the physician does not find complete signs of ripening of swelling, in swelling produced by kapha due to its deep rootedness or in swellings produced by injury, they would become confused and would mistake the ripe stage of swelling as unripe stages.

The physician should never get confused by seeing the below mentioned signs of swelling because they are the signs of unripe stage itself –

–        color of the swelling is similar to that of surrounding skin,
–        swelling is cold on touch,
–        swelling is stout (large),
–        presence of mild pain,
–        swelling is hard like a stone

The real physician should know the stages of swelling

भवन्ति चात्र:-
आमं विपच्यमानं एक्वं च यो भिषक् ।
जानीयात् स भवेद्वैद्यः शेषास्तस्करवृत्तय ः ॥६॥

One verse here –

Only that physician or surgeon who clearly recognizes different stages of swelling i.e. unripe, ripening and ripe can be called as real physician. The other physicians who do not have the knowledge of these stages of swelling are crooks. 

Dosha Sambandha

वातादृते नास्ति रूजा न पाकः पित्तदृते नास्ति कफाच्च  पूयः
तस्मात् समस्तान् परिपाककाले पचन्ति शोफांस्त्रय एव दोषाः ॥७॥
कालान्तरेणाभ्युदितं तु पित्तं कृत्वा वशो वातकफौ प्रसह्य ।
 पचत्यतः शोणितमेव पाको मतोऽपरेषां द्वितीयः ॥८॥

Pain can never occur without the involvement of vata.

Suppuration or ripening would never occur without the involvement of pitta.

Pus would never be formed without the involvement of kapha.

Therefore, all the doshas are involved in ripening the swelling (edema) during the stage of ripening of oedema.

Some expert scholars give a different opinion about the ripening of swellings. According to them ‘in due course of time, pitta which would become immensely aggravated would suppress vata and kapha forcibly and cause ripening of blood only’.

Chedana Kala: Proper time for incising

 तत्र, आमच्छेदे मांससिरास्नायुसन्ध्यस्थिव्यापादनमतिमात्रं शोणितातिप्रवृत्तिर्वेदना-प्रादुर्भावोऽवदरणमनेकोपद्रवदर्शनं  क्षरविद्रधिर्वा भवति। स यदा भयमोहाभ्यां पक्वमप्यपक्वमिति मन्यमानश्चिरमुपेक्षते व्याधिं वैद्यस्तदा गम्भीरानुगतोद्वारमलभमानः पूय स्वमश्रयमवदार्योत्सङ्गं महान्तमवकाशं कृत्वा नाडीं जनयित्वा कृच्छ्रसाध्यो भवत्यसाध्यो वेति॥९॥

When the swelling is cut open in the unripe stage it would cause –

–        great destruction of muscles, veins, ligaments, joints and bone,
–        too much of bleeding,
–        development of pain,
–        tearing, and
–        appearance of many complications (secondary diseases) or
–        development of a traumatic abscess

Sometimes, in spite of the swelling being ripe, the physician considers and diagnoses the swelling as unripe due to fear or ignorance. As a result, he ignores the swelling for a long time without treating it. In such cases, the pus remaining deep inside will not get an exit opening to come out. This pus causes a great tear above in its own place. This leads to formation of big and deep sinuses. This condition either becomes curable with difficulty or even incurable.

भवति चात्र:-
यश्छिनत्त्याममज्ञानाद्यश्च पक्वमुफेक्षते ॥
श्र्वपचाविव मन्तव्यौ तावनिश्चितकारिणौ ॥१०॥

One verse here –

The below mentioned (both) types of physicians are considered equivalent to outcasts who follow and perform uncertain actions

1.            physicians / surgeons who would cut the unripe swellings with ignorance, when it shouldn’t be
2.            physicians / surgeons would ignore the ripe swelling without cutting it, when it has to be

Purvopachara: Preoperative regimen

प्राक् शस्त्रकर्मणश्चेष्टं भोजयेदातुरं भिषक ।
मद्यपं पाययेन्मद्यं तीक्ष्णं यो वेदनाऽसहः ॥११॥
न मूर्च्छत्यन्नसंयोहान्मत्तःशस्त्रं न बुध्यते ।
तस्मादवश्यं भोक्तव्यं रोगेषूक्तेषु कर्मणि ॥१२॥
प्राणो ह्याभ्यन्तरो नृणां बाह्यप्राणगुणान्वितः ।
धारयत्यविरोधेन शरीरं पाञ्चभौतिकम्॥१३॥

Before undertaking the surgery, the physician should make the patient consume good food i.e. the food which the patient desires and is also compatible with him or her. The physician should make the patient drink strong wine to a patient who is unable to tolerate the pain of the surgical process and is habituated to drinking wine.

The patient will not faint in the presence of food i.e. when he consumes food. Similarly, he would not experience the pain of surgery when he gets intoxicated by consumption of strong wines. Therefore, before conducting surgical procedures in those diseases wherein giving food to the patient has been mentioned, the food should necessarily be given.

Food is considered as external prana i.e. life supplied from outside. This prana supports the prana i.e. life inside the body. When the internal prana is supported by the external prana i.e. food, they maintain the body which is composed of pancha bhutas i.e. five primary elements, without opposition.

Suppuration of swelling and prognosis

अल्पो महान् वा क्रियाया विना यः समुच्छ्रितः पाकमुपैति शोफः ।
विशालमूलो विषमं विदग्धः स कृच्छ्रतां यात्यवगाढदोषः ॥१४॥

The swelling which is either small or big if left untreated will grow up and undergo ripening. Such a swelling gets deep rooted, spreads irregularly and widely and improperly cooked (immature). The doshas in such swelling would get deep (gets seated in deeper tissues) and become difficult to cure.

What type of swelling would ripen quickly?

आलोपविस्त्रावणशोधनैस्तु सम्यक् प्रयुक्तैर्यदि नोपशाम्येत्।
पच्येतशीघ्रं सममल्पमूलः स पिण्डितश्र्चोरि चोन्नतःस्यात्॥१५॥

The swelling would ripen quickly if –

–        it does not subside even after alepa – application of medicinal pastes, visravana – draining and shodhana – cleansing – all properly done,
–        it is still found to be even,
–        it is not deep rooted
–        it bulges up like a round mass

कक्षं समासाद्य यथैव वह्रिर्वाय्वीरितःसंदहति प्रसह्य ।
तथैव पूयोऽप्यविनिःसृतो हि मांसं सिराः स्नायुच खादतीह॥१६॥

A spark of fire inside the hay would get increased being stimulated by the wind and would eventually burn up the entire heap of grass and everything else around it in quick time.

Similarly, the pus which has not been drained out of the swelling and remains therein would eventually destroy all the muscles, veins and ligaments present around it.

Shopha  Upakrama: Treatment of swelling

आदौ विम्लापनं कुर्याद्धितीयमवसेचनम् ।
तृतीयमुपनाहं  तु चतुर्थी पाटनक्रियाम् ॥१७॥
पञ्चमं शोधनं कुर्यात् षष्ठं रोपणमिष्यते ।
 एते क्रमा व्रणस्योक्ताः सप्तमं वैकृतापहम् ॥१८॥

Firstly Vimlapanaa i.e. softening of swelling by kneading with fingers should be done.

The second treatment is Avasecana – bloodletting.

The third one is Upanaha – warm poultices.

The fourth one is Patana – cutting / incising.

The fifth treatment is Sodhana – cleaning.

The sixth one is Ropana – healing and

The seventh one is Vaikrtapaha – removing, warding off the abnormalities.

These are the seven successive treatments for VranaShopha i.e., ulcer associated with swelling.

इति श्रीसुश्रृतसंहिरायां सूत्रस्थाए आमपक्वैषणीयो नाम सप्तदशोऽध्यायः ॥१७॥

Thus ends the Seventeenth chapter named Amapakvaisaniya in Susrutasthana of Susruta Samhita.