Sushruta Samhita Nidanasthana Chapter 3 Ashmari Nidanam (Diagnosis of Urinary Calculi)

The 3rd chapter of Nidanasthana of Sushruta Samhita is named as Ashmari Nidanam. This chapter deals with Diseases of the Nervous System.

अथातोऽश्मरीणां निदानं व्याख्यास्यामः ||१||
यथोवाच भगवान् धन्वन्तरिः ||२||
We will now expound Ashmari Nidanam – diagnosis of urinary calculi, as revealed by the venerable Dhanvantari.

Asmaribheda: Kinds of Calculii

चतस्रोऽश्मर्यो भवन्ति; श्लेष्माधिष्ठानाः; तद्यथा- श्लेष्मणा, वातेन, पित्तेन, शुक्रेण चेति ||३||
There are four kinds of Asmari (urinary calculi / urinary stone) which manifest by residing in (formed from) kapha (i.e. all four kinds of asmari are formed from kapha), such as those born from kapha, vata, pitta and sukra (semen) separately.

Samprapti: Pathogenesis

तत्रासंशोधनशीलस्यापथ्यकारिणः प्रकुपितः श्लेष्मा मूत्रसम्पृक्तोऽनुप्रविश्य बस्तिमश्मरीं जनयति ||४||
In persons who do not undergo purification regularly and who indulge in unhealthy foods and activities, Kapha gets aggravated, combines with urine, reaches the urinary bladder, and staying there produces Asmari i.e. calculi (stones).

Purvarupa: Premonitory symptoms

तासां पूर्वरूपाणि- ज्वरो बस्तिपीडारोचकौ मूत्रकृच्छ्रं बस्तिशिरोमुष्कशेफसां वेदना कृच्छ्रावसादो बस्तगन्धित्वं मूत्रस्येति ||५||
यथास्ववेदनावर्णं दुष्टं सान्द्रमथाविलम् |
पूर्वरूपेऽश्मनः कृच्छ्रान्मूत्रं सृजति मानवः ||६||
The premonitory symptoms of Asmari are as below mentioned –

• fever,
• pain in the bladder,
• loss of taste, difficulty in urination,
• pain in the head of the bladder, scrotum and penis;
• troublesome body aches and
• urine having the smell of the goat
• specific symptoms and color of the Dosha producing the disease,
• urine becoming vitiated, thick and turbid and
• the person passes urine with difficulty

Rupa: Signs and symptoms

अथ जातासु नाभिबस्तिसेवनीमेहनेष्वन्यतमस्मिन् मेहतो वेदना मूत्रधारासङ्गः सरुधिरमूत्रता मूत्रविकिरणं गोमेदकप्रकाशमत्याविलं ससिकतं विसृजति; धावनलङ्घनप्लवनपृष्ठयानोष्णाध्वगमनैश्चास्य वेदना भवन्ति ||७||
After manifestation, the person has pain in the area of the umbilicus, bladder, raphae (perineal), penis and other areas nearby during micturation, interruption of stream of urine, urine mixed with blood, urine scattering (spreading in many streams), urine resembling gomedaka (dolomite stone) in color (light yellow), very turbid, and containing sand (gravel). There is pain during running, jumping, swimming, riding, exposure to sunlight, long walks etc.

Kaphaja Ashmari

तत्र श्लेष्माश्मरी श्लेष्मलमन्नमभ्यवहरतोऽत्यर्थमुपलिप्याधः परिवृद्धिं प्राप्य बस्तिमुखमधिष्ठाय स्रोतो निरुणद्धि, तस्य मूत्रप्रतिघाताद्दाल्यते भिद्यते निस्तुद्यत इव च बस्तिर्गुरुः शीतश्च भवति; अश्मरी चात्र श्वेता स्निग्धा महती कुक्कुटाण्डप्रतीकाशा मधूकपुष्पवर्णा वा भवति, तां श्लैष्मिकीमिति विद्यात् ||८||
In persons who consume food which increase Kapha too often, Kapha getting increased forms a coating at the bottom of the bladder. Then reaching the orifice of the bladder blocks it. Due to such blocking, the person feels the bladder as though being torn, punctured and pricked, heavy and cold. The stone is white, unctuous, big like a hen’s egg and similar to Madhuka flower in color (light yellow). This is to be understood as produced by shleshma (Kapha).

Pittaja Ashmari

पित्तयुतस्तु श्लेष्मा सङ्घातमुपगम्य यथोक्तां परिवृद्धिं प्राप्य बस्तिमुखमधिष्ठाय स्रोतो निरुणद्धि, तस्य मूत्रप्रतीघातादूष्यते चूष्यते दह्यते पच्यत इव बस्तिरुष्णवातश्च भवति; अश्मरी चात्र सरक्ता पीतावभासा कृष्णा भल्लातकास्थिप्रतिमा मधुवर्णा वा भवति, तां पैत्तिकीमिति विद्यात् ||९||
Kapha, combined with Pitta, forms lumps, which increase in size inside the bladder and then block the orifice of the bladder. Due to such blocking the person feels as though the bladder is hot inside, as being sucked (pulled), burnt and suppurating (ripening, forming an ulcer) and there is Ushnavata (burning and difficulty of micturition). The stones are slightly red, yellowish or black, resembling the seed of Bhallataka or honey in color. This should be understood as produced by pitta.

Vataja Ashmari

वातयुतस्तु श्लेष्मा सङ्घातमुपगम्य यथोक्तां परिवृद्धिं प्राप्य बस्तिमुखमधिष्ठाय स्रोतो निरुणद्धि, तस्य मूत्रप्रतीघातात्तीव्रा वेदना भवति, तदाऽत्यर्थं पीड्यमानो दन्तान् खादति, नाभिं पीडयति, मेढ्रं प्रमृद्नाति, पायुं स्पृशति, विशर्धते, विदहति, वातमूत्रपुरीषाणि कृच्छ्रेण चास्य मेहतो निःसरन्ति; अश्मरी चात्र श्यावा परुषा विषमा खरा कदम्बपुष्पवत्कण्टकाचिता भवति, तां वातिकीमिति विद्यात् ||१०||
Kapha, combined with Vata, forms lumps which grow in size, reach the orifice of the bladder and block the passage. Because of such obstruction, there is severe pain; suffering greatly from this pain, the person grinds his teeth, presses the umbilicus, squeezes the penis, touches the rectum often and makes sounds through it, feels burning sensation in the bladder, eliminates flatus, urine and feces with difficulty. During micturition; the stone is blue, coarse (rough) irregular (uneven), hard, and covered with thorns (projections) similar to that of Kadamba flower. This should be understood as produced by Vata.

Stones and children

प्रायेणैतास्तिस्रोऽश्मर्यो दिवास्वप्नसमशनाध्यशनशीतस्निग्धगुरुमधुराहारप्रियत्वाद्विशेषेण बालानां भवन्ति; तेषामेवाल्पबस्तिकायत्वादनुपचितमांसत्वाच्च बस्तेः सुखग्रहणाहरणा भवन्ति |
These kinds of Asmari (stones) generally develop in children especially, since they indulge in sleep during the day, consume both unhealthy and healthy foods, over-eating, consume foods which are unctuous (fatty), heavy (hard for digestion) and sweet in taste. Since their bladder is small in size and muscles of the bladder are not fully grown, holding the stone (with forceps) and pulling it out are easy.

Shukrashmari

महतां तु शुक्राश्मरी शुक्रनिमित्ता भवति ||११||
मैथुनविघातादतिमैथुनाद्वा शुक्रं चलितमनिर्गच्छद्विमार्गगमनादनिलोऽभितः सङ्गृह्य मेढ्रवृषणयोरन्तरे संहरति, संहृत्य चोपशोषयति; सा मूत्रमार्गमावृणोति , मूत्रकृच्छ्रं बस्तिवेदनां वृषणयोश्च श्वयथुमापादयति, पीडितमात्रे च तस्मिन्नेव प्रदेशे प्रविलयमापद्यते; तां शुक्राश्मरीमिति विद्यात् ||१२||
Sukramari (seminal calculi) – develops only in the aged (youth and old age) persons. Due to either interruption of coitus or too much of copulation, Sukra (semen) getting dislodged from its seat (testes) becomes obstructed from going out; then vata (aggravated) moving in wrong path (directions) withholds it (semen) between the penis and testicles and dries it up (stone), blocks the urinary passage, gives rise to difficult urination; pain and swelling of the bladder and testicles. When squeezed by the hand, it (stone) breaks into small pieces in that place itself. This should be understood as Sukrasmari (seminal calculi).

Secondary diseases of Ashmari

Another verse here
भवन्ति चात्र-
शर्करा सिकता मेहो भस्माख्योऽश्मरिवैकृतम् |१३|
Sarkara (urinary gravel), sikata meha (a variety of diabetes) and bhasmakhya roga (diseases called also as mutra sukra described in ch.58 of Utarasthana) all are complications (secondary diseases) of Asmari (renal calculi) only.

Mutra sharkara-urinary gravel

अश्मर्या शर्करा ज्ञेया तुल्यव्यञ्जनवेदना ||१३||
पवनेऽनुगुणे सा तु निरेत्यल्पा विशेषतः |
सा भिन्नमूर्तिर्वातेन शर्करेत्यभिधीयते ||१४||
Sarkara (sand or gravel) should be understood as Asmari (urinary stone) itself, because of similarity in shape and symptoms. When small in size, it (gravel) comes out when Pavana (Vata) is normal. The same (stone) when broken into pieces by Vata is known as Sarkara (urinary gravel).

Signs and symptoms of Sharkara: Urinary gravel

हृत्पीडा सक्थिसदनं कुक्षिशूलं च वेपथुः |
तृष्णोर्ध्वगोऽनिलः कार्ष्ण्यं दौर्बल्यं पाण्डुगात्रता ||१५||
अरोचकाविपाकौ तु शर्करार्ते भवन्ति च |१६|
Pain in the region of the heart, weakness of the thighs, pain in the abdomen, tremors, thirst, upward movement of Vata (reverse peristalsis), emaciation, debility, yellowish-white color / pallor of the body, loss of taste and improper digestion are the symptoms of the persons suffering from urinary gravel.

Symptoms caused by obstructed calculi

मूत्रमार्गप्रवृत्ता सा सक्ता कुर्यादुपद्रवान् ||१६||
दौर्बल्यं सदनं कार्श्यं कुक्षिशूलमरोचकम् |
पाण्डुत्वमुष्णवातं च तृष्णां हृत्पीडनं वमिम् ||१७||
When obstructed while it is coming out of the urinary passage, it gives rise to complications (secondary diseases) such as debility, exhaustion, emaciation, and abdominal pain, loss of taste, anemia, burning micturition, thirst, pain in region of heart and vomiting.

Mutrashaya: Urinary bladder

नाभिपृष्ठकटीमुष्कगुदवङ्क्षणशेफसाम् |
एकद्वारस्तनुत्वक्को मध्ये बस्तिरधोमुखः ||१८||
बस्तिर्बस्तिशिरश्चैव पौरुषं वृषणौ गुदः |
एकसम्बन्धिनो ह्येते गुदास्थिविवराश्रिताः ||१९||
अलाब्वा इव रूपेण सिरास्नायुपरिग्रहः |
मूत्राशयो मलाधारः प्राणायतनमुत्तमम् ||२०||
पक्वाशयगतास्तत्र नाड्यो मूत्रवहास्तु याः |
तर्पयन्ति सदा मूत्रं सरितः सागरं यथा ||२१||
सूक्ष्मत्वान्नोपलभ्यन्ते मुखान्यासां सहस्रशः |
नाडीभिरुपनीतस्य मूत्रस्यामाशयान्तरात् ||२२||
जाग्रतः स्वपतश्चैव स निःस्यन्देन पूर्यते |
आमुखात्सलिले न्यस्तः पार्श्वेभ्यः पूर्यते नवः ||२३||
घटो यथा तथा विद्धि बस्तिर्मूत्रेण पूर्यते |२४|
Basti (Mutrasaya) is situated in the midst of the umbilicus, back, waist, scrotum, rectum, groins and penis, has one orifice (only) and thin skin (layers, covering), placed facing downwards. It is shaped like alabu (pitcher gourd) and supported by sira (veins / blood vessels) and snayu (ligaments).Basti (urinary bladder), Bastisira (fundus), Paurusa (prostate), Vrsana (testicles), and Guda (rectum) are interrelated (connected) and situated inside the cavity of the pelvis.
This mutrasaya (urinary bladder) is a receptacle of mala (waste products) and an important seat of life.
Nadis (tubes / ducts) known as mutravaha (ducts of urine) present in the Pakvasaya (large intestine), satisfy the bladder (filling it) by bringing urine always (continuously) just like the rivers (satisfying) the ocean. The mouths (openings) of these thousands of ducts are not visible because of their minuteness; these carry urine from the interior of the amasaya (stomach and small intestine), fill the bladder by oozing through its wall, both during waking and sleeping states (throughout day and night continuously). Just as a fresh earthen pot kept immersed in water up to its mouth (neck) gets filled with water through its sides, in the same way, it should be understood that the bladder also gets filled with urine.
In the same manner vata, pitta and kapha also enter into the urinary bladder, by oozing through its wall along with urine and produce calculi (stone).

Analogy for formation of stone in urinary bladder

एवमेव प्रवेशेन वातः पित्तं कफोऽपि वा ||२४||
मूत्रयुक्तमुपस्नेहात् प्रविश्य कुरुतेऽश्मरीम् |२५|
अप्सु स्वच्छा(स्था)स्वपि यथा निषिक्तासु नवे घटे ||२५||
कालान्तरेण पङ्कः स्यादश्मरीसम्भवस्तथा |
संहन्त्यापो यथा दिव्या मारुतोऽग्निश्च वैद्युतः ||२६||
तद्वद्बलासं बस्तिस्थमूष्मा संहन्ति सानिलः |२७|
Just as water, though clear, when kept undisturbed for some time in an earthen pot, forms slush (deposit) below in course of time, similarly is the formation of stone inside the bladder. Just as rain water solidifies (in the sky) by (the action of) wind, fire (heat) and lightning, similarly the fire (pitta), anila (vata) solidify the balasa (kapha) present in the urinary bladder.

Role of Vata located in urinary bladder in causation of many disorders

मारुते प्रगुणे बस्तौ मूत्रं सम्यक् प्रवर्तते |
विकारा विविधाश्चापि प्रतिलोमे भवन्ति हि ||२७||
मूत्राघाताः प्रमेहाश्च शुक्रदोषास्तथैव च |
मूत्रदोषाश्च ये केचिद्वस्तावेव भवन्ति हि ||२८||
When Vata is normal in the urinary bladder, urine flows out properly, but when it (vata) moves (acts) in improper manner, different kinds of diseases develop; retention of urine, diabetes, disorders of semen and all other urinary disorders, arise from the urinary bladder itself.

इति सुश्रुतसंहितायां निदानस्थानेऽश्मरीनिदानां नाम तृतीयोऽध्यायः ||३||
Thus ends the Third chapter by name Asmari Nidanam In Nidana Sthana of Susruta Samhita.