Trishothiya Adhyaya

Trishothiya Adhyaya
Section/Chapter	Sutra Sthana Chapter 18
Tetrad/Sub-section	Roga Chatushka
Preceding Chapter	Kiyanta Shiraseeya
Succeeding Chapter	Ashtodariya
Other Sections	Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana

(Sutra Sthana Chapter 18, Chapter on Three Types of Swellings)

Abstract

The preceding chapter (Kiyanta Shiraseeya) provided details on diseases of the vital organs with signs of swellings. This Trishothiya Adhyaya of Roga Chatushka (tetrad on diseases) describes various kinds of swellings/distension as well as causative factors for endogenous and exogenous swellings/distensions, their locations in the body and their modes of treatment. Further,the pathophysiology of various diseases along with their specific diagnostic criteria have been described in the chapter.

Keywords: Swellings, endogenous causes, exogenous causes, shotha, nija-agantuja, generalized edema, localized edema

Introduction

In the previous chapter, diseases of vital organs like head, heart, and the urinary system, signs of dhatu kshaya (depletion of dhatu) and pidika (papules) with signs of swellings were described. This chapter deals with the etiology and symptomatology of endogenous and exogenous as well as local and generalized swellings and distensions. The name of the chapter denotes three types of swellings but later in the text, these swellings are classified into various types based upon several etiopathological factors and location. This chapter is important from the standpoint of diagnostics as it describes the main causes of all diseases that can be endogenous (innate origin) and exogenous (external agents). Some of the causative factors that can trigger non-infectious and infectious inflammations include traumatic injuries, contact with poisonous plants, animals, insect bites, animal bites, frost bite, and burns. The body’s reaction to invading micro-organisms, in terms of vitiation of dosha, can be observed and appropriate course of action can be planned.

Inflammation is an important pathology that includes tumor (swelling) as a cardinal sign. Further, classifications of shotha (swelling/distension) based on cause, predominance of dosha, and prognosis as per site of swelling are explained. Principles of identification of new diseases are also elucidated. The normal functions of dosha and their importance in disease conditions is emphasized. Thus, the chapter is fundamental in knowing disease.

Sanskrit text, Transliteration and English Translation

अथातस्त्रिशोथीयमध्यायं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athātastriśōthīyamadhyāyaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAtastrishothIyamadhyAyaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

Now we will discuss the chapter on three types of shotha i.e. swellings. Thus, said Lord Atreya. [1-2]

Three types of shotha

त्रयः शोथा भवन्ति वातपित्तश्लेष्मनिमित्ताः, ते पुनर्द्विविधा निजागन्तुभेदेन||३||

trayaḥ śōthā bhavanti vātapittaślēṣmanimittāḥ, tē punardvividhā nijāgantubhēdēna||3||

trayaH shothA bhavanti vAtapittashleShmanimittAH, te punardvividhA nijAgantubhedena||3||

There are three types of shothas (swelling) i.e. vataja, pittaja and kaphaja. Further, they can be classified into two i.e. nija (endogenous) and agantuja (exogenous). [3]

Causes of exogenous swelling

तत्रागन्तवश्छेदनभेदनक्षणनभञ्जनपिच्छनोत्पेषण प्रहारवधबन्धनवेष्टनव्यधन पीडनादिभिर्वाभल्लातकपुष्पफलरसात्मगुप्ताशूकक्रिमिशूकाहितपत्रलतागुल्मसंस्पर्शनैर्वा स्वेदनपरिसर्पणावमूत्रणैर्वा विषिणांसविषप्राणिदंष्ट्रादन्तविषाणनखनिपातैर्वा सागरविषवातहिमदहनसंस्पर्शनैर्वा शोथाः समुपजायन्ते||४||

tatrāgantavaśchēdanabhēdanakṣaṇanabhañjanapicchanōtpēṣaṇa prahāravadhabandhanavēṣṭanavyadhana pīḍanādibhirvābhallātakapuṣpaphala rasātmaguptāśūkakrimiśūkāhitapatralatāgulmasaṁsparśanairvā svēdanaparisarpaṇāvamūtraṇairvāviṣiṇāṁ saviṣaprāṇidaṁṣṭrādantaviṣāṇanakhanipātairvā sāgaraviṣavātahimadahanasaṁsparśanairvā śōthāḥsamupajāyantē||4||

tatrAgantavashchedanabhedanakShaNanabha~jjanapicchanotpeShaNa prahAravadhabandhanaveShTanavyadhana pIDanAdibhirvAbhallAtakapuShpaphala rasAtmaguptAshUkakrimishUkAhitapatralatAgulmasaMsparshanairvA svedanaparisarpaNAvamUtraNairvAviShiNAM saviShaprANidaMShTrAdantaviShANanakhanipAtairvA sAgaraviShavAtahimadahanasaMsparshanairvA shothAH samupajAyante||4||

Causes of agantuja shotha (exogenous swelling): Common etiological factors of agantuja shotha include chhedana (excision), bhedana (incision), kshanana (churning of bones), bhanjana (breaking), pichhana (excess squeezing), utprashana (grinding), prahaara (hitting), vadha (stroking), bandhana (binding), veshtana (twisting), vyadhana (piercing), peedana (pressing) etc. In addition to these traumas some other factors such as coming in contact with the juice of flowers or fruits of some plants such as bhallātaka (Semicarpus anacardium), atmagupta (Mucuna pruriens) or getting bitten or stung by certain insects or touching irritant leaves, climbers, shrubs, sweat or urine of poisonous animals or even coming in physical contact with them, or getting injured by their teeth, horns and nails, or exposure to marine or poisonous air, or exposure to excess cold or burns may also result in agantuja shotha. [4]

Diagnosis and treatment of exogenous swelling

ते पुनर्यथास्वं हेतुव्यञ्जनैरादावुपलभ्यन्ते निजव्यञ्जनैकदेशविपरीतैः;बन्धमन्त्रागदप्रलेपप्रतापनिर्वापणादिभिश्चोपक्रमैरुपक्रम्यमाणाः प्रशान्तिमापद्यन्ते||५||

tē punaryathāsvaṁ hētuvyañjanairādāvupalabhyantē nijavyañjanaikadēśaviparītaiḥ;bandhamantrāgadapralēpapratāpanirvāpaṇādibhiścōpakramairupakramyamāṇāḥpraśāntimāpadyantē||5||

te punaryathAsvaM hetuvya~jjanairAdAvupalabhyante nijavya~jjanaikadeshaviparItaiH;bandhamantrAgadapralepapratApanirvApaNAdibhishcopakramairupakramyamANAH prashAntimApadyante||5||

Exogenous swellings can be primarily identified by characteristic signs of injury and localization. After some time, they become similar to endogenous swellings (due to vitiation of dosha). They are treated by bandage, mantra (holy chants), antidotes, local application of medicines, fomentation, cooling measures etc. [5]

General causes of endogenous swellings

निजाः पुनः स्नेहस्वेदवमनविरेचनास्थापनानुवासनशिरोविरेचनानामयथावत्प्रयोगान्मिथ्यासंसर्जनाद्वाछर्द्यलसकविसूचिकाश्वासकासातिसारशोषपाण्डुरोगोदरज्वरप्रदरभगन्दरार्शोविकारातिकर्शनैर्वा कुष्ठकण्डूपिडकादिभिर्वाछर्दिक्षवथूद्गारशुक्रवातमूत्रपुरीषवेगधारणैर्वा कर्मरोगोपवासाध्वकर्शितस्य वासहसाऽतिगुर्वम्ललवणपिष्टान्नफलशाकरागदधिहरितकमद्यमन्दकविरूढनवशूकशमीधान्यानूपौदक-पिशितोपयोगान्मृत्पङ्कलोष्टभक्षणाल्लवणातिभक्षणाद्गर्भसम्पीडनादामगर्भप्रपतनात् प्रजातानां चमिथ्योपचारादुदीर्णदोषत्वाच्च शोफाः प्रादुर्भवन्ति; इत्युक्तः सामान्यो हेतुः||६||

nijāḥ punaḥ snēhasvēdavamanavirēcanāsthāpanānuvāsanaśirōvirēcanānāmayathāvatprayōgānmithyāsaṁsarjanādvāchardyalasakavisūcikāśvāsakāsātisāraśōṣapāṇḍurōgōdarajvarapradarabhagandarārśōvikārātikarśanairvākuṣṭhakaṇḍūpiḍakādibhirvā chardikṣavathūdgāraśukravātamūtrapurīṣavēgadhāraṇairvākarmarōgōpavāsādhvakarśitasya vāsahasā'tigurvamlalavaṇapiṣṭānnaphalaśākarāgadadhiharitakamadyamandakavirūḍhanavaśūkaśamīdhānyānūpaudaka-piśitōpayōgānmr̥tpaṅkalōṣṭabhakṣaṇāllavaṇātibhakṣaṇādgarbhasampīḍanādāmagarbhaprapatanāt prajātānāṁ camithyōpacārādudīrṇadōṣatvācca śōphāḥ prādurbhavanti; ityuktaḥ sāmānyō hētuḥ||6||

nijAH punaH snehasvedavamanavirecanAsthApanAnuvAsanashirovirecanAnAmayathAvatprayogAnmithyAsaMsarjanAdvAchardyalasakavisUcikAshvAsakAsAtisArashoShapANDurogodarajvarapradarabhagandarArshovikArAtikarshanairvA kuShThakaNDUpiDakAdibhirvAchardikShavathUdgArashukravAtamUtrapurIShavegadhAraNairvA karmarogopavAsAdhvakarshitasya vAsahasA~atigurvamlalavaNapiShTAnnaphalashAkarAgadadhiharitakamadyamandakavirUDhanavashUkashamIdhAnyAnUpaudaka-pishitopayogAnmRutpa~gkaloShTabhakShaNAllavaNAtibhakShaNAdgarbhasampIDanAdAmagarbhaprapatanAt prajAtAnAM ca mithyopacArAdudIrNadoShatvAccashophAH prAdurbhavanti; ityuktaH sAmAnyo hetuH||6||

Nija shotha i.e. endogenous swelling could be caused due to any of the following factors:

Iatrogenic factors: Improper administration of snehana (oleation), swedana (sudation), vamana (therapeutic emesis), virechana (therapeutic purgation), asthapana basti (non-unctuous enema), anuvasana basti (unctuous enema), shirovirechana (nasal errhines) and/or samsarjana krama (dietetic regimen after purification therapy).
Complication of other diseases: It can also result as complication of chhardi (vomiting), alasaka (delayed and obstructive digestive process), visuchika (cholera), shwasa (dyspnoea), kasa (cough), atisara (diarrhea), shosha (tuberculosis or pthysis ), pandu roga (anemia), udara roga (abdominal diseases including ascitis), jwara (pyrexia), pradara (excessive vaginal discharge), bhagandara (fistula-in-ano), arsha (piles) excessive emaciation, skin disorders, worm infestation, pidika (boils) etc.
Lifestyle: It may be due to suppression of natural urges like vomiting, sneezing, belching, ejaculation, flatus, micturition, defecation, excessive weakness caused by therapeutic purification procedures, chronic diseases, fasting, and excessive walking.
Dietary factors: Excess intake of too heavy diet, sour, salty, preparations of rice flour/maida/pastry, fruits, vegetables, raga preparations or pickles, curd, green salads, wine, unfermented curd, sprouted and new corn and cereals, consumption of meat of animals in marshy places or of acquatic animals such as certain types of fish, eating clay or pieces of earthen pots or bricks, or eating excessive salt (resulting in swelling).
Ante-natal and post-natal factors: Due to excessive pressure of gravid uterus, abortion, pre mature delivery and improper follow up of puerperal regimen, doshas get aggravated and produce shotha. [6]

Specific causes of swelling due to dosha dominance

Swelling due to vata dominance

अयं त्वत्र विशेषः- शीतरूक्षलघुविशदश्रमोपवासातिकर्शनक्षपणादिभिर्वायुः [१] प्रकुपितस्त्वङ्मांसशोणितादीन्यभिभूय शोफंजनयति; स क्षिप्रोत्थानप्रशमो भवति, तथा श्यामारुणवर्णः प्रकृतिवर्णो वा, चलः स्पन्दनः खरपरुषभिन्नत्वग्रोमा छिद्यत इवभिद्यत इव पीड्यत इव सूचीभिरिव तुद्यते पिपीलिकाभिरिव संसृप्यते सर्षपकल्कावलिप्त इव चिमिचिमायते सङ्कुच्यतआयम्यत इवेति वातशोथः (१);

ayaṁ tvatra viśēṣaḥ- śītarūkṣalaghuviśadaśramōpavāsātikarśanakṣapaṇādibhirvāyuḥ [1]prakupitastvaṅmāṁsaśōṇitādīnyabhibhūya śōphaṁ janayati; sa kṣiprōtthānapraśamō bhavati, tathāśyāmāruṇavarṇaḥ prakr̥tivarṇō vā, calaḥ spandanaḥ kharaparuṣabhinnatvagrōmā chidyata iva bhidyata ivapīḍyata iva sūcībhiriva tudyatē pipīlikābhiriva saṁsr̥pyatē sarṣapakalkāvalipta iva cimicimāyatē saṅkucyataāyamyata ivēti vātaśōthaḥ (1);

ayaM tvatra visheShaH- shItarUkShalaghuvishadashramopavAsAtikarshanakShapaNAdibhirvAyuH [1] prakupitastva~gmAMsashoNitAdInyabhibhUya shophaMjanayati; sa kShiprotthAnaprashamo bhavati, tathA shyAmAruNavarNaH prakRutivarNo vA, calaH spandanaH kharaparuShabhinnatvagromA chidyata iva bhidyata ivapIDyata iva sUcIbhiriva tudyate pipIlikAbhiriva saMsRupyate sarShapakalkAvalipta iva cimicimAyate sa~gkucyata Ayamyata iveti vAtashothaH (1);

Vata gets vitiated due to excess intake of sheeta (cold things), ruksha (rough or low calorie), laghu (very light), vishada (non-slimy substance) diets, shrama (excessive exertion), upavasa (excessive fasting), ati-karshan (emaciation), and kshapana (wasting). This vitiated vata gets into and stays within twak (skin), mamsa (muscle tissue), along with rakta (blood) and produces shotha, i.e., swelling. This swelling increases as well as subsides quickly, black or reddish in color, fleeting, pulsating, with coarse skin, rough and broken hair. The person feels different types of pain sensation like chhidyati (excision), bhidyati (incision), suchibhiriva (piercing by needles/pricking), crawling of ants, irritation (as if pasted with mustard) and a feeling of contraction or expansion. These are some of the traits of swelling caused by vata. [1]

Swelling due to pitta dominance

उष्णतीक्ष्णकटुकक्षारलवणाम्लाजीर्णभोजनैरग्न्यातपप्रतापैश्च पित्तं प्रकुपितं त्वङ्मांसशोणितान्यभिभूय शोथं जनयति; सक्षिप्रोत्थानप्रशमो भवति, कृष्णपीतनीलताम्रावभास उष्णो मृदुः कपिलताम्ररोमा उष्यते दूयते धूप्यते ऊष्मायते स्विद्यतेक्लिद्यते न च स्पर्शमुष्णं च सुषूयत इति पित्तशोथः (२);

uṣṇatīkṣṇakaṭukakṣāralavaṇāmlājīrṇabhōjanairagnyātapapratāpaiśca pittaṁ prakupitaṁtvaṅmāṁsaśōṇitānyabhibhūya śōthaṁ janayati; sa kṣiprōtthānapraśamō bhavati,kr̥ṣṇapītanīlatāmrāvabhāsa uṣṇō mr̥duḥ kapilatāmrarōmā uṣyatē dūyatē dhūpyatē ūṣmāyatē svidyatēklidyatē na ca sparśamuṣṇaṁ ca suṣūyata iti pittaśōthaḥ (2);

uShNatIkShNakaTukakShAralavaNAmlAjIrNabhojanairagnyAtapapratApaishca pittaM prakupitaM tva~gmAMsashoNitAnyabhibhUya shothaM janayati; sakShiprotthAnaprashamo bhavati, kRuShNapItanIlatAmrAvabhAsa uShNo mRuduH kapilatAmraromA [2] uShyate dUyate dhUpyate UShmAyate svidyate klidyate na casparshamuShNaM ca suShUyata [3] iti pittashothaH (2);

Pitta is vitiated due to excessive intake of hot, irritant, pungent, alkaline, salt, sour food, taking food when ailing from indigestion, or due to excessive exposure to heat and sunlight. This gets into the skin, muscle tissue, or blood and produces swelling. It also increases and subsides quickly. The affected part becomes blackish, yellow, bluish, copper-tinged, hot, or soft with brown and coppery hair. It gives a burning sensation of various forms and could be hot, sweaty, and moist. The affected region could be tender to touch and very sensitive to heat. These are the traits of swelling due to pitta dosha. [2]

Swelling due to kapha dominance

गुरुमधुरशीतस्निग्धैरतिस्वप्नाव्यायामादिभिश्च श्लेष्मा प्रकुपितस्त्वङ्मांसशोणितादीन्यभिभूय शोथं जनयति; सकृच्छ्रोत्थानप्रशमो भवति, पाण्डुश्वेतावभासो गुरुः स्निग्धः श्लक्ष्णः स्थिरः स्त्यानः शुक्लाग्ररोमा स्पर्शोष्णसहश्चेतिश्लेष्मशोथः (३);

gurumadhuraśītasnigdhairatisvapnāvyāyāmādibhiśca ślēṣmā prakupitastvaṅmāṁsaśōṇitādīnyabhibhūyaśōthaṁ janayati; sa kr̥cchrōtthānapraśamō bhavati, pāṇḍuśvētāvabhāsō guruḥ snigdhaḥ ślakṣṇaḥ sthiraḥstyānaḥ śuklāgrarōmā sparśōṣṇasahaścēti ślēṣmaśōthaḥ (3);

gurumadhurashItasnigdhairatisvapnAvyAyAmAdibhishca shleShmA prakupitastva~gmAMsashoNitAdInyabhibhUya shothaM janayati; sa kRucchrotthAnaprashamobhavati, pANDushvetAvabhAso guruH snigdhaH shlakShNaH sthiraH styAnaH shuklAgraromA sparshoShNasahashceti shleShmashothaH (3);

Kapha is vitiated due to excessive use of heavy to digest, sweet, cold and unctuous food, excessive sleep, sedentary life, etc. Vitiated kapha inhabits the skin, muscle tissues, and blood, causing swelling. A kapha-induced swelling grows slowly and subsides with difficulty. Affected part becomes pale, whitish, heavy, unctuous, smooth, stable, thick, with white hair, tolerant of touch and heat This is the swelling caused due to kapha.

Different types due to involvement of more than one dosha

यथास्वकारणाकृतिसंसर्गाद्द्विदोषजास्त्रयः शोथा भवन्ति; यथास्वकारणाकृतिसन्निपातात् सान्निपातिक एकः; एवं [४]सप्तविधो भेदः||७||

yathāsvakāraṇākr̥tisaṁsargāddvidōṣajāstrayaḥ śōthā bhavanti; yathāsvakāraṇākr̥tisannipātāt sānnipātikaēkaḥ; ēvaṁ [4] saptavidhō bhēdaḥ||7||

yathAsvakAraNAkRutisaMsargAddvidoShajAstrayaH shothA bhavanti; yathAsvakAraNAkRutisannipAtAt sAnnipAtika ekaH; evaM saptavidho bhedaH||7||

Through the combination of the causes and symptoms of two doshas (dwidoshaja), three types of swelling occur. Similarly, a sannipatika shotha is caused by the combination of respective causes and symptoms of all three doshas. Thus swelling is of seven types. [7]

Various types of shotha and cardinal sign

प्रकृतिभिस्ताभिस्ताभिर्भिद्यमानो द्विविधस्त्रिविधश्चतुर्विधः सप्तविधोऽष्टविधश्च शोथ उपलभ्यते, पुनश्चैक एवोत्सेधसामान्यात्||८||

prakr̥tibhistābhistābhirbhidyamānō dvividhastrividhaścaturvidhaḥ saptavidhō'ṣṭavidhaśca śōthaupalabhyatē, punaścaika ēvōtsēdhasāmānyāt||8||

prakRutibhistAbhistAbhirbhidyamAno [5] dvividhastrividhashcaturvidhaH saptavidho~aShTavidhashca shotha upalabhyate, punashcaika [6] evotsedhasAmAnyAt||8||

On the basis of causative factors and classifications from different views, swelling may be of two, three, four, seven or eight types Again, there is only one type with common sign of ‘swelling’. [8]

Brief description of specific features

भवन्ति चात्र- शूयन्ते यस्य गात्राणि स्वपन्तीव रुजन्ति च| पीडितान्युन्नमन्त्याशु वातशोथं तमादिशेत्||९||

यश्चाप्यरुणवर्णाभः शोथो नक्तं प्रणश्यति| स्नेहोष्णमर्दनाभ्यां च प्रणश्येत् स च वातिकः||१०||

यः पिपासाज्वरार्तस्य दूयतेऽथ विदह्यते| स्विद्यति क्लिद्यते गन्धी स पैत्तः स्वयथुः स्मृतः||११||

यः पीतनेत्रवक्त्रत्वक् पूर्वं मध्यात् प्रशूयते| तनुत्वक् चातिसारी च पित्तशोथः स उच्यते||१२||

शीतः सक्तगतिर्यस्तु कण्डूमान् पाण्डुरेव च| निपीडितो नोन्नमति श्वयथुः स कफात्मकः||१३||

यस्य शस्त्रकुशच्छिन्नाच्छोणितं न प्रवर्तते| कृच्छ्रेण पिच्छा स्रवति स चापि कफसम्भवः||१४||

निदानाकृतिसंसर्गाच्छ्वयथुः स्याद्द्विदोषजः| सर्वाकृतिः सन्निपाताच्छोथो व्यामिश्रहेतुजः||१५||

bhavanti cātra- śūyantē yasya gātrāṇi svapantīva rujanti ca| pīḍitānyunnamantyāśu vātaśōthaṁ tamādiśēt||9||

yaścāpyaruṇavarṇābhaḥ śōthō naktaṁ praṇaśyati| snēhōṣṇamardanābhyāṁ ca praṇaśyēt sa ca vātikaḥ||10||

yaḥ pipāsājvarārtasya dūyatē'tha vidahyatē| svidyati klidyatē gandhī sa paittaḥ svayathuḥ smr̥taḥ||11||

yaḥ pītanētravaktratvak pūrvaṁ madhyāt praśūyatē| tanutvak cātisārī ca pittaśōthaḥ sa ucyatē||12||

śītaḥ saktagatiryastu kaṇḍūmān pāṇḍurēva ca| nipīḍitō nōnnamati śvayathuḥ sa kaphātmakaḥ||13||

yasya śastrakuśacchinnācchōṇitaṁ na pravartatē| kr̥cchrēṇa picchā sravati sa cāpi kaphasambhavaḥ||14||

nidānākr̥tisaṁsargācchvayathuḥ syāddvidōṣajaḥ| sarvākr̥tiḥ sannipātācchōthō vyāmiśrahētujaḥ||15||

bhavanti cAtra- shUyante yasya gAtrANi svapantIva [1] rujanti ca| pIDitAnyunnamantyAshu vAtashothaM tamAdishet||9||

yashcApyaruNavarNAbhaH shotho naktaM praNashyati| snehoShNamardanAbhyAM ca praNashyet sa ca vAtikaH||10||

yaH pipAsAjvarArtasya dUyate~atha vidahyate| svidyati klidyate gandhI sa paittaH svayathuH smRutaH||11||

yaH pItanetravaktratvak [2] pUrvaM madhyAt prashUyate| tanutvak cAtisArI ca pittashothaH sa ucyate||12||

shItaH [3] saktagatiryastu kaNDUmAn pANDureva ca| nipIDito nonnamati [4] shvayathuH sa kaphAtmakaH||13||

yasya shastrakushacchinnAcchoNitaM [5] na pravartate| kRucchreNa picchA sravati sa cApi kaphasambhavaH||14||

nidAnAkRutisaMsargAcchvayathuH syAddvidoShajaH| sarvAkRutiH sannipAtAcchotho vyAmishrahetujaH||15||

Specific features of vataja, paittika and kaphaja swellings

In the case of vataja swelling, affected body parts are swollen, and there is a feeling of numbness, pain, the swelling rebounds immediately after releasing pressure (pitting edema). It is reddish in color and subsides during night, by application of unctuous and hot massage. [9-10]

In the case of paittika or pittaja swelling, the patient suffers from excessive thirst and fever, and in the affected parts there is a sensation of burning, sweating, moisture and foul smell. Patients have yellow eyes, face and skin, thin skin, diarrhea and the ailment emanates from the middle of the body (abdomen and trunk). [11-12]

In kaphaja swelling, the patient has cold, immobile, itchy, and pale swelling that does not rebound after pressure (solid edema). These swellings do not bleed on cutting with a sharp weapon or kusha grass but instead ooze a slimy discharge. [13-14]

As mentioned earlier, there is a combination of causes and symptoms of two doshas, called dwidoshaja. A sannipataja swelling, on the other hand, combines the causes and symptoms of all the three doshas. [15]

Prognosis

यस्तु पादाभिनिर्वृत्तः शोथः सर्वाङ्गगो भवेत्| जन्तोः स च सुकष्टः स्यात् प्रसृतः स्त्रीमुखाच्च यः||१६||

यश्चापि गुह्यप्रभवः स्त्रिया वा पुरुषस्य वा| स च कष्टतमो ज्ञेयो यस्य च स्युरुपद्रवाः||१७||

yastu pādābhinirvr̥ttaḥ śōthaḥ sarvāṅgagō bhavēt| jantōḥ sa ca sukaṣṭaḥ syāt prasr̥taḥ strīmukhācca yaḥ||16||

yaścāpi guhyaprabhavaḥ striyā vā puruṣasya vā| sa ca kaṣṭatamō jñēyō yasya ca syurupadravāḥ||17||

yastu pAdAbhinirvRuttaH shothaH sarvA~ggago bhavet| jantoH sa ca sukaShTaH syAt prasRutaH strImukhAcca yaH||16||

yashcApi guhyaprabhavaH striyA vA puruShasya vA| sa ca kaShTatamo j~jeyo yasya ca syurupadravAH||17||

A swelling that starts from the feet and spreads all over the body and which starts from the face in women can only be cured with difficulty. In men or women, swellings that emanate from the genitalia, as well as all complicated variants of edema are mostly difficult to cure. [16-17]

Complications of shotha

छर्दिः श्वासोऽरुचिस्तृष्णा ज्वरोऽतीसार एव च| सप्तकोऽयं सदौर्बल्यः शोफोपद्रवसङ्ग्रहः||१८||

chardiḥ śvāsō'rucistr̥ṣṇā jvarō'tīsāra ēva ca| saptakō'yaṁ sadaurbalyaḥ śōphōpadravasaṅgrahaḥ||18||

chardiH shvAso~arucistRuShNA jvaro~atIsAra eva ca| saptako~ayaM sadaurbalyaH shophopadravasa~ggrahaH||18||

Vomiting, breathlessness, anorexia, excessive thirst, pyrexia, diarrhea and weakness - these are seven complications of shotha. [18]

Different types of swelling at specific sites: Upajivhika: यस्य श्लेष्मा प्रकुपितो जिह्वामूलेऽवतिष्ठते| आशु सञ्जनयेच्छोथं जायतेऽस्योपजिह्विका||१९|| yasya ślēṣmā prakupitō jihvāmūlē'vatiṣṭhatē| āśu sañjanayēcchōthaṁ jāyatē'syōpajihvikā||19|| yasya shleShmA prakupito jihvAmUle~avatiShThate| Ashu sa~jjanayecchothaM [1] jAyate~asyopajihvikA||19||

When the vitiated kapha emanates or begins from the root of the tongue and causes swelling suddenly, is called upajivhika (ranula or hypertrophied solitary lingual papilla). [19] Galashundika: यस्य श्लेष्मा प्रकुपितः काकले व्यवतिष्ठते| आशु सञ्जनयेच्छोफं करोति गलशुण्डिकाम्||२०|| yasya ślēṣmā prakupitaḥ kākalē vyavatiṣṭhatē| āśu sañjanayēcchōphaṁ karōti galaśuṇḍikām||20|| yasya shleShmA prakupitaH kAkale vyavatiShThate| Ashu sa~jjanayecchophaM [2] karoti galashuNDikAm||20|| The Vitiated kapha inhabits at uvula and produces swelling suddenly, that is called Galashundika(uvulitis). [20] Galaganda: यस्य श्लेष्मा प्रकुपितो गलबाह्येऽवतिष्ठते| शनैः सञ्जनयेच्छोफं गलगण्डोऽस्य जायते||२१|| yasya ślēṣmā prakupitō galabāhyē'vatiṣṭhatē| śanaiḥ sañjanayēcchōphaṁ galagaṇḍō'sya jāyatē||21|| yasya shleShmA prakupito galabAhye~avatiShThate| shanaiH sa~jjanayecchophaM [3] galagaNDo~asya jAyate||21||

A swelling that is caused when a vitiated kapha affects the throat from the outside, and gradually produces swelling , is called galaganda (goitre). [21] Galagraha: यस्य श्लेष्मा प्रकुपितस्तिष्ठत्यन्तर्गले स्थिरः| आशु सञ्जनयेच्छोफं जायतेऽस्य गलग्रहः||२२|| yasya ślēṣmā prakupitastiṣṭhatyantargalē sthiraḥ| āśu sañjanayēcchōphaṁ jāyatē'sya galagrahaḥ||22|| yasya shleShmA prakupitastiShThatyantargale sthiraH| Ashu sa~jjanayecchophaM [4] jAyate~asya galagrahaH||22||

When the vitiated kapha, firmly located inside the throat causes swelling suddenly, it causes galagraha (pharyingitis). [22] Visarpa: यस्य पित्तं प्रकुपितं सरक्तं त्वचि सर्पति| शोफं सरागं जनयेद्विसर्पस्तस्य जायते||२३|| yasya pittaṁ prakupitaṁ saraktaṁ tvaci sarpati| śōphaṁ sarāgaṁ janayēdvisarpastasya jāyatē||23|| yasya pittaM prakupitaM saraktaM tvaci sarpati| shophaM sarAgaM janayedvisarpastasya [5] jAyate||23||

When a vitiated pitta (with rakta, or blood) spreads through the skin, it causes swelling with redness. Such a swelling is called visarpa i.e. erysipelas. [23] Pidika: यस्य पित्तं प्रकुपितं त्वचि रक्तेऽवतिष्ठते| शोथं सरागं जनयेत् पिडका तस्य जायते||२४|| yasya pittaṁ prakupitaṁ tvaci raktē'vatiṣṭhatē| śōthaṁ sarāgaṁ janayēt piḍakā tasya jāyatē||24|| yasya pittaM prakupitaM tvaci rakte~avatiShThate| shothaM sarAgaM janayet [6] piDakA tasya jAyate||24||

When the vitiated pitta is located within the skin and rakta, swelling and redness appears causing pidika i.e. boils or pustules. [24] Tilaka-pipplava-vyanga-neelika: यस्य प्रकुपितं पित्तं शोणितं प्राप्य शुष्यति| तिलका पिप्लवो व्यङ्गा नीलिका तस्य जायते||२५|| yasya prakupitaṁ pittaṁ śōṇitaṁ prāpya śuṣyati| tilakā piplavō vyaṅgā nīlikā tasya jāyatē||25|| yasya prakupitaM pittaM shoNitaM prApya shuShyati| tilakA piplavo vya~ggA nIlikA tasya jAyate||25||

When the vitiated pitta goes into rakta and gets absorbed there where?, it causes tilaka (moles), piplu (port-wine marks), vyanga (blemish/spots), or nilika (blue-black moles). [25] Shankhaka: यस्य पित्तं प्रकुपितं शङ्खयोरवतिष्ठते| श्वयथुः शङ्खको नाम दारुणस्तस्य जायते||२६|| yasya pittaṁ prakupitaṁ śaṅkhayōravatiṣṭhatē| śvayathuḥ śaṅkhakō nāma dāruṇastasya jāyatē||26|| yasya pittaM prakupitaM sha~gkhayoravatiShThate| shvayathuH sha~gkhako nAma dAruNastasya jAyate||26||

When a vitiated pitta inhabits the temporal regions of the head, severe and fatal swellings known as shankhaka (saggital sinus thrombosis/ intracranial growth/ temporal arteritis) are caused. [26] Karnamulika shotha (swelling at base of ears): यस्य पित्तं प्रकुपितं कर्णमूलेऽवतिष्ठते| ज्वरान्ते दुर्जयोऽन्ताय शोथस्तस्योपजायते||२७|| yasya pittaṁ prakupitaṁ karṇamūlē'vatiṣṭhatē| jvarāntē durjayō'ntāya śōthastasyōpajāyatē||27|| yasya pittaM prakupitaM karNamUle~avatiShThate| jvarAnte durjayo~antAya shothastasyopajAyate||27||

When the vitiated pitta is located at the base of ears, a severe, incurable and fatal swelling arises at the terminal stage of the fever. [27] Pliha [splenomegaly]: वातः प्लीहानमुद्धूय कुपितो यस्य तिष्ठति| शनैः परितुदन् पार्श्वं प्लीहा तस्याभिवर्धते||२८|| vātaḥ plīhānamuddhūya kupitō yasya tiṣṭhati| śanaiḥ paritudan pārśvaṁ plīhā tasyābhivardhatē||28|| vAtaH plIhAnamuddhUya kupito yasya tiShThati| shanaiH paritudan [7] pArshvaM plIhA tasyAbhivardhate||28||

When the vitiated vata inhabits and elevates the spleen, it causes a gradual prickly pain in the sides, causing vliha vriddhi i.e. splenomegaly. [28] Gulma [abdominal lumps]: यस्य वायुः प्रकुपितो गुल्मस्थानेऽवतिष्ठते| शोफं सशूलं जनयन् गुल्मस्तस्योपजायते||२९|| yasya vāyuḥ prakupitō gulmasthānē'vatiṣṭhatē| śōphaṁ saśūlaṁ janayan gulmastasyōpajāyatē||29|| yasya vAyuH prakupito gulmasthAne~avatiShThate| shophaM sashUlaM janayan gulmastasyopajAyate||29||

When the vitiated vata inhabits in the abdominal region causing swelling and pain, it causes gulma. [29] Vriddhi [scrotum enlargement]: यस्य वायुः प्रकुपितः शोफशूलकरश्चरन्| वङ्क्षणाद्वृषणौ याति वृद्धिस्तस्योपजायते||३०|| yasya vāyuḥ prakupitaḥ śōphaśūlakaraścaran| vaṅkṣaṇādvr̥ṣaṇau yāti vr̥ddhistasyōpajāyatē||30|| yasya vAyuH prakupitaH shophashUlakarashcaran| va~gkShaNAdvRuShaNau yAti vRuddhistasyopajAyate||30|| When the vitiated vata moves from the groins to testicles causing swelling and pain, it causes vriddhi i.e. testicular swellings. [30] Udara [abdominal diseases]: यस्य वातः प्रकुपितस्त्वङ्मांसान्तरमाश्रितः| शोथं सञ्जनयेत् कुक्षावुदरं तस्य जायते||३१|| yasya vātaḥ prakupitastvaṅmāṁsāntaramāśritaḥ| śōthaṁ sañjanayēt kukṣāvudaraṁ tasya jāyatē||31|| yasya vAtaH prakupitastva~gmAMsAntaramAshritaH| shothaM sa~jjanayet kukShAvudaraM tasya jAyate||31||

When the vitiated vata located between the skin and muscles produces swelling in the abdomen, it is known as udara roga i.e. diseases of abdominal cavity. [31] Anaha (obstruction in abdomen): यस्य वातः प्रकुपितः कुक्षिमाश्रित्य तिष्ठति| नाधो व्रजति नाप्यूर्ध्वमानाहस्तस्य जायते||३२|| yasya vātaḥ prakupitaḥ kukṣimāśritya tiṣṭhati| nādhō vrajati nāpyūrdhvamānāhastasya jāyatē||32|| yasya vAtaH prakupitaH kukShimAshritya tiShThati| nAdho vrajati nApyUrdhvamAnAhastasya jAyate||32||

When the vitiated vata is stuck in the belly and moves neither upwards nor downwards (neither passed through flatus nor through belching), it causes aanaha (obstruction in abdomen). [32] Tumors: रोगाश्चोत्सेधसामान्यदधिमांसार्बुदादयः| विशिष्टा नामरूपाभ्यां निर्देश्याः शोथसङ्ग्रहे||३३|| rōgāścōtsēdhasāmānyadadhimāṁsārbudādayaḥ| viśiṣṭā nāmarūpābhyāṁ nirdēśyāḥ śōthasaṅgrahē||33|| rogAshcotsedhasAmAnyadadhimAMsArbudAdayaH| vishiShTA nAmarUpAbhyAM nirdeshyAH shothasa~ggrahe||33||

Various diseases with names and features such as adhimamsa (fleshy growth or extra growth of muscles), and arbuda (tumors) are included in the family of shotha due to the common appearance of swelling. [33] Rohini (diphtheria): वातपित्तकफा यस्य युगपत् कुपितास्त्रयः| जिह्वामूलेऽवतिष्ठन्ते विदहन्तः समुच्छ्रिताः||३४|| जनयन्ति भृशं शोथं वेदनाश्च पृथग्विधाः| तं शीघ्रकारिणं रोगं रोहिणीति विनिर्दिशेत्||३५|| त्रिरात्रं परमं तस्य जन्तोर्भवति जीवितम्| कुशलेन त्वनुक्रान्तः क्षिप्रं सम्पद्यते सुखी||३६||

vātapittakaphā yasya yugapat kupitāstrayaḥ| jihvāmūlē'vatiṣṭhantē vidahantaḥ samucchritāḥ||34|| janayanti bhr̥śaṁ śōthaṁ vēdanāśca pr̥thagvidhāḥ| taṁ śīghrakāriṇaṁ rōgaṁ rōhiṇīti vinirdiśēt||35|| trirātraṁ paramaṁ tasya jantōrbhavati jīvitam| kuśalēna tvanukrāntaḥ kṣipraṁ sampadyatē sukhī||36|| vAtapittakaphA yasya yugapat kupitAstrayaH| jihvAmUle~avatiShThante vidahantaH samucchritAH||34|| janayanti bhRushaM shothaM vedanAshca pRuthagvidhAH| taM shIghrakAriNaM rogaM rohiNIti vinirdishet||35|| trirAtraM paramaM tasya jantorbhavati jIvitam| kushalena tvanukrAntaH [8] kShipraM sampadyate sukhI||36||

When all the three doshas get aggravated simultaneously and inhabit the base of the tongue, they cause severe burning sensation, acute/intense swelling and various types of pain. This fatal disease is known as rohini (diphtheria). If afflicted with this ailment and left untreated, the patient could die in three days. But if treated by an expert physician quickly, one can recover almost immediately. [34-36] Prognosis of diseases: सन्ति ह्येवंविधा रोगाः साध्या दारुणसम्मताः| ये हन्युरनुपक्रान्ता मिथ्याचारेण वा पुनः||३७|| साध्याश्चाप्यपरे सन्ति व्याधयो मृदुसम्मताः| यत्नायत्नकृतं येषु कर्म सिध्यत्यसंशयम्||३८|| असाध्याश्चापरे सन्ति व्याधयो याप्यसञ्ज्ञिताः| सुसाध्वपि कृतं येषु कर्म यात्राकरं भवेत्||३९|| सन्ति चाप्यपरे रोगा येषु कर्म न सिध्यति| अपि यत्नकृतं बालैर्न तान् विद्वानुपाचरेत्||४०|| साध्याश्चैवाप्यसाध्याश्च व्याधयो द्विविधाः स्मृताः| मृदुदारुणभेदेन ते भवन्ति चतुर्विधाः||४१|| santi hyēvaṁvidhā rōgāḥ sādhyā dāruṇasammatāḥ| yē hanyuranupakrāntā mithyācārēṇa vā punaḥ||37|| sādhyāścāpyaparē santi vyādhayō mr̥dusammatāḥ| yatnāyatnakr̥taṁ yēṣu karma sidhyatyasaṁśayam||38|| asādhyāścāparē santi vyādhayō yāpyasañjñitāḥ| susādhvapi kr̥taṁ yēṣu karma yātrākaraṁ bhavēt||39|| santi cāpyaparē rōgā yēṣu karma na sidhyati| api yatnakr̥taṁ bālairna tān vidvānupācarēt||40|| sādhyāścaivāpyasādhyāśca vyādhayō dvividhāḥ smr̥tāḥ| mr̥dudāruṇabhēdēna tē bhavanti caturvidhāḥ||41|| santi hyevaMvidhA rogAH sAdhyA dAruNasammatAH| ye hanyuranupakrAntA mithyAcAreNa [10] vA punaH||37|| sAdhyAshcApyapare [11] santi vyAdhayo mRudusammatAH| yatnAyatnakRutaM yeShu karma sidhyatyasaMshayam||38|| asAdhyAshcApare santi vyAdhayo yApyasa~jj~jitAH| susAdhvapi kRutaM yeShu karma yAtrAkaraM bhavet||39|| santi cApyapare rogA yeShu karma na sidhyati| api yatnakRutaM bAlairna tAn vidvAnupAcaret||40|| sAdhyAshcaivApyasAdhyAshca vyAdhayo dvividhAH smRutAH| mRududAruNabhedena te bhavanti caturvidhAH||41|| There are certain curable diseases that become fatal if improperly managed or not given adequate treatment. There are other curable diseases that are mild and get alleviated certainly with or without effort. There are incurable diseases, considered “palliable”, in which appropriate treatment enables the patient to move along. And finally, there are other incurable diseases that do not respond to any treatment. At times, ignorant physicians treat these enthusiastically. However, the wise should not treat them. Thus, diseases are primarily of two types: curable and incurable, and depending upon their severity and responsiveness to drugs, are further categorized into two sub-categories within each of these types. [37-41]

Criteria for classification of diseases:

त एवापरिसङ्ख्येया भिद्यमाना भवन्ति हि| रुजावर्णसमुत्थानस्थानसंस्थाननामभिः ||४२|| व्यवस्थाकरणं तेषां यथास्थूलेषु सङ्ग्रहः| तथा प्रकृतिसामान्यं विकारेषूपदिश्यते||४३|| ta ēvāparisaṅkhyēyā bhidyamānā bhavanti hi| rujāvarṇasamutthānasthānasaṁsthānanāmabhiḥ ||42|| vyavasthākaraṇaṁ tēṣāṁ yathāsthūlēṣu saṅgrahaḥ| tathā prakr̥tisāmānyaṁ vikārēṣūpadiśyatē||43|| ta evAparisa~gkhyeyA bhidyamAnA bhavanti hi| rujAvarNasamutthAnasthAnasaMsthAnanAmabhiH [12] ||42|| vyavasthAkaraNaM [13] teShAM yathAsthUleShu sa~ggrahaH| tathA prakRutisAmAnyaM vikAreShUpadishyate||43|| There are several diseases classified on the basis of type of pain, appearance (color), etiology, site, symptoms and name. Their systematic classification has been attempted in the form of some gross disease families or classes. However, in other cases general principle may be followed. [42] Identification of new diseases: विकारनामाकुशलो न जिह्रीयात् कदाचन| न हि सर्वविकाराणां नामतोऽस्ति ध्रुवा स्थितिः||४४|| स एव कुपितो दोषः समुत्थानविशेषतः| स्थानान्तरगतश्चैव जनयत्यामयान् बहून् ||४५|| तस्माद्विकारप्रकृतीरधिष्ठानान्तराणि च| समुत्थानविशेषांश्च बुद्ध्वा कर्म समाचरेत्||४६|| यो ह्येतत्त्रितयं ज्ञात्वा कर्माण्यारभते भिषक्| ज्ञानपूर्वं यथान्यायं स कर्मसु न मुह्यति||४७|| vikāranāmākuśalō na jihrīyāt kadācana| na hi sarvavikārāṇāṁ nāmatō'sti dhruvā sthitiḥ||44|| sa ēva kupitō dōṣaḥ samutthānaviśēṣataḥ| sthānāntaragataścaiva janayatyāmayān bahūn ||45|| tasmādvikāraprakr̥tīradhiṣṭhānāntarāṇi ca| samutthānaviśēṣāṁśca buddhvā karma samācarēt||46|| yō hyētattritayaṁ jñātvā karmāṇyārabhatē bhiṣak| jñānapūrvaṁ yathānyāyaṁ sa karmasu na muhyati||47|| vikAranAmAkushalo na jihrIyAt kadAcana| na hi sarvavikArANAM nAmato~asti dhruvA sthitiH||44|| sa eva kupito doShaH samutthAnavisheShataH| sthAnAntaragatashcaiva janayatyAmayAn bahUn [14] ||45|| tasmAdvikAraprakRutIradhiShThAnAntarANi ca| samutthAnavisheShAMshca buddhvA karma samAcaret||46|| yo hyetattritayaM j~jAtvA karmANyArabhate bhiShak| j~jAnapUrvaM yathAnyAyaM [15] sa karmasu na muhyati||47|| One should not be ashamed of one’s inability to name a disease, since all disorders cannot be given standard names. There are innumerable diseases because the same vitiated dosha causes various disorders according to variations in etiology and location. Hence one should initiate any treatment after acquiring complete knowledge of the nature of the disease as well as its pathogenesis, location and etiological factors. The one who initiates the treatment after knowing all these things, rationally and according to prescribed procedure, does not get confused in actions. [44-47]

Discussion on dosha:

नित्याः प्राणभृतां देहे वातपित्तकफास्त्रयः| विकृताः प्रकृतिस्था वा तान् बुभुत्सेत पण्डितः||४८|| nityāḥ prāṇabhr̥tāṁ dēhē vātapittakaphāstrayaḥ| vikr̥tāḥ prakr̥tisthā vā tān bubhutsēta paṇḍitaḥ||48|| nityAH prANabhRutAM dehe vAtapittakaphAstrayaH| vikRutAH prakRutisthA vA tAn bubhutseta paNDitaH||48|| vata, pitta and kapha - these three doshas are always present in the body of all living beings. The learned should know about their normal or abnormal states. [48] Functions of normal vata dosha: उत्साहोच्छ्वासनिः श्वासचेष्टा धातुगतिः समा| समो मोक्षो गतिमतां वायोः कर्माविकारजम्||४९|| utsāhōcchvāsaniḥ śvāsacēṣṭā dhātugatiḥ samā| samō mōkṣō gatimatāṁ vāyōḥ karmāvikārajam||49|| utsAhocchvAsaniH shvAsaceShTA dhAtugatiH samA| samo mokSho gatimatAM vAyoH karmAvikArajam||49|| Enthusiasm, inspiration, expiration, movements, normal processing of dhatu (body tissues), and normal elimination of excreta are the normal functions of vayu (vata). [49] Functions of normal pitta dosha: दर्शनं पक्तिरूष्मा च क्षुत्तृष्णा देहमार्दवम्| प्रभा प्रसादो मेधा च पित्तकर्माविकारजम्||५०|| darśanaṁ paktirūṣmā ca kṣuttr̥ṣṇā dēhamārdavam| prabhā prasādō mēdhā ca pittakarmāvikārajam||50|| darshanaM paktirUShmA ca kShuttRuShNA dehamArdavam| prabhA prasAdo medhA ca pittakarmAvikArajam||50||

Vision, digestion, (production of) heat, hunger, thirst, softness in body, luster, serenity and intelligence are the normal functions of pitta. [50]

Functions of normal kapha dosha: स्नेहो बन्धः स्थिरत्वं च गौरवं वृषता बलम्| क्षमा धृतिरलोभश्च कफकर्माविकारजम्||५१|| snēhō bandhaḥ sthiratvaṁ ca gauravaṁ vr̥ṣatā balam| kṣamā dhr̥tiralōbhaśca kaphakarmāvikārajam||51|| sneho bandhaH sthiratvaM ca gauravaM vRuShatA balam| kShamA dhRutiralobhashca kaphakarmAvikArajam||51|| Unctuousness, binding, firmness/stability, heaviness, virility, strength, forbearance, restraint and absence of greed are the properties of kapha. [51] Diagnosis of abnormal state of dosha: वाते पित्ते कफे चैव क्षीणे लक्षणमुच्यते| कर्मणः प्राकृताद्धानिर्वृद्धिर्वाऽपि विरोधिनाम्||५२|| vātē pittē kaphē caiva kṣīṇē lakṣaṇamucyatē| karmaṇaḥ prākr̥tāddhānirvr̥ddhirvā'pi virōdhinām||52|| vAte pitte kaphe caiva kShINe lakShaNamucyate| karmaNaH prAkRutAddhAnirvRuddhirvA~api virodhinAm||52||

Any decrease in vata, pitta and kapha is thus indicated by a decrease in their natural functions or increase in functions of opposite dosha. (this is indicated by the properties associated with any of these doshas for example, reduced unctuousness indicates a decrease in kapha, etc). [52] दोषप्रकृतिवैशेष्यं नियतं वृद्धिलक्षणम्| दोषाणां प्रकृतिर्हानिर्वृद्धिश्चैवं परीक्ष्यते||५३|| dōṣaprakr̥tivaiśēṣyaṁ niyataṁ vr̥ddhilakṣaṇam| dōṣāṇāṁ prakr̥tirhānirvr̥ddhiścaivaṁ parīkṣyatē||53|| doShaprakRutivaisheShyaM niyataM vRuddhilakShaNam| doShANAM prakRutirhAnirvRuddhishcaivaM parIkShyate||53|| Conversely, any aggravation in dosha is indicated by an increase in their normal functions. Thus normalcy, decrease and aggravation of dosha are examined. [53] तत्र श्लोकाः- सङ्ख्यां निमित्तं रूपाणि शोथानां साध्यतां न च| तेषां तेषां विकाराणां शोथांस्तांस्तांश्च पूर्वजान्||५४|| विधिभेदं विकाराणां त्रिविधं बोध्यसङ्ग्रहम्| प्राकृतं कर्म दोषाणां लक्षणं हानिवृद्धिषु||५५|| वीतमोहरजोदोषलोभमानमदस्पृहः| व्याख्यातवांस्त्रिशोथीये रोगाध्याये पुनर्वसुः||५६|| tatra ślōkāḥ- saṅkhyāṁ nimittaṁ rūpāṇi śōthānāṁ sādhyatāṁ na ca| tēṣāṁ tēṣāṁ vikārāṇāṁ śōthāṁstāṁstāṁśca pūrvajān||54|| vidhibhēdaṁ vikārāṇāṁ trividhaṁ bōdhyasaṅgraham| prākr̥taṁ karma dōṣāṇāṁ lakṣaṇaṁ hānivr̥ddhiṣu||55|| vītamōharajōdōṣalōbhamānamadaspr̥haḥ| vyākhyātavāṁstriśōthīyē rōgādhyāyē punarvasuḥ||56|| tatra shlokAH- sa~gkhyAM nimittaM rUpANi shothAnAM sAdhyatAM na ca| teShAM teShAM vikArANAM shothAMstAMstAMshca pUrvajAn||54|| vidhibhedaM vikArANAM trividhaM bodhyasa~ggraham| prAkRutaM karma doShANAM lakShaNaM hAnivRuddhiShu||55|| vItamoharajodoShalobhamAnamadaspRuhaH| vyAkhyAtavAMstrishothIye rogAdhyAye punarvasuH||56||

Summary of the chapter: Types, causes, symptoms and prognoses of swelling, of various diseases, types of diseases, definitions of the three doshas, normal functions and symptoms of decrease and aggravation of doshas - all these have been explained in this chapter on three types of swellings by Punarvasu , who is free from tamas and rajas qualities, doshas, greed, conceit, pride and ambition.[54-56] Tattva Vimarsha: • Shotha (swelling) is associated with tridosha and occurs due to endogenous and exogenous factors. • The exogenous factors cause swelling first and then vitiate dosha. This leads to exogenous swellings getting transformed into endogenous swellings. • Any treatment of swelling depends upon the causative factors and doshas associated with it. [5] • Endogenous swelling can be caused by iatrogenic factors (e.g., poor administration of Panchakarma), complications arising from other diseases, consumption of improper food articles (e.g., allergic reactions to nuts or grains), not following proper ante-natal/post-natal regimen, etc. [6] • Etiological factors specific to each dosha are involved in the pathogenesis of swelling.[7] • The prognosis of swelling depends upon the involvement of dosha, the affected part and location of dosha accumulation. [16-41] • There are innumerable diseases classified on the basis of type of pain, appearance (color), etiology, site, symptoms and name. [42] • All the diseases cannot be named with standard nomenclature. [44] • For knowing and treating a new disease that has not been described in the text, the underlying dosha, its location, etiological factors, and the movement of dosha should be well identified. Then pathogenesis should become evident and rational treatment can be started. [45-47] • Three doshas - vata, pitta and kapha - are always present in the body of living beings. The learned should know about their normal and vitiated states. [48] • Enthusiasm, inspiration, expiration, movements, processing of dhatu (body tissues) and elimination of excreta are natural functions of of a normal vata.[49] • Vision, digestion, heat production, hunger, thirst, softness in body, luster, serenity and intelligence are the natural functions of a normal pitta. [50] • Unctuousness, binding, firmness/stability, heaviness (maintaining volume/mass), virility, strength, forbearance, restraint and absence of greed are the natural functions of of a normal kapha. [51] • The decrease (or increase) of these doshas in a body can be best diagnosed by a decrease (or increase) in the functions mentioned above. The alternate method to examine the status is to check functions of other (opposite) dosha. Thus the status of dosha can be investigated based on their representative functions only.[52] Vidhi Vimarsha: Classification of shotha (swelling/ distension): Depending on etiological factors diseases are grossly divided in to two categories. First one are nija (endogenous) diseases which are caused by endogenous factors i.e. the whole disease process starts within the body, although the provocation or aggravating factors may come from outside but the complete phenomenon of pathogenesis occurs inside body in a systematic way. According to Ayurvedic concepts full-fledged involvement of vata, pitta and kapha dosha is present here. The second type of swelling is known as agantuja (exogenous) in which the etiological factors are extraneous, which could be physical or environmental. Many times they bypass routine disease courses and causes disease in very short course of time. Conventional involvement of doshas take place later on i.e. after manifestation of disease. In addition to the types of swellings mentioned by Charaka, Sushruta has added rakta as a separate type. [Su. Su. 17/4]. Sushruta has also emphasized on vishaja (caused due to poisons) as another type while mentioning treatment. [Su. Chi. 23/3]. Vagbhata has differentiated types based on causes of injuries (abhighataja) and contact with poisons (vishaja). Further he has mentioned two types of shotha on the basis of distribution in body i.e. sarvanga (generalized) and ekang (localized). According to its manifestation he has described three categories i.e. prathu (diffused spread), unnat (elevated) and grathit (nodular) [A.H. Ni. 13/22, 23]. On the basis of prognosis, Madhava has divided shotha into three i.e. urdhvagata (in upper part of body), madhyagata (in the middle part) and adhogata (in the lower part) [Ma.ni.-36/17]. These types are of clinical importance since they help understand the origin of the swelling and the pre-dominant dosha involved in it. [3] Etiology of swelling: The exogenous factors produce sudden swellings most of the time while endogenous swellings mostly occur gradually. Any type of trauma, direct or indirect, will produce a swelling first. Some plants contain allergens which may cause allergic reactions such as severe itching. Scorpion, wasp, honey bee, spider stings or their touch can cause inflammatory reaction including edema. Excessive cold air or prolonged contact with ice may cause frostbite like symptoms and swelling causes weakness of the affected organ resembling a paralytic disorder. [4] In chikitsa sthanam, few other causes, such as the people who never do any physical activity, neither they adopt internal purification e.g. vamana, virechana etc., nor they take external purification by means of bath; may develop shotha (Ca.chi. 12/6). Some other etiological factors e.g. intake of kata-sharkara i.e. burned sugar and lime, practice of sexual intercourse during indigestion or travelling by vehicles with jerky movements may also produce shotha [Su. Chi. 23/4]. Few other causes of nija shotha described are sleeping during the day and working at night, and intake of dry and domestic animal meat in diet [A.H. Ni. 13/26]. During bio-purification procedures there is a loss of some body contents. When procedures are optimally performed then only unwanted materials are lost, but if the procedures are improperly administered, then certain amount of necessary body contents may also get removed which may result in many diseases. Besides, some nutrients may not get absorbed or metabolized properly. Due to these reasons deficiency of proteins, iron and other nutrients may occur causing edema in the long term. Similar pathology is found in many chronic disorders due to malnutrition, few of which are mentioned here. Violation of dietary rules is responsible for many shotha disorders. Eating of clay and pieces of earthen pots may cause worm infestations, thereby causing anemia or malnutrition, and in due course of time will result in edema2. Excessive use of salt will result in sodium retention and edema3. Lastly, recurrent abortions, miscarriages, intra-uterine death, and ante-natal problems may cause anemia and hypo-proteinaemia resulting in edema. In conventional medicine many mechanisms have been described to explain edema. Among these, increased capillary hydrostatic pressure, decreased plasma oncotic pressure, increased capillary permeability, sodium and water retention, and lymphatic obstruction4 are important. Above mechanisms can be studied in context of vataja, paittika and kaphaja types of shotha. [6] Differential diagnosis of types of swelling: Character/dosha vata dominance pitta dominance kapha dominance Duration Quick onset and regression Quick onset and regression Slow onset and difficult regression Appearance black or reddish blackish, yellow, bluish, coppery tinge pallor, whitish Nature Fleeting/moving/pulsating, quickly regress when pressed Hot, tender Immobile, stable, doesn’t regress quickly when pressed Skin and hair on affected part coarse, rough and broken Soft, thin with brown and coppery hair, perspiring and moist heavy, unctuous, smooth, stable, thick, with white hair. Sensation at affected part Like excising, incising, piercing by needles/pricking], feeling of crawling ants, has irritating sensation as if pasted with mustard, contracts or expands burning sensations of various types, hot, intolerant to heat and touch tolerant of touch and heat Time of increase & decrease Increases in day, reduces at night -- Increases at night, reduces in day Pacifying Hot and unctuous massage -- -- Types of shotha, location: The appearance of vātaja shotha can be correlated with the increased hydrostatic pressure mechanism of edema. The features are similar to edema caused by cardiac diseases where congestion is a major cause of increased hydrostatic pressure in vessels5. Through the day, due to gravity, water goes down the body and gets retained in lower limbs causing edema in the evening hours. During night (i.e., at rest), the retained water redistributes and the edema subsides. Edema of cardiac origin is pitting in type, similar to vataja shotha. Kaphaja shotha, on the other hand, could be due to hypoproteinaemia in liver diseases or due to proteinuria in renal diseases6. In renal edema, swelling is typically facial and manifests early in the morning. Sometimes these swellings are too hard, as found in cases of malignancies or tumors. The swellings of paittika/pittaja type are mostly inflammatory in nature. [9-15] Distribution of shotha and prognosis: kapha dosha are typically found in upper body parts, pitta in middle body parts and vata in lower body parts. Doshas situated in amashaya (stomach) cause shotha in the upper body, those situated in pakwashaya (large bowel) cause shotha in the middle body and those situated in malashaya (rectum) cause shotha in the lower body parts, whereas more than one dosha leads to shotha in the whole body [Su.chi.23/6]. Shotha in the middle body parts and generalized edema are difficult to cure. A shotha that has spread across half of the body is invariably fatal and a shotha that spreads upward from the lower parts (or from the top towards lower body parts) is incurable [Su.chi. 23/7-8]. Swellings of flanks, abdomen, throat and vital parts are incurable. Excessively bulky and rough swellings are also incurable. Swellings in children, old people and very weak patients are incurable (Ma.ni.-36/20). [16-17] Complications: Improper treatment or care of any existing edema-causing disease can lead to upadravas, or complications caused due to obstruction caused by accumulated fluid in the interstitial spaces leading to improper circulation. This hampers the normal movement of vata leading to various complications. If we consider modern etiopathogenesis of edema, then it is clear that all the complications described here are consequences of either edema or its associated disease. For example, hypertension is an etiological factor for heart and renal failure which are common causes of edema. Sometimes, pulmonary edema develops due to many reasons resulting in dyspnea. Anorexia may be due to hepatic pathology itself or may be due to congestion (as in the case of congestive heart failure)7. Excessive thirst may be due to induced or spontaneous diuresis leading to dehydration. Pyrexia, diarrhea and weakness can develop because of associated infections or other systemic ailments. [18] Various locations of shotha: Sushruta described galashundi as kanthashundi, a condition indicated by breathlessness, coughing and thirst. He mentioned the role of rakta along with kapha in causing the condition. (Su.ni.-16/41). Visarpa is a kind of inflammatory swelling mostly caused due to infection. In the context of kshudra rogas (curable diseases), tilaka (mole) is black in color, similar to size of sesame seed, painless and is flat (Su.ni.-13/43). Similarly vyanga (pigmentation) as painless, fine, black color circles (Su.ni.-13/45,46). Same manifestation over the face or other body parts is called nilika (Su.ni.-13/46). In addition to pitta, Sushruta has mentioned involvement of vata, kapha and rakta in the affliction of shankhaka roga (saggital sinus thrombosis/intracranial growth/temporal arteritis) (Su.ut.-25/16-18). In Madhava Nidanam it is described as a very severe and fatal condition that, by causing blockages in the head and throat, can kill the patient in three days [Ma.ni.-60/15]. Karnamoola shotha (swelling at base of ear/parotitis) has been described as a complication of sannipataja jwara (Ca.chi.-3/287). Pliha vriddhi (splenomegaly) has been described as plīhodara (Ca.chi.-13/35-38). Sushruta has described plihodara, due to intake of irritant and slimy food items, as a cause for aggravation of rakta and kapha. Gulma is a very special disease class described in Ayurveda, because it is neither mentioned independently in modern medicine nor it can be correlated with any disease. The problems or symptoms described in reference to gulma are practically found in clinical practice therefore it should be considered exclusively(Ca.chi.-5 & ch.ni.-3). In Aanaha (distension of abdomen), not only is the movement of vata hampered but the vitiated vata also dries the stool. Therefore, the patient of aanaha complains of constipation along with flatulence. Two causes of aanaha are: impaired peristalsis of the stomach and that of the large bowel (Su.utt.-57/20-22). Vriddhi roga (hydrocele and hernia) has been described to be of seven types i.e. vataja, pittaja, kaphaja, raktaja, medoja, mutraja and antraja. (A.H.Ni.-11/21-31). The antraja vriddhi may be correlated with swelling of the hernia and is said to be incurable. Sushruta has described five types of rohini (diptheria) i.e. vataja, pittaja, kaphaja, raktaja and sannipataja (Su.ni.-16/47-50). Upajihvika, galashundika, galagraha, rohini, are basically infectious disorders affecting the mouth and throat area. Galaganda closely resembles goitre which is caused due to thyroid disorders. Visarpa and pidika are caused due to skin infections, whereas tilaka, piplu, vyanga and nilika are the problems present in skin due melanin pigment disorders. Pliha vridhi or spleenomegaly is condition where spleen gets enlarged due to many reasons such as infections, hematological disorders, malignancies etc. Gulma, udara roga, aanaha are diseases mainly located and related to gastrointestinal tract, having main features of fullness or protuberance. Eight udara rogas described in Ayurveda are actually diseases present as protuberances in abdomen. But all udara rogas are not directly related to the gastrointestinal tract e.g. plihodara (splenomegaly), yakradaludara (hepatomegaly), and jalodara (ascites). Still their manifestation is similar to shotha i.e. swellings. Swelling at the roots of ears, commonly known as Karnamool shotha (Parotitis), is mostly due to viral infections. Vriddhi roga is a kind of hernia, i.e., inguinal, femoral, umbilical or incision hernia with visible swelling. Adhimansa (increased muscles bulk) and arbuda(tumor) are swellings associated with extra or new growth that could be benign or malignant. Rohini can be closely correlated with diphtheria which is caused by a bacterial infection i.e. Corynibacterium diphtheriae8. It can affect many sites in the body but most commonly the throat where if not treated properly may cause death due to suffocation or asphyxia. [19-36] Dosha and disease: Over the years, as a result of changes in lifestyle, multiple etiological factors, and decreased body resistance, new diseases are appearing. Therefore, naming all the diseases is a problem that all branches of medical sciences face. In modern medicine where the cause of a disease is not very clear, symptom-based or descriptive diagnosis is given to various conditions, e.g., APD (Acid Peptic Diseases) is the term given to problems having symptoms of hyperacidity, pain in the abdomen, indigestion etc. Similarly, NUD (Non Ulcer Dyspepsia) term is applied to the symptoms of indigestion without pain. CAD (Coronary Artery Disease), CHD (Congenital Heart Disease), CVA (Cerebro- Vascular Accidents), COPD (Chronic Obstructive Pulmonary Disease), HE (Hepatic-encephalopaty), Renal parenchymal disease, Coagulopathies, Myopathies, Neuropathies, etc. are a few other examples of grouping various ailments by their symptoms. In a similar manner, certain Ayurvedic conditions have been grouped into Twak vikara (skin disorders), Udara vikara, Mutra vikara, Mano vikara, vāta vikara, pitta vikara, kapha vikara etc. and an appropriate course of treatment is administered after understanding the possible etiopathogenesis. [44-47] If we analyze doshas, then we observe that all solid and watery contents of our body are made up of kapha. Most enzymes, digestive functions and all warmth in body can be attributed to pitta. And all types of micro or macro-movements in our bodies are performed by vata. Therefore, our body and the associated constituents and life-processes could be attributed to the three doshas, along with body tissues (dhatus), and secretions (mala). In all circumstances, doshas, dhatus and malas play an important role and are considered as roots of the body [A.H.Ni. 11/1]. [48] vata, pitta and kapha are further sub-categorized into five types of each. They all have their specific sites in the body and specific functions applicable to those sites. (Sha.Pu.Kh. 5/27-35). Specific sites of these doshas are mentioned in (Ca.Su. 20/8). [49-51] Many functions and gunas of doshas are mostly interrelated (especially opposite to each other). For instance, vata and kapha properties are mostly opposite to pitta properties. Therefore, their functions increase or decrease in inverse relation to each other. [52] Typical functions of aggravated dosha are described such as emaciation, blackening, willingness of warm things, tremors, flatulence, constipation, impaired body power, insomnia, incapability of grasping objects by sense organs, delirium, vertigo and lustlessness are functions or presentations of aggravated vata. Yellowish discoloration of stool, urine, nails and skin, reduction in appetite, thirst, burning and sleep are due to aggravated pitta, whereas anorexia, excessive salivation, laziness, heaviness, white discoloration of body, coldness and loss of muscle tone, increase in breathlessness, coughing and sleep are due to aggravated kapha [A.H.Su. 11/5-7]. [53] References 1. Charaka samhita ; Nidana sthana - 1/10 2. Charak samhita ; chikitsa sthanam –16/30 3. Pathology by Harsh mohan; chapter-5 page (66-67), 3rd edition 4. Pathology by Harsh mohan; chapter-5 page (64-70), 3rd edition. 5. Manual of practical medicine by R. Alagappan; chapter-3(page-159), 3rd edition. 6. Manual of practical medicine by R. Alagappan, chapter-7 page-369-371, 3rd edition. 7. Manual of practical medicine by R. Alagappan, chapter-3 page-159, 3rd edition. 8. Textbook of microbiology – Orient Longman, chapter-26 page-23, 4th edition.