Kiyanta Shiraseeya Adhyaya

Kiyanta Shiraseeya Adhyaya

Section/Chapter	Sutra Sthana Chapter 17
Tetrad/Sub-section	Roga Chatushka
Preceding Chapter	Chikitsaprabhritiya
Succeeding Chapter	Trishothiya
Other Sections	Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana

(Sutra Sthana Chapter 17, Chapter on the Diseases of the Head)

Abstract

This is the first chapter of Roga Chatushka (tetrad of diseases) dealing with description related to diseases of the trimarma (three vital organs – the head, heart, and the urinary bladder (basti)). The etiopathogenesis of these diseases is detailed. Various diseases are caused due to permutations and combinations of dosha imbalances. The chapter describes signs of depletion of dhatu and mala. It also highlights the disorders of oja as well as madhumeha (diabetes mellitus, a disease of the basti), and carbuncles produced as its complications. This chapter also describes various types of dosha gati (movements of dosha). The comprehensive information about principles of basic Ayurvedic pathology is included in the chapter.

Keywords: Shiroroga (diseases of head), hridaya roga(diseases of heart), imbalances in dosha, dhatu-kshaya, mala-kshaya, pidaka, madhumeha, dosha-gati, sannipata, samsarga, ojokshaya, ojas, signs of depletion of dosha, dhatu and mala, disorders of oja, movement of dosha.

Introduction

After describing the guidelines for clinical Ayurveda practice in tetrad of previous chapters of Nirdesha Chatushka, information about priniciples of basic Ayurvedic pathology in causing disease is detailed in Roga Chatushka (tetrad on disease information).

The present chapter begins with an enumeration of diseases afflicting the head and describes the significance of head, followed by the description of five varieties of head diseases with headache as the main symptom and five types of heart diseases with different clinical presentations. Thereafter, sixty two permutations and combinations in the form of sannipata (involvement of three doshas) and samsarga (involvement of two doshas), based on variations in quantum of increased or decreased state of involved doshas, along with descriptions of symptoms of twelve varieties of sannipata have been described in this chapter. Also described are eighteen conditions caused by decrease of doshas, dhatus, mala and ojas, along with plausible reasons for all the decrease taking place in the body. Further, definition and characteristics of ojas have been provided in brief with a specific variety of Avrita Madhumeha (diabetes due to obstructive vata) in which ojas is excreted out in urine. The description of avrita madhumeha resembles diabetes mellitus type II (NIDDM) and seems to represent the disease of third marma (vital organ) i.e. basti. Skin infection is a common complication of diabetes mellitus. Therefore it is described in detail under the heading of prameha pidika (carbuncles). Seven types of inflammatory swellings viz. sharavika, kacchapika, jalini, sarshapi, alaji, vinata and vidradhi are described in detail with a disclaimer stating that these can also occur independently due to vitiation of medas. The chapter ends with references to various gati (states) of dosha that are related to health as well as disease.

The diseases related to trimarma, or the three vital organs, have also been described in the 26th chapter of Chikitsa Sthana (titled Trimarmiya Chikitsa adhyaya) and later in 9th chapter of Siddhi Sthana (titled Trimarmiya Siddhi Adhyaya). While the Sutra Sthana helps provide the fundamental approaches to treating these diseases, the Chikitsa Sthana primarily addresses the management aspects and Siddhi Sthana describes the internal and external traumas of these organs. As per Ayurveda, there are 107 marmas that are considered to be points of prana (vital energy) and are located in various parts of the body. It is accepted that injuries to marma -external, internal or psychological - may either cause immediate death or permanent deformities (some of which may cause complications and death at a later stage). Among these 107 marmas, Charaka has given utmost importance to the head, the heart and the urinary bladder. Among these three, the head is foremost as it is central to all senses and is the prime location of prana. This is the reason why other texts have compared human body with an inverted-tree model (with roots at the top and branches at the bottom).

The siroroga, or the disease(s) of the head, are various clinical representations of headache and vary depending upon dosha-dominance and krimi-infestation. Though headache is a common form of five major types of siroroga, different manifestations of headache can give an idea of the predominant dosha which may further decide the course of treatment. Similarly hridroga (heart diseases) and diseases associated with the urinary bladder mentioned in this chapter are also due to dosha predominance and krimi infestation.

Various permutations and combinations of dosha have been analysed that help in understanding the pathogenesis of a disease. It is always a matter of debate as to why there are so many diseases and why does a disease have so many different manifestations or forms, depending upon an individual. One answer is that the dosha involved in pathogenesis varies in the forms of either vriddhi (increase) or kshaya (decrease), and that a typical permutation or combination of such doshas can manifest the disease in a different way. The verses 45, 46, and 47 deal with ashayapkarsha (pulling dosha from its location) in which a dominant or increased vata pulls the normal pitta and kapha away from their “seats” and manifests its own features there. Therefore, confusion can occur in the diagnosis and management of the disease. In addition, the concept of vikalpa samprapti (variable pathogenesis) can be a reason for such varied presentations of the disease, since per vikalpa samprapti, the involvement of various properties of dosha may differ depending upon the etiological factors. Eighteen types of kshaya (decreased state) of dosha, dhatu, mala and ojas that may play a significant role in disease pathogenesis are also considered in this chapter. Madhumeha (Diabetes mellitus) which is also termed as ojomeha in other texts is one of the prameha where excessive kshaya of ojas takes place. One of its presentations (or forms) is caused due to avaranajanya samprāpti (obstructive pathogenesis), as explained in this chapter. Madhumeha is one among twenty types of prameha characterised by excessive frequency and quantity of urination. The primary dosha associated with madhumeha is vata and two types of pathogenesis of madhumeha have been discussed in Charaka Samhita. In the first type, dhātukshaya (decreased state of body tissue) causes vata provocation and all the clinical features of a vitiated vata are present in the patient of kshayaja madhumeha (Diabetes mellitus type 1) (Charaka Nidana 4/36-44). In the second type, there is an initial involvement of kapha, pitta, mamsa and medas dhātu, that in turn make avarana (to get covered or overlapped) of vata leading to manifestation of madhumeha (diabetes mellitus type 2) where features of kapha, pitta, medas and mamsa dushti are also observed. Here, therefore, the main line of treatment (i.e., for Type 2) involves pacifying kapha, pitta, medas and mamsa. Various gati of dosha that are responsible for healthy and diseased states are dealt at the end of the chapter. Charaka has also stressed upon the significance of a regular healthy diet. It can be said that in the 17th chapter, a multi-faceted approach to understanding various presentations of diseases has been mentioned, aided with examples.

Sanskrit Text, Transliteration and English Translation

अथातः कियन्तःशिरसीयमध्यायं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

Athātaḥ kiyantaḥśirasīyamadhyāyaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAtaH kiyantaHshirasIyamadhyAyaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

Now we will expound the chapter on 'How many diseases are of the head?’ Thus said Lord Atreya. [1-2]

Queries by Agnivesha

कियन्तः शिरसि प्रोक्ता रोगा हृदि च देहिनाम्| कति चाप्यनिलादीनां रोगा मानविकल्पजाः||३||

क्षयाः कति समाख्याताः पिडकाः कति चानघ!| गतिः कतिविधा चोक्ता दोषाणां दोषसूदन!||४||

kiyantaḥ śirasi prōktā rōgā hr̥di ca dēhinām| kati cāpyanilādīnāṁ rōgā mānavikalpajāḥ||3||

kṣayāḥ kati samākhyātāḥ piḍakāḥ kati cānagha!| gatiḥ katividhā cōktā dōṣāṇāṁ dōṣasūdana!||4||

kiyantaH shirasi proktA rogA hRudi ca dehinAm| kati cApyanilAdInAM rogA mAnavikalpajAH||3||

kShayAH kati samAkhyAtAH piDakAH kati cAnagha!| gatiH katividhA coktA doShANAM doShasUdana!||4||

(Agnivesha asked the questions) “Oh God! How many are the diseases of head and heart of human beings? How many are the disorders caused by the varied combinations of discordant vata and other doshas? How many are the disorders caused by kshaya? How many are the papules (pidika)? O Holy One and Dispeller of Dosha! How many types of gati of dosha are there? [3-4]

Answers by Atreya

हुताशवेशस्य वचस्तच्छ्रुत्वा गुरुरब्रवीत्| पृष्टवानसि यत् सौम्य! तन्मे शृणु सविस्तरम्||५||

hutāśavēśasya vacastacchrutvā gururabravīt| pr̥ṣṭavānasi yat saumya! tanmē śr̥ṇu savistaram||5||

hutAshaveshasya vacastacchrutvA [1] gururabravIt| pRuShTavAnasi yat saumya! tanme shRuNu savistaram||5||

On hearing the above questions of Agnivesha, Guru Atreya said “O gentle one! Hear me for the detailed description” [5]

Number of diseases

दृष्टाः पञ्च शिरोरोगाः पञ्चैव हृदयामयाः| व्याधीनां ह्यधिका षष्टिर्दोषमानविकल्पजा||६||

dr̥ṣṭāḥ pañca śirōrōgāḥ pañcaiva hr̥dayāmayāḥ| vyādhīnāṁ hyadhikā ṣaṣṭirdōṣamānavikalpajā||6||

dRuShTAH pa~jca shirorogAH pa~jcaiva hRudayAmayAH| vyAdhInAM hyadhikA ShaShTirdoShamAnavikalpajA||6||

“There are five shiroroga (diseases of head) and five hridroga (diseases of heart). On the basis of permutations and combinations of dosha, there are sixty-two disorders” [6]

दशाष्टौ च क्षयाः सप्त पिडका माधुमेहिकाः| दोषाणां त्रिविधा चोक्ता गतिर्विस्तरतः शृणु||७||

daśāṣṭau ca kṣayāḥ sapta piḍakā mādhumēhikāḥ| dōṣāṇāṁ trividhā cōktā gatirvistarataḥ śr̥ṇu||7||

dashAShTau ca kShayAH sapta piDakA mAdhumehikAH| doShANAM trividhA coktA gatirvistarataH [2] shRuNu||7||

“There are eighteen varieties of kshaya, seven varieties of pidika (pustule/carbuncles) caused due to madhumeha and three courses (gati) of dosha. These are being described in detail henceforth” [7]

Causes of diseases of head

सन्धारणाद्दिवास्वप्नाद्रात्रौ जागरणान्मदात्| उच्चैर्भाष्यादवश्यायात् प्राग्वातादतिमैथुनात्||८||

गन्धादसात्म्यादाघ्राताद्रजोधूमहिमातपात्| गुर्वम्लहरितादानादति शीताम्बुसेवनात्||९||

शिरोऽभिघाताद्दुष्टामाद्रोदनाद्बाष्पनिग्रहात् | मेघागमान्मनस्तापाद्देशकालविपर्ययात्||१०||

वातादयः प्रकुप्यन्ति शिरस्यस्रं च दुष्यति| ततः शिरसि जायन्ते रोगा विविधलक्षणाः||११||

sandhāraṇāddivāsvapnādrātrau jāgaraṇānmadāt| uccairbhāṣyādavaśyāyāt prāgvātādatimaithunāt||8||

gandhādasātmyādāghrātādrajōdhūmahimātapāt| gurvamlaharitādānādati śītāmbusēvanāt||9||

śirō'bhighātādduṣṭāmādrōdanādbāṣpanigrahāt | mēghāgamānmanastāpāddēśakālaviparyayāt||10||

vātādayaḥ prakupyanti śirasyasraṁ ca duṣyati| tataḥ śirasi jāyantē rōgā vividhalakṣaṇāḥ||11||

sandhAraNAddivAsvapnAdrAtrau jAgaraNAnmadAt| uccairbhAShyAdavashyAyAt prAgvAtAdatimaithunAt||8||

gandhAdasAtmyAdAghrAtAdrajodhUmahimAtapAt| gurvamlaharitAdAnAdati shItAmbusevanAt||9|| shiro~abhighAtAdduShTAmAdrodanAdbAShpanigrahAt [1] |

meghAgamAnmanastApAddeshakAlaviparyayAt||10|| vAtAdayaH prakupyanti shirasyasraM ca duShyati| tataH shirasi jAyante rogA vividhalakShaNAH||11||

Suppression of natural urges, day-sleep, insomnia, intoxication, talking too loudly, exposure to frost, exposure to wind from the front, excessive sex, inhalation of unwholesome (or toxic) smell, exposure to dust, smoke, cold and sun, over eating of heavy, sour and green food, use of very cold water, trauma to the head, formation of products of improper digestion and metabolism in the body (i.e., ama), excessive weeping or suppression of tears, cloudy weather, irritation of mind/anxiety (manastapa), and anomalous climate/season are the general causative factors of shiroroga. The above factors provoke or vitiate vata, affecting rakta (blood circulation) in the head leading to shiroroga with various symptoms [8-11]

Importance of the Head

प्राणाः प्राणभृतां यत्र श्रिताः सर्वेन्द्रियाणि च| यदुत्तमाङ्गमाङ्गानां शिरस्तदभिधीयते||१२||

prāṇāḥ prāṇabhr̥tāṁ yatra śritāḥ sarvēndriyāṇi ca| yaduttamāṅgamāṅgānāṁ śirastadabhidhīyatē||12||

prANAH prANabhRutAM yatra shritAH sarvendriyANi ca| yaduttamA~ggamA~ggAnAM shirastadabhidhIyate||12||

Shira (head) is foremost among all organs as it is the region of the body where the vital centres and all the senses (indriya) of a living-being are located It is vital (uttama) amongst all the other organs of the body [12]

Diseases of the Head

अर्धावभेदको वा स्यात् सर्वं वा रुज्यते शिरः| प्रतिश्यामुखनासाक्षिकर्णरोगशिरोभ्रमाः||१३||

अर्दितं शिरसः कम्पो गलमन्याहनुग्रहः| विविधाश्चापरे रोगा वातादिक्रिमिसम्भवाः||१४||

ardhāvabhēdakō vā syāt sarvaṁ vā rujyatē śiraḥ| pratiśyāmukhanāsākṣikarṇarōgaśirōbhramāḥ||13||

arditaṁ śirasaḥ kampō galamanyāhanugrahaḥ| vividhāścāparē rōgā vātādikrimisambhavāḥ||14||

ardhAvabhedako vA syAt sarvaM vA rujyate shiraH| pratishyAmukhanAsAkShikarNarogashirobhramAH||13||

arditaM shirasaH kampo galamanyAhanugrahaH| vividhAshcApare rogA vAtAdikrimisambhavAH||14||

Hemicrania (ardhavabhedaka), headache (sarvam va rujyate shiraḥ) (i.e., that which may involve whole of head), coryza (pratishyaya), disorders of mouth, nose, eyes, and ears (mukhanasakshikarṇaroga), giddiness/vertigo (shirobhramaḥ), facial paralysis (ardita), tremors of the head (shirasaḥ kampa), stiffness of the neck, nape and jaw (galamanyāhanugrahah) and other such diseases of the head are caused by dosha and micro-organisms/worms (krimi). [13-14]

Types of Diseases of Head

पृथग्दिष्टास्तु ये पञ्च सङ्ग्रहे परमर्षिभिः| शिरोगदांस्ताञ्छृणु मे यथास्वैर्हेतुलक्षणैः||१५||

pr̥thagdiṣṭāstu yē pañca saṅgrahē paramarṣibhiḥ| śirōgadāṁstāñchr̥ṇu mē yathāsvairhētulakṣaṇaiḥ||15||

pRuthagdiShTAstu ye pa~jca sa~ggrahe paramarShibhiH| shirogadAMstA~jchRuNu me yathAsvairhetulakShaNaiH||15||

As mentioned in Ashtodariya Adhyaya, there are five types of shiroroga that are described here with their etiological factors , signs and symptoms [15]

Vata-dominant diseases of the Head

उच्चैर्भाष्यातिभाष्याभ्यां तीक्ष्णपानात् प्रजागरात्| शीतमारुतसंस्पर्शाद्व्यवायाद्वेगनिग्रहात्||१६||

उपवासादभीघाताद्विरेकाद्वमनादति| बाष्पशोकभयत्रासाद्भारमार्गातिकर्शनात्||१७||

शिरोगताः सिरा वृद्धो वायुराविश्य कुप्यति| ततः शूलं महत्तस्य वातात् समुपजायते||१८||

uccairbhāṣyātibhāṣyābhyāṁ tīkṣṇapānāt prajāgarāt| śītamārutasaṁsparśādvyavāyādvēganigrahāt||16||

upavāsādabhīghātādvirēkādvamanādati| bāṣpaśōkabhayatrāsādbhāramārgātikarśanāt||17||

śirōgatāḥ sirā vr̥ddhō vāyurāviśya kupyati| tataḥ śūlaṁ mahattasya vātāt samupajāyatē||18||

uccairbhAShyAtibhAShyAbhyAM tIkShNapAnAt [1] prajAgarAt| shItamArutasaMsparshAdvyavAyAdveganigrahAt||16||

upavAsAdabhIghAtAdvirekAdvamanAdati| bAShpashokabhayatrAsAdbhAramArgAtikarshanAt||17||

shirogatAH [2] sirA vRuddho vAyurAvishya kupyati| tataH shUlaM mahattasya vAtAt samupajAyate||18||

Indulgence in loud speech, excessive talk, strong drinks, awaking till late night, exposure to cold wind, excessive sexual act, suppression of natural physical urges, fasting, trauma, excessive/strong vamana or virechana, excessive weeping, grief, fear, terror, excessive-load carrying, way-faring, severe emaciation leads to provocation of vata which by affecting the vessels of the head gets further provoked and produces severe pain in head [16-18]

निस्तुद्येते भृशं शङ्कौ घाटा सम्भिद्यते तथा| सभ्रूमध्यं ललाटं च तपतीवातिवेदनम्||१९||

वध्येते स्वनतः श्रोत्रे निष्कृष्येते इवाक्षिणी| घूर्णतीव शिरः सर्वं सन्धिभ्य इव मुच्यते||२०||

स्फुरत्यति सिराजालं स्तभ्यते च शिरोधरा| स्निग्धोष्णमुपशेते च शिरोरोगेऽनिलात्मके||२१||

nistudyētē bhr̥śaṁ śaṅkau ghāṭā sambhidyatē tathā| sabhrūmadhyaṁ lalāṭaṁ ca tapatīvātivēdanam||19||

vadhyētē svanataḥ śrōtrē niṣkr̥ṣyētē ivākṣiṇī| ghūrṇatīva śiraḥ sarvaṁ sandhibhya iva mucyatē||20||

sphuratyati sirājālaṁ stabhyatē ca śirōdharā| snigdhōṣṇamupaśētē ca śirōrōgē'nilātmakē||21||

nistudyete bhRushaM sha~gkau ghATA [3] sambhidyate tathA| sabhrUmadhyaM [4] lalATaM ca tapatIvAtivedanam||19||

vadhyete [5] svanataH shrotre niShkRuShyete ivAkShiNI| ghUrNatIva shiraH sarvaM sandhibhya iva mucyate||20||

sphuratyati sirAjAlaM stabhyate ca shirodharA| snigdhoShNamupashete ca shiroroge~anilAtmake||21||

Intense pain in both the temples, splitting sensation in the nape, excessive heat and pain in forehead and between the eyebrows region, severe cutting pain and dissonances in ear, feeling as if the eyes are being gouged out, dizziness, sense of separateness in all the joints, excessive throbs in blood vasculature, stiffness of neck are the symptoms of vataja shiroroga. Use of hot and unctuous things provides relief in vata type of headache [19-21]

Pitta-dominant diseases of the Head

कट्वम्ललवणक्षारमद्यक्रोधातपानलैः| पित्तं शिरसि सन्दुष्टं शिरोरोगाय कल्पते||२२||

kaṭvamlalavaṇakṣāramadyakrōdhātapānalaiḥ| pittaṁ śirasi sanduṣṭaṁ śirōrōgāya kalpatē||22||

kaTvamlalavaNakShAramadyakrodhAtapAnalaiH| pittaM shirasi sanduShTaM shirorogAya kalpate||22||

Excessive use of pungent, sour, salty and alkali substances and wine, exposure to sun (or heat) and anger leads to provocation of pitta, which by lodging in the head produces paittika shiroroga [22]

Symptoms of pittaja shiroroga

दह्यते रुज्यते तेन शिरः शीतं सुषूयते | दह्येते चक्षुषी तृष्णा भ्रमः स्वेदश्च जायते||२३||

dahyatē rujyatē tēna śiraḥ śītaṁ suṣūyatē | dahyētē cakṣuṣī tr̥ṣṇā bhramaḥ svēdaśca jāyatē||23|| dahyate rujyate tena shiraH shItaM suShUyate [1] | dahyete cakShuShI tRuShNA bhramaH svedashca jAyate||23||

Burning sensation and pain in the head, desire for cold things, burning sensation in the eyes, thirst, giddiness and perspiration are the symptoms of paittika shiroroga [23]

Kapha-dominant diseases of head

आस्यासुखैः स्वप्नसुखैर्गुरुस्निग्धातिभोजनैः| श्लेष्मा शिरसि सन्दुष्टः शिरोरोगाय कल्पते||२४||

āsyāsukhaiḥ svapnasukhairgurusnigdhātibhōjanaiḥ| ślēṣmā śirasi sanduṣṭaḥ śirōrōgāya kalpatē||24||

AsyAsukhaiH svapnasukhairgurusnigdhAtibhojanaiH| shleShmA shirasi sanduShTaH shirorogAya kalpate||24||

Due to sedentary life-style, excessive sleep, indulgence in intake of heavy and unctuous meals or excessive food intake, kapha gets provoked in the head and produces kaphaja shiroroga [24]

Symptoms of kaphaja shiroroga

शिरो मन्दरुजं तेन सुप्तं स्तिमितभारिकम्| भवत्युत्पद्यते तन्द्रा तथाऽऽलस्यमरोचकः||२५||

śirō mandarujaṁ tēna suptaṁ stimitabhārikam| bhavatyutpadyatē tandrā tathālasyamarōcakaḥ||25||

shiro mandarujaM tena suptaM stimitabhArikam| bhavatyutpadyate tandrA tathA~a~alasyamarocakaH||25||

Dull headache, numbness, stiffness and heaviness in head, drowsiness, laziness and anorexia are the symptoms of kaphaja shiroroga [25]

Three dosha-dominant disease of head

वाताच्छूलं भ्रमः कम्पः पिताद्दाहो मदस्तृषा| कफाद्गुरुत्वं तन्द्रा च शिरोरोगे त्रिदोषजे||२६||

vātācchūlaṁ bhramaḥ kampaḥ pitāddāhō madastr̥ṣā| kaphādgurutvaṁ tandrā ca śirōrōgē tridōṣajē||26||

vAtAcchUlaM bhramaH kampaH pitAddAho madastRuShA| kaphAdgurutvaM tandrA ca shiroroge tridoShaje||26||

In tridoshaja shiroroga aching pain, giddiness and tremors occur due to vata, burning sensation, intoxication and thirst occur due to pitta, and heaviness and drowsiness occur due to kapha [26]

Etiological factors and pathogenesis of disease of head due to parasites/micro-organisms (krimija shiroroga)

तिलक्षीरगुडाजीर्णपूतिसङ्कीर्णभोजनात्| क्लेदोऽसृक्कफमांसानां दोषलस्योपजायते||२७||

ततः शिरसि सङ्क्लेदात् क्रिमयः पापकर्मणः| जनयन्ति शिरोरोगं जाता बीभत्सलक्षणम्||२८||

tilakṣīraguḍājīrṇapūtisaṅkīrṇabhōjanāt| klēdō'sr̥kkaphamāṁsānāṁ dōṣalasyōpajāyatē||27||

tataḥ śirasi saṅklēdāt krimayaḥ pāpakarmaṇaḥ| janayanti śirōrōgaṁ jātā bībhatsalakṣaṇam||28||

tilakShIraguDAjIrNapUtisa~gkIrNabhojanAt| kledo~asRukkaphamAMsAnAM doShalasyopajAyate||27||

tataH shirasi sa~gkledAt krimayaH pApakarmaNaH| janayanti shirorogaM jAtA bIbhatsalakShaNam||28||

When a person with provoked dosha indulges in excessive intake of sesame, milk, molasses,takes meals even when previous meal has not properly digested, eats putrefied or promiscuous food, and/or takes incompatible diet - it causes pathological discharges of rakta, kapha and māmsa, wherein parasites are produced, leading to krimija shiroroga with dreadful symptoms [27-28]

Symptoms of krimaja shiroroga

व्यधच्छेदरुजाकण्डूशोफदौर्गत्यदुःखितम् | क्रिमिरोगातुरं विद्यात् क्रिमीणां दर्शनेन च||२९||

vyadhacchēdarujākaṇḍūśōphadaurgatyaduḥkhitam | krimirōgāturaṁ vidyāt krimīṇāṁ darśanēna ca||29||

vyadhacchedarujAkaNDUshophadaurgatyaduHkhitam [1] | krimirogAturaM vidyAt krimINAM darshanena [2] ca||29||

The patient of krimija shiroroga suffers from piercing, cutting or aching pains in the head with itching, swelling and foul smelling and detectable parasites [29]

Etiological factors and pathogenesis of vata-dominant disease of heart (vataja hridroga)

शोकोपवासव्यायामरूक्षशुष्काल्पभोजनैः | वायुराविश्य हृदयं जनयत्युत्तमां रुजम्||३०||

śōkōpavāsavyāyāmarūkṣaśuṣkālpabhōjanaiḥ | vāyurāviśya hr̥dayaṁ janayatyuttamāṁ rujam||30||

shokopavAsavyAyAmarUkShashuShkAlpabhojanaiH [1] | vAyurAvishya hRudayaM janayatyuttamAM rujam||30||

Grief, fasting, over-exercise, intake of rough (non oily or ununctuous) or dry food articles, or food items of low nutritional value are the key etiological factors of vatika hridroga. Provoked vata , due to these causes, produces severe chest pain by affecting the heart [30]

Symptoms of vatika hridroga

वेपथुर्वेष्टनं स्तम्भः प्रमोहः शून्यता दरः | हृदि वातातुरे रूपं जीर्णे चात्यर्थवेदना||३१||

vēpathurvēṣṭanaṁ stambhaḥ pramōhaḥ śūnyatā daraḥ | hr̥di vātāturē rūpaṁ jīrṇē cātyarthavēdanā||31||

vepathurveShTanaM stambhaH pramohaH shUnyatA daraH [2] | hRudi vAtAture rUpaM jIrNe cAtyarthavedanA||31||

The symptoms of vataja hridroga are extra systole/ fibrillation, cardiac cramps, pauses in cardiac beats, stupor, sensation of emptiness in the cardiac region, and murmur (dara). The patient suffers from severe chest pain at the time of completion of digestion of the meal [31]

Etiological factors and pathogenesis of pitta-dominant heart diseases (paittika hridroga)

उष्णाम्ललवणक्षारकटुकाजीर्णभोजनैः| मद्यक्रोधातपैश्चाशु हृदि पित्तं प्रकुप्यति||३२||

uṣṇāmlalavaṇakṣārakaṭukājīrṇabhōjanaiḥ| madyakrōdhātapaiścāśu hr̥di pittṁ prakupyati||32||

uShNAmlalavaNakShArakaTukAjIrNabhojanaiH| madyakrodhAtapaishcAshu hRudi pittM prakupyati||32||

Excessive intake of hot, sour, pungent, salty and alkaline food articles, alcohol, exposure to sun, and anger are the etiological factors of paittika hridroga [32]

Symptoms of paittika hridroga

हृद्दाहस्तिक्तता वक्रे तिक्ताम्लोद्गिरणं क्लमः| तृष्णा मूर्च्छा भ्रमः स्वेदः पित्तहृद्रोगलक्षणम्||३३||

hr̥ddāhastiktatā vakrē tiktāmlōdgiraṇaṁ klamaḥ| tr̥ṣṇā mūrcchā bhramaḥ svēdaḥ pittahr̥drōgalakṣaṇam||33||

hRuddAhastiktatA vakre tiktAmlodgiraNaM klamaH| tRuShNA mUrcchA bhramaH svedaH pittahRudrogalakShaNam||33||

Burning sensation in the precordial region, bitter taste in mouth, sour eructation, exhaustion, thirst, fainting, giddiness and perspiration are the symptoms of paittika hridroga [33]

Etiological factors and pathogenesis of kapha-dominant heart diseases (kaphaja hridroga)

अत्यादानं गुरुस्निग्धमचिन्तनमचेष्टनम्| निद्रासुखं चाभ्यधिकं कफहृद्रोगकारणम्||३४||

atyādānaṁ gurusnigdhamacintanamacēṣṭanam| nidrāsukhaṁ cābhyadhikaṁ kaphahr̥drōgakāraṇam||34||

atyAdAnaM gurusnigdhamacintanamaceShTanam| nidrAsukhaM cAbhyadhikaM kaphahRudrogakAraNam||34||

Over-eating, intake of heavy and fatty food substances, worry-free and sedentary lifestyle, excessive sleep are the etiological factors of kaphaja hridroga [34]

Symptoms of kaphaja hridroga

हृदयं कफहृद्रोगे सुप्तं स्तिमितभारिकम्| तन्द्रारुचिपरीतस्य भवत्यश्मावृतं यथा||३५||

hr̥dayaṁ kaphahr̥drōgē suptaṁ stimitabhārikam| tandrāruciparītasya bhavatyaśmāvr̥taṁ yathā||35||

hRudayaM kaphahRudroge suptaM stimitabhArikam| tandrAruciparItasya bhavatyashmAvRutaM yathA||35||

Numbness, stiffness and heaviness in the precordial area, a stony sensation in the heart region, drowsiness and anorexia are the symptoms of kaphaja hridroga [35]

Etiological factors and pathogenesis of three dosha-dominant heart diseases (tridoshaja hridroga)

हेतुलक्षणसंसर्गादुच्यते सान्निपातिकः| (हृद्रोगः कष्टदः कष्टसाध्य उक्तो महर्षिभिः)

hētulakṣaṇasaṁsargāducyatē sānnipātikaḥ| (hr̥drōgaḥ kaṣṭadaḥ kaṣṭasādhya uktō maharṣibhiḥ)

hetulakShaNasaMsargAducyate sAnnipAtikaH| (hRudrogaH kaShTadaH kaShTasAdhya ukto maharShibhiH)

In tridoshaja hridroga, the etiological factors and symptoms of all the three doshika types of hridroga are present. (tridoshaja hridroga is considered most troublesome disease by great sages)[35½]

Etiological factors and pathogenesis of krimija hridroga

त्रिदोषजे तु हृद्रोगे यो दुरात्मा निषेवते||३६||

तिलक्षीरगुडादीनि ग्रन्थिस्तस्योपजायते| मर्मैकदेशे सङ्क्लेदं रसश्चास्योपगच्छति||३७||

सङ्क्लेदात् क्रिमयश्चास्य भवन्त्युपहतात्मनः| मर्मैकदेशे ते जाताः सर्पन्तो भक्षयन्ति च||३८||

tridōṣajē tu hr̥drōgē yō durātmā niṣēvatē||36||

tilakṣīraguḍādīni granthistasyōpajāyatē| marmaikadēśē saṅklēdaṁ rasaścāsyōpagacchati||37||

saṅklēdāt krimayaścāsya bhavantyupahatātmanaḥ| marmaikadēśē tē jātāḥ sarpantō bhakṣayanti ca||38||

tridoShaje tu hRudroge yo durAtmA niShevate||36||

tilakShIraguDAdIni granthistasyopajAyate| marmaikadeshe sa~gkledaM rasashcAsyopagacchati||37||

sa~gkledAt krimayashcAsya bhavantyupahatAtmanaH| marmaikadeshe te jAtAH sarpanto bhakShayanti ca||38||

An unfortunate person already suffering from tridoshaja hridroga, if further indulges in excessive intake of sesame, milk, and molasses, then he develops thrombosis (granthi) in the rasavaha srotas of the heart, leading to softening of the affected area and making it vulnerable to worm infestations. This infestation then spreads and consumes (bhakṣyanti) the heart tissues. It is krimija hridroga [36-38]

Symptoms of krimija hridroga

तुद्यमानं स हृदयं सूचीभिरिव मन्यते| छिद्यमानं यथा शस्त्रैर्जातकण्डूं महारुजम्||३९||

हृद्रोगं क्रिमिजं त्वेतैर्लिङ्गैर्बुद्ध्वा सुदारुणम्| त्वरेत जेतुं तं विद्वान् विकारं शीघ्रकारिणम्||४०||

tudyamānaṁ sa hr̥dayaṁ sūcībhiriva manyatē| chidyamānaṁ yathā śastrairjātakaṇḍūṁ mahārujam||39||

hr̥drōgaṁ krimijaṁ tvētairliṅgairbuddhvā sudāruṇam| tvarēta jētuṁ taṁ vidvān vikāraṁ śīghrakāriṇam||40||

tudyamAnaM sa hRudayaM sUcIbhiriva manyate| chidyamAnaM yathA shastrairjAtakaNDUM mahArujam||39||

hRudrogaM krimijaM tvetairli~ggairbuddhvA sudAruNam| tvareta jetuM taM vidvAn vikAraM shIghrakAriNam||40||

The patient of krimija hridroga feels severe pain in the precordial region and complains of itching, as if the heart is being pricked and pierced with needles or cut open by weapons. Krimija hridroga is a very grave heart condition and may lead to immediate death. Therefore it should be promptly diagnosed and managed [39-40]

Sixty two permutations and combinations of samsarga and tridosha

(I). Thirteen types of sannipata

द्व्युल्बणैकोल्बणैः षट् स्युर्हीनमध्याधिकैश्च षट्| समैश्चैको विकारास्ते सन्निपातास्त्रयोदश||४१||

dvyulbaṇaikōlbaṇaiḥ ṣaṭ syurhīnamadhyādhikaiśca ṣaṭ| samaiścaikō vikārāstē sannipātāstrayōdaśa||41||

dvyulbaNaikolbaNaiH ShaT syurhInamadhyAdhikaishca ShaT| samaishcaiko vikArAste sannipAtAstrayodasha||41||

There are 13 conditions of sannipata of dosha (combination of all three dosha), out of these, three conditions are with a dominance of two doshas (other one dosha comparatively less increased), three conditions are with dominance of only one dosha (others two dosha comparatively less increased), six conditions with diminished, moderate and dominant doshas, and one condition with equal aggravation of all three doshas [41]

(II). Nine types of samsarga

संसर्गे नव षट् तेभ्य एकवृद्ध्या समैस्त्रयः| पृथक् त्रयश्च तैर्वृद्धैर्व्याधयः पञ्चविंशतिः||४२||

saṁsargē nava ṣaṭ tēbhya ēkavr̥ddhyā samaistrayaḥ| pr̥thak trayaśca tairvr̥ddhairvyādhayaḥ pañcaviṁśatiḥ||42||

saMsarge nava ShaT tebhya [1] ekavRuddhyA samaistrayaH| pRuthak trayashca tairvRuddhairvyAdhayaH pa~jcaviMshatiH||42|| Samsarga means a combination of two provoked dosha and there are nine such combinations or samsargas. Of these, six samsargas have one dosha more provoked than the other. In the remaining three cases, both dosha are equally increased [42]

(III). Twenty-five conditions of kshina dosha

यथा वृद्धैस्तथा क्षीणैर्दोषेः स्युः पञ्चविंशतिः|

yathā vr̥ddhaistathā kṣīṇairdōṣēḥ syuḥ pañcaviṁśatiḥ|

yathA vRuddhaistathA kShINairdoSheH syuH pa~jcaviMshatiH|

Similar to the combinations of increased dosha mentioned above, there are 25 conditions of kshina (decreased) dosha [42½]

(IV). Twelve sannipata of normal, increased and decreased dosha

वृद्धिक्षयकृतश्चान्यो विकल्प उपदेक्ष्यते||४३||

वृद्धिरेकस्य समता चैकस्यैकस्य सङ्क्षयः| द्वन्द्ववृद्धिः क्षयश्चैकस्यैकवृद्धिर्द्वयोः क्षयः ||४४||

vr̥ddhikṣayakr̥taścānyō vikalpa upadēkṣyatē||43||

vr̥ddhirēkasya samatā caikasyaikasya saṅkṣayaḥ| dvandvavr̥ddhiḥ kṣayaścaikasyaikavr̥ddhirdvayōḥ kṣayaḥ ||44||

vRuddhikShayakRutashcAnyo vikalpa upadekShyate||43||

vRuddhirekasya samatA caikasyaikasya sa~gkShayaH| dvandvavRuddhiH kShayashcaikasyaikavRuddhirdvayoH kShayaH [2] ||44||

There is another form of sannipata where the doshas are present in normal, decreased or increased combinations, and such cases are of 12 types there. Out of these, six conditions are where one dosha is increased, the second is normal and the third is decreased. In three types of combinations, two dosha are increased and the third decreased. Finally, there are three types of combinations where one dosha is increased and the other two are decreased. [43-44]

Twelve types of irregular (vishama) sannipata (combination of dosha)

1. Normal pitta, decreased kapha and increased vata sannipata

प्रकृतिस्थं यदा पित्तं मारुतः श्लेष्मणः क्षये| स्थानादादाय गात्रेषु यत्र यत्र विसर्पति||४५||

तदा भेदश्च दाहश्च तत्र तत्रानवस्थितः| गात्रदेशे भवत्यस्य श्रमो दौर्बल्यमेव च||४६||

prakr̥tisthaṁ yadā pittaṁ mārutaḥ ślēṣmaṇaḥ kṣayē| sthānādādāya gātrēṣu yatra yatra visarpati||45||

tadā bhēdaśca dāhaśca tatra tatrānavasthitaḥ| gātradēśē bhavatyasya śramō daurbalyamēva ca||46||

prakRutisthaM yadA pittaM mArutaH shleShmaNaH kShaye| sthAnAdAdAya gAtreShu yatra yatra visarpati||45||

tadA bhedashca dAhashca tatra tatrAnavasthitaH| gAtradeshe bhavatyasya shramo daurbalyameva ca||46||

In a condition where kapha is decreased, vata that takes out normal pitta from its site and spreads it within the body. Wherever this pitta is placed, there is intermittent breaking pain and burning sensation as well as fatigue and weakness [46]

2.Normal kapha, increased vata and decreased pitta sannipata

प्रकृतिस्थं कफं वायुः क्षीणे पित्ते यदा बली| कर्षेत् कुर्यात्तदा शूलं सशैत्यस्तम्भगौरवम्||४७||

prakr̥tisthaṁ kaphaṁ vāyuḥ kṣīṇē pittē yadā balī| karṣēt kuryāttadā śūlaṁ saśaityastambhagauravam||47||

prakRutisthaM [1] kaphaM vAyuH kShINe pitte yadA balI| karShet kuryAttadA shUlaM sashaityastambhagauravam||47||

In a condition of decreased pitta, the increased vata that takes out normal kapha from its site and spreads it within the body. Wherever this kapha is placed, there is coliky pain, coldness, stiffness and heaviness [47]

3. Normal vata, decreased kapha, and increased pitta sannipata

यदाऽनिलं प्रकृतिगं पित्तं कफपरिक्षये| संरुणद्धि तदा दाहः शूलं चास्योपजायते||४८||

yadā'nilaṁ prakr̥tigaṁ pittaṁ kaphaparikṣayē| saṁruṇaddhi tadā dāhaḥ śūlaṁ cāsyōpajāyatē||48||

yadA~anilaM [2] prakRutigaM pittaM kaphaparikShaye| saMruNaddhi tadA dAhaH shUlaM cAsyopajAyate||48||

In a condition of grossly decreased kapha, when increased pitta obstructs the pathway of normal vata, causing burning sensation and coliky pain (shula) [48]

4. Normal kapha, decreased vata, and increased pitta sannipata

श्लेष्माणं हि समं पित्तं यदा वातपरिक्षये| सन्निरुन्ध्यात्तदा कुर्यात् सतन्द्रागौरवं ज्वरम्||४९||

ślēṣmāṇaṁ hi samaṁ pittaṁ yadā vātaparikṣayē| sannirundhyāttadā kuryāt satandrāgauravaṁ jvaram||49||

shleShmANaM [3] hi samaM pittaM yadA vAtaparikShaye| sannirundhyAttadA kuryAt satandrAgauravaM jvaram||49||

In case of a grossly decreased vata, increased pitta obstructs the normal kapha, causing fever accompanied with a feeling of heaviness and drowsiness [49]

5. Normal vata, decreased pitta, and increased kapha sannipata

प्रवृद्धो हि यदा श्लेष्मा पित्ते क्षीणे समीरणम्| रुन्ध्यात्तदा प्रकुर्वीत शीतकं गौरवं रुजम् ||५०||

pravr̥ddhō hi yadā ślēṣmā pittē kṣīṇē samīraṇam| rundhyāttadā prakurvīta śītakaṁ gauravaṁ rujam ||50||

pravRuddho hi yadA shleShmA pitte kShINe samIraNam| rundhyAttadA prakurvIta shItakaM gauravaM rujam [4] ||50||

In the case of decreased pitta, if increased kapha obstructs the normal vata leading to a sensation of cold, heaviness and pain [50]

6. Increased kapha, normal pitta, and decreased vata sannipata

समीरणे परिक्षीणे कफः पित्तं समत्वगम्| कुर्वीत सन्निरुन्धानो मृद्वग्नित्वं शिरोग्रहम् ||५१||

निद्रां तन्द्रां प्रलापं च हृद्रोगं गात्रगौरवम्| नखादीनां च पीतत्वं ष्ठीवनं कफपित्तयोः||५२||

samīraṇē parikṣīṇē kaphaḥ pittaṁ samatvagam| kurvīta sannirundhānō mr̥dvagnitvaṁ śirōgraham ||51||

nidrāṁ tandrāṁ pralāpaṁ ca hr̥drōgaṁ gātragauravam| nakhādīnāṁ ca pītatvaṁ ṣṭhīvanaṁ kaphapittayōḥ||52||

samIraNe parikShINe kaphaH pittaM samatvagam| kurvIta sannirundhAno mRudvagnitvaM shirograham [5] ||51||

nidrAM tandrAM pralApaM ca hRudrogaM gAtragauravam| nakhAdInAM ca pItatvaM ShThIvanaM kaphapittayoH||52||

In case of decreased vata, if increased kapha obstructs the normal pitta then it causes slow digestion,stiffness of head, excessive sleep, drowsiness, delirium, cardiac diseases, heaviness in the body, yellowness in nails etc and excess discharge of kapha-pitta[51-52]

7. Decreased vata,increased kapha, and pitta sannipata

हीनवातस्य तु श्लेष्मा पित्तेन सहितश्चरन्| करोत्यरोचकापाकौ सदनं गौरवं तथा||५३||

हृल्लासमास्यस्रवणं पाण्डुतां दूयनं मदम्| विरेकस्य च वैषम्यं वैषम्यमनलस्य च||५४||

hīnavātasya tu ślēṣmā pittēna sahitaścaran| karōtyarōcakāpākau sadanaṁ gauravaṁ tathā||53||

hr̥llāsamāsyasravaṇaṁ pāṇḍutāṁ dūyanaṁ madam| virēkasya ca vaiṣamyaṁ vaiṣamyamanalasya ca||54||

hInavAtasya tu shleShmA pittena sahitashcaran| karotyarocakApAkau sadanaM gauravaM tathA||53||

hRullAsamAsyasravaNaM pANDutAM dUyanaM madam| virekasya ca vaiShamyaM vaiShamyamanalasya ca||54||

In case of decreased vata when increased kapha, pitta spreads in the body causing anorexia, indigestion, asthenia, heaviness, nausea, salivation, anaemia, fumes sensation of mouth, throat and palate (dūyana), intoxication and irregularity of bowels and digestion [53-54]

8. Decreased pitta, increased kapha, and vata sannipata

हीनपित्तस्य तु श्लेष्मा मारुतेनोपसंहितः| स्तम्भं शैत्यं च तोदं च जनयत्यनवस्थितम्||५५||

गौरवं मृदुतामग्नेर्भक्ताश्रद्धां प्रवेपनम्| नखादीनां च शुक्लत्वं गात्रपारुष्यमेव च||५६||

hīnapittasya tu ślēṣmā mārutēnōpasaṁhitaḥ| stambhaṁ śaityaṁ ca tōdaṁ ca janayatyanavasthitam||55||

gauravaṁ mr̥dutāmagnērbhaktāśraddhāṁ pravēpanam| nakhādīnāṁ ca śuklatvaṁ gātrapāruṣyamēva ca||56||

hInapittasya tu shleShmA mArutenopasaMhitaH| stambhaM shaityaM ca todaM ca janayatyanavasthitam||55||

gauravaM mRudutAmagnerbhaktAshraddhAM pravepanam| nakhAdInAM ca shuklatvaM gAtrapAruShyameva ca||56||

In case of decreased pitta, the increased kapha and vata combine together , causing stiffness, coldness, unstable pricking pain, heaviness, diminution of digestion, disinclination for food, tremors, pallor of nails etc., and roughness of the body parts [53-56]

9. Decreased kapha, increased vata and pitta sannipata

मारुतस्तु कफे हीने पित्तं च कुपितं द्वयम्| करोति यानि लिङ्गानि शृणु तानि समासतः||५७||

भ्रममुद्वेष्टनं तोदं दाहं स्फुटनवेपने| अङ्गमर्दं परीशोषं दूयनं धूपनं तथा||५८||

mārutastu kaphē hīnē pittaṁ ca kupitaṁ dvayam| karōti yāni liṅgāni śr̥ṇu tāni samāsataḥ||57||

bhramamudvēṣṭanaṁ tōdaṁ dāhaṁ sphuṭanavēpanē| aṅgamardaṁ parīśōṣṁ dūyanaṁ dhūpanaṁ tathā||58||

mArutastu kaphe hIne pittaM ca kupitaM dvayam| karoti yAni li~ggAni shRuNu tAni samAsataH||57||

bhramamudveShTanaM todaM dAhaM sphuTanavepane| a~ggamardaM parIshoShM dUyanaM dhUpanaM tathA||58||

In case of decreased kapha and an increased vata and pitta combine together, causing giddiness, cramps, pricking pain, burning sensation, disruption, tremors, body-ache, dehydration, burning of mouth, throat and palate and smoke from mouth [57-58]

10. Decreased vata and pitta and increased kapha sannipata

वातपित्तक्षये श्लेष्मा स्रोतांस्यपिदधद्भृशम्| चेष्टाप्रणाशं मूर्च्छां च वाक्सङ्गं च करोति हि||५९||

vātapittakṣayē ślēṣmā srōtāṁsyapidadhadbhr̥śam| cēṣṭāpraṇāśaṁ mūrcchāṁ ca vāksaṅgaṁ ca karōti hi||59||

vAtapittakShaye shleShmA srotAMsyapidadhadbhRusham| ceShTApraNAshaM mUrcchAM ca vAksa~ggaM ca karoti hi||59||

In case of decreased vata and pitta and an increased kapha, obstruction of srotas causes complete loss of movement, loss of speech and fainting (59).

11. Decreased vata and kapha and increased pitta sannipata: वातश्लेष्मक्षये पित्तं देहौजः स्रंसयच्चरेत्| ग्लानिमिन्द्रियदौर्बल्यं तृष्णां मूर्च्छां क्रियाक्षयम्||६०|| vātaślēṣmakṣayē pittaṁ dēhaujaḥ sraṁsayaccarēt| glānimindriyadaurbalyaṁ tr̥ṣṇāṁ mūrcchāṁ kriyākṣayam||60|| vAtashleShmakShaye pittaM dehaujaH sraMsayaccaret| glAnimindriyadaurbalyaM tRuShNAM mUrcchAM kriyAkShayam||60|| In case of decreased vata and kapha with an increased pitta, by affecting the ojas causes malaise (glani), asthenia of senses, thirst, fainting and decreased physiological functions (60). 12. Decreased pitta and kapha and increased vata sannipata: पित्तश्लेष्मक्षये वायुर्मर्माण्यतिनिपीडयन्| प्रणाशयति सञ्ज्ञां च वेपयत्यथवा नरम्||६१|| pittaślēṣmakṣayē vāyurmarmāṇyatinipīḍayan| praṇāśayati sañjñāṁ ca vēpayatyathavā naram||61|| pittashleShmakShaye vAyurmarmANyatinipIDayan| praNAshayati sa~jj~jAM ca vepayatyathavA [6] naram||61|| In case of decreased pitta and kapha, an increased vata causes compression of the vital centres, adversely impacts consciousness, or leads to severe tremors throughout the whole body (61). General principle of symptoms of increased and decreased doṣha: दोषाः प्रवृद्धाः स्वं लिङ्गं दर्शयन्ति यथाबलम्| क्षीणा जहति लिङ्गं स्वं, समाः स्वं कर्म कुवेते||६२|| dōṣāḥ pravr̥ddhāḥ svaṁ liṅgaṁ darśayanti yathābalam| kṣīṇā jahati liṅgaṁ svaṁ, samāḥ svaṁ karma kuvētē||62|| doShAH pravRuddhAH svaM li~ggaM darshayanti yathAbalam| kShINA jahati li~ggaM svaM, samAH svaM karma kuvete||62|| An increase in dosha causes a consequent provocation, to the same extent as the increase, of a symptom of a disease. On the other hand a decrease of dosha leads to decreased or reduced functions. In normal conditions, doshas are in an equilibrium (62). Types of kshaya (decrease): वातादीनां रसादीनां मलानामोजसस्तथा| क्षयास्तत्रानिलादीनामुक्तं सङ्क्षीणलक्षणम् ||६३|| vātādīnāṁ rasādīnāṁ malānāmōjasastathā| kṣayāstatrānilādīnāmuktaṁ saṅkṣīṇalakṣaṇam ||63|| vAtAdInAM rasAdInAM malAnAmojasastathA| kShayAstatrAnilAdInAmuktaM sa~gkShINalakShaNam [1] ||63||

Now the symptoms of decrease of doshas, dhatus, mala, (i.e., excreta such as urine, feces, and excreta of nose, ears, eyes and mouth, as well as body hair) and ojas will be described. The symptoms of decreased doshas have already been described. (63). Decrease of rasa: घट्टते सहते शब्दं नोच्चैर्द्रवति शूल्यते| हृदयं ताम्यति स्वल्पचेष्टस्यापि रसक्षये||६४|| ghaṭṭatē sahatē śabdaṁ nōccairdravati śūlyatē| hr̥dayaṁ tāmyati svalpacēṣṭasyāpi rasakṣayē||64|| ghaTTate sahate shabdaM noccairdravati [2] shUlyate| hRudayaM tAmyati svalpaceShTasyApi rasakShaye||64||

Symptoms of diminution of rasa include restlessness (or feeling as if the heart is being churned), intolerance to loud sounds, acceleration of flow (tachycardia), pain and distress even with the slightest exertion (64). Decrease of rakta: परुषा स्फुटिता म्लाना त्वग्रूक्षा रक्तसङ्क्षये| paruṣā sphuṭitā mlānā tvagrūkṣā raktasaṅkṣayē| paruShA sphuTitA mlAnA tvagrUkShA raktasa~gkShaye| Symptoms of decrease of rakta include roughness, cracks, withering and dryness of skin.(65) Decrease of māmsa: मांसक्षये विशेषेण स्फिग्ग्रीवोदरशुष्कता||६५|| māṁsakṣayē viśēṣēṇa sphiggrīvōdaraśuṣkatā||65|| mAMsakShaye visheSheNa sphiggrIvodarashuShkatA||65||

Symptoms of decrease in mamsa include thinning specially of hips, neck and belly (65). Decrease of medas: सन्धीनां स्फुटनं ग्लानिरक्ष्णोरायास एव च| लक्षणं मेदसि क्षीणे तनुत्वं चोदरस्य च||६६|| sandhīnāṁ sphuṭanaṁ glānirakṣṇōrāyāsa ēva ca| lakṣaṇaṁ mēdasi kṣīṇē tanutvaṁ cōdarasya ca||66|| sandhInAM sphuTanaM glAnirakShNorAyAsa eva ca| lakShaNaM medasi kShINe tanutvaM [3] codarasya ca||66||

Symptoms of decrease of medas include cracking of the joints, lassitude of eyes, exhaustion and thinning of the abdomen (66). Decrease of asthi: केशलोमनखश्मश्रुद्विजप्रपतनं श्रमः| ज्ञेयमस्थिक्षये लिङ्गं सन्धिशैथिल्यमेव च||६७|| kēśalōmanakhaśmaśrudvijaprapatanaṁ śramaḥ| jñēyamasthikṣayē liṅgaṁ sandhiśaithilyamēva ca||67|| keshalomanakhashmashrudvijaprapatanaM shramaH| j~jeyamasthikShaye li~ggaM sandhishaithilyameva ca||67||

Symptoms of decrease of asthi are loss of scalp and body-hair, beard, nails and teeth, fatigue and loose joints (67). Decrease of majja: शीर्यन्त इव चास्थीनि दुर्बलानि लघूनि च| प्रततं वातरोगीणि क्षीणे मज्जनि देहिनाम्||६८|| śīryanta iva cāsthīni durbalāni laghūni ca| pratataṁ vātarōgīṇi kṣīṇē majjani dēhinām||68|| shIryanta iva cAsthIni durbalAni laghUni ca| pratataM [4] vAtarogINi kShINe majjani dehinAm||68||

Symptoms of decrease of majja are atrophy of bone tissues, weakness and lightness of bones and the patients suffers frequently from vata disorders (68). Decrease of shukra: दौर्बल्यं मुखशोषश्च पाण्डुत्वं सदनं श्रमः| क्लैब्यं शुक्राविसर्गश्च क्षीणशुक्रस्य लक्षणम्||६९|| daurbalyaṁ mukhaśōṣaśca pāṇḍutvaṁ sadanaṁ śramaḥ| klaibyaṁ śukrāvisargaśca kṣīṇaśukrasya lakṣaṇam||69|| daurbalyaM mukhashoShashca pANDutvaM sadanaM shramaH| klaibyaM shukrAvisargashca kShINashukrasya lakShaNam||69||

Symptoms of decrease of shukra include debility, dryness of mouth, pallor, asthenia, fatigue, impotency and absence of ejaculation (69). Decrease of purisha: क्षीणे शकृति चान्त्राणि पीडयन्निव मारुतः| रूक्षस्योन्नमयन् कुक्षिं तिर्यगूर्ध्वं च गच्छति||७०|| kṣīṇē śakr̥ti cāntrāṇi pīḍayanniva mārutaḥ| rūkṣasyōnnamayan kukṣiṁ tiryagūrdhvaṁ ca gacchati||70|| kShINe shakRuti cAntrANi pIDayanniva mArutaH| rUkShasyonnamayan kukShiM tiryagUrdhvaM ca gacchati||70||

In decrease of purisha, provoked vata causes painful peristalsis in the intestine which spreads upwards and oblique, causing distension of belly and dryness (70). Decrease of mutra: मूत्रक्षये मूत्रकृच्छ्रं मूत्रवैवर्ण्यमेव च| पिपासा बाधते चास्य मुखं च परिशुष्यति||७१|| mūtrakṣayē mūtrakr̥cchraṁ mūtravaivarṇyamēva ca| pipāsā bādhatē cāsya mukhaṁ ca pariśuṣyati||71|| mUtrakShaye mUtrakRucchraM mUtravaivarNyameva ca| pipAsA bAdhate cAsya mukhaM ca parishuShyati||71||

Symptoms of decrease of mutra include dysuria, discoloration of urine, excessive thirst and dryness of mouth (71). Decrease of malayana: मलायनानि चान्यानि शून्यानि च लघूनि च| विशुष्काणि च लक्ष्यन्ते यथास्वं मलसङ्क्षये||७२|| malāyanāni cānyāni śūnyāni ca laghūni ca| viśuṣkāṇi ca lakṣyantē yathāsvaṁ malasaṅkṣayē||72|| malAyanAni cAnyAni shUnyAni ca laghUni ca| vishuShkANi ca lakShyante yathAsvaM malasa~gkShaye||72||

There are five other minor mala (associated with minor orifices) viz. mala of nose, ears, eyes, mouth and skin. Their deficiencies lead to feeling of emptiness, lightness and dryness of the respective receptacle of that mala (72). Decrease of ojas: बिभेति दुर्बलोऽभीक्ष्णं ध्यायति व्यथितेन्द्रियः| दुश्छायो दुर्मना रूक्षः क्षामश्चैवौजसः क्षये||७३|| bibhēti durbalō'bhīkṣṇaṁ dhyāyati vyathitēndriyaḥ| duśchāyō durmanā rūkṣaḥ kṣāmaścaivaujasaḥ kṣayē||73|| bibheti durbalo~abhIkShNaM dhyAyati vyathitendriyaH| dushchAyo durmanA rUkShaH kShAmashcaivaujasaH kShaye||73||

The symptoms of decrease of ojas include timidity, debility, constant worry, discomfort of the senses, loss of lustre, neurasthenia, dryness and emaciation (73). Description of ojas: हृदि तिष्ठति यच्छुद्धं रक्तमीषत्सपीतकम्| ओजः शरीरे सङ्ख्यातं तन्नाशान्ना विनश्यति||७४|| hr̥di tiṣṭhati yacchuddhaṁ raktamīṣatsapītakam| ōjaḥ śarīrē saṅkhyātaṁ tannāśānnā vinaśyati||74|| hRudi tiShThati yacchuddhaM raktamIShatsapItakam| ojaH sharIre sa~gkhyAtaM tannAshAnnA vinashyati||74|| The clear and slightly red-yellowish substance situated in the heart is known as ojas. Its destruction leads to death (74).

प्रथमं जायते ह्योजः शरीरेऽस्मिञ्छरीरिणाम्| सर्पिर्वर्णं मधुरसं लाजगन्धि प्रजायते||७५|| (भ्रमरैः फलपुष्पेभ्यो यथा सम्भ्रियते मधु| तद्वदोजः स्वकर्मभ्यो गुणैः सम्भ्रियते नृणाम्||१||) prathamaṁ jāyatē hyōjaḥ śarīrē'smiñcharīriṇām| sarpirvarṇaṁ madhurasaṁ lājagandhi prajāyatē||75|| (bhramaraiḥ phalapuṣpēbhyō yathā sambhriyatē madhu| tadvadōjaḥ svakarmabhyō guṇaiḥ sambhriyatē nr̥ṇām||1||) prathamaM jAyate hyojaH sharIre~asmi~jcharIriNAm| sarpirvarNaM madhurasaM lAjagandhi prajAyate||75|| (bhramaraiH phalapuShpebhyo yathA sambhriyate madhu| tadvadojaH svakarmabhyo guNaiH sambhriyate nRuNAm||1||) Ojas is the very first substance created in the body of all living beings. Its color resembles that of ghee, tastes like honey and smells like roasted paddy (75). (As honey is collected by bees from various fruits and flowers, similarly ojas is collected by the inherent vital qualities of a man from the various physiological processes that take place in the body)(1). General etiological factors of ojas kshaya: व्यायामोऽनशनं चिन्ता रूक्षाल्पप्रमिताशनम्| वातातपौ भयं शोको रूक्षपानं प्रजागरः||७६|| कफशोणितशुक्राणां मलानां चातिवर्तनम्| कालो भूतोपघातश्च ज्ञातव्याः क्षयहेतवः||७७|| vyāyāmō'naśanaṁ cintā rūkṣālpapramitāśanam| vātātapau bhayaṁ śōkō rūkṣapānaṁ prajāgaraḥ||76|| kaphaśōṇitaśukrāṇāṁ malānāṁ cātivartanam| kālō bhūtōpaghātaśca jñātavyāḥ kṣayahētavaḥ||77|| vyAyAmo~anashanaM cintA rUkShAlpapramitAshanam| vAtAtapau bhayaM shoko rUkShapAnaM prajAgaraH||76|| kaphashoNitashukrANAM malAnAM cAtivartanam| kAlo bhUtopaghAtashca j~jAtavyAH kShayahetavaH||77|| Excessive exercising, fasting, worrying, fear, grief, taking dry, scanty and limited meals, dry beverages, exposure to wind and sun, insomnia, excessive excretion of mucus, blood, semen and excretions, adverse season or old age, major mental illness (Bhuta-Upaghāta) are the general causative factors for kshaya (decrease) of ojas (76-77).

Etiological factors and pathogenesis of avrita madhumeha (diabetes due to obstructive pathogenesis) : गुरुस्निग्धाम्ललवणान्यतिमात्रं समश्नताम्| नवमन्नं च पानं च निद्रामास्यासुखानि च||७८|| त्यक्तव्यायामचिन्तानां संशोधनमकुर्वताम्| श्लेष्मा पित्तं च मेदश्च मांसं चातिप्रवर्धते||७९|| तैरावृतगतिर्वायुरोज आदाय गच्छति| यदा बस्तिं तदा कृच्छ्रो मधुमेहः प्रवर्तते||८०|| gurusnigdhāmlalavaṇānyatimātraṁ samaśnatām| navamannaṁ ca pānaṁ ca nidrāmāsyāsukhāni ca||78|| tyaktavyāyāmacintānāṁ saṁśōdhanamakurvatām| ślēṣmā pittaṁ ca mēdaśca māṁsaṁ cātipravardhatē||79|| tairāvr̥tagatirvāyurōja ādāya gacchati| yadā bastiṁ tadā kr̥cchrō madhumēhaḥ pravartatē||80|| gurusnigdhAmlalavaNAnyatimAtraM samashnatAm| navamannaM ca pAnaM ca nidrAmAsyAsukhAni ca||78|| tyaktavyAyAmacintAnAM saMshodhanamakurvatAm| shleShmA pittaM ca medashca mAMsaM cAtipravardhate||79|| tairAvRutagatirvAyuroja [1] AdAya gacchati| yadA bastiM tadA kRucchro madhumehaH pravartate||80|| Excessive taking of heavy, unctuous, sour, and salty articles, eating of newly harvested cereals and newly prepared wines/drinks, excessive sleep, sedentary habits, avoidance of exercise or thinking/worry and not doing śhodhana (purification) lead to excessive increase in kapha, pitta, meda and mamsa. These obstruct the pathways of vata leading to aavrita vata condition. Thus provoked vata takes out ojas from its sites and brings it to basti causing madhumeha which is difficult to treat (78-80). Symptoms of avrita madhumeha: स मारुतस्य पित्तस्य कफस्य च मुहुर्मुहुः| दर्शयत्याकृतिं गत्वा क्षयमाप्यायते पुनः||८१|| sa mārutasya pittasya kaphasya ca muhurmuhuḥ| darśayatyākr̥tiṁ gatvā kṣayamāpyāyatē punaḥ||81|| sa mArutasya pittasya kaphasya ca muhurmuhuH| darshayatyAkRutiM gatvA kShayamApyAyate punaH||81||

In this condition of madhumeha, the symptoms of vata, pitta and kapha are frequently manifested. The symptoms subside for some time, but again reappear later (81). Sapta pidika (seven papules/pustules/carbuncles) उपेक्षयाऽस्य जायन्ते पिडकाः सप्त दारुणाः| मांसलेष्ववकाशेषु मर्मस्वपि च सन्धिषु||८२|| शराविका कच्छपिका जालिनी सर्षपी तथा| अलजी विनताख्या च विद्रधी चेति सप्तमी||८३|| upēkṣayā'sya jāyantē piḍakāḥ sapta dāruṇāḥ| māṁsalēṣvavakāśēṣu marmasvapi ca sandhiṣu||82|| śarāvikā kacchapikā jālinī sarṣapī tathā| alajī vinatākhyā ca vidradhī cēti saptamī||83|| upekShayA~asya jAyante [2] piDakAH sapta dAruNAH| mAMsaleShvavakAsheShu marmasvapi ca sandhiShu||82|| sharAvikA kacchapikA jAlinI sarShapI tathA| alajI vinatAkhyA ca vidradhI ceti saptamI||83||

If the diabetic condition is neglected, seven types of pidika (pustules) are produced. These pidika occur in fleshy spaces, vital parts (marma) and joints. The names of these seven pidikā are sharavika, kacchapika, jalini, sarshapi, alaji, vinata and vidhradi (82-83) 1. Sharavika: अन्तोन्नता मध्यनिम्ना श्यावा क्लेदरुगन्विता| शराविका स्यात् पिडका शरावाकृतिसंस्थिता||८४|| antōnnatā madhyanimnā śyāvā klēdaruganvitā| śarāvikā syāt piḍakā śarāvākr̥tisaṁsthitā||84|| antonnatA madhyanimnA shyAvA kledaruganvitA| sharAvikA syAt piDakA sharAvAkRutisaMsthitA||84||

The edges of sharavika pidika are raised and middle part is depressed, and its colour is dusky-red. It is accompanied by slough (kleda) and pain. As its shape is like that of an earthen saucer (sharavika), hence its name(84). 2. Kacchapika: अवगाढार्तिनिस्तोदा महावास्तुपरिग्रहा| श्लक्ष्णा कच्छपपृष्ठाभा पिडका कच्छपी मता||८५|| avagāḍhārtinistōdā mahāvāstuparigrahā| ślakṣṇā kacchapapr̥ṣṭhābhā piḍakā kacchapī matā||85|| avagADhArtinistodA mahAvAstuparigrahA| shlakShNA kacchapapRuShThAbhA piDakA kacchapI matA||85||

Kacchapika (carbuncle) is deeply and extensively infiltrated, with distress and pricking pain. It has a smooth surface like that of tortoise (Kacchapa), therefore, its name (85). 3. Jalini: स्तब्धा सिराजालवती स्निग्धास्रावा महाशया| रुजानिस्तोदबहुला सूक्ष्मच्छिद्रा च जालिनी||८६|| stabdhā sirājālavatī snigdhāsrāvā mahāśayā| rujānistōdabahulā sūkṣmacchidrā ca jālinī||86|| stabdhA sirAjAlavatI snigdhAsrAvA mahAshayA| rujAnistodabahulA sUkShmacchidrA ca jAlinI||86|| Jalini pidika is extensive, hard, covered with a network of vessels with unctous discharge, having severe pricking type pain and having minute openings on the surface. It is called Jalini because it resembles a net or a web (86). 4. Sarshapi: पिडका नातिमहती क्षिप्रपाका महारुजा| सर्षपी सर्षपाभाभिः पिडकाभिश्चिता भवेत्||८७|| piḍakā nātimahatī kṣiprapākā mahārujā| sarṣapī sarṣapābhābhiḥ piḍakābhiścitā bhavēt||87|| piDakA nAtimahatI kShiprapAkA mahArujA| sarShapI sarShapAbhAbhiH piDakAbhishcitA bhavet||87||

Sarshapi pidika is not very big but very painful and suppurates quickly and is surrounded by mustard seed-like boils. (87). 5. Alaji: दहति त्वचमुत्थाने तृष्णामोहज्वरप्रदा| विसर्पत्यनिशं दुःखाद्दहत्यग्निरिवालजी||८८|| dahati tvacamutthānē tr̥ṣṇāmōhajvarapradā| visarpatyaniśaṁ duḥkhāddahatyagnirivālajī||88|| dahati tvacamutthAne tRuShNAmohajvarapradA| visarpatyanishaM duHkhAddahatyagnirivAlajI||88||

Alaji pidika commences with a burning sensation in the skin accompanied by fever and thirst. It steadily spreads all over the body and causes severe distress with a fire-like burning sensation (88). 6. Vinata: अवगाढरुजाक्लेदा पृष्ठे वाऽप्युदरेऽपि वा| महती विनता नीला पिडका विनता मता||८९|| avagāḍharujāklēdā pr̥ṣṭhē vā'pyudarē'pi vā| mahatī vinatā nīlā piḍakā vinatā matā||89|| avagADharujAkledA pRuShThe vA~apyudare~api vA| mahatI vinatA nIlA piDakA vinatA matA||89|| Vinatā pidika is extremely painful form of pustule. It is soft, situated either on back or abdomen, very extensive and depressed in the middle and bluish in colour. It is known as vinata because it is depressed or deep (89). 7. Vidradhi-(1) bahya vidradhi: विद्रधिं द्विविधामाहुर्बाह्यामाभ्यन्तरीं तथा| बाह्या त्वक्स्नायुमांसोत्था कण्डराभा महारुजा||९०|| vidradhiṁ dvividhāmāhurbāhyāmābhyantarīṁ tathā| bāhyā tvaksnāyumāṁsōtthā kaṇḍarābhā mahārujā||90|| vidradhiM dvividhAmAhurbAhyAmAbhyantarIM tathA| bAhyA tvaksnAyumAMsotthA kaNDarAbhA mahArujA||90|| Vidradhi (abscess) is of two types viz. external and internal. External abscess occurs on skin and flesh. It looks like tendon and can cause severe pain (90). Aetiology and pathogenesis of internal abscess: शीतकान्नविदाह्युष्णरूक्षशुष्कातिभोजनात्| विरुद्धाजीर्णसङ्क्लिष्टविषमासात्म्यभोजनात्||९१|| व्यापन्नबहुमद्यत्वाद्वेगसन्धारणाच्छ्रमात्| जिह्मव्यायामशयनादतिभाराध्वमैथुनात्||९२|| अन्तःशरीरे मांसासृगाविशन्ति यदा मलाः| तदा सञ्जायते ग्रन्थिर्गम्भीरस्थः सुदारुणः||९३|| हृदये क्लोम्नि यकृति प्लीह्नि कुक्षौ च वृक्कयोः| नाभ्यां वङ्क्षणयोर्वाऽपि बस्तौ वा तीव्रवेदनः||९४|| śītakānnavidāhyuṣṇarūkṣaśuṣkātibhōjanāt| viruddhājīrṇasaṅkliṣṭaviṣamāsātmyabhōjanāt||91|| vyāpannabahumadyatvādvēgasandhāraṇācchramāt| jihmavyāyāmaśayanādatibhārādhvamaithunāt||92|| antaḥśarīrē māṁsāsr̥gāviśanti yadā malāḥ| tadā sañjāyatē granthirgambhīrasthaḥ sudāruṇaḥ||93|| hr̥dayē klōmni yakr̥ti plīhni kukṣau ca vr̥kkayōḥ| nābhyāṁ vaṅkṣaṇayōrvā'pi bastau vā tīvravēdanaḥ||94|| vidradhiM dvividhAmAhurbAhyAmAbhyantarIM tathA| bAhyA tvaksnAyumAMsotthA kaNDarAbhA mahArujA||90|| shItakAnnavidAhyuShNarUkShashuShkAtibhojanAt| viruddhAjIrNasa~gkliShTaviShamAsAtmyabhojanAt||91|| vyApannabahumadyatvAdvegasandhAraNAcchramAt| jihmavyAyAmashayanAdatibhArAdhvamaithunAt||92|| antaHsharIre mAMsAsRugAvishanti [1] yadA malAH| tadA sa~jjAyate granthirgambhIrasthaH sudAruNaH||93|| hRudaye klomni yakRuti plIhni kukShau ca vRukkayoH| nAbhyAM va~gkShaNayorvA~api bastau vA tIvravedanaH||94||

Excessive use of cold/stale, irritant, hot, un-unctuous and dry food articles, diet with incompatible or unwholesome articles, indigestion, spoiled foods, irregular eating, imbibing spoiled and excessive wines, suppression of natural urges, fatigue, exercise in distorted postures, excessive sleep, carrying heavy loads, excessive wayfaring and excessive sex-activity are the etiological factors of internal abscess. The dosha provoked by the above mentioned factors, when it enters the flesh and blood of the internal organs of the body, gives rise to deep-rooted nodule-like swellings with severe pain. It is a severe condition that occurs in the heart, pharynx (kloma), liver, spleen, stomach, kidney, navel, groin and bladder (91-94). Etymology of vidradhi: दुष्टरक्तातिमात्रत्वात् स वै शीघ्रं विदह्यते| ततः शीघ्रविदाहित्वाद्विद्रधीत्यभिधीयते||९५|| duṣṭaraktātimātratvāt sa vai śīghraṁ vidahyatē| tataḥ śīghravidāhitvādvidradhītyabhidhīyatē||95|| duShTaraktAtimAtratvAt sa vai shIghraM vidahyate| tataH shIghravidAhitvAdvidradhItyabhidhIyate||95|| Excessively provoked rakta causes quick softening and formation of pus. Owing to its quickly suppurating (vidahi) characteristic, it is called vidradhi (95).

Three types of vidradhi: व्यधच्छेदभ्रमानाहशब्दस्फुरणसर्पणैः| वातिकीं, पैत्तिकीं तृष्णादाहमोहमदज्वरैः||९६|| जृम्भोत्क्लेशारुचिस्तम्भशीतकैः श्लैष्मिकीं विदुः| सर्वासु च महच्छूलं विद्रधीषूपजायते||९७|| vyadhacchēdabhramānāhaśabdasphuraṇasarpaṇaiḥ| vātikīṁ, paittikīṁ tr̥ṣṇādāhamōhamadajvaraiḥ||96|| jr̥mbhōtklēśārucistambhaśītakaiḥ ślaiṣmikīṁ viduḥ| sarvāsu ca mahacchūlaṁ vidradhīṣūpajāyatē||97|| vyadhacchedabhramAnAhashabdasphuraNasarpaNaiH| vAtikIM, paittikIM tRuShNAdAhamohamadajvaraiH||96|| jRumbhotkleshArucistambhashItakaiH shlaiShmikIM viduH| sarvAsu ca [2] mahacchUlaM vidradhIShUpajAyate||97||

All types of abscesses are very painful. Besides pain, the following symptoms may occur depending upon the dosha: Vātaja vidradhi: A vata type of an abscess is marked by a sensation of piercing or cutting pain. It can spread all over the body and exhibits various other symptoms such as giddiness, distension of abdomen, gurgling sound and throbbing. Pittaja vidradhi: Thirst, burning pain, stupefaction, intoxication and fever are the symptoms of pittaja vidradhi. Kaphaja vidradhi: Yawning, retching, anorexia, rigidity and chills are the symptoms of kapha type of vidradhi (96-97).

Symptoms of ripened abscess: शस्त्रास्त्रैर्भिद्यत इव चोल्मुकैरिव दह्यते| विद्रधी व्यम्लता याता वृश्चिकैरिव दश्यते||९८|| śastrāstrairbhidyata iva cōlmukairiva dahyatē| vidradhī vyamlatā yātā vr̥ścikairiva daśyatē||98|| shastrAstrairbhidyata [3] iva colmukairiva dahyate| vidradhI vyamlatA yAtA vRushcikairiva dashyate||98||

On ripening of the abscess, the patient feels pain as if cut by a weapon or as if burnt by coal or as if stung by a scorpion (98). Pus discharge according to type of abscess: तनु रूक्षारुणं श्यावं फेनिलं वातविद्रधी| तिलमाषकुलत्थोदसन्निभं पित्तविद्रधी||९९|| श्लैष्मिकी स्रवति श्वेतं पिच्छिलं बहलं बहु| लक्षणं सर्वमेवैतद्भजते सान्निपातिकी||१००|| tanu rūkṣāruṇaṁ śyāvaṁ phēnilaṁ vātavidradhī| tilamāṣakulatthōdasannibhaṁ pittavidradhī||99|| ślaiṣmikī sravati śvētaṁ picchilaṁ bahalaṁ bahu| lakṣaṇaṁ sarvamēvaitadbhajatē sānnipātikī||100|| tanu rUkShAruNaM shyAvaM phenilaM vAtavidradhI| tilamAShakulatthodasannibhaM pittavidradhI||99|| shlaiShmikI sravati shvetaM picchilaM bahalaM bahu| lakShaNaM sarvamevaitadbhajate sAnnipAtikI||100|| In vata type of abscess, the discharge is thin, ununctuous, dusky-red and frothy. In pitta type of abscess, the discharge resembles decocted water of sesame, black-gram or horse-gram. In kapha type of abscess, the colour of the discharge is whitish, slimy, thick and profuse. In sannipata type of vidradhi , a mix of symptoms of all the three dosha type can be found in the abscess (99-100)

Symptoms of vidradhi according to organ involved: अथासां विद्रधीनां साध्यासाध्यत्वविशेषज्ञानार्थं स्थानकृतं लिङ्गविशेषमुपदेक्ष्यामः-तत्र प्रधानमर्मजायां विद्रध्यांहृद्धट्टनतमकप्रमोहकासश्वासाः, क्लोमजायां पिपासामुखशोषगलग्रहाः, यकृज्जायां श्वासः, प्लीहजायामुच्छ्वासोपरोधः,कुक्षिजायां कुक्षिपार्श्वान्तरांसशूलं, वृक्कजायां पृष्ठकटिग्रहः, नाभिजायां हिक्का, वङ्क्षणजायां सक्थिसादः, बस्तिजायांकृच्छ्रपूतिमूत्रवर्चसत्वं चेति||१०१|| athāsāṁ vidradhīnāṁ sādhyāsādhyatvaviśēṣajñānārthaṁ sthānakr̥taṁ liṅgaviśēṣamupadēkṣyāmaḥ- tatrapradhānamarmajāyāṁ vidradhyāṁ hr̥ddhaṭṭanatamakapramōhakāsaśvāsāḥ, klōmajāyāṁpipāsāmukhaśōṣagalagrahāḥ, yakr̥jjāyāṁ śvāsaḥ, plīhajāyāmucchvāsōparōdhaḥ, kukṣijāyāṁkukṣipārśvāntarāṁsaśūlaṁ, vr̥kkajāyāṁ pr̥ṣṭhakaṭigrahaḥ, nābhijāyāṁ hikkā, vaṅkṣaṇajāyāṁsakthisādaḥ, bastijāyāṁ kr̥cchrapūtimūtravarcasatvaṁ cēti||101|| athAsAM vidradhInAM sAdhyAsAdhyatvavisheShaj~jAnArthaM sthAnakRutaM li~ggavisheShamupadekShyAmaH- tatra pradhAnamarmajAyAM vidradhyAMhRuddhaTTanatamakapramohakAsashvAsAH, klomajAyAM pipAsAmukhashoShagalagrahAH, yakRujjAyAM shvAsaH, plIhajAyAmucchvAsoparodhaH, kukShijAyAMkukShipArshvAntarAMsashUlaM, vRukkajAyAM pRuShThakaTigrahaH, nAbhijAyAM hikkA, va~gkShaNajAyAM sakthisAdaH, bastijAyAMkRucchrapUtimUtravarcasatvaM [1] ceti||101||

Now the curability-incurability, the symptoms of abscesses in specific bodily organs are described as follows: Symptoms of vidradhi in the heart: Cardiac flutter, dyspnoea, stupefaction, cough and breathlessness are the symptoms of abscess in the heart. Symptoms of vidradhi in the kloma: thirst, dryness of mouth and sore throat are the symptoms of abscess in the kloma. Symptoms of vidradhi in the liver: Breathlessness is the symptom of abscess in the liver. Symptoms of vidradhi in the spleen: Impediment of breathing is the symptom of abscess in the spleen. Symptoms of vidradhi in the stomach (kukshi): Pain localized to the region between stomach and a side of the body (extending up to the shoulder) are the symptoms of abscess in in the stomach (kukshi). Symptoms of vidradhi in the kidney: Rigidity of back and waist is the symptom of abscess in the kidney. Symptoms of vidradhi in the navel (nabhi): Hiccups is the symptom of abscess in the umbilical region (nabhi). Symptoms of vidradhi in the groin: Weakness of the thigh is the symptom of abscess in groin. Symptoms of vidradhi in the urinary bladder: Painful micturition and defecation and putrid urine and faeces are the symptoms of abscess in the urinary bladder (101).

Route of discharge: पक्वप्रभिन्नासूर्ध्वजासु मुखात् स्रावः स्रवति, अधोजासु गुदात्, उभयतस्तु नाभिजासु||१०२|| pakvaprabhinnāsūrdhvajāsu mukhāt srāvaḥ sravati, adhōjāsu gudāt, ubhayatastu nābhijāsu||102|| pakvaprabhinnAsUrdhvajAsu mukhAt srAvaH sravati, adhojAsu gudAt, ubhayatastu nAbhijAsu||102|| Suppurated internal abscesses burst and the pus is discharged. The discharge of the abscesses situated in the organs above the navel comes out from mouth, of situated below the umbilicus comes out from anus and of around the navel may come from either of the routes (102). Prognosis of abscesses: आसां हृन्नाभिबस्तिजाः परिपक्वाः सान्निपातिकी च मरणाय; शेषाः पुनः कुशलमाशुप्रतिकारिणंचिकित्सकमासाद्योपशाम्यन्ति| तस्मादचिरोत्थितां विद्रधीं शस्त्रसर्पविद्युदग्नितुल्यां स्नेहविरेचनैराश्वेवोपक्रमेत् सर्वशो गुल्मवच्चेति||१०३|| āsāṁ hr̥nnābhibastijāḥ paripakvāḥ sānnipātikī ca maraṇāya; śēṣāḥ punaḥ kuśalamāśupratikāriṇaṁcikitsakamāsādyōpaśāmyanti| tasmādacirōtthitāṁ vidradhīṁ śastrasarpavidyudagnitulyāṁ snēhavirēcanairāśvēvōpakramēt sarvaśōgulmavaccēti||103|| AsAM hRunnAbhibastijAH paripakvAH sAnnipAtikI ca maraNAya; sheShAH punaH kushalamAshupratikAriNaM cikitsakamAsAdyopashAmyanti| tasmAdacirotthitAM vidradhIM shastrasarpavidyudagnitulyAM snehavirecanairAshvevopakramet sarvasho gulmavacceti||103|| The abscesses occurring in the heart, umbilicus and urinary bladder as well as of sannipātika type, if suppurated, have bad prognosis and may lead to death. Remaining types of abscess ,if treated immediately by an expert physician, are curable. Therefore immediately on appearance of the internal abscess, it should be managed promptly with effective measures that can act quickly, else it may harm just like an injury caused by a weapon, bite by a snake and burning by lightening or fire. These abscesses may be managed by oleation and purgation therapies as well as all the measures of gulma (103). Pidika can occur without prameha: भवन्ति चात्र- विना प्रमेहमप्येता जायन्ते दुष्टमेदसः| तावच्चैता न लक्ष्यन्ते यावद्वास्तुपरिग्रहः||१०४|| bhavanti cātra- vinā pramēhamapyētā jāyantē duṣṭamēdasaḥ| tāvaccaitā na lakṣyantē yāvadvāstuparigrahaḥ||104|| bhavanti cAtra- vinA pramehamapyetA jAyante duShTamedasaH| tAvaccaitA na lakShyante yAvadvAstuparigrahaH||104|| Here are verses again- Pustules (pidika) can also occur due to vitiation of medas in a person who is not suffering from prameha. Such pustules do not become visible till they become extensive in size (104). Prognosis of pidikā: शराविका कच्छपिका जालिनी चेति दुःसहाः| जायन्ते ता ह्यतिबलाः प्रभूतश्लेष्ममेदसः||१०५|| śarāvikā kacchapikā jālinī cēti duḥsahāḥ| jāyantē tā hyatibalāḥ prabhūtaślēṣmamēdasaḥ||105|| sharAvikA kacchapikA jAlinI ceti duHsahAH| jAyante tA hyatibalAH prabhUtashleShmamedasaH||105||

Sharavika, kacchapika and jalini types of pidika are formed due to excessive kapha and medas, and therefore can become very severe and cause unbearable pain (105).

सर्षपी चालजी चैव विनता विद्रधी च याः| साध्यः पित्तोल्बणास्तास्तु सम्भवन्त्यल्पमेदसः||१०६|| sarṣapī cālajī caiva vinatā vidradhī ca yāḥ| sādhyaḥ pittōlbaṇāstāstu sambhavantyalpamēdasaḥ||106|| sarShapI cAlajI caiva vinatA vidradhI ca yAH| sAdhyaH pittolbaNAstAstu sambhavantyalpamedasaH||106||

Sarshapi, alaji , vinata and vidradhi occur due to dominance of pitta in a person having low medas and are curable (106). Bad prognostic pidika: मर्मस्वंसे गुदे पाण्योः स्तने सन्धिषु पादयोः| जायन्ते यस्य पिडिकाः स प्रमेही न जीवति||१०७|| marmasvaṁsē gudē pāṇyōḥ stanē sandhiṣu pādayōḥ| jāyantē yasya piḍikāḥ sa pramēhī na jīvati||107|| marmasvaMse gude pANyoH stane sandhiShu pAdayoH| jAyante yasya piDikAH sa pramehI na jIvati||107|| A diabetic person does not survive if he gets pidika in vital-parts, shoulder, anus, hands, breast, joints, and feet (107). Miscellanous pidika: तथाऽन्याः पिडकाः सन्ति रक्तपीतासितारुणाः| पाण्डुराः पाण्डुवर्णाश्च भस्माभा मेचकप्रभाः||१०८|| मृद्व्यश्च कठिनाश्चान्याः स्थूलाः सूक्ष्मास्तथाऽपराः| मन्दवेगा महावेगाः स्वल्पशूला महारुजः||१०९|| tathā'nyāḥ piḍakāḥ santi raktapītāsitāruṇāḥ| pāṇḍurāḥ pāṇḍuvarṇāśca bhasmābhā mēcakaprabhāḥ||108|| mr̥dvyaśca kaṭhināścānyāḥ sthūlāḥ sūkṣmāstathā'parāḥ| mandavēgā mahāvēgāḥ svalpaśūlā mahārujaḥ||109|| tathA~anyAH piDakAH santi raktapItAsitAruNAH| pANDurAH pANDuvarNAshca bhasmAbhA mecakaprabhAH||108|| mRudvyashca kaThinAshcAnyAH sthUlAH sUkShmAstathA~aparAH| mandavegA mahAvegAH svalpashUlA mahArujaH||109||

There are some other types of papules or pustules (pidika) with the following characteristics: Colour: There may be some other types of pidika having red, yellow, dark, dusky-red, grey, yellowish, white, ash-colour and blackish appearance. Some pustules are soft and others are hard Some pustules are big and others are minute Some pustules are slow developing while others develop quickly Some pustules are slightly painful while others are very painful. (108-109) ता बुद्ध्वा मारुतादीनां यथास्वैर्हेतुलक्षणैः| ब्रूयादुपचरेच्चाशु प्रागुपद्रवदर्शनात्||११०||

tā buddhvā mārutādīnāṁ yathāsvairhētulakṣaṇaiḥ| brūyādupacarēccāśu prāgupadravadarśanāt||110|| tA buddhvA mArutAdInAM yathAsvairhetulakShaNaiH| brUyAdupacareccAshu prAgupadravadarshanAt||110||

The wise physician should diagnose the above pustules on the basis of the causative factors and characteristics of involved dosha and treat these appropriately (and quickly) before these advance into complications (110). Complications of pustules (pidika): तृट्श्वासमांससङ्कोथमोहहिक्कामदज्वराः| वीसर्पमर्मसंरोधाः पिडकानामुपद्रवाः||१११|| tr̥ṭśvāsamāṁsasaṅkōthamōhahikkāmadajvarāḥ| vīsarpamarmasaṁrōdhāḥ piḍakānāmupadravāḥ||111|| tRuTshvAsamAMsasa~gkothamohahikkAmadajvarAH| vIsarpamarmasaMrodhAH piDakAnAmupadravAH||111|| Thirst, dyspnoea, sloughing of flesh, stupor, hiccup, toxaemia, fever, spreading inflammatory swelling and obstruction in function of the vital organs are the complications of pustules (111). States (gati) of dosha: क्षयः स्थानं च वृद्धिश्च दोषाणां त्रिविधा गतिः| ऊर्ध्वं चाधश्च तिर्यक्च विज्ञेया त्रिविधाऽपरा||११२|| त्रिविधा चापरा कोष्ठशाखामर्मास्थिसन्धिषु| इत्युक्ता विधिभेदेन दोषाणां त्रिविधा गतिः||११३||

kṣayaḥ sthānaṁ ca vr̥ddhiśca dōṣāṇāṁ trividhā gatiḥ| ūrdhvaṁ cādhaśca tiryakca vijñēyā trividhā'parā||112|| trividhā cāparā kōṣṭhaśākhāmarmāsthisandhiṣu| ityuktā vidhibhēdēna dōṣāṇāṁ trividhā gatiḥ||113|| kShayaH sthAnaM ca vRuddhishca doShANAM trividhA gatiH| UrdhvaM cAdhashca tiryakca vij~jeyA trividhA~aparA||112|| trividhA cAparA koShThashAkhAmarmAsthisandhiShu| ityuktA vidhibhedena doShANAM trividhA gatiH||113|| Decrease, normalcy and increase are the three states of doshas. Other three courses of doshas are upward, downward and oblique/transverse movement. Yet another set of three states of dosha are by their movement to koshtha (thoraco-abdominal cavity), shakha (tvak and dhatus except rasa) and vital-organs, bones and joints. Thus are described various states of doshas (112-113). Seasonal course of doshas: चयप्रकोपप्रशमाः पित्तादीनां यथाक्रमम्| भवन्त्येकैकशः षट्सु कालेष्वभ्रागमादिषु||११४|| गतिः कालकृता चैषा चयाद्या पुनरुच्यते|११५| cayaprakōpapraśamāḥ pittādīnāṁ yathākramam| bhavantyēkaikaśaḥ ṣaṭsu kālēṣvabhrāgamādiṣu||114|| gatiḥ kālakr̥tā caiṣā cayādyā punarucyatē|115| cayaprakopaprashamAH pittAdInAM yathAkramam| bhavantyekaikashaH ShaTsu kAleShvabhrAgamAdiShu||114|| gatiH kAlakRutA caiShA cayAdyA punarucyate|115| Accumulation, provocation and pacification of pitta, vata and kapha respectively occur individually and sequentially in the six seasons beginning with the rainy season (e.g., pitta accumulation in rainy season, etc). These courses (of accumulation, provocation and/or pacification) of dosha are known as seasonal courses of doshas.(114).

Physiological and pathological course of dosha: गतिश्च द्विविधा दृष्टा प्राकृती वैकृती च या||११५|| पित्तादेवोष्मणः पक्तिर्नराणामुपजायते| तच्च पित्तं प्रकुपितं विकारान् कुरुते बहून्||११६|| प्राकृतस्तु बलं श्लेष्मा विकृतो मल उच्यते| स चैवौजः स्मृतः काये स च पाप्मोपदिश्यते||११७|| सर्वा हि चेष्टा वातेन स प्राणः प्राणीनां स्मृतः| तेनैव रोगा जायन्ते तेन चैवोपरुध्यते||११८|| gatiśca dvividhā dr̥ṣṭā prākr̥tī vaikr̥tī ca yā||115|| pittādēvōṣmaṇaḥ paktirnarāṇāmupajāyatē| tacca pittaṁ prakupitaṁ vikārān kurutē bahūn||116|| prākr̥tastu balaṁ ślēṣmā vikr̥tō mala ucyatē| sa caivaujaḥ smr̥taḥ kāyē sa ca pāpmōpadiśyatē||117|| sarvā hi cēṣṭā vātēna sa prāṇaḥ prāṇīnāṁ smr̥taḥ| tēnaiva rōgā jāyantē tēna caivōparudhyatē||118|| gatishca dvividhA dRuShTA prAkRutI vaikRutI ca yA||115|| pittAdevoShmaNaH paktirnarANAmupajAyate| tacca pittaM [1] prakupitaM vikArAn kurute bahUn||116|| prAkRutastu balaM shleShmA vikRuto mala ucyate| sa caivaujaH smRutaH kAye sa ca pApmopadishyate||117|| sarvA hi ceShTA vAtena sa prANaH prANInAM smRutaH| tenaiva rogA jAyante tena caivoparudhyate||118|| Another set of courses of dosha are physiological and pathological. Normally, heat generated by pitta digests the food but when the same pitta is in a provoked state, it causes various disorders. Similarly, normal kapha contributes to body-strength but when vitiated, it becomes waste material (mala). Normal kapha is also responsible for ojas, however on provocation, it could cause various ailments in the body. Vāta is responsible for all types of movements in living beings and represents life of living-beings, but vitiated vata causes many diseases and is even responsible for causing death (115-118).

नित्यं सन्निहितामित्रं समीक्ष्यात्मानमात्मवान्| नित्यं युक्तः परिचरेदिच्छन्नायुरनित्वरम्||११९|| nityaṁ sannihitāmitraṁ samīkṣyātmānamātmavān| nityaṁ yuktaḥ paricarēdicchannāyuranitvaram||119|| nityaM sannihitAmitraM samIkShyAtmAnamAtmavAn| nityaM yuktaH paricaredicchannAyuranitvaram||119|| A person desiring to live the full span of life should remain self controlled and live with great caution assuming that he is constantly surrounded by the foes to his health (119). Summary: तत्र श्लोकौ- शिरोरोगाः सहृद्रोगा रोगा मानविकल्पजाः| क्षयाः सपिडकाश्चोक्ता दोषाणां गतिरेव च||१२०|| कियन्तःशिरसीयेऽस्मिन्नध्याये तत्त्वदर्शिना| ज्ञानार्थं भिषजां चैव प्रजानां च हितैषिणा||१२१|| tatra ślōkau- śirōrōgāḥ sahr̥drōgā rōgā mānavikalpajāḥ| kṣayāḥ sapiḍakāścōktā dōṣāṇāṁ gatirēva ca||120|| kiyantaḥśirasīyē'sminnadhyāyē tattvadarśinā| jñānārthaṁ bhiṣajāṁ caiva prajānāṁ ca hitaiṣiṇā||121|| tatra shlokau- shirorogAH sahRudrogA rogA mAnavikalpajAH| kShayAH sapiDakAshcoktA doShANAM gatireva ca||120|| kiyantaHshirasIye~asminnadhyAye tattvadarshinA| j~jAnArthaM bhiShajAM caiva prajAnAM ca hitaiShiNA||121|| Here are two recapitulate verses: The diagnosis of diseases of the head, diseases of the heart, diseases caused by minute pathological conditions of the doshas, conditions caused by decreased doshas, inflammatory swellings and various courses of doshas have been described in this chapter entitled 'how many are the diseases of the head', by the well-wisher of mankind, the great sage Atreya, for the enlightenment of the physicians (120-121). इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते श्लोकस्थाने कियन्तःशिरसीयो नाम सप्तदशोऽध्यायः||१७|| Ityagniveśakr̥te Tantre Carakapratisamskr̥te ślokasthāne kiyantaḥśirasīyo Nāma saptadaśoadhyāyaḥ ||17|| Thus seventeenth chapter of Sutra Sthāna compiled by Agniveśa and revised by Charaka entitled kiyantahshirasi adhyaya is completed (17).

Tattva Vimarsha

• There are 107 Marmas which are points of prana (vital energy) and are located in various parts of body. Three of them, the head, the heart and the urinary bladder are most important. • All control centers of sense and locomotion, along with that of prana (vital energy) are located in the head. • Clinical pathology involving rakta along with analysis of dosha vitiation is essential to the diagnosis of diseases of the head. • Diseases of the head and the heart can be identified according to the dominance of a dosha (or multiple doshas) and diagnosed as per their etiology and symptomatology. • Various permutation and combinations of increase and decrease of dosha can occur inside the body affecting the physiological functions. • Tridoshika disequlibrium is a precursor to diseases and their pathogenesis varies with level of vriddhi (increase) or kshaya (decrease) and a typical permutation or combination of such doshas can lead to different manifestations of the disease. • Increased and decreased states of dosha and vitiation of a particular dosha depends upon the exposure to causative factors in diet and lifestyle. • The increased or decreased dosha state can be identified by clinical appearance of their increased or decreased functions. Thus clinical diagnosis based on observations is more important than pathological or radiological investigations. • A normal dosha can also exhibit some signs. Increased vata can pull normal pitta and kapha away to places other than their normal location to manifest their own features there. • Ojas is the first substance formed in a living being and the sustenance of life depends upon the quality and quantity of ojas. Death can occur due to destruction of ojas. • kapha, pitta, meda, mamsa, ojas and obstructed vata are important pathogenic factors in madhumeha (diabetes). • Diseases can occur due to different states or movements of dosha like increased or decreased state, upward or downward movements, or movement from center of body to periphery or to vital centers. This also depends upon the environmental and seasonal changes. • Digestion, temperature and heat in the body is mainly controlled by pitta. Strength of body depends upon kapha. Whereas vata is responsible for all movements and and vitality.

Vidhi Vimarsha

Indriya Buddhi (centres of senses in the brain): While describing pancha-panchaka principle of perception by five jnanaindriya [Cha. Su. 8/3], Charaka mentions five indriya (senses), five indriya adhisthana (sense organs), five indriya dravya (specific matter which enable the senses to perceive), five artha (specific objects to be perceived by sense) and five indriya-buddhi (final sensation). The five indriya are the five senses and the five indriya adhisthāana are the five external sites of senses for example eyes for vision and ears for hearing, but site of the indriya-buddhi is not mentioned. In this regard, the following observations may be taken into consideration: Charaka mentions that prānavāhi srotāmsi of indriya are situated in the head and are connected with the body as sun is connected with its rays. Therefore, diseases such as ardita (facial paralysis), ceshtā nāsha (paralysis) and disorders of eye movement etc are due to trauma to the head [Ca Sii 9/4]. In this chapter, the physical location of all the indriya has been mentioned to be the head, hence on the basis of these observations, it can be concluded that the indrya-buddhi are also situated in head. Indriya buddhi is that vital part of a sense that decides the final knowledge of the perceived object. Hence sense centres situated in the cortex region of the brain represent the indriya buddhi (12). Classification of shiroroga: Generally, shiroroga implies any type of disease afflicting the head. Therefore, Charaka enlisted diseases such as hemicrania (ardhavabhedaka), headache (sarvam va rujyati shirah), coryza (pratishyaya), diseases of mouth, nose, eyes and ears which cause headache (mukha-nasa-akshi-karna-roga), giddiness/vertigo (sirobhramah), facial paralysis (ardita), tremors of the head (shirasah kampa) and stiffness of the neck, nape and jaw (gala-manya-hanu-grahah) as shiroroga. Hence, in general, shiroroga includes diseases occurring in the skull, its orifices and the structure related to it. As per this classification shiroroga includes vatika, paittika, kaphaja, sannipataja and krimija shiroroga. In addition, in Siddhi Sthana, four more diseases occurring in the head have been described in detail viz. shankhaka, ardhavabhedaka, suryavarta, and anantavata [Ca Si 9/71-87]. In these shiroroga, nasya(nasal errhines) has been indicated [Ca Si 9/88]. In all nine shiroroga (five in this chapter, and four in Siddhi Sthana) that mention headache as a key symptom. Other varieties of shiroroga mentioned in other texts are raktaja and kshayaja [Sushruta Uttara 25/3] and shirah-kampa [As Hr.Uttara 23/9].(Verse 6) The five types of hridroga described in this chapter are also caused by vitiated dosha and krimi. In all these conditions pain in the chest is a common feature, the intensity of which varies according to the involved dosha. For example in vata, pain is accompanied by extra systole/ fibrillation (vepathu), sense of emptiness in the heart region (shunyata), and hyperkinetic heart and thrill (dara). A pittaja type hridroga is indicated by a burning sensation in the precordial region with fainting, giddiness and perspiration. In kaphaja type hridroga, there is heaviness in the precordial area, suptam (bradycardia or decreased diastolic stretching) and a stony sensation (pericardial calcification as in constrictive pericarditis) in heart region. Description of krimija hridroga indicates a very serious condition. As mentioned earlier, infeststion starts with one chamber of the heart and then spreads and consumes (bhakshyanti) tissues across the entire heart.The patient of krimija hridroga feels severe pain in the precordial region, as if heart is being pricked/pierced by needles or cut by weapons and is a very grave heart condition that may lead to immediate death. Therefore it is a severe condition and should be promptly diagnosed and managed. It may manifest as chest pain, arrhythmia, heart failure, acute myocardial infarction-like syndrome with normal coronary arteries, ventricular arrhythmia, and loss of right ventricular function leading to sudden death. (Verse 36-40). Samsarga and Sannipata Combination of two provoked doshas leading to a disease is known as samsarga and when all the three provoked doshas combine then it is known as sannipata. In the combinations , some doshas may be in their normal state, while others may be slightly, moderately or excessively increased or in decrease state. Similarly they may be slightly, moderately or significantly decreased. In this way, on the basis of quantum of increase, decrease etc of the dosha, they can be classified into 62 types (verses from 41 to 62) as follows: • Sixty-two conditions of increased and decreased doshas, including: o 25 conditions of increased doshas:  Three conditions of sannipata where one dosha is increased but the other two doshas are excessively increased in comparison.  vataThree conditions of sannipata where two doshas are increased and one excessively increased  Six conditions of sannipata where one dosha is excessively increased, the second moderately increased and third slightly increased  One condition of sannipata where all the doshas are equally increased  Six conditions of samsarga where one dosha is increased and the others excessively increased  Three conditions of samsarga where both the doshas are equally increased  Three conditions of sannipata where single dosha is increased and others are normal In this way there are 25 conditions of increased dosha. o 25 conditions of decreased dosha. Here the doshas may be slightly decreased, moderately decreased and significantly decreased. The combinations follow the same pattern as above. o 12 conditions of sannipata where one dosha is normal, second is increased and the third is decreased In this way, 62 conditions of various combinations of normal, increased and decreased dosha have been mentioned in this chapter(verses from 41 to 62), of which only 12 types are described in detail. Chakrapāni mentions that combinations of dosha may occur in two ways i.e. prakriti-sama-samveta and vikriti-vishama-samveta. Prakriti-sama-samveta akin to a sugar and salt solution in water where the tastes of sugar and salt remain intact and in such types of samsarga or sannipata of doshas, no specific description is given in the text but simply mentioned that mix features of involved doṣha will present. On the other hand, vikriti-vishama-samveta a combination of provoked doshas wherein new symptoms are produced that are neither of any of the doshas involved. For example, red colour appears on mixing of white lime and yellow turmeric, and in such a case the specific symptoms produced by the combination are described. Here in 17th chapter, specific symptoms of 12 types of vikriti-vishama-samveta sannipata are given in detail, but symptoms of sama sannipata are not given as it is prakriti-sama-samveta (Verses 41-72). Table for Sannipata: Sr.No. vata pitta kapha Signs 1. Increased Normal Decreased Bheda (unstable breaking pain) and Daha (burning sensation),Shrama( fatigue) and Daurbalya (weakness) 2. Increased Decreased Normal Shula (Colicky pain), Shaitya (coldness), Stambha (stiffness) and Gaurava (heaviness) 3. Normal Increased Decreased Daha (burning sensation) and colicky pain (Shula) 4. Decreased Increased Normal Jwara (fever) accompanied with Gaurava (heaviness) and Tandra (drowsiness) 5. Normal Decreased Increased Sheetaka (cold), Gaurava (heaviness) and Ruja (pain) 6. Decreased Normal Increased Mruduagni (slow digestion), Shirograha (stiffness of head), Nidra (excessive sleep), Tandra (drowsiness), Pralap (delirium), Hridroga (heart disorders), Gatragaurava (heaviness in the body), Nakhadi pitatva (yellowness in nails etc) and kapha-pitta shthivana (spitting of kapha –pitta) 7. Decreased Increased Increased Arochaka (anorexia), Avipaka (indigestion), Sadana (asthenia), Gaurava (heaviness), Rhallasa (nausea), Aasya strava (salivation), pandu (anaemia), Duyata (fumy sensation sensation of mouth, throat and palate (Dūyana)), Mada (intoxication) and Vireka vaishmya (irregularity of bowels) and Anala vaishamya (irregular digestion) 8. Increased Decreased Increased Stambha (stiffness), Shaitya(coldness), Toda (unstable pricking pain), Gaurava (heaviness), Agni Mruduta (slow digestion), Ashraddha (disinclination for food), Pravepana (tremors), Nakha shuklata (pallor of nails etc), and Gatraparushya (roughness of the body parts) 9. Increased Increased Decreased Bhrama (giddiness),Udweshtana( cramps), Toda (pricking pain), Daha (burning sensation), Sphutana ( disruption/cracks),Vepana ( tremors), Angamarda (body-ache), Parishosha(dehydration/wasting), fumes sensation of mouth, throat and palate and smoke from mouth 10. Decreased Decreased Increased Obstruction of the Srotas, complete loss of movement, loss of speech and fainting 11. Decreased Increased Decreased affecting the Ojas causes malaise (Glāni), indriyadaurbalya (asthenia of senses), Trushna (thirst), Murchha (fainting) and Kriyakshayam (decreased physiological functions. 12. Increased Decreased Decreased Compression of the vital centres, destroys consciousness or excessively trembles the whole body

Ojas: Ojas is well known and defined in Ayurveda in terms of its functions, its importance, its types and its sites of functions within the body. It has been described in this text as a clear and slightly red-yellowish fluid situated in the heart is known as ojas, the destruction of which leads to death. Its colour resembles to that of ghee, taste is like honey and its smell is like that of roasted paddy (Verses 73-75). But its interpretation in modern physiological terms is confusing. In this chapter a hint has been given in this regard that ojas is a first thing created in the body of all living creatures. The symptoms of diminished ojas include timidity, debility, constant worry, discomfort of the senses, loss of lustre, neurasthenia, dryness and emaciation. Āvarita madhumeha (type 1 Diabetes mellitus): Two scenarios that cause provocation of vata have been mentioned: decrease of dhatu (dhatu kshaya) and avarana(cover) [Cha. Chi. 28/59]. The description of madhumeha, provided earlier in this chapter, provides a good example of aavarana. That a provoked or vitiated vata causes madhumeha has also been reiterated in the Nidana Sthana. All the factors that cause decrease of body tissues lead to provocation of vāta. But even though madhumeha is caused by a vitiated vata, its etiological factors also cause an increase in kapha and pitta. The comparison of nidana of madhumeha mentioned in these two different references is tabulated here: Causative Factors Causative factors of Dhatu kshayaja VaatikMadhumeha (Nidana Sthana) Causative factors of Aavaranjanya vatik Madhumeha ( Sutra Sthana) Excessive use of Rasa (Taste) Indulgence in intake of katu, tikta, kashaya rasa dominant food articles Indulgence in intake of, lavana and amla rasa dominant food articles Excessive use of Guna ruksha, laghu, shita, guru, snigdha, navam-anna-pana Food habit langhana samashana Life style Excessive indulgence in sex, exercise, late night awakening, Excessive sleep, or sedentary life style with no physical activities Shodhana Excessive shodhana aśhodhana Mental factors udvega tyakta-chintaa Increase of vata Increase of kapha, pitta, medas, mamsa and aavirita vata

It is obvious from the above table that in case of avarita, madhumeha initially causes an increase in kapha, pitta, meda and māmsa leading to an obstruction of functional pathways of vata, furthering its provocation, thereby increasing the severity of madhumeha. In such a condition, the treatment is apatarpana and not of vata i.e. santarpana (Verses 78-81). Prameha pidika mentioned in this chapter usually occurs as a complication of avaranjanaya samprapti of madhumeha as medas dushti occurs in this type of madhumeha, the factor, a must for pathogenesis of prameha pidika. This resembles with presentation of metabolic syndrome which includes dys-lipidemia (Verse 82-111). Charaka has mentioned seven varieties of prameha pidika whereas Sushruta and Vagbhata have added three more to this list that includes masoorika, putrini and vidarika. The Shiroroga described in this chapter are various clinical presentations of headache depending upon dosha dominance and krimi infestation. Krimi in Ayurveda is a generic term for a large number of pathological organisms ranging from microorganisms found in blood (raktaja krimi) to intestinal worms as well as external parasites such as lice [Cha. Vi. 7/11-13] As mentioned earlier in the document, the diseases of the head (verses 13-14) include hemicrania, coryza, headache (caused as a side-effect of diseases of the mouth, nose, eyes and ears), giddiness/vertigo, facial paralysis, tremors of the head, and stiffness of the neck, nape and jaw (there are additional varieties of shiroroga viz. frontal sinusitis, trigeminal neuralgia, and shankhaka are also described [Cha. Si. 9/70-87]. In contemporary science, headache is not a disease and can be vascular, myogenic, cervicogenic, and inflammatory in origin. The drug choices also depend upon the causative factors of headache. Similarly in Ayurveda, though headache is a common manifestation of all five types of diseases of the head, different forms of headache can give an idea of dosha predominance which may further decide the preference of procedures or drug in its treatment. The term headache implies pain in the region of cranial vault which is one of the most common and difficult clinical problems in medicine and can be due to serious intracranial conditions like raised intracranial pressure or space occupying lesion or various inflammatory changes of brain tissue or meninges. Further, any pain in the head may also be due to lesions in nearby structures such as the eyes and ear causing referred headache. The forms or manifestations of headache (and referred headache) associated with a sirōrōga may include migraine, stress induced headache, cluster headache, chronic paroxysmal hemicraina, and miscellaneous forms not associated with structural lesions or headache associated with vascular disorders. Similarly the five presentations of heart diseases have also been mentioned in this chapter that resemble different manifestations of chest pain and could be in the form of angina, pain associated with myocardial infarction and dissecting aortic aneurysm, pericarditis, oesophageal spasm, or musculo skeletal chest pain. The clinical picture of cardiac disorders is quite similar to the features of hridroga mentioned in Charaka Samhia, such as choking or constriction, squeezing, crushing, burning or aching chest pain, or a feeling of sharp, tearing or stabbing chest pain that is usually felt retrosternally and may radiate to the left arm or more rarely to the right arm and then to the throat, jaws and teeth, or through the back. In addition to the individual features of five types of hridaroga, in Chikitsa Sthana, the general sign and symptoms of hridroga such as discolouration, syncope, fever, cough, hiccups, dyspnoea, vomiting, water brash, chest discomfort, indigestion or distaste of mouth are also mentioned (Ca Ch 26/78). These are mentioned as common symptoms of heart disease in medicine books.

Carbuncles are common complications occurring in uncontrolled diabetes patients where the infection spreads extensively in the dermal and underlying soft tissue. This presents itself as a complex localized abscess or as several separate abscesses with multiple discharge sinuses usually caused due to staphylocooocus aureus infection. Thus, this chapter is very important as it deals with the disorders of three vital parts of the body (trimarma). It also describes very important aspects of pathogenesis caused due to combinations of vitiated dosha viz. samsarga and sannipata. The description of ojas is a unique concept of Ayurveda. The detailed descriptions along with etiological factors of each prameha pidika are very helpful in planning their prevention and cure. Table 2: Types of Pidika in different classics: Sr. No. Types of Pidikā Charaka Sushruta Vagbhata Bhoj Kashypa 1 Sharavika + + + + + 2 Kacchapika + + + Kurmika + 3 Jalini + + + + + 4 Sarshapi + + sarshapika sarshapika sarshapika 5 Alaji + + + + + 6 Vinata + + + - + 7 Vidradhi + + + + + 8 Masurika - + + Kullathika Arunshika 9 Putrini - + + Putrika - 10 Vidarika - + + + - (Verse 82-83)

Types of Vidradhi (Verse 101): Vidradi sthana Symptom Pradhanamarma (hridaya) hriddhattana (Palpitation) Tamak (dyspnoea) Pramoha Kasa (cough) Shvasa (breathlessness) Kloma Pipasa (dipsia) mukhashosha (dryness of mouth) Galagraha yakrit Shvasa (Breathlessness) Pliha Ucchvasoparodha (Impediment of breathing) kukṣi kukshi parshvantaram sa shulam (Pain referred to the region between side of abdomen extending up to flanks) vrikka prishtha kati graham (stiffness of back and waist) Nabhi Hikka (hiccups) vankshana Sakthisada (Weakness of the thigh) Basti kricchra puti mutra varcasatvam (Painful micturition and defecation and putrid urine and faeces)

Doshanam Trividha Gati (verse 112-114)

kshayah (Hypo) Urdhvam (Upward) kōṣṭha (Thoraco-abdominal cavity) sthānaṁ (Normal) adhaśca (Downward) śākhā (Skin dhatu except rasa) vr̥ddhi (Hyper) tiryaka (Transvers) marma asthi sandhi (Vital points, bones and joints)

                            Caya     (Accumulation)
                           Prakōpa (Provocation)
                          Praśama (Pacification)

  Glossary Āvrita Vāta (आवृत वात) : Provoked Vāta due to obstruction to its functional path Caya (चय) : Accumulation Dūyanam (दूयनं) : burning sensation of mouth, throat and palate Hridroga (हृद्रोगः) : Diseases of heart Koṣtha (कोष्ठ) : Thoraco-abdominal cavity Kṣaya (क्षयः) : Decrease Mādhumēh (मधुमेहः) : Diabetes mellitus Marma (मर्म) : Vital parts Piḍakāḥ (पिडकाः) : Papules Prakōpa (प्रकोप) : Provocation Prākr̥ta (प्राकृत) : Normal Pramēha (प्रमेह) : A group of clinical conditions wherein excessive urine occurs Pramitāśanam (प्रमिताशनम्) : Taking limited quantity of food/meals Praśama (प्रशम) : Pacified Sarṣapa (सर्षप) : mustard seeds Shākhā (शाखा) : Extremities, six Dhatu except Rasa and Tvak Sirājāla (सिराजाल) : Network of vessels Śirōrōga (शिरोरोगाः) : Diseases of head Śodhana (शोधन) : Purification, detoxification Sthānaṁ (स्थानं) : Normal, site Ulbaṇa (उल्बण) : Excessive Vaikr̥ta (वैकृत) : Abnormal Vidradhī (विद्रधी) : Abscess Vinatā (विनता) : Depressed or deep Vr̥ddhi (वृद्धि) : Increase Vr̥ścika (वृश्चिक) : scorpion