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=== Abstract ===

=== Abstract ===

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Chapter six of [[Nidana Sthana]], titled [[Shosha Nidana]], describes the basics of etiopathogenesis of ''shosharoga'' and its culmination in ''rajayakshma'' vis-à-vis pulmonary tuberculosis. ''Shosha'' is a progressive wasting disease (also called phthisis) which could be a precursor of tuberculosis as known today which occurs due to tubercular infection, phthisis and immune-compromised state. According to Charaka there are four primary causes of ''shosha'' viz. ''sahasa'' or over exertion, ''vegavidharana'' or suppression of natural urges, ''kshaya'' or pre-existing emaciation, and ''vishamasana'' or dietary errors. These four basic factors lead to progressive loss of strength (including immunity), vitiating the three doshas and culminating in ''rajayakshma'', a major organic disease that seems to be similar to various similar progressively wasting diseases presenting characteristically with signs and symptoms of Pulmonary Tuberculosis as seen today and has been  described in great clinical and therapeutic detail in [[Charaka Samhita]] [[Chikitsa Sthana]] chapter 8.

Chapter six of [[Nidana Sthana]], titled [[Shosha Nidana]], describes the basics of etiopathogenesis of ''shosharoga'' and its culmination in ''rajayakshma'' vis-à-vis pulmonary tuberculosis. ''Shosha'' is a progressive wasting disease (also called phthisis) which could be a precursor of tuberculosis as known today which occurs due to tubercular infection, phthisis and immune-compromised state. According to Charak there are four primary causes of ''shosha'' viz. ''sahasa'' or over exertion, ''vegavidharana'' or suppression of natural urges, ''kshaya'' or pre-existing emaciation, and ''vishamasana'' or dietary errors. These four basic factors lead to progressive loss of strength (including immunity), vitiating the three doshas and culminating in ''rajayakshma'', a major organic disease that seems to be similar to various similar progressively wasting diseases presenting characteristically with signs and symptoms of Pulmonary Tuberculosis as seen today and has been  described in great clinical and therapeutic detail in [[Charak Samhita]] [[Chikitsa Sthana]] chapter 8.

'''Keywords''': ''kshaya'', ''shosha'', ''yakshma'', ''sahasa'', ''visamashan'', ''Nidanarthakara Roga Vyadhiksamatva'', ''Ojakshaya'', chronic wasting diseases, Immune defense, ''Rasayana''.

'''Keywords''': ''kshaya'', ''shosha'', ''yakshma'', ''sahasa'', ''visamashan'', ''Nidanarthakara Roga Vyadhiksamatva'', ''Ojakshaya'', chronic wasting diseases, Immune defense, ''Rasayana''.

=== Introduction ===

=== Introduction ===

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There are three interrelated entities mentioned by Charaka in three distinct chapters within [[Charaka Samhita]]: [[Shosha Nidana]] (Ni.6), ''rajayakshma'' (Chi.8) and ''kshataksheena'' (Chi. 11).  

There are three interrelated entities mentioned by Charak in three distinct chapters within [[Charak Samhita]]: [[Shosha Nidana]] (Ni.6), ''rajayakshma'' (Chi.8) and ''kshataksheena'' (Chi. 11).  

''Shosha'' is the preparatory stage of gradual, generalized emaciation due to four distinct causative factors mentioned earlier which, if untreated or ignored, may lead to ''rajayakshma''. One of the contributing factors of ''shosha'' is indicative of systemic depletion of ''dhatu'' occurring due to divergent causes. An important point to note here is that ''shosha'' is different from ''kshataksheena'', a post-treatment stage of localized or generalized emaciation needing further intensive treatment.

''Shosha'' is the preparatory stage of gradual, generalized emaciation due to four distinct causative factors mentioned earlier which, if untreated or ignored, may lead to ''rajayakshma''. One of the contributing factors of ''shosha'' is indicative of systemic depletion of ''dhatu'' occurring due to divergent causes. An important point to note here is that ''shosha'' is different from ''kshataksheena'', a post-treatment stage of localized or generalized emaciation needing further intensive treatment.

Another commonly used term for ''shosha'' is ''kshaya'' (emaciation). However, it is imperative to clarify here that while ''shosha'' and ''kshaya'' are contextually similar and synonymous to ''yakshma'' ,  the specific meaning in [[Charaka Samhita]] is different for all the three stages of the disease. Ayurveda is not very stringent when it comes to discerning cause-effect. Cause and effect are largely considered a continuum. While discussing the issue of cause-effect relationship between ''kshaya-shosha-yakshma'', the concept of ''nidanarthakara roga'' has also to be kept in mind where one known disease or a morbid state can play as the ''nidana'' of another disease. That is why, ''kshaya'' is sometimes mentioned as cause of ''shosha'' too. The word ''kshaya'' in this particular context refers to pre-existing ''kshaya''. ''Kshaya'' is of two distinct types - ''anuloma kshaya'' and ''pratiloma kshaya''. ''Anulomakshaya'' is caused by the initial depletion of the ''ojas rasa'' situated in the heart, while ''pratiloma kshaya'' occurs due to an excessive indulgence in sexual activities leading to the depletion of ''shukradhatu'' which in turn leads to generalized ''vata vriddhi'' and ''vata'' induces ''shoshana'' of ''dhatus''. Both these variants contribute to ''shoshana'' (qualitative and quantitative depletion of ''sharira dhatus'' or body tissues).

Another commonly used term for ''shosha'' is ''kshaya'' (emaciation). However, it is imperative to clarify here that while ''shosha'' and ''kshaya'' are contextually similar and synonymous to ''yakshma'' ,  the specific meaning in [[Charak Samhita]] is different for all the three stages of the disease. Ayurveda is not very stringent when it comes to discerning cause-effect. Cause and effect are largely considered a continuum. While discussing the issue of cause-effect relationship between ''kshaya-shosha-yakshma'', the concept of ''nidanarthakara roga'' has also to be kept in mind where one known disease or a morbid state can play as the ''nidana'' of another disease. That is why, ''kshaya'' is sometimes mentioned as cause of ''shosha'' too. The word ''kshaya'' in this particular context refers to pre-existing ''kshaya''. ''Kshaya'' is of two distinct types - ''anuloma kshaya'' and ''pratiloma kshaya''. ''Anulomakshaya'' is caused by the initial depletion of the ''ojas rasa'' situated in the heart, while ''pratiloma kshaya'' occurs due to an excessive indulgence in sexual activities leading to the depletion of ''shukradhatu'' which in turn leads to generalized ''vata vriddhi'' and ''vata'' induces ''shoshana'' of ''dhatus''. Both these variants contribute to ''shoshana'' (qualitative and quantitative depletion of ''sharira dhatus'' or body tissues).

''Shosha'' and ''kshaya'' can be considered as independent clinical entities warranting independent strategies for diagnosis and treatment. Either of these may prove to be a ''nidanarthakara'' factor for the occurrence of ''rajayakshma'' (i.e., if ''shosha'' or ''kshaya'' are left untreated, could lead to ''rajayakshma''). ''Shosha'' is essentially a state of intractable emaciation, cachexia or consumption that could be equated to phthisis. It could be considered to be an intermediate state that may not necessarily exhibit any evidence of tubercular infection but because of persistent ''dhatukshaya''(depletion of tissues) it could be logically associated with an immunocompromised state. Some patients may catch infections that may manifest into a febrile state with probable bacteriological invasion warranting appropriate treatment on the lines of ''rajayakshma''. Because ''shosha'' and ''kshaya'' are intermediary states that are more of diagnostic significance than of significance from a core treatment perspective. Charaka wrote the chapter on ''shosha'' in [[Nidana Sthana]] , while on ''rajayakshma'' in [[Chikitsa Sthana]] with the same motive.

''Shosha'' and ''kshaya'' can be considered as independent clinical entities warranting independent strategies for diagnosis and treatment. Either of these may prove to be a ''nidanarthakara'' factor for the occurrence of ''rajayakshma'' (i.e., if ''shosha'' or ''kshaya'' are left untreated, could lead to ''rajayakshma''). ''Shosha'' is essentially a state of intractable emaciation, cachexia or consumption that could be equated to phthisis. It could be considered to be an intermediate state that may not necessarily exhibit any evidence of tubercular infection but because of persistent ''dhatukshaya''(depletion of tissues) it could be logically associated with an immunocompromised state. Some patients may catch infections that may manifest into a febrile state with probable bacteriological invasion warranting appropriate treatment on the lines of ''rajayakshma''. Because ''shosha'' and ''kshaya'' are intermediary states that are more of diagnostic significance than of significance from a core treatment perspective. Charak wrote the chapter on ''shosha'' in [[Nidana Sthana]] , while on ''rajayakshma'' in [[Chikitsa Sthana]] with the same motive.

It may appear that ''shosha'' and ''rajayakshma'' are synonymous because in this chapter there are brief descriptions of ''poorvarupa'' (preliminary signs) and ''ekadasha rupa'' (advanced stage) of ''yakshma''. However, the manifestation of ''rajayakshma'' has been described in detail only in the [[Chikitsa Sthana]].

It may appear that ''shosha'' and ''rajayakshma'' are synonymous because in this chapter there are brief descriptions of ''poorvarupa'' (preliminary signs) and ''ekadasha rupa'' (advanced stage) of ''yakshma''. However, the manifestation of ''rajayakshma'' has been described in detail only in the [[Chikitsa Sthana]].

While the focus of this chapter is to delineate the views of Charaka, Sushruta in his text differs in his views on the relationship between ''shosha'' and ''yakshma''. While Charaka considers them as dependent entities as mentioned above, Susruta considers ''shosha'' distinctly different disease that could manifest itself in any of seven different variants caused by seven different causative factors (''vyavaya'' or excessive sexual indulgence, ''shoka'' or sorrow, ''jara'' or rapid aging process, ''vyayama'' or excessive exercise, ''adhwagaman'' or excessive travelling, ''vrana'' or wound/trauma, and ''urakshata'' or chest injury.

While the focus of this chapter is to delineate the views of Charak, Sushruta in his text differs in his views on the relationship between ''shosha'' and ''yakshma''. While Charak considers them as dependent entities as mentioned above, Susruta considers ''shosha'' distinctly different disease that could manifest itself in any of seven different variants caused by seven different causative factors (''vyavaya'' or excessive sexual indulgence, ''shoka'' or sorrow, ''jara'' or rapid aging process, ''vyayama'' or excessive exercise, ''adhwagaman'' or excessive travelling, ''vrana'' or wound/trauma, and ''urakshata'' or chest injury.

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===Sanskrit text, Transliteration and English Translation===

===Sanskrit text, Transliteration and English Translation===

He is capable of treating the king who knows, in essence, the etiology, symptoms and prodroma of ''shosha''.

He is capable of treating the king who knows, in essence, the etiology, symptoms and prodroma of ''shosha''.

Thus, ends the sixth chapter on diagnosis of ''shosha'' in [[Nidana Sthana]] in the treatise composed by Agnivesha and redacted by Charaka. [16-17]

Thus, ends the sixth chapter on diagnosis of ''shosha'' in [[Nidana Sthana]] in the treatise composed by Agnivesha and redacted by Charak. [16-17]

=== ''Tattva Vimarsha'' ===

=== ''Tattva Vimarsha'' ===

=== ''Vidhi Vimarsha'' ===

=== ''Vidhi Vimarsha'' ===

The point of significance in this chapter is the identification of the intermediary clinical state called ''shosha'' which is the precursor to ''rajayakshma'', a pathological state warranting early diagnosis and treatment as a promotive health care strategy. Sushruta acknowledges the specific role of microbial infection through direct physical contacts as the real cause, while Charaka emphasizes upon the role of pre-existing progressive weakness and emaciation accompanied with lowered ''vyadhikshamatva'' (poor immune strength) as some of the key causative factors responsible for the entire spectrum of the disease complex that includes ''shosha, kshaya,'' and ''rajayakshma''. This fundamental idea for which Charaka devotes one full chapter in [[Nidana Sthana]] is an original contribution of Charaka, drawing specific attention to the fact that the host factor and host resistance against disease is more important than the causative microbial organism in case of contagious diseases like tuberculosis. It also endorses the Ayurvedic stand that the solution lies in enhancing or strengthening the immunity of the host and not merely in tackling the microorganisms afflicting the person. Use of antibiotics, as is prevalent in western medicine, is now dwindling because of their adverse side effects and rapidly emerging problems associated with drug resistance. In fact, there is now a growing consensus that an idea of an antibiotic war in medicine is anti-life and anti-health.

The point of significance in this chapter is the identification of the intermediary clinical state called ''shosha'' which is the precursor to ''rajayakshma'', a pathological state warranting early diagnosis and treatment as a promotive health care strategy. Sushruta acknowledges the specific role of microbial infection through direct physical contacts as the real cause, while Charak emphasizes upon the role of pre-existing progressive weakness and emaciation accompanied with lowered ''vyadhikshamatva'' (poor immune strength) as some of the key causative factors responsible for the entire spectrum of the disease complex that includes ''shosha, kshaya,'' and ''rajayakshma''. This fundamental idea for which Charak devotes one full chapter in [[Nidana Sthana]] is an original contribution of Charak, drawing specific attention to the fact that the host factor and host resistance against disease is more important than the causative microbial organism in case of contagious diseases like tuberculosis. It also endorses the Ayurvedic stand that the solution lies in enhancing or strengthening the immunity of the host and not merely in tackling the microorganisms afflicting the person. Use of antibiotics, as is prevalent in western medicine, is now dwindling because of their adverse side effects and rapidly emerging problems associated with drug resistance. In fact, there is now a growing consensus that an idea of an antibiotic war in medicine is anti-life and anti-health.

The recent advances in biomedical sciences unfolding the shape and role of genome, epigenome and microbiome in human health have partly proven the generic fact that our genes, our environment and “friendly” microbes are our collective friends and are an integral part of our being. They are protective tool for the immune-enhancing through positive life style, healthy dietetics and regulated use of ''rasayana'' remedies. ''Rasayanas'' are described in Ayurveda for promotive and preventive health care as well as for promotion of longevity.

The recent advances in biomedical sciences unfolding the shape and role of genome, epigenome and microbiome in human health have partly proven the generic fact that our genes, our environment and “friendly” microbes are our collective friends and are an integral part of our being. They are protective tool for the immune-enhancing through positive life style, healthy dietetics and regulated use of ''rasayana'' remedies. ''Rasayanas'' are described in Ayurveda for promotive and preventive health care as well as for promotion of longevity.

#A literary and conceptual study to identify the nature and strength of Bala or immune strength of human body and its scope in prevention and treatment of various diseases and to evaluate its contemporary application.

#A literary and conceptual study to identify the nature and strength of Bala or immune strength of human body and its scope in prevention and treatment of various diseases and to evaluate its contemporary application.

#Clinical and experimental studies on different ''rasayana'' remedies for their immunoenhancing effect in cases of ''kshaya,shosha'' and ''yakshma''.

#Clinical and experimental studies on different ''rasayana'' remedies for their immunoenhancing effect in cases of ''kshaya,shosha'' and ''yakshma''.

#To develop precise diagnostic criteria for the three disease states described by Charaka namely ''kshaya, shosha'' and ''yakshma'' including attempts to identify biomarkers, indicators and clinical rating scales to develop good diagnostic methodology to be used by Ayurvedic practitioners.

#To develop precise diagnostic criteria for the three disease states described by Charak namely ''kshaya, shosha'' and ''yakshma'' including attempts to identify biomarkers, indicators and clinical rating scales to develop good diagnostic methodology to be used by Ayurvedic practitioners.

=== References ===

=== References ===

#Charaka Samhita Vimana 7.9 on natural non-pathogenic organisms.

#Charak Samhita Vimana 7.9 on natural non-pathogenic organisms.

#Chakrapani on Charaka Samhita Vimana 7.9. “ÏarÍra- sahajÁstvaikÁh”

#Chakrapani on Charak Samhita Vimana 7.9. “ÏarÍra- sahajÁstvaikÁh”

#Charaka Samhita Vimana 11.13 about the pathogenic organism that grow in blood, mucus and faeces.

#Charak Samhita Vimana 11.13 about the pathogenic organism that grow in blood, mucus and faeces.

#Charaka Samhita Vimana 7.11, Sushruta Uttara Tantra 54.19-20 and Vagbhata Nidana 14.51 stating that pathogens grown on blood are minute and are invisible.

#Charak Samhita Vimana 7.11, Sushruta Uttara Tantra 54.19-20 and Vagbhata Nidana 14.51 stating that pathogens grown on blood are minute and are invisible.

#Sushruta Samhita Nidana 5.33-34 on the mode of transmission of diseases from person to person.

#Sushruta Samhita Nidana 5.33-34 on the mode of transmission of diseases from person to person.

#Charaka Samhita Nidana 3.6. Description on epidemics.  

#Charak Samhita Nidana 3.6. Description on epidemics.  

#Lakhotia and associates    Amalaki Rasayan in Drosophilia model

#Lakhotia and associates    Amalaki Rasayan in Drosophilia model

#Kuboyama,T. etal (2005) Neuritic regeneration and synoptic reconstruction induced by Withanolide-A.British Jour.Pharmacol. 144/7:961-971

#Kuboyama,T. etal (2005) Neuritic regeneration and synoptic reconstruction induced by Withanolide-A.British Jour.Pharmacol. 144/7:961-971