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Chapter 3 – Atisara Nidanam

The third chapter of Madhava Nidana deals with Atisara, which is termed as Diarrhoea.

गुर्वतिस्निग्धरुक्षोष्णद्रवस्थूलाति शीतलैः |
विरुद्धाध्यशन जीर्णैर्विषमैश्चापि भोजनैः || १ ||
स्नेहाध्यैरतियुक्तैश्च मिथ्या युक्तैर्विषैर्भयैः |
शोकादुष्टाम्बु मध्यातिपानैः सात्म्यर्तु पर्ययैः || २ ||
जलाभिरमणैर्वेगविघातैः कृमिदोषतः |
नृणां भवत्यतीसारो लक्षणं तस्य वक्ष्यते || ३ ||

gurvatisnigdharukṣoṣṇadravasthūlāti śītalaiḥ |
viruddhādhyaśana jīrṇairviṣamaiścāpi bhojanaiḥ || 1 ||
snehādhyairatiyuktaiśca mithyā yuktairviṣairbhayaiḥ |
śokāduṣṭāmbu madhyātipānaiḥ sātmyartu paryayaiḥ ||2||
jalābhiramaṇairvegavighātaiḥ krmidoṣataḥ |
nrṇāṃ bhavatyatīsāro lakṣaṇaṃ tasya vakṣyate || 3 ||

The following acts generate the disease atisara (diarrhoea):

  • Over indulgence in eatables that are hard to digest,
  • Very fatty; Very dry; Very hot; Very watery; Very hard; Very cold;
  • Intake of food items that contain incompatibles;
  • Meals taken in large quantities and very frequently;
  • Intake of meals that are not cooked and foods taken at unusual times.
  • Moreover, excess or improper usage of therapies like application of oil on the body and the like, poisons, fear, grief, drinking of polluted water,
  • Excess of alcoholic drinks, changes in accustomed habits and seasonal features,
  • Over indulgence in water sports, suppression of natural urges of the body and infestation by worms are also the factors that produce diarrhoea. 1-3

Pathogenesis of diarrhoea –

संशप्यापां धातुरग्निं प्रवृद्धः शक्रुन्मिश्रो वायुना अधः प्रणुन्नः |
सरत्यतीवातिसारं तमाहुर्व्याधिम् घोरं षड्विधं तं वदन्ति ||
एकैकशः सर्वशश्चापि दोषैः शोकेनान्यः षष्ट आमेन चोक्तः || ४ ||

saṃśapyāpāṃ dhāturagniṃ pravrddhaḥ śakrunmiśro vāyunā adhaḥ praṇunnaḥ |
saratyatīvātisāraṃ tamāhurvyādhim ghoraṃ ṣaḍvidhaṃ taṃ vadanti ||
ekaikaśaḥ sarvaśaścāpi doṣaiḥ śokenānyaḥ ṣaṣṭa āmena coktaḥ || 4 ||

When the liquid ingredients of the body increase in quantity, they subdue the digestive fire and get mixed with faecal matter which moves downwards and comes out and comes out by Vata and passed out repeatedly. This condition is called Atisara (Diarrhoea) which is severe and of six types. The six varieties are identified through the following: One from each of the three doshas , one from the combination of the three doshas together, the fifth one from grief and the sixth from the aama or undigested food. 4

Prodromal Features of Diarrhoea —

ह्रुन्नाभिपायूदरकुक्षितोदगात्रावसादानिलसन्निरोधाः |
विट्सङ्ग आध्मानमथाविपाको भविष्यतस्तस्य पुरः सराणि || ५ ||

hrunnābhipāyūdarakukṣitodagātrāvasādānilasannirodhāḥ |
viṭsaṅga ādhmānamathāvipāko bhaviṣyatastasya puraḥ sarāṇi ||5||

The premonitory features of diarrhoea are —

  • Pricking pain in the pericardial, umbilical, and anal regions and in the abdomen as well as in flanks,
  • lassitude in the body,
  • non elimination of flatus,
  • constipation,
  • distension of the abdomen and
  • indigestion of eatables. 5

Vata Type of Diarrhoea —

अरुणं फेनिलं रुक्षमल्पमल्पं मुहुर्मुहुः |
शकृदामं सरुक्शब्दं मारुतेनातिसार्यते || ६ ||

aruṇaṃ phenilaṃ rukṣamalpamalpaṃ muhurmuhuḥ |
śakrdāmaṃ sarukśabdaṃ mārutenātisāryate || 6 ||

In the vataja atisara (diarrhoea due to morbid increase vata dosha) faecal matter is reddish, frothy, and dry. Moreover, it is passed repeatedly in smaller quantities and with pain and sound. 6

Pitta type of Diarrhoea —

पित्तात् पीतं नीलमालोहितं वा तृष्णा – मूर्च्छा – दाह – पाकोपपन्नम् |

pittāt pītaṃ nīlamālohitaṃ vā trṣṇā – mūrcchā – dāha – pākopapannam |

Due to pitta the faeces in diarrhoea is yellow and bluish. Moreover, the patient has burning sensation and perianal suppuration in such cases.

Shleshma (Kapha) type of Diarrhoea —

शुक्लं सान्द्रं श्लेष्मणा श्लेष्मयुक्तं विस्रं शीतं हृष्टरोमा मनुष्यः || ७ ||

śuklaṃ sāndraṃ śleṣmaṇā śleṣmayuktaṃ visraṃ śītaṃ hrṣṭaromā manuṣyaḥ || 7 ||

The faeces in diarrhoea due to shleshma are white, solid in consistency, mixed with phlegm, have the smell of undigested stuff, and are cold in touch. Moreover, the patient has horripilation in such cases.

Diarrhoea of dosha triad –

वराहस्नेह मांसाम्बुसदृशं सर्व रूपिणं |
कृछ्र साध्यमतीसारं विध्याद्दोषत्रयोद्भवम् || ८ ||

varāhasneha māṃsāmbusadrśaṃ sarva rūpiṇaṃ |
krchra sādhyamatīsāraṃ vidhyāddoṣatrayodbhavam || 8 ||

Elimination of faeces resembling the fat of a wild boar or resembling the colour of the water in which mutton has been washed and the patient having characteristics of all the three doshas are seen in the atisara that has been caused due to the morbid increase of all the three doshas together. This is difficult to cure.

Diarrhoea caused by tridoshas has the faecal matter that looks like the fat of a pig (varahasneha) and/ or meat washed water (mamsaambu). The disease is associated with the signs and symptoms of all the three doshas (sarva rupinam) and it is difficult to cure. 8

Diarrhoea due to grief –

तैस्तैर्भावैः शोचतो अल्पशनस्य बाष्पोष्मा वै वह्निमाविश्य जन्तोः |
कोष्टं गत्वा क्षोभयेत्तस्य रक्तं तच्चाधस्तात् काकणन्ति प्रकाशं || ९ ||
निर्गच्छेद्वै विड्विमिश्रं ह्यविड्वा निर्गन्धं वा गन्धवद्वा अतिसारः |
शोकोत्पन्नो दुस्चिकित्स्यो अतिमात्रं रोगो वैध्यैः कष्ट एष प्रदिष्टः || १० ||

taistairbhāvaiḥ śocato alpaśanasya bāṣpoṣmā vai vahnimāviśya jantoḥ |
koṣṭaṃ gatvā kṣobhayettasya raktaṃ taccādhastāt kākaṇanti prakāśaṃ || 9 ||
nirgacchedvai viḍvimiśraṃ hyaviḍvā nirgandhaṃ vā gandhavadvā atisāraḥ |
śokotpanno duscikitsyo atimātraṃ rogo vaidhyaiḥ kaṣṭa eṣa pradiṣṭaḥ || 10 ||

In persons who are deeply afflicted with grief (due to loss of wealth, kith and kin and the like) and who take little or no eatables, the heat generated through tears, gets to the digestive fire and reaches the alimentary canal and ultimately disturbs the blood. The blood resembling the seed of Kakananti gets expelled out of the body either mixed with the faeces or alone and with or without bad smell. The type of diarrhoea caused by grief (shokaatisara) is difficult for management and the physicians also declare that it is difficult to cure. 9-10

Diarrhoea due to Aama (undigested stuff)–

अन्नाजीर्णात प्रद्रुताः क्षोभयन्तः कोष्टं दोषा धातु संघान्मलांश्च |
नानावर्णं नैकशः सारयन्ति शूलोपेतं षष्टमेनं वदन्ति || ११ ||

annājīrṇāta pradrutāḥ kṣobhayantaḥ koṣṭaṃ doṣā dhātu saṃghānmalāṃśca |
nānāvarṇaṃ naikaśaḥ sārayanti śūlopetaṃ ṣaṣṭamenaṃ vadanti || 11 ||

If the food is not properly digested, the doshas are vitiated by associating with the undigested stuff. It might move to wrong channels, vitiate the dhatus (tissues) and malas (waste products) and produce faeces of several colours. The passing of stool takes place frequently and it is accompanied with pain in the abdomen. This is the sixth kind known as aamatisara that is diarrhoea due to indigestion.

Characteristics of Aama afflicted and pakva faeces –

संसृष्टमेभिर्दोषैस्तु न्यस्तमप्स्ववसीदति |
पुरीषं भृशदुर्गन्धि पिच्छिलं चामसंज्ञितं || १२ ||
एतान्येव तु लिङ्गानि विपरीतानि यस्य वै |
लाघवं च विशेषेण तस्य पक्वं विनिर्देशेत् || १३ ||

saṃsrṣṭamebhirdoṣaistu nyastamapsvavasīdati |
purīṣaṃ bhrśadurgandhi picchilaṃ cāmasaṃjñitaṃ || 12 ||
etānyeva tu liṅgāni viparītāni yasya vai |
lāghavaṃ ca viśeṣeṇa tasya pakvaṃ vinirdeśet || 13 ||

The aama type of faeces are the faeces that are associated with the above doshas, that sink when dropped in water, that have very foul odour and that are full of mucus.

In the case features opposite to the above particularly that of the lightness of the stool are present, it indicates the pakva type of faeces. 12-13

Incurable Diarrhoea —

पक्वजाम्बवसंकाशं यकृत्खण्डनिभं तनु |
घृत – तैल – वसा – मज्जा – वेशवार – पयो – दधि || १४ ||
मांसधावनतोयाभं कृष्णं नीलारुणप्रभम् |
मेचकं स्निग्धकर्बूरम् चन्द्रकोपगतं घनं || १५ ||
कुणपं मस्तुलुङ्गाभम् सुगन्धि कुथितं बहु |
तृष्णा – दाह – तमः – श्वास – हिक्का – पार्श्वास्थि – शूलिनम् || १६ ||
संमुर्च्छारति – संमोहयुक्तं पक्ववलीगुदम् |
प्रलापयुक्तं च भिषग्वर्जयेदतिसारिणं || १७ ||
असंवृतगुदं क्षीणं दूराध्मातमुपद्रुतं |
गुदे पक्वे गतोष्माणामतिसार किणं त्यजेत् || १८ ||

pakvajāmbavasaṃkāśaṃ yakrtkhaṇḍanibhaṃ tanu |
ghrta – taila – vasā – majjā – veśavāra – payo – dadhi || 14 ||
māṃsadhāvanatoyābhaṃ krṣṇaṃ nīlāruṇaprabham |
mecakaṃ snigdhakarbūram candrakopagataṃ ghanaṃ || 15 ||
kuṇapaṃ mastuluṅgābham sugandhi kuthitaṃ bahu |
trṣṇā – dāha – tamaḥ – śvāsa – hikkā – pārśvāsthi – śūlinam ||16||
saṃmurcchārati – saṃmohayuktaṃ pakvavalīgudam |
pralāpayuktaṃ ca bhiṣagvarjayedatisāriṇaṃ || 17 ||
asaṃvrtagudaṃ kṣīṇaṃ dūrādhmātamupadrutaṃ |
gude pakve gatoṣmāṇāmatisāra kiṇaṃ tyajet || 18 ||

If the stool looks like the ripened fruit of Jambu, a piece of liver; it appears thin in consistency like ghee, oil, fat, bone marrow, meat preparation (veshavara), milk , curd, mutton wash; is black, reddish, collyrium – coloured, greasy, multi coloured, with lustre, very thick, has an odour of a dead body, looks like the brain contents, putrefied matter or has even a sweet smell and if the patient suffers with thirst, burning sensation, syncope, restlessness, delusion, ulceration in the anus and delirium, the physician should avoid such a patient. Also, if the elasticity of the anus gets ulcerated and the body temperature goes down, such a patient of diarrhoea should not be accepted for treatment by a wise physician. 14-18

श्वास शूल पिपसार्तंक्षीणं ज्वर निपीडितम् |
विशेषेण नरं वृद्धमतीसारो विनाशयेत् || १९ ||

śvāsa śūla pipasārtaṃkṣīṇaṃ jvara nipīḍitam |
viśeṣeṇa naraṃ vrddhamatīsāro vināśayet || 19 ||

The patient of diarrhoea suffering simultaneously from dyspnea, colic, thirst, emaciation and fever and those old in age might die due to this ailment. 19

(शोथं शूलं ज्वरं तृष्णां कासं श्वासमरोचकम् |
च्छर्दिं मूर्च्छाम् च हिक्कां च दृष्ट्वातीसारिणं त्यजेत् || )

(śothaṃ śūlaṃ jvaraṃ trṣṇāṃ kāsaṃ śvāsamarocakam |
cchardiṃ mūrcchām ca hikkāṃ ca drṣṭvātīsāriṇaṃ tyajet||)

If the complications of the ailment produce edema, colic pain, morbid thirst, fever, anorexia, vomiting as well as hiccups, the given case of atisara should be avoided by a wise physician as the symptom is incurable indeed.

Raktaatisara –

पित्तकृन्तियदा अत्यर्थं द्रव्याणयशनाति पैत्तिके |
तदोपजायते अभिक्षणंरक्तातिसार उल्बणः || २० ||

pittakrntiyadā atyarthaṃ dravyāṇayaśanāti paittike |
tadopajāyate abhikṣaṇaṃraktātisāra ulbaṇaḥ || 20 ||

Patients suffering or those who have suffered from pittatisara or even others who take foods and indulge in activities causing increase of pitta will develop quickly a dreaded disease called raktatisara (diarrhoea in which heavy bleeding occurs). 20

Pravahika (Dysentery) —

वायुः प्रवृद्धो निचितं बलासं नुदत्यधस्तादहिताशनस्य |
प्रवाहतो अल्पं बहुशो मलाक्तं प्रवाहिकां तां प्रवदन्ति तज्ज्ञाः || २१ ||

vāyuḥ pravrddho nicitaṃ balāsaṃ nudatyadhastādahitāśanasya |
pravāhato alpaṃ bahuśo malāktaṃ pravāhikāṃ tāṃ pravadanti tajjñāḥ ||21||

Among the individuals who regularly take unwholesome diet, excessively provoked vayu propels the accumulated mucus mixed with faeces down and expels it through anus. It is done repeatedly and in small quantities. The passing of stool is associated with severe griping. The wise people identify this condition as dysentery. 21

Varieties of Pravahika –

प्रवाहिका वातकृता सशूला, पित्तात् सदाहा, सकफा कफाच्च |
सशोणिता शोणितसम्भवा च, ताः स्नेहरुक्षप्रभवा मतास्तु |
तासामतीसारवदादिशेच्च लिङ्गं क्रमं चामविपक्वतां च || २२ ||

pravāhikā vātakrtā saśūlā, pittāt sadāhā, sakaphā kaphācca |
saśoṇitā śoṇitasambhavā ca, tāḥ sneharukṣaprabhavā matāstu |
tāsāmatīsāravadādiśecca liṅgaṃ kramaṃ cāmavipakvatāṃ ca || 22 ||

The Pravahika of vatika origin comes predominantly with intestinal colic. The pravahika of paittika origin manifests with a burning sensation during defecation. The pravahika of kapha origin manifests with mucus in the stools. The pravahika of shonita origin shows blood in the faeces with more moisture or little of it as the case may be. The other features of this disease and the method of determination of aama and pakva (inadequate or adequate processing) varieties of feaces are the same as those of diarrhoea. 22

Symptoms of elimination of diarrhoea —

यस्योच्चारं विना मूत्रं सम्यग्वायुश्च गच्छति |
दीप्ताग्नेर्लघु कोष्टस्य स्थितस्तस्योदरामयः || २३ ||

yasyoccāraṃ vinā mūtraṃ samyagvāyuśca gacchati |
dīptāgnerlaghu koṣṭasya sthitastasyodarāmayaḥ || 23 ||

If one does not defecate while passing urine and fart, if one’s digestive fire is kindled properly and if one feels lightness in the abdomen, it should be understood that his abdominal disease (diarrhoea, in the context) is alleviated. 23

इति श्रीविजयरक्षितकृतायां मधुकोश व्याख्यायामतीसारनिदानं समाप्तं ||

iti śrīvijayarakṣitakrtāyāṃ madhukośa vyākhyāyāmatīsāranidānaṃ samāptaṃ ||

Thus concludes the Chapter on Atisara.