Chapter 36 – Shotha Nidanam

The 36th chapter of Madhava Nidana is Shotha Nidanam which deals with Oedema, Anasarca. Anasarca is a medical condition that leads to general swelling of the whole body. It happens when your body tissues retain too much fluid due to several reasons. It differs from other types of edema that affect one or two parts of the body. The condition is also known as extreme generalized edema or massive edema. When it happens, it’s usually as a result of a severe underlying condition or organ damage.

Pathogenesis —

रक्त – पित्त – कफान् वायुर्दुष्टो दुष्टान् बहिः सिराः |
नीत्वा रुद्धगतिस्तैर्हि कुर्यात्त्वङ्गमांससंश्रयं || १||
उत्सेधं संहतं शोथं तमाहुर्निचयादतः |
सर्वं हेतुविषेशैस्तु रूपभेदान्नवात्मकम् || २ ||
दोषैः पृथग्द्वयैः सर्वैरभिघाताद्विषादपि |

rakta – pitta – kaphān vāyurduṣṭō duṣṭān bahiḥ sirāḥ |
nītvā ruddhagatistairhi kuryāttvaṅgamānsasanśrayaṁ || 1||
utsēdhaṁ sanhataṁ śōthaṁ tamāhurnicayādataḥ |
sarvaṁ hētuviṣēśaistu rūpabhēdānnavātmakam || 2 ||
dōṣaiḥ pr̥thagdvayaiḥ sarvairabhighātādviṣādapi |

The excess of Vata pushes out the increased blood (rakta), pitta and kapha to the exterior of the skin blocking its channels.This causes swelling of the skin and muscles. In view of its increased size, it is called as utsedha, samhata, and shotha. This pathological condition has been classified into nine kinds that is one from each dosha, one each from the combination of the two doshas, one from the combination of all the three doshas together, one from injury and one from poison.

Prodromal Features —

तत्पूर्वं दवथुः सिरायामो अङ्गगौरवम् || ३ ||

tatpūrvaṁ davathuḥ sirāyāmō aṅgagauravam || 3 ||

The main prodromal symptoms are —

• Mild burning sensation of the skin, eyes, nose
• Distension in the network of the veins and
• feeling of heaviness in the body parts. 3

Etiology and predisposing factors —

शुद्ध्यामयाभुक्त – कृशाबलानां क्षाराम्ल – तीक्ष्णोष्ण – गुरुपसेवा |
दध्याममृच्छाक – विरोधि – दुष्ट – गरोपसृष्टान्ननिषेवणम् च || ४ ||
अर्शांस्यचेष्टा न च देह शुद्धिर्मर्मोपघातो विषमा प्रसूतिः |
मिथ्योपचारः प्रतिकर्मणां च निजस्य हेतुः श्वयथोः प्रदिष्टः || ५ || 

śuddhyāmayābhukta – kr̥śābalānāṁ kṣārāmla – tīkṣṇōṣṇa – gurupasēvā |
dadhyāmamr̥cchāka – virōdhi – duṣṭa – garōpasr̥ṣṭānnaniṣēvaṇam ca || 4 ||
arśānsyacēṣṭā na ca dēha śuddhirmarmōpaghātō viṣamā prasūtiḥ |
mithyōpacāraḥ pratikarmaṇāṁ ca nijasya hētuḥ śvayathōḥ pradiṣṭaḥ || 5 ||

A person is weakened and emaciated by the improper management of different kinds of purifying therapies, effects of diseases and lack of eatables. The causes for systemic oedema of such weak persons are the

• intake of eatables that are alkaline, sour, heat – producing, hot, hard to digest, curds.

Intake of such items as uncooked eatables, mud, leafy vegetables, and incompatible recipes, spoilt and poisoned food is also instrumental in producing this disease. Other etiological factors of this include the

• Presence of Hemorrhoids,
• Absence of physical activity,
• Avoidance of the purifying measures for long periods
• Disorders of vital organs of the body,
• abnormal delivery in women and
• Improper administration of purifying therapies. 4-5

Symptoms of Shotha — 

सगौरवं स्यादनवस्थितत्वं सोत्सेधमूष्मा अथ सिरातनुत्वम् |
सलोमहर्षश्च विवर्णता च सामान्यलिङ्गं श्वयथोः प्रदिष्टं || ६ || 

sagauravaṁ syādanavasthitatvaṁ sōtsēdhamūṣmā atha sirātanutvam |
salōmaharṣaśca vivarṇatā ca sāmānyaliṅgaṁ śvayathōḥ pradiṣṭaṁ || 6 ||

Symptoms of Oedema include the following:

• Feeling of heaviness that go on increasing or decreasing frequently,
• Heat,
• Thinning of the veins,
• Hairs standing on ends and
• Discolouration. 6

Vataja Shotha — 

चलस्तनुत्वक् पुरुषो अरुणो असितः सुषुप्ति – हर्षार्तियुतो अनिमित्तत्तः |
प्रशाम्यति प्रोन्नमति प्रपिडितो दिवाबली च श्वयथुः समीरणात् || ७ ||

calastanutvak puruṣō aruṇō asitaḥ suṣupti – harṣārtiyutō animittattaḥ |
praśāmyati prōnnamati prapiḍitō divābalī ca śvayathuḥ samīraṇāt || 7 ||

Features of oedema generated due to morbid increase in vata include the following:

• Skin on the oedematous part turning movable, thin, rough, brown, or black in colour,
• The skin remaining insensitive.

This kind of oedema is subsided temporarily without any apparent cause. When pressed through fingers, there appear pits on the surface of skin but the pits disappear on their own after a little while. This type of Vataja oedema advances during the daytime.  7

Pittaja Shotha — 

मृदुः सगन्धो असित – पीतरागवान् भ्रम – ज्वर – स्वेद – तृषा – मदान्वितः |
य उष्यते स्पष्टरुगक्षिरागकृत् स पित्तशोथो भृशदाह – पाकवान् || ८ ||

mr̥duḥ sagandhō asita – pītarāgavān bhrama – jvara – svēda – tr̥ṣā – madānvitaḥ |
ya uṣyatē spaṣṭarugakṣirāgakr̥t sa pittaśōthō bhr̥śadāha – pākavān || 8 ||

Features of oedema caused by excess of pitta (Pitta Shotha) include the following:

• Skin on the oedematous part being soft,
• Emitting some smell;
• Its turning black, yellow, or red in colour,;
• Giddiness
• Fever
• perspiration,
• Thirst,
• Toxicity,
• Severe burning sensation in the affected part,
• Redness of the eyes, and
• Oedema forming quickly into an ulcer. 8

Kaphaja Shotha (Solid oedema) —

गुरुः स्थिरः पाण्डुररोचकान्वितः प्रसेक – निद्रा – वमि – वह्निमान्ध्यकृत् |
स कृच्छ्रजन्मप्रशमो निपीडितो न चोन्नमेद्रात्रिबली कफात्मकः || ९ || 

guruḥ sthiraḥ pāṇḍurarōcakānvitaḥ prasēka – nidrā – vami – vahnimāndhyakr̥t |
sa kr̥cchrajanmapraśamō nipīḍitō na cōnnamēdrātribalī kaphātmakaḥ || 9 ||

Features of oedema due to morbid increase in kapha (Kaphaja Shotha) include the following:

• the oedematous part being heavy and immovable;
• the patient having pallor,
• loss of appetite,
• too much of salivation
• Sleep
• Vomiting and
• Poor digestion.

In this condition, the swelling appears with pain. The ailment gets advanced and severe during the night hours. 9

Shotha due to combined Doshas —

निदाना आकृति संसर्गाच्छवयथुः स्याद् द्विदोषजः |
सर्वाकृतिः सन्निपातच्छोथो व्यामिश्रलक्षणः || १० ||

nidānā ākr̥ti sansargācchavayathuḥ syād dvidōṣajaḥ |
sarvākr̥tiḥ sannipātacchōthō vyāmiśralakṣaṇaḥ || 10 ||

In Dvidoshaja and sannipataja shothas presence of features of two doshas and the three doshas respectively must be noticed together. 10

Abhighataja (Traumatic and Allergic) Shotha —

अभिघातेन शस्त्रादिच्छेद – भेद – क्षतादिभिः |
हिमानिलोदध्यनिलैर्भल्लात – कपिकच्छुजैः || ११ ||
रसैः शूकैश्च संस्पर्शाच्छवयथुः स्याद्विसर्पवान् |
भृशोष्मा लोहिताभासः प्रायशः पित्तलक्षणः || १२ ||

abhighātēna śastrādicchēda – bhēda – kṣatādibhiḥ |
himānilōdadhyanilairbhallāta – kapikacchujaiḥ || 11 ||
rasaiḥ śūkaiśca sansparśācchavayathuḥ syādvisarpavān |
bhr̥śōṣmā lōhitābhāsaḥ prāyaśaḥ pittalakṣaṇaḥ || 12 ||

The traumatic and allergic oedemas are those conditions that are marked through inflammation caused by trauma, stab wounds caused by sharp instruments etc., and accidental wounds. Such types of oedema could also occur due to exposure to cold wind or sea breeze as well as through contact with oils of Bhallataka or Kapikacchu. These oedemas are characterized by excessive heat and reddish appearance and they are usually associated with the features of a paittika variety of shotha.  11-12

Vishaja (Poisonous) Shotha —

विषजः सविषप्राणिपरिसर्पण – मूत्रणात् |
दंष्ट्रा – दन्त – नखाघातादविषप्राणिनामपि || १३ ||
विण्मूत्र – शुक्रोपहतमलवद्वस्र सङ्करात् |
विषवृक्षानिलस्पर्शाद्ग्ररयोगावचूर्णनात् || १४ ||
मृदुश्चलो अवलम्बी च शीघ्रो दाह – रुजाकरः |

viṣajaḥ saviṣaprāṇiparisarpaṇa – mūtraṇāt |
danṣṭrā – danta – nakhāghātādaviṣaprāṇināmapi || 13 ||
viṇmūtra – śukrōpahatamalavadvasra saṅkarāt |
viṣavr̥kṣānilasparśādgrarayōgāvacūrṇanāt || 14 ||
mr̥duścalō avalambī ca śīghrō dāha – rujākaraḥ |

Factors leading to the oedema by poisons include the following:

• Poisonous animals crawling on the body, urinating, stinging, biting with teeth, scratching with nails;
• Contact with their faeces, urine, semen or coverings of even non – poisonous animals;
• Contaminated cloth, poisonous trees, belching , and artificial poisonous materials

An oedema that has been generated through poisons would make the swollen part of the skin soft and moveable and there would severe burning sensation
and pain in it and quickly so. The oedema has a tendency to move downward in the body. 13-14

Localised / generalised Oedema vis – a – vis Humours —

दोषाः श्वयथुमूर्ध्वं हि कुर्वन्त्यामाशयस्थिताः || १५ ||
पक्वाशयस्था मध्ये तु वर्चःस्थानगतास्त्वधः |
कृत्स्नदेहमनुप्राप्ताः कुर्युः सर्वसरं तथा || १६ || 

dōṣāḥ śvayathumūrdhvaṁ hi kurvantyāmāśayasthitāḥ || 15 ||
pakvāśayasthā madhyē tu varcaḥsthānagatāstvadhaḥ |
kr̥tsnadēhamanuprāptāḥ kuryuḥ sarvasaraṁ tathā || 16 ||

Doshas located in the stomach produce oedema in the upper parts of the body; Doshas located in the pakvashaya produce oedema in the middle regions of the body; whereas, doshas having reached the site of faeces produce oedema in the lower parts of the body. On the other hand, doshas spreading all over the body produce generalized oedema. 15-16

 Prognosis according to locations —

यो मध्यदेशे श्वयथुः स कष्टः सर्वगश्च यः |
अर्धाङ्गे रिष्टभूतः स्याध्यश्चोर्ध्वं परिसर्पति || १७ ||
श्वासः पिपासा छर्दिश्च दौर्बल्यं ज्वर एव च |
यस्य चान्ने रुचिर्नास्ति श्वयथुं तं विवर्जयेत् || १८ || 

yō madhyadēśē śvayathuḥ sa kaṣṭaḥ sarvagaśca yaḥ |
ardhāṅgē riṣṭabhūtaḥ syādhyaścōrdhvaṁ parisarpati || 17 ||
śvāsaḥ pipāsā chardiśca daurbalyaṁ jvara ēva ca |
yasya cānnē rucirnāsti śvayathuṁ taṁ vivarjayēt || 18 ||

Those cases of oedema, which are considered fatal, include the following:

• the one manifesting in the trunk,
• the one that moves to all the parts of the body,
• That which presents fatal characteristics.

Moreover, oedema seen only in half of the body, and that, which spreads upwards, is also dreadful one. Those patients of oedema must be rejected by wise physician who have an increased and difficult respiration, have developed a morbid thirst, vomiting, debility, fever, and lack of desire for foods. 17-18

According to the mode of onset —

अनन्योपद्रवकृतः शोथः पादसमुत्थितः |
पुरुषं हन्ति नारीं च मुखजो गुह्यजो द्वयम् ||

ananyōpadravakr̥taḥ śōthaḥ pādasamutthitaḥ |
puruṣaṁ hanti nārīṁ ca mukhajō guhyajō dvayam ||

The cases of oedema, which are also considered fatal include the following:

• Oedema not caused by its own specific causes,
• The one appearing in the feet in men and in the face in women, and
• the one appearing in the genital organs.

Those cases of oedema that are of recent onset and that remain without further complications can only be cured.

Oedema of good prognosis —

 नवो अनुपद्रवः शोथः साध्यो असाध्यः पुरेरितः || १९ || 

navō anupadravaḥ śōthaḥ sādhyō asādhyaḥ purēritaḥ || 19 ||

Oedema that is new and without complications is curable while the old one is incurable.19

विवर्जयेत् कुक्ष्युदराश्रितं च तथा गले मर्मणि संश्रितं च |
स्थूलः खरश्चापि भवेद्विवजर्यो यश्चापि बाल – स्थविराबलानाम् || २० ||

vivarjayēt kukṣyudarāśritaṁ ca tathā galē marmaṇi sanśritaṁ ca |
sthūlaḥ kharaścāpi bhavēdvivajaryō yaścāpi bāla – sthavirābalānām || 20 ||

The patients of oedema who are refused treatment (as they are incurable) include the following:

• Who have oedema in the stomach, neck and vital organs;
• Have an oedema very large in size and which is hard and also that which is affecting children, and the very aged, and women. 17-20

इति श्रीमाधवकरविरचिते माधवनिदाने शोथनिदानं समाप्तम् || ३६ ||

iti śrīmādhavakaraviracitē mādhavanidānē śōthanidānaṁ samāptam || 36 ||

Thus concludes the chapter on Shotha.

Source — 

1. Anasarca