The Duality of Disease in Ayurveda

In the Aṣṭāñga Hṛdaya Vāgbhaṭa delineates two types of treatment based on the Ṣaḍvidha upakrama, consisting of laṅghana and bṛṃhaṇa. Also referred to in other texts as apatarpaṇa and santarpaṇa, the reduction of the Ṣaḍvidha upakrama to the dualism of laṅghana and bṛṃhaṇa reflects the notion that all disease can be classified as a state of ‘excess’ (takman) or ‘deficiency’ (balāsa). First described in the Atharvaveda, takman is the archetype of all disease, personified as a demon that attacks the patient’s body “inflaming them like a searing fire” (5:22). In Āyurveda, takman is correlated with jvara, or ‘fever’, which is given an important status in every classical text as the first disease to be described, usually in much greater detail than any other disease, providing key therapeutic strategies that resonate in the treatment of many other diseases. According to the Atharvaveda the ‘brother’ of takman is balāsa, a “firmly-settled heart-disease that racks the bones and rends the limbs” (6:14), which in Āyurveda is correlated with rājayakṣma, or ‘consumption’. Similar to jvara (takman), which utilizes the therapeutic rationale of laṅghana upakrama, the treatment of rājayakṣma (balāsa) draws upon bṛṃhaṇa upkrama, and is the primary model in the treatment of deficiency disease. In the following two sections, the twin diseases of jvara and rājayakṣma are presented to illustrate the paired strategies of laṅghana and bṛṃhaṇa.

Jvara: fever

According to traditional sources including the Mahābhārata, jvara or ‘fever’ is described as the ‘lord of all disease’, which sprung forth in a fiery wrath from the third eye of Rūdra (Śiva) when Dakṣa insulted him by not including Śiva in his ritual sacrifice. Once set loose, this fiery creature called Virabhadra destroyed Dakṣa and his sacrifice, and was set loose upon the world as jvara. Thus fever is a disease characterized by heat, and is associated with a failure to observe proper conduct (i.e. diet and lifestyle).
According to Caraka jvara is of two types: one caused by ‘intrinsic’ (njia) factors, and the other caused by ‘extrinsic’ (āgantu) factors (Ni 1:4). Among those caused by innate factors fever is of seven types: one from each doṣa, one from a combination of two doṣāḥ, and one from a combination of all three doṣāḥ. In contrast, there are a great variety of ‘extrinsic’ (āgantu) factors that cause fever, including infection, poisoning, animal or insect bites, sudden changes in weather, intense emotions, and the influence of bhūta (‘demons’), i.e. āgantu, or ‘extrinsic’ factors.

Nija jvara: intrinsic factors in fever

Intrinsic (nija) factors in jvara relate to the doṣāḥ becoming increased by their respective causes, which then enter into the ‘stomach’ (āmāśaya) and combine with āma. This results in the obstruction of the ‘channels’ (srotāṃsi) which inhibits perspiration, and drives the ‘digestive fire’ (agni) to the periphery of the body, increasing body temperature. According to Vāgbhaṭa the premonitory symptoms (pūrvarūpa) of jvara include lassitude; drowsiness; lack of motivation; bad breath; loss of appetite; excessive yawning; lacrimation; bodyache; indigestion; weakness and fatigue; excessive sleep; goosebumps; leg pain; impatience; a desire for sour/pungent/salty flavors and dislike of sweet; thirst; sensitivity to light and sound; and temperature intolerance (Ni 2:6-10).
Once fully manifested, each type of fever expresses signs and symptoms (rūpa) associated with a specific doṣa or combination of doṣāḥ:

  • Vāta: irregular progression of symptoms; fluctuating temperature; fluctuation between mild and severe symptoms; increase of symptoms during the vāta kāla (e.g. end of the day, autumn); dark-red discoloration and roughness of nails, eyes, face, urine, stool and skin; localized and migrating body pain, characterized spasm, cracking, breaking and constriction; tinnitus; temporal headache; astringent taste in mouth; painful teeth; dry heaving; dryness of mouth and throat; difficulting sneezing or burping; aversion to food; anorexia; indigestion; malaise; yawning; exhaustion; shivering; giddiness; delirium; insomnia; goosebumps; and a preference for warmth.
  • Pitta: high fever; increase of symptoms during the pitta kāla (e.g. mid-day, summer); intense burning sensations; mucosal inflammation; thirst; giddiness; fainting; vomiting of bile; diarrhea; anorexia; delirium; skin rashes; green or yellowish discoloration of the nails, eyes, mouth, urine, feces and skin; and a preference for cold.
  • Kapha: feeling of coldness; mild increase in temperature; increase of symptoms during the kapha kāla (e.g. morning, spring); lethargy and heaviness; anorexia; excessive catarrh and mucus; sweet taste in mouth; nausea; vomiting; excessive sleep and drowsiness; cough; dyspnea; coryza; whitish discoloration of the nails, eyes, mouth, urine, feces and skin; stiffness; itchy skin; nausea and vomiting; goosebumps; and a preference for warmth.
  • Vāta-pitta: signs and symptoms of both vāta and pitta jvara, as well as headache, fainting, vomiting, burning sensations, delusion, dryness of the throat and mouth, restlessness, joint pain, insomnia, thirst, dizziness, goosebumps, and excessive yawning or talking.
  • Vāta-kapha: signs and symptoms of both vāta and kapha jvara, as well as a mild increase in temperature, loss of appetite, joint pain, headache, coryza, dyspnea, cough, constipation, coldness, lassitude, weakness of vision, dizziness and stupor.
  • Pitta-kapha: signs and symptoms of both pitta and kapha jvara, as well as alternating coldness and burning sensations, stiffness of body, sweating, thirst, cough, increased discharge of mucus or bile, delusion, thick coating on the tongue, and a bitter taste in the mouth.
  • Vāta-pitta-kapha (sannipātaja): signs and symptoms of all three doṣāḥ, as well as a rapid fluctuation between feelings of coldness and burning sensation, joint pain, headache, lacrimation, redness of eyes, earache, tinnitus, thick hairy coating on tongue, drowsiness, fainting, delirium, cough, dyspnea, anorexia, giddiness, hemoptysis, thirst, insomnia, angina, anhidrosis, constipation, dehydration, groaning, dark-red rashes, ulceration, heaviness of the abdomen, and weak digestion that does not resolve despite treatment.

The classical texts describe three phases of jvara: taruṇa, madhya and jīrna. Taruṇa refers to the ‘fresh’ fever, which begins with the first onset of the fully manifested symptoms, lasting for a period of seven days. Madhya refers to the middle stage of fever, lasting from day seven to day twelve. The term jīrna refers to an ‘old’ fever, which lasts beyond twelve days, and if the fever persists beyond 21 days it is a separate disease called jīrna jvara. Such fevers are caused by improper treatment, the aggravation of vāta, or are secondary to another disease (e.g. rājayakṣma). The result of jīrna jvara is a deficiency of the dhātavaḥ and if neglected further other diseases such as splenomegaly.
If the fever takes an irregular course, and comes and goes at different intervals, this is called viṣama jvara. According to Suśruta viṣama jvara is caused by small amounts of the aggravated doṣa(s) remaining somewhere within the dhātavaḥ (Utt. 39:62-64). If the fever is continuous with no breaks for seven, ten or twelve days it is santata jvara, and relates to a vitiation of rasa. If the fever occurs only once during the day and night, it relates to a vitiation of both rasa and rakta, and is called satataka jvara. If the fever occurs only once a day it is called anyedyuṣka, and relates to a vitiation of both rakta and māṃsa. If the fever occurs every third day it is called tṛtiyaka, and relates to a vitiation of rakta, māṃsa, and medas. If the fever occurs every four days it is called caturthaka, and relates to a vitiation of rakta, māṃsa, medas and asthi. Suśruta also states that viṣama jvara can be caused by ‘extrinsic’ (āgantu) factors.

Treatment of nija jvara

Treatment of jvara caused by ‘instrinsic factors’ (nija) is based upon general treatments to resolve fever, used in combination with specific measures to balance to doṣa(s) involved. As alluded to in the introduction to jvara when Rūdra destroys Dakṣa for his impropriety, fever is caused by a failure to observe a healthy lifestyle, including the consumption of unwholesome foods, which aggravates the doṣāḥ and weaken the digestive fire. Thus as the cause of nija jvara is fundamentally related to a derangement of the jaṭharāgni, specific measures are given to restore appetite through the application of laṅghana krama. Due to their negative effects upon digestion, antifebrile medication to suppress the fever is not given at the outset of treatment, and is not given until āma is resolved.
Vāgbhaṭa states that the first measure in jvara is ‘drinking warm water’ (uṣṇāṃbupāna), particularly in the presence of āma, in fevers caused by vāta and kapha, but not in fever caused by pitta alone (in which cool or room temperature water is given) (Ci 1:11-13). The avoidance of food is generally recommended in all types of fever except in vāta jvara, fever secondary to ‘consumption’ (rājayakṣma), fever from ‘extrinsic’ (āgantu) factors, and chronic fever (jīrna jvara). In conjunction with fasting, measures to induce sveda (‘sweat’) are introduced, except in pitta jvara, including keeping the patient warm (e.g. blankets, steambath etc.) and drinking warm water to promote sweating. Except in vāta jvara the patient is counseled to wait for a period of ‘time’ (kāla) until the appetite returns before eating any food. Vāgbhaṭa also mentions the utility of vamana karma (‘emesis therapy’) when the fever is accompanied by nausea or cough; is caused by eating an excess of greasy and sweet food; or when the fever appears after eating – all of which indicates an increase in kapha and āma (Ci 1:4-8). As a general remedy for fever and thirst, the Aṣṭāñga Hṛdaya recommends a formula called Ṣaḍangapānīya, prepared by decocting one karśa (12 g) each of Mustaka, Candana, Śuṇṭhī, Ambu, Parpaṭa, and Uśīra in one prastha (750 mL) of water, reduced by half, and given to the patient when cooled to room temperature (Ci 1:15-16).
When the patient’s appetite is restored after a few days and āma is digested, Vāgbhaṭa states that the next stage in treatment is yavāgū, or the ‘drinking of gruel’ (Ci 1:21). Yavāgū refers to a thin soup prepared from various cereals, including rice and barley, that is easily digestible. As the patient’s digestion improves over a period of days, the gruel becomes progressively thicker and more dense to supply more nutrition. This staged approach to the introduction of dietary articles is discussed more fully under saṃsarjana krama, or the ‘graduated diet’.
For fever Vāgbhaṭa generally recommends yavāgū prepared with lāja (‘puffed rice’), along with herbs to enhance digestion such as Śuṇṭhī, Dhānyāka, Pippalī, and saindhava. Likewise, yavāgū can be prepared with a decoction of Ṣaḍangapānīya, mentioned previously. While yavāgū is generally given warm, if there is a great increase in pitta it is given at room temperature, mixed with honey. Beyond these basic recipes, Vāgbhaṭa mentions a series of herbal decoctions that can be used to prepare the gruel, one karṣa (12 g) of the herbs decocted in one prastha (768 mL) of water, reduced by half:

  • For body pain: Vyāghrī and Gokṣura
  • For diarrhea: Pṛṣniparṇī, Balā, Bilva, Nāgara, Utpala, Dhānyaka, and Dāḍima
  • For cough and dyspnea: roots of Bṛhati, Kaṇṭakārī, Śālaparṇī, Pṛṣṇiparṇī, and Gokṣura
  • For mucus and catarrh: barley yavāgū, prepared with the roots of Bilva, Kāṣmarī, Agnimañthā, Pāṭalā, and Śyonāka
  • For constipation: barley fried in ghṛta, prepared with Āmalaka and Pippalī
  • For intestinal obstruction: Cavikā, Pippalīmūla, Drākṣā, Āmalaka, and Nāgara
  • For rectal pain: Kola, Vṛkṣāmla, Kalaśī, Dhāvanī, and Śrīphala
  • For absence of perspiration, sleep or thirst: Āmalaka, Nāgara, and sugar
  • For vomiting, thirst, burning sensations: Badara, Mṛdvīkā, Sārivā, Mustā, Candana, and honey

As the patient’s appetite improves yavāgu is followed by the staged approach of saṃsarjana krama, gradually increasing the density and complexity of the food.
When āma is digested and the doṣāḥ are ‘ripened’ (pakva) through the application of yavāgu, the next stage in fever management is the application of herbs that have a ‘bitter’ (tikta) and ‘pungent’ (kaṭu) flavor, in the form of fresh juices, infusions, decoctions or powders. The bitter flavor is used specifically to reduce pitta, whereas pungent flavor is used to reduce kapha. Herbs that have an ‘astringent’ (kaśāya) flavor are avoided in fever, as anything astringent prevents the doṣāḥ from being properly expelled. Likewise, herbs with a sweet, sour or salty taste increase the production of āma. The following are a list of simple herbal decoctions utilized in the treatment of fever:

Vātaja jvara

  • Decoction of Durālabha, Guḍūcī, Mustā, and Nāgara (Aṣṭañga Hṛdaya)
  • Decoction of Pippalīmūla, Guḍūcī, and Śuṇṭhī (Aṣṭañga Hṛdaya)
  • Decoction of Bṛhati, Kaṇṭakārī, Śālaparṇī, Pṛṣṇiparṇī, and Gokṣura (Aṣṭañga Hṛdaya)

Pittaja jvara

  • Decoction of either Iñdrayava, Ghana, and Kaṭuka, mixed with honey (Aṣṭañga Hṛdaya)
  • Decoction of Mustā and Parpaṭaka (Aṣṭañga Hṛdaya)
  • Decoction of Dhanvayāsa and Bhūnimba, mixed with honey (Aṣṭañga Hṛdaya)

Kaphaja jvara

  • Decoction of either Vatsaka, Mūrvā, Kaṭuka, Marica, Elā, or Ajamoda (Aṣṭañga Hṛdaya)
  • Decoction of Vāsaka, Mustā, Ārdraka and Durālabha (Aṣṭañga Hṛdaya)

Vātapittaja jvara

  • Decoction of Guḍūcī, Parpaṭaka, Mustā, Kirātatikta, and Śuṇṭhī (Yogaratnāka)
  • Decoction of Triphalā, Gambhārī, Rāsnā, Āragvadha, and Vāsaka (Yogaratnāka)

Vātakaphaja jvara

  • Decoction of either Vacā, Kaṭuka, Pāṭhā, Āragvadha or Vatṣaka, with powder of Pippalī (Aṣṭañga Hṛdaya)
  • Decoction of Vyāghrī, Śuṇṭhī, and Guḍūcī, with powder of Pippalī (Aṣṭañga Hṛdaya)

Kaphapittaja jvara

  • Decoction of either Āragvadha, Iñdrayava, Pāṭali, Nimba, or Guḍūcī, taken with honey (Aṣṭañga Hṛdaya)
  • Decoction of Kaṭuka, Vāsaka, Uśīra, Trāyañtī, Triphalā, Guḍūcī, Paṭola, Ativiṣa, Nimba, Mūrva, and Dhanvayasāka (Aṣṭañga Hṛdaya)

Sannipātaja jvara

  • Decoction of Vyāghrī, Devadāru, Haridrā, Ghana, Paṭola bark, Nimba bark, Triphalā, and Kaṭuka (Aṣṭañga Hṛdaya)
  • Decoction of Nāgara, Puṣkara root and Guḍūcī (Aṣṭañga Hṛdaya)

The decoctions (kvātha) listed above are prepared according to the method described under the pañca kaṣāya, dosed between 1-2 pala (48-96 mL), taken 2-3 times daily. According to Vāgbhaṭa, all of the decoctions indicated for vāta and pitta should be mixed with a little ghṛta (Ci 1:86-89) as an anupāna, which has a special ability to resolve fever after āma has been dispelled. These medicinal decoctions should be taken before meals on an empty stomach, except in children, the aged, in pregnancy or in the weak, in which case they can be taken with or after meals. In addition to these decoctions, more complex formulae that have an ability to reduce fever in all three doṣāḥ are often prescribed simultaneously. These include several formulas discussed in the Bhaiṣajyaratnāvalī, including Sudarśana cūrṇa, Jvarabhairava cūrṇa, Amṛtāriṣṭa, Mṛgamadāsava and Mṛtyuñjayarasa. If after applying these remedies the fever persists, Vāgbhaṭa indicates that śodhana karma (‘purificatory treatment’) can be applied, including the used of vamana for kapha jvara and virecana for pitta jvara.

Treatment of jīrna jvara

Jīrna jvara relates to a chronic fever that lasts beyond twelve days, and has not responded to the application of laṅghana. In such cases there is a concern that prolonged fever has a catabolic effect upon the dhātavaḥ, leading to an increase in vāta. Thus where the fever persists, and in patients that are otherwise unsuitable for śodhana karma, measures are taken to pacify the fever. Among the different methods described by Vāgbhaṭa are kṣīrapāna (‘drinking of milk’), indicated in jīrna jvara characterized by vāta and pitta, medicated with different herbs including Śuṇṭhī, Drākṣā, Balā, Yaṣṭīmadhu, Sārivā, Candana, Vyāghrī and Pippalī. Likewise, Suśruta recommends Pañcagavya ghṛta in jīrna jvara, comprised of equal parts milk, yoghurt, ghṛta, cow’s urine and the liquid expressed from cow dung, decocted with a ‘paste’ (kalka) of herbs comprised of Triphalā, Citraka, Mustā, Haridrā, Dāruharidrā, Ativiṣā, Vacā, Viḍanga, Trikaṭu, Cavya, and Devadāru. Vasti karma (p. 263) utilizing both anuvāsana and nirūha vasti is recommended in jīrna jvara, using the standard formulas or medicated with herbs that are jvaraghna, including Paṭola, Nimba, Kaṭuka, Balā, Gokṣura, Yaṣṭīmadhu, Āragvadha, and Mustā. Nasya is also recommended by Vāgbhaṭa: virecana nasya for jīrna jvara with headache and congestion, and bṛṃhaṇa nasya with a feeling of emptiness of the head and burning sensation. Abhyaṅga is similarly mentioned in the treatment of jīrna jvara, utilizing medicated oils including Balā taila, Lākṣādi taila, Balāsvagandhalākṣādi taila, Narāyaṇa taila, and Vāsācandanādi taila. Other measures utilized in jīrna jvara include dhūmapāna, gaṇḍusa and kavalagraha.

Treatment of viṣama jvara

The treatment of viṣama jvara is essentially the same as for any other fever, treating the patient on the basis of the doṣāḥ that are expressed. Vāgbhaṭa recommends a specific combination of herbs for each of the five types of viṣama jvara (Ci 1: 48-51):

  1. Santata jvara: decoction of Kuṭaja, Paṭola, and Kaṭuka
  2. Satataka jvara: decoction of Paṭola, Sārivā, Mustā, Pāṭhā, and Kaṭuka
  3. Anyedyuṣka jvara: decoction of Paṭola, Nimba, Triphalā, Mṛdvīkā, Mustā, and Vatṣaka
  4. Tṛtiyaka jvara: decoction of Kirātatikta, Amṛtā, Candana, and Śūṇṭhī
  5. Caturthaka jvara: decoction of Dhātrī, Musta, and Amṛtā, taken with honey

Suśruta recommends both vamana and virecana in the treatment of viṣama jvara, and in particular mentions the utility of ghṛta, which has a special ability to penetrate into the various tissues of the body to expel the small quantity of the vitiated doṣāḥ that persists. Among the different ghṛta-based compounds is a simple ghṛta prepared with Laśuna taken before meals, as well as a formula comprised of equal parts Triphala, the Pañcakola (i.e. Pippalī, Pippalīmūla, Cavya, Citraka and Nāgara) and Agnimañtha, along with an equal part yoghurt, ghṛta, and paste of Lodhra (Utt. 39: 204-205).

Āgantu jvara: extrinsic factors in fever

Āgantu jvara relates to all other causes of fever not directly caused by a vitiation of the doṣāḥ, including trauma, infection (e.g. typhoid, malaria), poisoning (e.g. heavy metals, toxic plants or fungi), animal or insect bites, environmental contaminants (e.g. pollen), intense emotions (e.g. lust, grief, fear, anger), curses, black magic, and the influence of bhūta (‘demons’). Where the cause can be identified it is treated directly, and general measures to resolve fever are undertaken, although laṅghana does not apply if āma is not present. For infections including typhoid, malaria, and Lyme disease, general remedies such as Sudarśana cūrṇa and Mṛtyuñjayarasa are given, along with specific herbs that address any signs or symptoms of the vitiated doṣāḥ. For poisoning the measures described under the teaching of Agada tantra (viṣagaravairodhika praśamana) are utilized, including vamana or virecana to expel the toxin, nasya (to restore consciousness), along with the internal or topical application of antitoxin remedies including Koṣātaki, Agnika, Pāṭhā, Sūryavallī, Guḍūcī, Harītakī, Haridrā, Punarnavā, Madhūka, Padmakeśara, and Candana (AH, Utt. 35:17-23). For fever caused by environmental contaminants such as pollen or fungus, Vaidya Mana suggests remedies such as Alarasāyana and Mṛtyuñjayarasa (Bajracharya 2011, 152). For fever caused by emotions, the appropriate psychological therapy is undertaken, either by satisfying the emotion, e.g. recommending sexual intercourse in fever caused by lust, or opposing it, e.g. inducing anger in fever caused by fear or grief, or using sexual intimacy to satisfy fever caused by anger (Bajracharya 2011, 151).
Beyond these basic causes, Āyurveda also describes a myriad number of spiritual factors that cause fever, and, in particular, are common to pediatric conditions. Such diseases are recognized as an affliction of the graha and bhūta and are treated with spiritual therapies including mantra cikitsā, rūpa cikitsā, gandhā cikitsā, rasa cikitsā, and sparśa cikitsā (Bajracharya 2011, 81-86). Mantra cikitsā (‘sound therapy’) consists of the recitation of certain mantra by the patient or those attending them, or by inscribing them on some object and then wearing this as a talisman. Many different mantra are considered auspicious, but specific mantrāḥ are prescribed on the basis of the signs and symptoms of the patient, which indicates the particular graha and bhūta that is manifest. Among the many different mantrāḥ, what are typically referred to as the śāntiḥ mantrāḥ can be used generally to ward off negative influences, such as this one from the invocation to the Māṇḍūkya Upaniṣad:

ॐ भद्रं कर्णेभिः श्रुणुयाम देवाः ।
भद्रं पश्येमाक्षभिर्यजत्राः स्थिरैरन्ङ्गैस्तुष्टुवागं सस्तनूभिः ।
व्यशेम देवहितम् यदायुः । स्वस्ति न इन्द्रो वृद्धश्रवाः ।
स्वस्ति नः पूषा विश्ववेदाः । स्वस्ति नस्तार्क्ष्यो अरिष्टनेमिः ।
स्वस्ति नो ब्रिहस्पतिर्दधातु ॐ शान्तिः शान्तिः शान्तिः ॥

oṃ bhadraṃ karṇebhiḥ śruṇuyāma devāḥ
bhadraṃ paśyemākṣabhiryajatrāḥ sthirairanṅgaistuṣṭuvāgaṃ sastanūbhiḥ
vyaśema devahitam yadāyuḥ svasti na indro vṛddhaśravāḥ
svasti naḥ pūṣā viśvavedāḥ svasti nastārkṣyo ariṣṭanemiḥ
svasti no brihaspatirdadhātu oṃ śāntiḥ śāntiḥ śāntiḥ

“Aum! Salutation to the Shining Ones! May we hear auspicious words with the ears. While engaged in worship, may we see auspicious things with the eyes. While praising the gods with steady limbs, may we enjoy a life that is beneficial to the Gods. May Indra of ancient fame be auspicious to us. May the all-knowing Pūṣā (god of the earth) be propitious to us. May Tārkṣya, the destroyer of evil, be well disposed towards us. May Brihaspati ensure our welfare. Aum! Peace! Peace! Peace!”
Rūpa cikitsa (‘figure therapy’) relies on the use of sacred geometry and other sacred images, including yantra and maṇḍala, as well as images of the protector deities such as Śiva, Viṣṇu, Mañjuśrī, and the Bhaiṣajyaguru (Medicine Buddha). Specific yantra such as the Nārasimha yantra and Maha Sudarśana yantra are drawn outside and inside the dwelling of the patient, inscribed on talismans, and images of protecter deities are brought to the patient so they can contemplate them. Gandhā cikitsā (‘odor therapy’) relates to the application of different scents, usually in the form of a medicinal incense (dhūpa) that is burnt in proximity to the patient to ward off negative influences. In the Aṣṭāñga Hṛdaya Vāgbhaṭa makes mention of Aparājita dhūpa in the treatment of fever caused by the graha and bhūta, prepared from Guggulu, Dhyāma, Vacā, Sarja, Nimba, Arka, Aguru, and Devadāru (Ci 39:163). Rasa cikitsā (‘flavor therapy’) makes use of an ‘offering’ (bali) in the form of a sumptuous morsel of food which is offered to the patient. The deliciousness of the bali in turn draws the bhūta or graha into it, after which time the bali is offered to a deity, and then discarded in a suitable location, such as a riverbank, at the cemetery grounds, or at a crossroads (Bajracharya 2011, 85). Sparśa cikitsā (‘contact therapy’) involves the use of ‘sacred objects’ (maṇi) including talismans, jewels, herbs or animal products (e.g. gorocanā) that are believed to have special powers, or have been imbued with qualities through meditation and worship. In sparśa cikitsā the object is either handled or worn by the patient next to the skin to dispel negative influences.

Rājayakṣma: wasting disease

Rājayakṣma means the ‘king of wasting disease’, and according to the Atharvaveda, rājayakṣma or balāsa, is the brother of jvara (takman). The Mahābhārata tells us that rājayakṣma arose as a curse uttered by Dakṣa, directed at his son-in-law Candramas, the King of the Moon. The reason for this curse is that despite Candramas being wedded to 27 of Dakṣa’s daughters, he was infatuated with only one named Rohiṇī, and spent all his time enjoying her company and ignored the rest. Enraged by Candramas’ failure to give attention to all his daughters equally, Dakṣa uttered a curse that began to cause the Moon to waste away. This in turn caused all the herbs on earth including the sacred herb Soma to wither and die, and the Gods with great concern asked Dakṣa to withdraw his curse. While Dakṣa tells them he cannot withdraw his curse, he says that if Candramas bathes in the Sarasvati river he will regain his original luster and brightness. As the curse was never completely obviated however, Candramas continues to wax and then wane in the heavens as the phases of the moon, bathing every month on the new moon to regain his original lustre.
According to traditional Indian mythology, the Moon is the guardian of all the healing plants including Soma, which gives the Gods their celestial powers. Thus an affliction to the Moon represents an affliction to vitality, and just as the Moon wanes, rājayakṣma represents a disease of gradual diminishment leading to death. As this tale suggests, this wasting occurs as the result of the heedless indulgence in sexual pleasure (kama), and a failure to live up to one’s responsibilities (dharma). Caraka states that rājayakṣma has four essential causes:

  • Sāhasa: excessive physical and mental exertion
  • Saṃdhāraṇa: suppression of natural urges (see p. 175)
  • Kṣaya: depletion of śukra (‘semen’), ojas, and sneha, i.e. The unctuousness of the body
  • Viṣamāśana: unwholesome diet and lifestyle (see p. 147) (ni 6:3)

Once aggravated by these factors vāta becomes vitiated, in turn aggravating both pitta and kapha. As a result of this increase there is a constriction in the channels of the body, impairing the flow of rasa, leading to a great increase in kapha simultaneous with a dimishment of the ‘bodily tissues’ (dhātavaḥ). Vāgbhaṭa states that the premonitory symptoms (pūrvarūpa) of rājayakṣma are: excessive mucus and catarrh; sneezing; a sweet taste in the mouth; weakness of digestion; perceiving one’s environment or body as unclean; nausea; vomiting; lack of strength; edema of the face and feet; cough; excessive sleep and drowsiness; a craving for meat, wine and sexual intercourse; excessive growth of the hair and nails; dreaming that one is being carried away by different creatures, including butterflies, lizards, snakes, monkeys, dogs or birds; dreaming of deforestation, dry rivers, desolation, smoke, falling stars, and forest fires (Ci 5:7-13).
If the etiological factors persist rājayakṣma ripens with fully manifested signs and symptoms (rūpa), which Caraka lists as being eleven in number, including nasal and sinus congestion, cough, dyspnea, hoarseness, vomiting of mucus, hemoptysis, chest pain, shoulder pain, fever, diarrhea and loss of appetite (Ni 6:14). Rājayakṣma is a tridoṣaja disease, and each of the symptoms are correlated with one of the doṣāḥ: thus vāta produces body pain and hoarseness; pitta produces fever, hemoptysis, and diarrhea; and kapha promotes vomiting, cough, dyspnea, catarrh, and weakness of digestion. As the condition progresses it causes the wasting of the dhātavaḥ and an increase in wastes (mala), and in such cases Vāgbhaṭa states that patient draws strength from the ‘feces’ (purīṣa) (Ci 5:19-22).
Rājayakṣma is often correlated with pulmonary tuberculosis, but it also relates to other diseases characterized by a loss of ojas and a wasting of the ‘bodily tissues’ (dhātavaḥ) including HIV/AIDS, cancer, multiple sclerosis and iatrogenesis from chemotherapy, radiation, and immunosuppressant drugs.

Treatment of rājayakṣma

The treatment of rājayakṣma is based upon a number of different elements, including diet and lifestyle, along with both purificatory and palliative measures. Vaidya Mana states that despite the fact that rājayakṣma is a tridoṣaja disease, the most important consideration is to control vāta (Bajracharya 2009, 185). To this end Vāgbhaṭa recommends a bṛṃhaṇa diet, comprised of dietary articles such as rice, wheat, barley, mudga (green gram), aged wine, milk, ghṛta, goat meat, and especially the meat of carnivorous animals (e.g. crow, owl, jackal, tiger, mongoose, etc.) (Ci 5:5-6). The diet should make copious use of dīpanapācana herb, and be prepared in such as fashion to enhance digestibility, with an emphasis on warming soups and stews. For example, Vāgbhaṭa recommends a stew of goat meat, barley, and horsegram, prepared with Pippalī, Nāgara, Dāḍima and Āmalaka, mixed with ghṛta (Ci 5:10-11). Likewise, a milk decoction prepared with Daśamūla and ghṛta, taken with Pippalī cūrṇa and honey, is consumed on a regular basis to alleviate body pain, cough, dyspnea, and fever (Ci 5:19-20). The patient should follow a balanced lifestyle based on the principles of dinācaryā (p. 101), following the rules of a wholesome diet (p. 147), the proper restraint of the senses (p. 173), and the avoidance of prajñaparādha (p. 174). Sexual activity in rājayakṣma should be avoided in order to preserve śukra and ojas.
For patients who are strong with a great increase of the doṣāḥ, Vāgbhaṭa suggests a course of śodhana, utilizing the pūrva karma (p. 239), followed by vamana (p. 257) and virecana (p. 260). Vamana therapy should make use of emetics such as Madanaphala in combination with unctuous materials such as milk, syrups, meat soup or yavāgū (‘thin gruel’), mixed with ghṛta (Ci 5:2). Likewise, virecana should utilize purgative herbs such as Trivṛt and Āragvadhā, mixed with similarly unctuous ingredients including sugar, honey and ghṛta; or mixed with milk, Drākṣā juice, Vidārī, Kāśmaryā or meat soup (Ci 5:3-4).
Beyond diet, lifestyle and śodhana, there are a number of palliative medications including a class of medications called rasāyana (‘rejuvenatives’) that can be taken to help overcome rājayakṣma (p. 278). Other medications are targeted to address specific signs and symptoms, such as remedies for hoarseness, catarrh, anorexia, vomiting, cough, dyspnea, wasting, diarrhea, and fever. As described earlier, Vāgbhaṭa states that the patient draws strength from the feces, indicating that chronic diarrhea is a particularly dangerous symptom in the patient emaciated by rājayakṣma (Ci 5:72-73). The following are examples of medications traditionally used in the treatment of rājayakṣma:
To resolve nasal catarrh (nāsāsrāva) and hoarseness (svārasāda)

  • Gandūṣa and kavalagraha (p. 105)
  • Nasya karma (p. 269)
  • Dhūmapāna (p. 109)

To resolve anorexia (arocaka) and control vomiting (chardi)

  • Four parts Āmalaka juice and one part Candana, mixed with honey
  • Cold infusion of Guḍūcī, taken with honey
  • Elādi cūrṇa, 1-2 g with honey and ghṛta

To alleviate cough (kāsa), dyspnea (svāsa) and hemoptysis (urakṣata)

  • Vāsāvaleha, one karṣa (12 g), taken with milk
  • Sitopalādi cūrṇa, 1-2 g with honey and ghṛta

To alleviate wasting (kṣaya), boost vitality (ojas) and restore lung function

  • Cyavanaprāśa, one karṣa (12 g), taken with milk
  • Drākṣāriṣṭa, one pala (24 mL), taken after meals

To alleviate diarrhea (atīsāra) and restore digestion

  • Yavānyādi cūrṇa, 2-3 g with honey and ghṛta
  • Tālīśyādya cūrṇa, 2-3 g with honey and ghṛta

To reduce fever (jvara)

  • Sudarśana cūrṇa, 2-3 g with water
  • Mṛtyuñjayarasa, 3 pills twice daily