AH-Su-Chapter 13: Doshopakramaniyam दोषोपक्रमणीयं / Treatment of Dosha Imbalance and Aama

Treatment for Vata imbalance (increase) –  Vriddha Vata chikitsa—

वातस्तोपक्रमः स्नेहःस्वेदः संशोधनं मृदु
स्वादम्ललवणोष्णानि भोज्यानि अभ्यङ्ग मर्दनम् १
वेष्टनं त्रासनं सेको मद्यं षैष्टिकगौडिकम्
स्निग्धोष्णबस्तयो बस्तिनियमः सुखशीलिता २
दीपनैः पाचनैः सिद्धाः स्नेहाश्चः अनेकयोनयः
विशेषात्मेद्य पिशितरस तैलानुवासनम् ३

Treatment options for increased Vata Dosha are-
Sneha – oleation-oral administration of oil / ghee / fat and external oil massage
Sveda – Sudation – diaphoresis, sweating therapy
Mrudu Samshodhana – Mild purification procedure, Mild Panchakarma (Vamana and Virechana). Excess of Panchakarma might lead to Vata increase.
Svadu Amla Lavana Ushna Bhojya – foods which are of sweet, sour and salt taste;
Abhyanga – Oil massage
Mardana – simple massage
Veshtana – wrapping / covering the body/ organ with cloth
Trasana – Threatening, frightening
Seka – pouring of herbal decoctions / oils on the affected part
Paishtika Goudika Madya – wine prepared from corn flour and jaggery- molasses
Snigdha Ushna Basti – enema therapy with fat-oil, enema with drugs of hot potency
Sukhasheelata – comforting the patient
Deepana Pachana Siddha Sneha – medicated fats of different kinds- sources prepared with drugs causing increase  of hunger and improving digestion;
Medya Pishita Taila Anuvasana – oleation enema prepared from juice of fatty meat and oil- 1-3

Treatment for Pitta imbalance (increase) – Vriddha Pitta Chikitsa

पित्तस्य सर्पिषः पानं स्वादुशीतैः विरेचनम्
स्वादुतिक्तकशायाणि भोजनानि औषदानि च ४
सुगन्धिशीतहृद्यानां गन्धानामुपसेवनम् ५
कर्पूरचन्दनौशीरैःअनुलेपः क्षणे क्षणे
प्रदोषश्चन्द्रमाः सौधं हारि गीतं हिमो अनिलः ६
अयन्त्रणसुखं मित्रं पुत्रः सन्दिग्धमुग्धवाक्
छन्दानुवर्तिनो दाराः प्रियाः शील विभूषिताः ७
शीताम्बुधारागर्भाणि गृहाणि उद्यान दीर्घिकाः
सुतीर्थ विपुल स्वच्छसलिलाशय सैकते ८
साम्भोजजल तीरान्ते कायमाने द्रुमाकुले
सोम्या भावाः पयः सर्पिर्विरेकश्च विशेषतः ९

Treatment options for increased Pitta Dosha are –

Sarpi paana – drinking of Ghrita (clarified Butter). It can be plain or medicated, based on physician’s advice.
Svadu, sheeta Virechana – purgation therapy with drugs of sweet taste and cold potency,
Intake of foods and drugs having sweet, bitter and astringent tastes.
Inhaling of fumes from herbs that are coolant, pleasant and cordial
Anointing the body with camphor, sandalwood paste, Vetiver paste, very frequently.
Residing on terraces lit by moonlight in the evenings, enjoying pleasant music and soft cold breeze, company of friends who do not restrain him, of sons who speak cordially and with innocence.
Spending time with wife, who is obedient, pleasing and virtuous;
Residing in houses equipped with fountains emitting cooled water, parks and ponds,
Spending time in houses near water reservoirs having clean water, sand, lotus, flowers, and trees, with a calm mind;
Consuming milk, ghee and Purgation therapy (Virechana)

Treatment for Kapha imbalance (increase) – Vriddha Kapha Chikitsa

श्लेष्मणा विधिना युक्त तीक्ष्णं वमनरेचनम्
अन्नं रूक्षाल्पतीक्ष्णोष्णं कटुतिक्तकषायकम् १०
दीर्घकालस्थितं मद्यं रतिप्रीतिः प्रजागरः
अनेकरूपो व्यायामः चिन्ता रूक्षं विमर्दनम् ११
विशेषात् वमनं यूषः क्षौद्रं मेदोघ्नमौषधम्
धूमोपवासगण्डूषा निःसुखत्वं सुखाय च १२

Treatment options for increased Kapha Dosha are-
Vidhiyukta Teekshna Vamana Virechana – Strong emesis and purgation in accordance with prescribed procedure,
Consuming food which are dry,
Consuming food in limited quantity
Consuming food that have Teekshna (strong, piercive), Ushna (hot), pungent, bitter and astringent taste,
Old wine
Sexual activity
keeping awake at night,
Exercises of different kinds,
Worry,
Dry massage of the body;
Vamana – emesis therapy,
drinking of soups- of grains
Use of honey,
Therapies and medicines that reduce fat,
Inhalation of medicinal smoke,
Fasting,
Gargling
Facing difficulties 10-12

उपक्रमः पृथक्दोषान् यो अयमुद्दिश्य कीर्तितः
संसर्गसन्निपातेषु त यथास्वं विकल्पयेत्

The different treatment prescribed for each Dosha individually, may be combined appropriately in conditions of combinations of two or three Doshas.  13

ग्रैष्मः प्रायो मरुत्पित्ते वासन्त कफमारुते ।
मरुतो योगवाहित्वात, कफपित्ते तु शारदः ॥१४॥

Generally the treatment for the combination of Vata and Pitta is similar to the regimen of summer- described in Chapter 3.

For Kapha and Vata combination treatment, it is similar to the regimen of Vasanta- spring because Maruta- Vata is Yogavahi; Yogavahi means, Vata, when associated with Pitta, boosts Pitta Dosha, when it is associated with Kapha, it boosts Kapha Dosha.
For the combination of Kapha and Pitta the treatment shall be similar to the regimen of Sarad- Autum .14

चय एव जयेद्दोषं कुपितं तु अविरोधयन् ।
सर्वकोपे बलीयांसं शेषदोष अविरोधतः ॥१५॥

The Doshas should be treated properly when there are in Chaya stage (mild increase) only.
In their stage of Kopa (Dosha enhanced imbalance), they should be vanquished without opposing /  interfering with one another Dosha.
When there is simultaneous enhanced increase (Kopa) of all the three Doshas, the most powerful / most aggravated Dosha should controlled first, without opposing the remaining Doshas. 15

प्रयोगः शमयेव्याधिमेकं यो अन्यमुदीरयेत्
ना असौ विशुद्धः शुद्धस्तु शमयेद्यो न कोपयेत्

That treatment which cures one disease and gives rise to another disease- sooner or later,  is not Shuddha- pure/ good/appropriate;
A pure treatment is that which cures one – diseases and does not give rise to another. 16

Movement of Dosha from Digestive Tract to Body Tissues and vice versa – 

व्यायामात् ऊष्मणः तैक्ष्ण्यात् अहिताचरणादपि
कोष्ठाच्छाखास्थिमर्माणि द्रुतत्वान्मारुतस्य च

Movement from Koshta to Shakha - By the effect of exercise,  increase of heat, unsuitable/unhealthy activities and due to quick movement of Vata, the increased Doshas move out of the Kostha (gastrointestinal tract) to the Shakhas- tissues, Asthi – bones and Marmas- vital organs and vulnerable points.

दोषा यान्ति तथा तेभ्यः स्रोतोमुखविशोधनात्
वृद्ध्यात् अभिष्यन्दनात्पाकात्कोष्ठं वायोश्च निग्रहात्
तत्रस्थाश्च विलम्बेरन् भूयो हेतुप्रतीक्षणः
ते कालादिबलं लब्ध्वा कुप्यन्ति अन्याश्रयेष्वपि

Movement from Shakha to Koshta - Doshas move from body channels and tissues to the gastro intestinal tract,
by the effect of purification, clearing and widening of the minute body channels.
By further increase of Doshas,
By liquefaction,
By maturity,
By Balancing and controlling Vata.

When Doshas move from one place to other, they remain there for some time, waiting for an exciting factor. After deriving strength by season, time etc, they get further aggravated and move to other places as well. 17-19

Native and foreign Doshas:-  Sthayi- and Agantu Doshas:-

तत्रान्य स्थानसंस्थेषु तदीयामबलेषु तु
कुर्याच्चिकित्साम्  स्वामेव बलेनान्यामिमाविदु

Treatment should be done- especially on priority to that Dosha which has travelled into the seats of other Doshas and which is weak,
Priority should also be given to that Dosha which, by its own strength overcomes other Doshas.

Agantu Dosha – 

आगन्तुं शमयेद्दोषं स्थानिनं प्रतिकृत्य वा

Foreign Dosha, should be treated either after treating the Sthanika (native Dosha) or even otherwise. The choice of Dosha, to be treated first depends on the level of aggravation and strength of Doshas. 20

Triyak gata Dosha -

प्रायस्तिर्यग्गता दोषाः क्लेशयन्त्यातुरांश्चिरम्
कुर्यान्न तेषु  त्वरया देहाग्निबलवित् क्रियाम्
शमयेत्तान् प्रयोगेण सुखं वा कोष्ठमानयेत्
ज्ञात्वा कोष्ठप्रपन्नांश्च यथासन्नं विनिर्हरेत्

Usually, the Triyaggata Doshas – which are not localized in the gastrointestinal tract but localized in the tissues, cause troubles to the patient for a long time; they should not be treated in haste. They should be carefully treated only afterdetermining the strength of the body and digestive activity.

They should be mitigated with stipulated palliative treatment or they should be brought into the alimentary tract and then they should be expelled out by the nearby route (either by mouth – by emeisis – Vamana or by anal route, by purgation – Virechana). 21-22

Effects of Doshas associated with Ama  - SamaDosha Lakshana -

स्रोतोरोध बलभ्रंश गौरव अनिल मूढताः
आलस्यापक्तिनिष्ठीवमलसङ्गारुचिक्लमाः
लिङ्गं मलानां सामानां, निरामाणां विपर्ययः

When imbalanced Doshas get associated with Ama (a factor of indigestion / false metabolism), it is called as Saama Dosha. (Sa aama Dosha, Sa means ‘with’). The features that are seen due to Sama Dosha are -

Srotorodha -  Obstruction of the channels, pores
Balabhramsha – loss of strength,
Gaurava – feeling of heaviness of the body,
Anila Moodata – inactivity of Anila-vata,
Alasya – laziness, lassitude,
Apakti – loss of digestive power,
Nishteeva – Person spits saliva frequently, more of expectoration,
Malasanga – constipation or low frequency of urination leading to accumulation of wastes
Aruchi – anorexia,
Klama – exhaustion
The opposites of the above symptoms are of the Nirama Doshas –Doshas not mixed up with the Ama. (undigested materials) 23-24

Origin of Ama – Amotpatti-

ऊष्मणो अल्पबलत्वेन धातुमाद्यं अपाचितम्
दुष्टं आमाशयगतं रसमामं प्रचक्षते

Soon after digestion process, the useful part gets separated from the waste. The useful, nutrition rich part is called as Rasa dhatu.
Due to lack of digestion strength, The Rasa Dhatu does not form well, it remains in raw, weak form. It gets vitiated,  it stays in the Amashaya (stomach and intestines) itself, and becomes ‘Ama’. 25

अन्ये दोषेभ्य एवतिदुष्टेभ्यो अन्योन्य मूर्च्छनात्
कोद्रवेभ्यो विषस्येव वदन्त्यामस्य सम्भवम्

Other authors opine that Ama gets formed from intimate mixing with one another of greatly increased Doshas. 26

साम निरुक्ति
आमेन तेन सम्पृक्ता दोषा दूष्याश्च दूषिताः
सामा इत्युपदिश्यन्ते ये च रोगास्तदुद्भवाः

The Doshas and Dusyas (the Dhatus and Malas) which get mixed with this Ama are designated as Sama – mixed with Ama;

The diseases originating from this Saama dosha are called as Saama Vyadhi. 27

Saama Dosha chikitsa—treatment of Sama Doshas :-

सर्वदेह प्रविसृतान्  सामान् दोषान् न निर्हरेत्
लीनान् धातुषु अनुत्क्लिष्टान्  फलादामाद्रसानिव
आश्रयस्य हि नाशाय ते स्युः दुर्निर्हरत्वतः

The Sama Doshas which are spread all over the body, which are lurking in the Dhatus and which are not moving out of their places of accumulation, should not be forced out by purification Panchakarma therapies like emesis, purgations etc.

Just as attempts of extracting juice from an unripe fruit leads to destruction, the dwelling place itself will get destroyed if Doshas are tried to expel out along with Ama. 28

Right approach in Sama Dosha treatment - Sama Doshas should be treated

पाचनैर्दीपनैः स्नेहैस्तान्  स्वेदैश्च परिष्कृतान्
शोधयेत् शोधनैः काले यथासन्नं यथाबलम्

- first with drugs which are digestive and which increase hunger;
- next with oleation and sudation therapies (Snehana, Svedana) and
- finally they should be expelled out with Shodhana therapies- emesis, purgation at the proper time, and in accordance with the strength of the patient. 29

हत्याशु युक्तं वक्त्रेण द्रव्यमामाशयान्मलान्
घ्राणेन चोर्ध्वजत्रूत्थान् पक्वाधानाद्गुदेन च

Drugs administered through the mouth, bring out the Malas-  Doshas from the Amasaya- stomach and small intestines;
Drugs administered through the nose bring out the Doshas from the parts above the shoulders and  Drugs administered through the rectum bring out the Doshas from the Pakvasaya – large intestine. 30

उत्क्लिष्टानध ऊर्ध्वं वा न चामान्वहतः स्वयम्
धारयेदौषधैर्दोषान् विधृतास्स्ते हि रोगदाः

Saama Doshas which are greatly increased and going out of the body on their own accord, either in the upward or downward routes- vomiting and purging respectively should not be stopped by medicines, for they produce diseases, if they are stopped. 31

प्रवृत्तान् प्रागतो दोषानुपेक्षेत हिताशिनः
विबद्धान् पाचनैस्तैस्तैः पाचयेन्निर्हरेत वा

Such Doshas which are going out should be ignored in the early stage and the patient should be given suitable foods- light food;
Next in the second stage they should be cooked with digestive drugs or removed out by purification (Panchakarma) therapies. 32

Time for eliminating Dosha out of the body - 

श्रावणे कार्तिके चैत्रे मासि साधारणे क्रमात् ३३
ग्रीष्मवर्षाहिमाचितान् वाय्वादीन् आशु निर्हरेत्

Vata which undergoes mild increase (Chaya) in Greeshma (summer) should be removed from the body (by basti- enema) in Shravana masa (August)
Pitta which undergoes mild increase in Varsha (rainy season), should be expelled out of the body in kartika Month (by Virechana – purgation)
Kapha which undergoes mild increase in Shishira (winter) should be expelled out in Chaitra month (April) by Vamana. 33

अत्युष्णवर्षशीता हि ग्रीष्मवर्षाहिमागमाः
सन्धौ साधारणे तेषां दुष्टान् दोषान् विशोधयेत्

Greeshma, Varsa and Hemanta [summer, rainy season and winter]- have too much of heat, rain and cold respectively; in the period in between these, known as Sadharana Kala; the Doshas should be cleared out. 34

कृत्वा शीतोष्णवृष्टीनां प्रतीकारं यथायथम्
प्रयोजयेत्क्रियां प्राप्तं क्रियाकालं न हापयेत्

After having overcome the effects of cold, hot and rainy seasons suitably- by adopting appropriate protective methods necessary treatment – therapies should be administered;
The Kriyakala- period of abnormal activity, stages of disease evolution should not be allowed to progress- further. 36

Aushadha Sevana Kala – time of administration of medicines:-

युञ्ज्यादनन्नमन्नादौ मध्ये अन्ते कवलान्तरे
ग्रासे ग्रासे मुहुः सान्नं सामुद्रं निशि चौषधम् ३७

Medicines should be administered,
1. ananna –  on empty / when there is no food- in the stomach ;
2. annadau – just before food or at the beginning of food intake,
3. anna madhye – during / in between food intake
4. anna ante – at the end of food intake.
5. kavalantare – in between morsels
6. grase grase – with each morsel
7. muhu: – repeatedly, many a times a day
8. sa annam – mixed with food
9. samudgam – before and after food
10 nishi – at night, bed time

कफोद्रेके गदे अनन्नं बलिनो रोगरोगिणोः
अन्नादौ विगुणे अपाने, समाने मध्य ईष्यते
व्याने अन्ते प्रातराशस्य, सायमाशस्य तूत्तरे
ग्रासग्रासान्तयोः प्राणे प्रदुष्टे मातरिश्वनि
मुहुर्मुहुर्विषच्छर्द्दिहिध्मातृट्श्वासकासिषु
योज्यं संभोज्यं भेषज्यं भोज्यैश्वित्रैररोचके
कम्पाक्षेपहिध्मासु सामुद्गं लघुभोजिनाम
ऊर्ध्वजत्रुविकारेषु स्वप्नकाले प्रशस्यते

Medicines should be administered,
1. Ananna –  on empty stomach – For diseases arising from increase of Kapha, which are severe and for persons who are strong, the time of administration of medicine shall be when there is no food- in the stomach ;
2. Annadau – just before food or at the beginning of food intake – in disorders of Apanavata,
3. Anna Madhye – During / in between food intake – in disorders of Samana vata
4. Anna ante – at the end of food intake – in disorders of Vyana vata at the end of the morning meal, in disorders of Udana vata at the end   of evening meal.
5. Kavalantare – in between morsels – in disorders of Prana- vata
6. Grase Grase – With each morsel – in anorexia, loss of taste it shall be mixed with different kinds of tasty foods
7. Muhu: – Repeatedly, many a times a day – in diseases produced by poison, vomiting,  hiccup, thirst, dysponea and cough
8. Sa annam – Mixed with food – in anorexia
9. Samudgam – before and after food – in tremors, Akshepaka (convulsions), Hiccup,
10 Nishi – at night, bed time – for diseases affecting head and neck. 37

Thus ends the thirteenth chapter called Doshopakramaniya in sutrasthana of Astanga hrudaya composed by Vaghata.