Shat Kriya Kala – ‘Stage-Wise Disease Management’

Article by Dr Raghuram Y.S. MD (Ay) and Dr Manasa
‘Prevention is better than cure’ has always been a golden standard and underlined principle for health.
Proper quality, quantity and timely ‘balanced diet’, good sleep, sex and exercise, freedom from stress and extremes of emotions, attending the urges and or reflexes of the body as and when they get manifested, making a protocol and adapting to the activities of a day (Dinacharya – Diurnal adaptation or rules of daily living) and activities in a season (Ritucharya – Seasonal adaptation or Rules of seasonal living) etc help in preventing a wide array of diseases, at the same time helping us to keep fit and healthy. This is one dimension of prevention of diseases.
The other dimension of prevention of diseases is ‘an early diagnosis of the illness in its budding stages’.

Introduction

The art of understanding a disease and its stages of pathogenesis was probably explained for the first time in Ayurveda in a very comprehensive way.

Not only understanding a disease and making an accurate diagnosis, but also to have a minute track of each and every stage of pathogenesis of a disease is a must for any medical science, if it is aiming at both preventive and curative aspects of a disease management. By preventive aspect, I mean ‘diagnosing a disease at its budding or earliest level’.

If the subtle changes occurring in the body (after getting exposed to causative factors) i.e. the initial stages of pathogenesis can be found out at the earliest, we would have terminated an illness before it has even thought of manifesting.

This helps in avoiding unnecessary medication, want of aggressive treatment approaches, unwanted expenditures, undue waste of time, bothering stress for self and care-takers, and sickness absenteeism from jobs.

How happy would we all be if a doctor just advices diet and life-style corrections without prescribing any medicines when we approach him or her for an illness or sickness which we have thought to be of a serious form?

How soothing it would be if the doctor declares that the illness we are having is just in its earlier stages, not good enough to cause any damage and can be got rid of in quick time with the help of simple home remedies, some rest and lifestyle corrections and also that we might resume work and daily activities in a day or two?

Of course, we would be immediately relieved by at least 1/3 of our illness. To be informed that the magnitude of illness is feeble, by itself is soul soothing and relaxing.

This article will be focusing on the discussion related to diagnosing the disease at various stages of its manifestation.

These stages are called Shat Kriya Kala or 6 time periods for managing a disease. The things will get clearer as we progress ahead into our discussion.

Shat Kriya Kala

What is Shat Kriya Kala?
Shat means 6 (the number six)
Kriya means Action or treatment
Kala means Time or period

Now, summing up the 3 terms – Shat Kriya Kala means ‘Appropriate time periods to take action or plan / implement treatment’

Now let us see how a disease starts and progresses, before trying to understand what Kriya Kala is all about!
We know that for any disease process to start, there should be some causative factors on its backdrop.

The causative factors of a disease are called ‘Nidana’ in Ayurveda.

The Nidana’s may be of 2 types –
Bahya Nidana (External factors or Causative factors):
These include all the causative factors supplied to the body from the outside i.e. infections (microorganisms), exposure to dust, smoke or allergens, incompatible foods, injuries etc

These extrinsic factors disturb the ‘Dosha’s’, the 3 forms of energy in the body which control all the activities, when they are in a state of equilibrium. The vitiation of Dosha’s is a mandatory process for the onset of the diseases.

These contaminated Dosha’s invade, get lodged in and damage the weak or susceptible tissues and set up the platform for the onset of a disease.

These Dosha’s can also block or clog the channels and duct systems of transportation (Srotas) in the body and initiate a disease process at the site of block.

Abhyantara Nidana’s (Internal or intrinsic causative factors of a disease):
The vitiated Dosha’s, Vata, Pitta and Kapha either independently or in combinations are the internal factors for causing a disease. no disease is manifested unless one or more dosha’s are vitiated.

The Dosha’s are either vitiated after being triggered by external causative factors (bahya nidana’s) or can also get vitiated independently.

Thus, in short, the disease process begins and progresses in the below mentioned way or chronology –
Consumption or exposure to Nidana’s — Vitiation of one or more Doshas — Spread off vitiated Dosha’s all over the body — Vitiated Dosha’s invading and getting localized in weak and susceptible dhatu’s or tissues — Damage of the tissues — Disease manifestation — Complications

This gives us a clarification that the dosha’s do not undergo heavy vitiation and produce a disease overnight.
The Dosha’s take their time in getting through various stages of vitiation and gradually give origin to a disease, if they are not diagnosed or left unattended in their initial stages of vitiation. Thus formation of a disease is a gradual process.

Baseline understanding is that – The disease is a game of Doshas. The Dosha’s take time to undego vitiation; this takes place in various stages.

In the initial stages, the Dosha’s increase in quantum at their own sites and later tend to trespass into the sites, tissues or organs occupied or belonging to the other Dosha’s.

The Dosha’s overflow and spread all through the body in search of weak, susceptible dhatu’s (tissues). When they find such tissues, the morbid dosha’s invade, occupy and damage the tissues.

When the damage gets severe, the disease gets manifested with full blown signs and symptoms.When the disease is not treated even in this stage, complications get manifested.

These stages through which the morbid Dosha’s gradually gain strength and tend to produce disease, its signs and symptoms and complications are called Kriya Kala’s.

Why these stages of vitiation of Dosha’s are called Kriya Kala?
The initial stages of diseases wherein, being vitiated by the Nidana’s, the Dosha’s gradually accumulate, increase and tend to spread are the stages of pathogenesis wherein the background for the manifestation of the disease is being created.

The disease is not yet manifested but the signs and symptoms of Dosha vitiation and aggravation are seen.
With treatment perspective, these stages of Dosha vitiation are easily manageable. It is the right Kala (time period) for Kriya (treatment).

Dosha Kriyakala

If the disease is diagnosed and treated in these earlier stages of pathogenesis, the dosha’s can be stopped from progressing to the further stages of pathogenesis.

Since it matters only with dealing the vitiated dosha’s and since the tissues have not yet been invaded by the morbid dosha’s, the treatment becomes easy.

This stage is called ‘Dosha Kriyakala’ because here only the Dosha’s get disturbed and they are not strong enough to produce a disease or initiate a disease process.

Remember, the disease process will be initiated when the dosha’s spreading all over the body get lodged in weak dhatu’s and damage them.

This stage of pathogenesis or vitiation of dosha’s comprises of 3 stages. They are –
Sanchaya or Chaya – Stage of accumulation of Dosha’s (in their own sites)
Prakopa – Stage of aggravation or exacerbation of Dosha’s (at their own sites)
Prasara – Stage of liquification and spreading of Dosha’s (dosha’s overflow and spread all through the body)

These 3 stages of pathogenesis are easy to treat because the tissue or organ damage has not yet occurred

Vyadhi Kriyakala

The later stages of the disease wherein the vitiated dosha’s (not diagnosed and managed in their earlier stages of vitiation i.e. Sanchaya, Prakopa and Prasara) get even more aggressive and invade the tissues and the events which follow the invasion are difficult to manage.

When the morbid Dosha’s invade the dhatu’s the doshas get lodged therein. This contact of morbid Dosha’s and susceptible Dhatu’s gives rise to premonitory symptoms (Purvarupa) of the diseases. These symptoms indicated that a disease is about to get manifested in near future and a suitable background is being laid in the body.

If the disease is not managed at this stage, the Dosha’s further damage the Dhatu’s. now the disease gets clearly manifested with its clearcut signs and symptoms (Rupas or Lakshanas).

If the disease is not managed even in this stage, it leads to manifestation of complications wherein the disease gets out of reach of treatment.

This stage is called ‘Vyadhi Kriya Kala’ and comprises of 3 stages.
They are –
Sthana Samshraya – Stage of invasion of tissues and lodgement of Dosha’s in Dhatu’s (Stage of premonitory symptoms or stage of prodromata of a disease)
Vyakta or Vyakteebhava – Stage of manifestation of disease
Bheda – Stage of complications

These 3 stages of the disease are difficult to handle with the context of treatment. In these 3 stages, the tissue damage, signs and symptoms of the disease and complications would have manifested making the clinical picture of the disease difficult and hard to handle. Many times, the disease gets impossible to manage and also may lead to death.

Thus, the 3 stages of Dosha vitiation in ‘Dosha Kriya Kala’ and the other 3 stages of dosha vitiation and disease manifestation in ‘Vyadhi Kriya Kala’ put together are called Shat Kriya Kala or 6 appropriate time periods to take action or to implement treatment.

With treatment perspective –
The diseases are easy to handle in the first stage and gets difficult to manage in each of the consecutive stages of Kriyakala. Thus the Sanchaya stage is the easiest one to handle and the stage of Bheda is the most difficult one to manage.Thus these 6 stages of Dosha vitiation and disease manifestation are called ‘KriyaKalas’.

Classification of Kriya Kala

There are two schools of thought pertaining to classification of Kriya Kala.
First school of thought, about Kriya Kala:
Charaka and Vagbhata have mentioned and described only 2 stages of Dosha Vruddhi (pathological increase of Dosha’s). They called it Sanchaya (stage of accumulation) and Prakopa (stage of aggravation). Vagbhata, the author of Ashtanga Sangraha has mentioned a 3rd stage called Shamana or Prashamana, which means a stage of spontaneous recovery (pacification) of Dosha’s and remission from disease.

Charaka and Vagbhata have explained these 3 stages of Dosha vitiation in correlation to seasonal changes.

Vata Dosha:
Sanchaya – takes place in Grishma rutu (Summer season)
Prakopa – takes place in Varsha rutu (Monsoon, rainy season)
Prashamana – takes place in Sharad Rutu (Autumn season)

Pitta Dosha:
Sanchaya – takes place in Varsha Rutu (Monsoon, rainy season)
Prakopa – takes place in Sharad Rutu (Autumn season)
Prashamana – takes place in Hemanta Rutu (early winter)

Kapha Dosha:
Sanchaya – takes place in Shishira Rutu (Late winter)
Prakopa – takes place in Vasanta Rutu (Spring season or early summer)
Prashamana – takes place in Greeshma Rutu (Summer season)

Now, we get a doubt here – If a Dosha or a set of Doshas undergo pathological aggravation and gets pacified by selves; then where is the question of manifestation of a disease?

Particular doshas tend to get aggravated in particular seasons. There is a natural tendency for this to happen in everyone. Let me explain this with an example.

In case of Kapha – Cold climate of Shishira rutu (cold climate or winter) helps in accumulation and consolidation of Kapha, just like the water gets precipitated to become ice in cold season. This is called Kapha Chaya or Sanchaya.

If we are careful in managing the principles of Rutucharya (rules and regulations with respect to food, lifestyle etc. to be followed during particular seasons), the Kapha doesn’t get aggravated in the coming season i.e. Vasanta season (Spring).

The next season will be Vasanta Ritu (spring or early summer). Due to heat of Vasanta ritu, the consolidated Kapha liquefies and spreads all over the body, just like the ice melts on exposure to heat. This is Kapha Prakopa.

This takes place in all of us but doesn’t produce a disease in everyone. If the person is susceptible to a disease and has low immunity, the vitiated Dosha’s tend to damage the tissues further to cause a disease.

If the person is strong enough, is not susceptible for hiring diseases, has immense immunity, the Doshas do not tend to be pathogenic.

With the onset of the following season in Greeshma (peak summer) Rutu, the Kapha being a water predominant Dosha, will get pacified spontaneously as its water content disintegrates due to the antagonizing heat of summer. This stage is called Prashamana or Natural pacification of Doshas.

Even in those who are susceptible to catch up a disease in Vasanta Rutu, if Kapha Prakopa is diagnosed at the earliest and managed and if Rutucharya is properly adapted, the doshas will get pacified. The onset of Grishma season (peak summer) will hasten the recovery process.

Similarly the Chaya, Prakopa and Prashama of other Dosha’s too have to be understood.

Giving a gist of Charaka and Vagbhatas explanation of Rutu Kriya Kala, we can tell that the Dosha’s naturally (due to impact of seasons) tend to accumulate in the body in a particular season, i.e. if the season is in accordance to the dosha, it will tend to increase or vitiate the dosha (and if the season is antagonistic to the dosha, it causes pacification of dosha). In the following season, the same dosha tend to get vitiated.

This vitiated Dosha will have the below said courses –
If there is no susceptibility to form disease, if the immunity of the person is very good and if proper seasonal management (Rutucharya) is followed with discipline, the vitiated doshas do not produce a disease. This Dosha will naturally regress in the following season due to favorable climate (antagonistic season) for its pacification.

If there is susceptibility for disease formation, the immunity of the patient being low and if the regulations to be followed in that season (Rutucharya) are not taken care of, the vitiated Doshas will aggravate further, damage the tissues and cause diseases. Here natural Prashamana of Doshas doesn’t take place due to availability of unfavorable conditions.

If the vitiation of Dosha is taken care of in the Prakopa stage or in the season of Prakopa, the Doshas can still be prevented from creating havoc or disease process in the body

Thus the formation of disease or not is determined by the fact on how the Dosha vitiation behaves and transforms in the season of vitiation and also on how many supporting or antagonizing factors are available for the Dosha Prakopa to sustain and progress or to get pacified in the following season.

Thus, the formation of disease is also explained by Charaka and Vagbhata but in a concealed way, within the term ‘Prakopa’.

The stages of Dosha vitiation and disease formation explained by Sushruta in Shat-Kriyakala, namely ‘Prasara, Sthana Samshraya, Vyakta or Vyaktibhava and Bheda’ are embedded and included in the ‘Prakopa’ stage explained by Charaka and Vagbhata

It is not that Charaka or Vagbhata have not mentioned the other stages of Dosha vitiation as broadly as Sushruta, they have explained them but they have not done it at a place. The information of ‘Kriya Kalas’ explained by Sushruta are available in Charaka Samhita and Ashtanga Sangraha in a scattered form.

Both of them have explained Purva Rupas (premonitory symptoms), Rupas (Signs and symptoms) and Upadrava’s (complications) of diseases, which fit into the Sthana Samshraya, Vyaktibhava and Bheda stages explained by Sushruta. Prasara is an advanced stage of Prakopa, without which, Sthanasamshraya and Vyakta stages are not possible.

Therefore, Prasara explained by Sushruta can be included under Prakopa itself. The Samprapti (stages of manifestation of disease) explained by Charaka and Vagbhata for almost many diseases is a consequence or resultant of all the 6 stages of Kriya Kala.

Rutu Sandhi is a beautiful concept of ‘Management of seasonal junction’ explained in Ayurveda. Each season runs for 2 months of a calendar year. Thus 6 seasons (as per Hindu calendar) cover a period of 12 months of an year.

The last 7 days of the previous season and the beginning 7 days of the following season put together is called ‘Rutu Sandhi’ or ‘Seasonal Junction’. From health perspective, this is an important period.

In RutuSandhi, one has to slowly give up the practices of the previous season and gradually start getting into the practices (related to diet, lifestyle etc) of the coming season.

With this the person will learn to get adapted to the new season. Or else, the sudden change of season may come with many shocks and the person may immediately get susceptible to hire the diseases of the new season.

Example, the final 7 days of Grishma Ritu (Peak summer season) and the first 7 days of its succeeding season, i.e. Varsha Ritu (monsoon or rainy season) forms Ritu Sandhi for Varsha rutu.

In this, one has to gradually give up the practices of Greeshma Rutu in the last 7 days of Gresshma Rutu and start learning to adapt the new practices needed to be healthy in Varsha Rutu. Similarly we have 6 RituSandhis in a year, at the junctions of every 2 seasons.

Second school of thought, about Kriya Kala:
Sushruta has given an elaborate explanation of Kriya Kala and has mentioned 6 stages of Dosha Vitiation and disease formation. They are called Shat Kriya Kalas.

Shat Kriya Kala

Shat Kriya Kala – six stages of disease manifestation: 
Sanchaya or Chaya – Stage of accumulation of Doshas (in their own sites)
Prakopa – Stage of aggravation or exacerbation of Doshas (at their own sites)
Prasara – Stage of liquification and spreading of Doshas (doshas overflow and spread all through the body)
Sthana Samshraya – Stage of invasion of tissues and lodgement of Doshas in Dhatus (Stage of premonitory symptoms or stage of prodromata of a disease)
Vyakta – Stage of manifestation of disease
Bheda – Stage of complications

In the upcoming paragraphs we shall discuss about these 6 stages in detail.

Sanchaya

1st Kriya Kala – Sanchaya or Chaya, the stage of accumulation of Doshas in their own sites –
Sanchaya means accumulation. Increase of Dosha’s in their own sites is called Sanchaya. Dalhana, the commentator of Sushruta Samhita text defines Sanchaya as ‘Samhati Rupa Vriddhi’ (cumulative form of increase).

Every dosha has its own abode or abodes. Each Dosha will have multiple abodes among which one will be the main site of their stay. They can be considered as controlling stations of that particular Dosha.

The main sites of Vata are:
Pakwashaya – Large intestine, it is the predominant site of Vayu
Kati – Pelvis, hips
Sakti – Thighs
Shrotra – Ears
Asthi – Bone tissue
Sparshana indriya – Sense organ of touch, Skin

The main sites of Pitta are:
Nabhi – Navel region, it is the predominant site of Pitta
Aamashaya – Stomach or upper gut
Sweda – Sweat
Lasika – Serum, Lymph
Rudhira – Blood tissue
Rasa – Plasma, nutritional fluid
Druk – Eye
Sparshanam – Skin

The main sites of Kapha are:
Uras – Chest, it is the predominant site of Kapha
Kantha – Throat
Shiras – Head
Kloma – Pancreas, Trachea, Water regulating centres
Parvani – Inter-phalangeal joints
Aamashaya – Stomach or upper part of digestive tract
Rasa – Plasma, nutritional fluid
Meda – Fat tissue
Ghrana – Nose
Jihwa – Tongue

The Doshas getting increased in their respective sites, is called Sanchaya. Example, Vata increasing in Pakwashaya, Asthi etc organs, Pitta increasing in Nabhi, Rakta etc norgans and tissues, Kapha increasing in Ura, Amashaya, Rasa etc organs and tissues is called Sanchaya stage of these doshas respectively.

In the stage of Sanchaya, the person develops a strong aversion towards the causes responsible for Sanchaya of vitiated Doshas. For example, when we take a heavy meal, the heaviness of the abdomen and drowsiness will result. Naturally we develop aversion towards food in the presence of these symptoms.

In the same way, there will be a liking towards Sanchaya Vyatireka Karanas or causes antagonistic to Sanchaya of Doshas.

Example, When Vata Sanchaya takes place, we may feel increased coldness and we develop aversion to cold foods and comforts. On the contrary, we will be attracted towards its opposites (opposite quality of cold and antagonistic of Vata) i.e. hot foods and comforts.

Symptoms of Sanchaya:
Vata Sanchaya – Stabdha Purna Koshtata, i.e. Hardness or rigidity of intestines or hollow spaces of the abdomen and a feeling of fullness inside them (Hypo-peristalsis of intestines)
Pitta Sanchaya – Peeta avabhasata i.e. yellowish tinge of the skin
Kapha Sanchaya – Manda Ushmata i.e. low temperature (hypothermia), Gourava i.e. Feeling of heavinesss in the body and Alasya i.e. Laziness

If the doctor is intelligent enough to identify these features and treat them at this stage only, the vitiated doshas will get subsided and no further stages like Prakopa, Prasara etc will take place.

In short, the identification of Sanchaya is done just by observing the Dosha Lakshanas (symptoms of dosha vitiation) in a most primitive and feeble manner and slight uneasiness felt by the patient.

Prakopa

2nd Kriya Kala – Prakopa, the stage of aggravation of Doshas in their own sites –
The 2nd stage of dosha vitiation is called Prakopa. This stage occurs on the backdrop of Sanchaya. In the 2nd stage, the doshas further vitiate in their respective sites but do not leave their original places.

The Doshas liquefy in this stage and tend to overflow from their places so as to encroach the whole body, trespassing the organs and tissues meant to be abodes of other doshas.

This is called as Vilayana Rupa Vriddhi (increase of doshas or expansion of doshas through liquification). In this, the doshas are inclined to leave its original site, but fail to do the same.

Types of Prakopa –
Prakopa is basically of 2 types. They are:
Sachaya Prakopa (Sachaya – with chaya, Prakopa – aggravation):
This is a typical Prakopa wherein the doshas undergo chayavastha (stage of accumulation) and gradually progress to the stage of Prakopa when it is not attended in the first stage of pathogenesis. This type of Prakopa takes some time to develop unless the immunity and contributory factors of disease are too strong.

It is also called as Apathyaja Prakopa because it is increased in the previous Ritu or season due to apathy sevana (non-observance of dietetic and behavioural regime, consumption of unwholesome foods and activities) and moreover it is further increased by apathy sevana again in the succeeding Rutu (season).

This type of Prakopa tends to progress into formation of disease and needs to be dealt with by administration of Shodhana (body cleansing) treatments like Vamana (therapeutic emesis), Virechana (therapeutic purgation) etc.

Achaya Prakopa (Achaya – without chaya, Prakopa – vitiation):
In this type of dosha vitiation, the doshas jump directly to prakopa stage without passing through the chayavastha or stage of chaya. Thus in Achaya prakopa, there is direct prakopa of doshas.

The causative factors causing this are so strong that they immediately aggravate the doshas without giving them too much of time to accumulate and slowly progress towards vitiation stage.

It is also called as Pathyaja Prakopa i.e. the dosha or doshas will not increase in its Rutukala (season) because of observing Pathyakrama (wholesome practices related to food and lifestyle) of the season concerned.

So this does not require any Samshodhana (body cleansing or detoxification treatments) treatments like Vamana, virechana etc.

Causes for Dosha Prakopa –
(Ref – Sushruta Sutra 21/27)

Causes for Vata Prakopa:
Gunas (qualities vitiating Vata): Ruksha (dry), Kshobhaka (irritant), Sheeta (cold), Laghu (light) etc
Rasa (tastes vitiating Vata): Kashaya (astringent), Tikta (bitter), Katu (Pungent)
Ahara (Foods vitiating Vata): Sushka Shaaka (dry vegetables), Sushka Matsya (dry fish), Jangala Mamsa (meat of animals living in desert regions), Kodrava (ragi) etc
Vihaara (activities vitiating Vata): Vyayama (excessive exercise), Apatarpana (malnutrition), Prapatana (injury), Bhagna (fracture), Kshaya (wasting), Jaagarana (awakening all night), Vegadharana (suppression of natural body urges or reflexes), Shoka (grief), Traasa (fear), Vyavaaya (excessive sexual indulgence) etc
Natural causes: At the end of digestion, Later part of the day (Evening), Varsha Rutu (monsoon season), Later part of the night (end part of night)

Causes for Pitta Prakopa:
Gunas (qualities vitiating Pitta): Ushna (hot), Vidaahi (corrosive), Teekshna (irritant) etc
Rasa (tastes vitiating Pitta): Katu (Pungent), Amla (sour), Lavana (salt)
Ahara (Foods vitiating Pitta): Katu, Vidahi ahara (Chillies, condiments, fried foods, spices), Tila (sesame), Dadhi (curds especially sour ones), Sura (kind of alcoholic or fermented drink, any alcoholic drink in that matter), Sukta and Amla (alcoholic drinks) etc
Vihaara (activities vitiating Pitta): Tapa / santapa (excessive exposure to sun or fire), Krodha (anger), upavasa (starving), Atimaithuna (excessive sexual indulgence) etc
Natural causes: During digestion, Mid-day, Sharad Rutu (autumn season), and Midnight

Causes for Kapha Prakopa:
Gunas (qualities vitiating Kapha): Guru (heavy), Sheeta (cold), Drava (liquids), Snigdha (oily) etc
Rasa (tastes vitiating Kapha): Madhura (Sweet), Amla (sour), Lavana (salt)
Ahara (Foods vitiating Kapha): Snigdha ahara (oily foods), Ksheera vikara (milk and its products), Ikshu Vikara (sugarcane and its products, sweets), Bhakshya (sweets and high caloric foods), Apupa (flour preparations), Sarpishpura (sweets prepared or processed in ghee)
Vihaara (activities vitiating Kapha): Avyayama (deficit exercise, lazy and sedentary life), Atisantarpana (over nutrition), Diwaswapna (excessive sleeping during day time), Adhyashana (frequent or binge eating), etc
Natural causes: Immediately after food (meals), Early morning, Vasantha Rutu (spring season), Early hours of night

Prakopa Lakshanas (symptoms of dosha vitiation) –
Symptoms of Vata Prakopa:
Koshta Toda: Pricking sensation in the abdomen
Koshta sancharana: Sounds in the abdomen or feeling of air moving in the tummy

Vata Vriddhi Lakshanas or symptoms of Vata increase can also be included in this context.
They are:
Kaarshnya – Blackish discolouration
Kaarshya – Emaciation
Ushna Kamitwa – Desire for hot foods, substances, climate and comforts
Kampa – Tremors
Aanaha – Flatulence
Shakrut graham – Constipation
Bala bhramsa – Fatigue, loss of immunity and strength
Nidra Bhramsa – Insomnia
Indriya Bhramsa – Failure of perception by the sense organs
Pralapa – Delerium
Bhrama – Vertigo
Deenata – Pathetic look, helplessness

Some more Prakopa lakshanas (Pathological manifestation of vitiated Vata):
Sramsa – visceroptosis (displacement of an organ or organs from their original places)
Vyaasa – Dilatation of organs or tissues beyond their normal limits
Vyadha – Feeling as if beaten by sticks
Swaapa – Numbness
Saada – Inertia (stoppage of functioning in some organs or parts of organs)
Ruk – Pain
Toda – Pricking pain
Bheda – Splitting or gnawing pain
Sanga – Retention of materials without being evacuated or pushed forwards
Anga bhanga – Dropping of an organ
Sankocha – Spasm or contractures
Varta – Twisting sensation
Harshanam – Hyperaesthesia and tingling sensation
Kampa – Tremors
Parushya – Roughness and scaling
Soushirya – Necrosis, resulting in formation of pores
Soshana – Dehydration
Spandana – Twitching and ticks
Veshtana – squeezing pain
Sthambha – Rigidity
Kashaya Rasata – feeling of astringent taste in the mouth, spasticity
Shyaava Aruna varnata – Blackish and brownish discoloration

Symptoms of Pitta Prakopa:
Amlika: Sour or acidic belching (erructations), heart burn
Pipasa: Thirst
Paridaham: Burning sensation

Pitta Vriddhi Lakshanas or symptoms of Pitta increase can also be included in this context.
They are:
Peeta Vin-mutra-netra-twak – Yellowish discolouration of stools, urine, skin and eyes
Kshut adhikyata – Excessive hunger (bulimia)
Trishnadhikya – Polydypsia (excessive thirst)
Alpa Nidrata – Insomnia
Daha – Burning sensation

Some more Prakopa lakshanas (Pathological manifestation of vitiated Pitta):
Daha – Burning sensation
Raaga – Reddish discolouration
Ushna – Excessive heat
Paka – Inflammation
Sweda – Increased sweating
Kleda – Excessive moisture
Srava – Discharges
Kotha – Gangrene
Sadanam – Dysfunction
Moorchanam – Exhaustion
Mada – Stupor
Katu Amla Rasatwa – Feeling of pungent and sour tastes in the mouth or their effects emaciation and fermentation are manifested
Peetha Rakta varnata – Yellow and red discolouration

Symptoms of Kapha Prakopa:
Annavidwesha: Aversion to food
Hridayotkleda: Heaviness of the chest, nausea

Kapha Vriddhi Lakshanas or symptoms of Kapha increase can also be included in this context.
They are:
Agnisadana – Indigestion
Praseka – Excessive salivation
Gourava – Heaviness of the body
Alasya – Laziness
Shwaitya – Pallor or whitish discolouration of body parts
Shaitya – Feeling of coldness
Shlatha angatwa – Feeling of extreme debility
Shwaasa – Dyspnoea
Kaasa – Cough
Atinidrata – Excessive sleepiness

Some more Prakopa lakshanas (Pathological manifestation of vitiated Kapha):
Sneha – Excessive fat
Kaathinya – Hardness
Kandu – Itching
Sheetatwa – Coldness
Gourava – Feeling of heaviness
Bandha – Sticky nature
Upalepa – Coating
Sthaimitya – Feeling as if the body is covered by a wet or damp cloth
Shopha – Swelling
Apakti – Indigestion
Atinidrata – Excessive sleep
Shwetatwam – Whitish discolouration

The stage of Prakopa demands an immediate action by presenting the above said signs and symptoms. But if the disease is not attended even in this stage, the dosha vitiation will progress to the 3rd stage, i.e. Prasaravastha.

Prasara

3rd Kriya Kala – Prasara, the stage of overflow of vitiated doshas, leaving their sites and spreading all over the body –
The third stage of pathogenesis or dosha vitiation is called Prasara. Prasara means to spread.

The Doshas which have undergone Vilayana (acquired liquid form and molten state) and have developed a tendency to overflow from their respective sites are in a state of Prasara.

The vitiated doshas on leaving their respective sites will start spreading to the other parts of the body, through different channels (srotases) of the body.

Just as the rice, flour and water when mixed together and placed in a container grow up in quantity and overflow from the brim (sides) of the vessel, similarly, the doshas also after leaving their original Ashaya (organ) get mixed up together and overflow to different places.

Just as the water of a tank, after passing out from its walls gets mixed up with the dirty water and debris outside the tank, the doshas also will get mixed up with other doshas when once they fail to confine to their sites, and form into groups of single doshas, 2 doshas, 3 doshas and 4 doshas along with Rakta or blood and are likely to form one or the other of the following groups.

Depending on the permutations and combinations of Doshas involved in Prasara, we have 15 types of Prasara.
They are as follows:
Single Doshas: 4 types
Vata
Pitta
Kapha
Rakta

Two Doshas: 6 types
Vata-Pitta
Vata-Kapha
Pitta-Kapha
Vata-Rakta
Kapha-Rakta
Pitta-Rakta

Three Doshas: 4 types
Vata-pitta-kapha
Vata-kapha-rakta
Pitta-kapha-rakta
Vata-pitta-rakta

Four Doshas: 1 type
Vata-pitta-kapha-rakta

Note: Sushruta being a surgeon, has also named Rakta or contaminated blood as the 4th dosha (contaminant).

Gati of Doshas undergoing Prasara –
When the Doshas are undergoing Prasara or overflow, they tend to take one or the other of the below mentioned directions (courses) and cause disease in the direction of their flow.

The direction in which the Dosha in Prasara moves is called Dosha Gati (movement or direction of movement of dosha). This is an important step in the formation of a disease or disease process.

Urdhwa Gati – In this, the doshas tend to move upwards and may cause diseases like Chardi (vomiting), diseases of ear, nose, throat, eye, Unmada (insanity, mania), Apasmara (epilepsy), Hikka (hiccough), Shwasa (dyspnoea, breathing problems), Kasa (cough) etc

Adho Gati – In this, the doshas tend to move downwards and may cause diseases like Atisara (diarrhoea), Shleepada (filariasis), Kroshtu shirshaka (swelling of knee) etc

Tiryak Gati – In this, the doshas tend to move side wards or laterally (crosswards) and may cause diseases like Charma vyadhis (skin diseases), Sirapurana (Hypertension), Akshepaka (tetanus), Apatantraka (Hysteria) etc

The vitiated doshas may also take the following 3 courses during their Prasara stage –
Koshta or Abhyantara Roga Marga – When the vitiated doshas move within the body or internal passages / pathways and viscera, they tend to cause diseases like Chardi (vomiting), Atisara (diarrhoea), Shoola (colic or pain abdomen), Gulma (abdominal tumours), Vibandha (constipation) etc. The diseases are more oriented and caused in the alimentary tract or visceral organs.

Shaakas or Bahya Roga Marga – When the vitiated doshas move in the tissues of the body (tissues or dhatus are known as shaakas), or the external pathway, they tend to cause diseases like Rakta rogas (blood borne diseases), Galaganda (goitre), Gandamala (lymphadenitis), Apachi (matted, suppurated or burst out lymph glands), Medoroga (obesity or diseases caused due to disturbance in fat metabolism), Napumsakata (impotence) etc. the diseases are mainly caused in the skin and tissues like blood, muscle, fat etc

Marma-Asthi-Sandhiga or Madhyama Roga Marga – When the vitiated doshas move in the Marma (vital organs and tissues of the body), bones and joints or the middle pathway, they tend to cause diseases like Hridroga (heart diseases), Unmada (insanity or mania), Apasmara (epilepsy), Ashmari (urinary calculi or stones), Prameha (urinary diseases or diabetes), Amavata (rheumatoid arthritis), Sandhigata vata (osteoarthritis), etc. The diseases are mainly caused in the Marmas, bones, joints, bone marrow and reproductive tissues

Causes of transit of (movement of or spread of) doshas towards Shakas (tissues) –
The movement of vitiated doshas towards susceptible tissues (dhatus) is an essential step in the formation of disease. For this to happen, the doshas should have undergone the stages of sanchaya, prakopa and prasara.

The below said factors (one or more of the below mentioned factors) facilitate or motivate the doshas to spread towards the shakas or tissues –
Vyayaama – over exertion or excessive exercise
Teekshnata of Ushma – Vitiation of Pachaka Pitta or severe increase of intensity of the internal fire
Apathy sevana – Improper dietetic and behavioural regime during the phase of ill-health
Vata Prakopa – Vitiation of Vata

How to bring back the doshas from shakas to Koshta?
Bringing the doshas back to the Koshta (from shaaka) is very essential step in the management or treatment of diseases.

If the doshas are allowed to stay in the tissues, they get lodged in the tissues and damage them leading to the onsed of disease process. This amalgamation of vitiated doshas and shaakas (dhatus) is called sthana-samshraya which is the 4th stage of pathogenesis or dosha vitiation (will be discussed after this).

Therefore it becomes essential to bring them back to koshta and throw them out through Shodhana (body cleansing treatments like Vamana – therapeutic emesis, Virechana – therapeutic purgation etc). The doshas may return to their original sites either by natural means or by therapeutic means.

The below said steps (one or more of the below mentioned) facilitate or motivate the doshas to return back to koshta from shaakas –
Vriddhi – Further increasing the doshas in the shaaka and enabling them to overflow back into the koshta
Vishyandana – Liquification of congested material and enabling it to flow back
Paaka – Ripening of doshas, as by fomentation (swedana), fasting (upavasa) etc measures
Srotomukha Vishodana – Clearance of the channels or pathways
Vata Nigraha – Control of Vata

Prasara Lakshanas – Symptoms of spread of doshas:
(Ref – Sushruta Sutra 21/32)

Symptoms of Vata Prasara:
Vimarga Gamana – Regurgitation
Atopa – Flatulence and gurgling sounds in bowels

Symptoms of Pitta Prasara:
Osha – Sense of boiling
Chosha – Squeezing sensation
Paridaha – Burning sensation
Dhoomayana – Feeling as if the body is boiling

Symptoms of Kapha Prasara:
Arochaka – Anorexia
Avipaka – Dyspepsia
Chardi – Vomiting
Angasaada – Inactivity of organs

The principle of treatment at this stage is to correct the Ashaya (organ) into which an unconcerned dosha has entered. Example, in Pravahika (dysentery) the kapha of Amashaya (stomach) reaches Pakwashaya (large intestine), the site of Vata. Here the vitiated kapha will be controlled on its own accord, if Vataghna treatment is given.

If proper diagnosis is done in this stage and timely treatment implemented, the dosha vitiation will be checked and will not progress to the next stage i.e. stage of Sthana Samshraya.

Sthana Samshraya

4th Kriya Kala – Sthana Samshraya, the stage of localisation of vitiated doshas in the dhatus or tissues, setting of disease process, giving origin to pre-monitory symptoms of a disease (Purvarupas) –
Sthana means place or site, Samshraya means to get lodged or to stay or to localize. Sthana-samshraya is the 4th stage of pathogenesis or dosha vitiation.

The stage continues from the stage of Prasara. The doshas which are travelling all through the body will find a weak tissue or an organ as settlement.

On invading the weak or susceptible organ, the dosha will get localized in that particular tissue or organ. This localization of morbid dosha in a tissue or organ is called Dosha-Dushya Sammurchana (mixing up or amalgamation of dosha and dushya, dushya=tissues).

This interaction and reaction between dosha and dushya (tissue) is mandatory for a disease to maniest. On localization, the vitiated doshas will slowly start damaging the tissue or organ and will cause disease pertaining to that tissue or organ.

The mechanism of their localization is ‘Like a wandering cloud when obstructed by a mountain, rains in that spot where it gets obstructed’ the doshas also while circulating throughout the body when get obstructed by deranged srotas (channels) or organ, they produce a disease at that particular place.

(Ref – Sushruta Sutra 21/33)
Depending on the organ or organs in which the vitiated doshas would settle down in the stage of Sthana samshraya, the diseases manifested in that organ or those organs has been listed down –
Udara (abdomen) – When the doshas get lodged or localized in the abdomen, the diseases like Gulma (intestinal or abdominal tumours), Vidradhi (internal abscess), Udara (abdominal diseases, ascites etc), Agnimandhya (loss of appetite), Anaha (flatulence), Vishuchika (gastro-enteritis) etc are formed

Vasti (Urinary bladder) – When the doshas get lodged or localized in the urinary bladder, the diseases like Prameha (poly urea and diabetes), Ashmari (urinary calculus), mutraghata (retention of urine) etc are formed

Medhra (penis) – When the doshas get lodged or localized in the penis, the diseases like Niruddha Prakasha (phimosis), Upadamsha (chancre), Shuka dosha (venereal warts) etc are formed

Guda (rectum and anus) – When the doshas get lodged or localized in the rectum and or anus, the diseases like Bhagandara (fistula in ano), Arshas (piles) etc are formed

Vrishana (testicles and scrotum) – When the doshas get lodged or localized in the testicles and or scrotum, the diseases like Vriddhi (hydrocele, hernia) etc are formed

Oordhwa jatru (above the region of neck) – When the doshas get lodged or localized above the region of the neck, the diseases pertaining to eye, ear, nose and throat are formed

Twak, Mamsa, Rakta (skin, muscle, blood) – When the doshas get lodged or localized in the skin, muscles and blood, the diseases like Kushta (skin diseases), Visarpa (herpes) etc are formed

Medas (fat) – When the doshas get lodged or localized in the fat tissue, the diseases like Granthi (lipoma or cysts), Apachi (matted glands), Arbuda (tumours), Galaganda (goitre) etc are formed

Asthi (bone) – When the doshas get lodged or localized in the bone tissue, the diseases like Asthi Vriddhi (bone tumour), Anushayi (cold abscess) etc are formed

Pada (feet) – When the doshas get lodged or localized in the feet, the diseases like Shleepada (filariasis), Vata-Rakta (gout), Vata kantaka (spur or arthritis of ankle joint) etc are formed

Sarvanga (whole system) – When the doshas get lodged or localized in the whole body, the diseases like Jwara (fever), Sarvanga Vata (Tetanus) etc are formed

When the morbid doshas get lodged in the dhatus (tissues), the reaction of the tissue or organ to the invasion gives rise to a set of symptoms which will indicate that some disease will be formed in near future.

The dosha-dushya sammurchana will be weak and in a beginning stage. As a result, the symptoms will also be weak and be manifested in a feeble form.

These symptoms of a ‘would be’ disease are called as Purvarupas or Prak rupas (prodromata or premonitory symptoms). Therefore the 4th stage is also called as Purvarupa avastha or ‘stage of prodromata’.

Proper diagnosis and treatment given in this stage will halt the further pathology. The Dosha-dushya sammurchana will be aborted and the disease will come to a halt even before it is manifested.

If the progression of dosha vitiation or lodgement in tissues is not aborted, the pathogenesis will step into the next stage i.e. Vyakta or Vyakti bhava stage.

Vyakta

5th Kriya Kala – Vyakta or Vyakti-bhava, the stage of manifestation of disease with its full blown signs and symptoms –
The 5th stage of pathogenesis will be called Vyakta or Vyakteebhava wherein the disease gets manifested in its fullest form. This stage is a continuous stage of Sthana-samshraya avastha.

In vyakta avastha, the dosha-dushya sammurchana which has commenced in the 4th stage will come to a completion. Now, the doshas have got stubbornly lodged deeper into the dhatus (tissues). The tissue or organ damage is more in comparison to the 4th stage.

The signs and symptoms are clearly manifested and will denote (or explain) that disease. The disease is named in this stage of pathogenesis. The signs and symptoms of the manifested disease are called ‘Rupas’.

Therefore this stage is also called as ‘Rupa avastha’. The treatment at this stage will either be symptom specific (if the disease has not yet been named) or disease specific (after the disease has been named or diagnosed)

Consequence of Vyakta stage – The disease will get manifested in its full blown form. The disease will comprise of its characteristic signs and symptoms, like rise in temperature of fever, joint pains in arthritis, loose stools in diarrhoea etc. one or the other of the diseases which were mentioned in the stage of Sthanasamshraya (4th stage) will appear in a definite form with most of its signs and symptoms.

The disease like Shopha (inflammation), arbuda (tumours) etc and the systemic diseases like Jwara, Atisara etc will set in their clear cut symptoms. This stage is called as Rupa avastha because Rupas (symptoms) are formed).

When the disease is neglected or not treated in this stage, the dosha vitiation will have a further progression. The progression of pathogenesis will lead to manifestation of complications in the 6th stage or Bheda avastha.

Bheda

6th Kriya Kala – Bheda, the stage of manifestations of complications –
The 6th stage of dosha vitiation is called Bheda Avastha (stage of complications). If in the Vyakta stage, the disease is managed properly, the dosha vitiation will be brought to a halt.

But if proper treatment is not given to the patient even after attaining the stage of 5th Kriyakala (Vyaktibhava), the doshas will pass on to the 6th Kriyakala, the Bhedavastha or the stage of complications.

The inflammatory conditions like Vidradhi, Vranashodha (Abscess, boil) etc, will get ruptured and a permanent scar tissue will be formed at the site of inflammation or infection. This change is described as Vranabhava (formation of scar), because a scar will never leave the body until its death.

The non-inflammatory conditions like Jwara (fever), Atisara (diarrhoea) etc become chronic and stubborn. If this stage also is neglected the disease becomes Asadhya (incurable).

The chain of events which are likely to occur from this stage onwards is –
A disease may lead to some other disease and the former disease may get subsided. This is called Nidanarthakara roga i.e. one disease becoming the causative factor for another disease. Here, a disease will act like a Nidana (causative factor).
The disease, without getting subsided may give rise to some other disease. The 2nd disease which will be formed will be called as Upadrava or a complication or Udarka or sequel. Both these diseases can coexist making the condition severely complicated.

Benefits of knowing Kriya Kala

Sushruta tells ‘Only the person who has the perfect knowledge of the 6 stages of dosha vitiation namely Sanchaya, Prakopa, Prasara, Sthana Samshraya, Vyakti and Bheda can become a successful physician’

Sushruta also tells that the Doshas when pacified or destroyed in the first stage of the disease i.e. Sanchaya, the doshas do not progress to the further stages of vitiation (Prakopa, Prasara etc).

But if the dosha vitiation is not tackled in the earlier stages, they do progress to the next stages. The successive stages of dosha vitiation will be complicated and difficult to handle in comparison to its predecessor.

Kriya Kalas, as we have seen are the stages of pathogenesis or dosha vitiation wherein the successive stages get more and more difficult to handle in comparison to their predecessor stages. Therefore the treatment becomes easier when the disease process is diagnosed and proper measures are taken at the earliest.

The further stages are not formed when the dosha vitiation is diagnosed at the earliest. The doshas when diagnosed and controlled in the Sanchaya stage, the vitiation does not progress to the 2nd stage i.e. the stage of Prakopa.

When the dosha vitiation is traced in the 2nd stage (Prakopa), the dosha vitiation do not progress to the 3rd stage of pathogenesis i.e. Prasara stage. Thus, the earlier the disease process is traced and the earlier we implement effective action and treatment, we sould successfully have aborted the successive stages of disease formation.

If the vitiating and progressing doshas are neglected they spread into different tissues one after the other and becomes deep rooted. Then, one cannot cure or manage such conditions as it is not possible to take out a deep-rooted tree.

Moreover, the disease becomes resistant to medicine and nullifies the Oushadha veerya (power of medicines). The disease starts as a small insignificant disturbance in the body and gradually affects the deeper parts taking out the strength and life of the unfortunate patient ultimately.

Therefore a physician willing to make his patient hale and healthy and who wants to find unparalleled success and fame in the clinical practice must learn to diagnose the disease at the earliest and catch the culprit by its collar when it is just in a sprouting condition.

This will help him or her to implement successful treatment. For this to happen, the precise and thorough knowledge of Kriya Kala is a must.

Just before finish –
Early diagnosis of a disease forms the key to unravel the secrets of ‘effective and comprehensive treatment’. A physician who thoroughly knows and learns the Shat Kriya Kalas will be able to not only make a proper and accurate diagnosis of a disease but also will be able to detect the disease at its earliest.

He will be able to make out the subtle changes in health and will be capable to prevent the disease from progressing to the further stages, which when happens will make the disease complicated and difficult to handle.

The Shat Kriyakala also becomes the best tool to prevent many diseases and also to treat the diseases effectively in its earliest stages. On the other side, it is also the responsibility of the patient to keep a track of the subtle pathological changes takes place in the body and not to neglect these indications.

It is also their prime responsibility to bring these changes into the notice of the physician so that he or she will be able to provide effective medicines, treatment or remedy and about the disease process at the earliest.

After all the termination of the disease and providing effective cure is not only the responsibility of a physician but is indeed a team work in which the patient should participate sincerely and should have an interest to conquer his ailments.
Click to Consult Dr Raghuram Y.S. MD (Ayu). Email: drraghuramys@gmail.com