Sushruta Samhita Sutrasthana Chapter 21: Vranaprashna Adhyaya (Question Concerning Wounds)

The 21st chapter of Sutrasthana of Sushruta Samhita is named as Vranaprashna Adhyaya. This chapter deals with the Question Concerning Wounds.

अथतो व्रणप्रश्नमध्यायं व्याख्यास्यामः ॥१॥
यथोवाच भगवान् धन्वन्तरीः ॥२॥

We will now expound the chapter by name vranaprashna- question, Information concerning wounds; as revealed by the venerable Dhanvantari.

Dosha Pramukhya: Importance of the Doshas

वातपित्तश्लेष्माण एव देहसंभवहेतवः । तैरेवाव्यापन्नैरधोमध्योर्ध्वसन्निविष्टैः शरीरमिदं धार्यतेऽगारमिव स्थूणाभिस्तिसृभिः, अतश्च त्रिस्थूणमाहुरेके। त एव च व्यापन्नाः प्रलयहेतवः । तदेभिरेव शोणितचतुर्थैः संभवस्थितिप्रलयेष्व प्यविरहितं शरीरं भवति ॥३॥

The Tristhunas – The three doshas i.e. Vata, Pitta and Shlesma (kapha) only, are the main causes for the origin of the body. The body is supported by these doshas just like the house is supported by three pillars when these doshas are not abnormal i.e. in a state of balance and when they are functionally spread out in the lower, middle and upper parts of the body respectively (vata in lower, pitta in middle and kapha in upper part of the body).
Therefore, the three doshas are called tristhunas i.e. ‘three pillars’ (of the body) by some authorities.
The same doshas become causes for destruction of the body when they become abnormal. The three doshas along with the blood, which is the fourth dosha are present at all times i.e. during the birth, existence and destruction of the body.

The body never exists without kapha, pitta and vata

भवति चात्र:-
नर्ते देहः कफादस्ति न पित्तान्न च मारुतात् ।
शोणितादपि वा नित्यं देह एतैस्तु धार्यते ॥४॥

One verse here:-
It is also true that the body never exists without kapha, pitta, vata and shonita – blood. The body of human beings is always supported by these entities.

Nirukti: Etymology

तत्र “वा: गतिगन्धनयो: इति धातुः “तप: संतापे, ’श्लिष’ आलिङ्ग्ने, एतेषां कृद्विहितैः प्रत्ययैर्वातः पित्तं श्लेष्पेति च रुपाणि भवन्ति॥५॥

Vata – The term Vata is derived from the verbal root ‘va’ which means movement and with addition of preposition to it.
Pitta – The term Pitta is derived from the verbal root ‘tap’ which means ‘to cause heat’.
Kapha – The term Sleshma which also means Kapha, is derived from the verbal root ‘slish’ which means ‘to embrace or to adhere’.

Dosha Sthana: Seats of the Doshas

दोषस्थानान्यत ऊर्ध्वं वक्ष्याम:- तत्र समासेन वातः श्रोणिगुदसंश्रयः ; तदुपर्यधो नाभेः पक्वाशयः, पक्वामाशयमध्यं पित्तस्यः आमाशयः श्लेष्मणः ॥६॥

After this, we shall mention the dosha sthana i.e. seats of the doshas in the body.
The seats of the three doshas are mentioned below in brief –

अतः परं पञ्जधा विभज्यन्ते। तत्र वातस्य वातव्याधौ वक्ष्यामः ; पित्तस्य यकृत्प्लीहानौ ह्र्दयं दृष्टिस्त्वक पूर्वोक्तं च; श्लेष्मण उरः शिरः कण्टो जिह्वामूलं सन्धय इति पूर्वोक्तं च; एतानि खलु दोषाणां स्थानान्यव्यापन्ननाम् ॥७॥

Subdivisions of doshas –
Each of these doshas i.e. vata, pitta and kapha are divided into five divisions. The five divisions of Vata will be enumerated in the first chapter of Nidana Sthana i.e. chapter on ‘Vata Vyadhi’.
Below mentioned are the seats of the doshas in their state of normalcy (when they are not abnormal) –
Seats of Pitta –

• Yakrit – liver
• Pliha – spleen
• Hrdaya – heart
• Drshti – eye / vision
• Twak – skin and
• Others mentioned earlier
  Seats of Kapha –
• Urah – chest
• Sirah – head
• Kantha – throat
• Jihvamula – root of the tongue
• Sandhi – bony joints and
• Others mentioned earlier

Analogy to describe the functions of vata, pitta and kapha

भवति चात्र:-
विसर्गादानविक्षेपैः सोमसूर्यानिला यथा ॥
धारयन्ति जगद्देहं कफपित्तानिलास्तथा ॥८॥

One verse here:-
Soma i.e. moon (water) supports the body of this world (creation) through Visarga Karma i.e. by releasing or providing the strength. Surya i.e. sun (fire) similarly supports the world through Adana Karma i.e. by withdrawing the strength. Likewise, Anila or Vata i.e. air through its Viksepa Karma i.e. function of initiating all actions supports the body of the world. Similarly, Kapha, through its moon-like functions i.e. visarga, Pitta – through its sun-like functions i.e. adana and Vata – through its air-like functions i.e. vikshepa – support this human body.
(We need to note that in the human body soma or water is represented by sleshma i.e. kapha, surya or fire is represented by pitta and air is represented by vata.)

Pitta Vis-a-vis Agni

तत्र जिज्ञास्यं किं पित्तव्यतितेकादन्योऽग्रिः?आहोस्वित् पित्तमेवाग्रिरिति?।
अत्रोच्यते-न खलु पित्तव्यतिरेकादन्योऽग्रिरुपलभ्यते, आग्रेयत्वात् पित्ते दहनपचनादिष्वभि-प्रवर्तमानेऽग्रिवदुपचारः क्रियतेऽन्तरग्रिरिति; क्षीणे ह्यग्रिगुणे तस्तमानद्रव्योपयोगात्, अतिवृद्धे शीतक्रियोपयोगात्, आगमाच्च पश्यामो न खलु पित्तव्यतिरेकादन्योऽग्रिरिति ॥९॥

In relation to agni and pitta, there occurs a debatable point which leads to a question of interest. Apart from pitta, is there a separate agni – fire or is pitta itself the agni?
The answer is ‘No’. Apart from pitta, we do not find any other agni in the body. Due to the presence of properties of agni – fire in it and since it does the functions of burning, cooking (digesting the food) and such other functions similar to agni, pitta itself is considered as Agni in the body. Agni itself is present in the form of pitta in the body of human beings.
When these functions like burning, cooking etc are increased to abnormal levels in the body, as caused by increased pitta, it is treated on similar lines of treating the agni. This pitta is designated as antaragni (internal fire, digestive fire). Similarly when pitta having the qualities / properties of agni (fire) undergoes decrease, its (pitta) increase is brought about by administering drugs which are having similar properties as those of agni i.e. having hot quality and potency (like chitraka, shunti, pippali etc). When pitta undergoes increased cold potency (quality) drugs are administered (which are having qualities opposite to those of agni).
Supporting this, there is no mention of agni apart from pitta as existing in the human body even in the scriptures which are authoritative treatises of Ayurveda.
Therefore, we can conclude that there is no separate fire inside the body other than pitta, both are one and the same.

Pancha vidha Pitta: Five divisions of Pitta

तच्चादृष्टहेतुकेन विशेषेण पक्वामाशयमध्यस्थं पित्तं चतुर्विधमन्नपानं पचति, विवेचयति च दोषरसमूत्रपुरीषाणि; तत्रस्थमेव चात्मशक्त्या शोषाणां पित्तस्थानानां शरीरस्य चाग्रिकर्मणाऽनुग्रहं करोति, तस्मिन् पित्ते पाचकोऽग्रिरिति, संज्ञा; यत्तु यकृत्प्लीह्नोः पित्तं तस्मिन् रञ्जकोऽग्रिरिति संज्ञा, स रसस्य रागकृदुक्तः; यत् पित्तं हृदयस्थं तस्मिन् साधकोऽग्रिरिति संज्ञा, सोऽभिप्रार्थितमनोरथसाधनकृदुक्तः यदृष्ट्चां पित्तं तस्मिन्नालोचकोऽग्रिरिति संज्ञा, स रूप ग्रहणाधिकृतः ; यत्तु त्वति पित्तं तस्मिन् भ्राजकोग्रिरिति संज्ञा, सोऽभ्यङ्गपरिषेकावगाहालेपनादीनां क्रियाद्रव्याणां पक्ता छायानां च प्रकाशकः ॥१०॥

1. Pachaka Pitta
   The Pitta located between Pakvashaya and Amashaya acts naturally by adrshta hetus i.e. unseen causes i.e. by chance or due to the deeds done in the previous birth.
   Functions – This pitta –

• digests four types of foods that we consume,
• separates / bifurcates the doshas, rasa – essence of food, mutra – urine and purisha – feces and waste products of foods and
• being in its own seat, it helps the other sites of pitta located elsewhere in the body, to function normally by bestowing the properties of fire
  This pitta is known as Pacakagni or Pachaka Pitta i.e. pitta responsible for digestion of food.

2. Ranjaka Pitta
Location – Yakrit – liver and Pleeha – spleen
Functions – bestows red color to Rasa Dhatu and converts it into blood
Also called as – Ranjaka Agni

3. Sadhaka Pitta
Location – Hrudaya – heart
Function – helps in fulfilling the desires of the mind
Also called as – Sadhaka Agni

4. Alochaka Pitta
Location – Drushti – eyes / vision
Functions – perception of forms / vision
Also called as – Alochaka Agni

5. Bhrajaka Pitta
Location – Twak – skin
Functions – responsible for digesting and absorbing the substances reaching into the skin through anointing, bathing, washing, immersing, poultices etc. It also helps in expression of shades and colors on the skin.
Qualities of Pitta
भवति चात्र-
पित्तं तीक्ष्णं द्रवं पूति नीलं पीतं तथैव च ।
उष्णं कटुरसं चैव विदग्धं चाम्लमेव च ॥११॥

One verse here:-
Pitta is –

• Tikshna – penetrating (into the tissues),
• Drava – liquid,
• Puti – fetid (bad smelling),
• Nila – blue in color or
• Pita – yellow in color
• Ushna – hot in potency,
• Katu rasam – pungent in taste in its normal state and
• Amla rasam – sour in taste when it is improperly cooked or burnt

Kapha and its functions in the body

अत ऊर्ध्वं श्लेष्मस्थानान्यनुव्याख्यास्यामः । तत्र, आमाशयः पित्ताशयस्योपरिष्टात् तत्प्रत्यनीकत्वादूर्ध्वगतित्वोत्तेजसः, चन्द्र इव आदित्यस्य, चतुर्विधस्यांहरस्याधारः, स च तत्रौदकैगुणैराहारः प्रक्लिन्नो भिन्नसंघातः सुखजरो भवति ॥१२॥
माधुर्यात् पिच्छिलत्वाच्च प्रक्लेदित्वात्तथैव च ॥
आमाशये संभवति श्लेष्मा मधुरशीतलः ॥१३॥

After this, the seats of Sleshma – Kapha will be described.
In the body, Amashaya is located above Pittashaya (seats of pitta, mainly liver and gallbladder), because of opposite qualities and also due to upward motion of Agni, just like the moon is to the sun. Amashaya is also the place for all four kinds of foods that we eat.
Kapha has properties similar to that of water. With these properties it moistens the food, splits them into smaller particles and digestes them easily.
Kapha which is sweet in taste and cold in nature is produced in the Amashaya by the sweet taste, sliminess property and moistened state of the food in the amashaya.

Pancha vidha kapha and divisions of kapha

स तत्रस्थ एव स्वशक्त्या शोषाणां श्लेष्मस्थानानां शरीस्य चोदककर्मणऽनुग्रहं करोति ; उरः स्थस्त्रिकसन्धारणमात्मवीर्येणान्नरससहितेन हृदयावलम्बलं करोतिः जिह्वामूलकण्ठस्थो जिह्वेन्द्रियस्य सौम्यत्वात् सम्यत्वात् सम्यकरसज्ञने वर्तते, शिरःस्थः स्रेहसंतर्पणाधिकृतत्वादिन्द्रियाणामात्मवीर्येणानुग्रहं करोति; सन्धिस्थः श्लेष्मा सर्वसन्धिसम्श्लेषात् सर्वसन्धिसंश्लेषात् सर्वसन्ध्यनुग्रहं करोतिः

Udaka Karma means water like properties and actions / functions of kapha. Kapha, being in its own seat (Amashaya) helps and supports the other seats of kapha located elsewhere in functioning properly and normally. (This is kledaka kapha)
One type of Kapha is located between Uras = chest and Trika – meeting place of head and two arms (upper back). This kapha by its own properties combined with the properties of the essence of food, supports the Hrdaya – heart. (This is Avalambaka Kapha)
Another subtype of Kapha resides in the Jihvamula i.e. base of the tongue and Kantha – throat. This kapha, by the moistness of Jihva indriya – tongue (organs of taste perception) helps in proper perception of taste. (This is Bodhaka Kapha).
There is one more subtype of Kapha which resides in the Shiras – head. This kapha by its natural unctuousness and nourishing qualities nourishes the indriyas i.e. sense organs located in the head and enables them to perform their functions (perception) properly. (This is Tarpaka Kapha).
One more subtype of Kapha resides in all the Sandhis i.e. bony joints of the body. This kapha holds the joints firmly and enables easy movement of the joints. (This is Shleshaka Kapha).

Sleshma guna: Properties of Kapha

भवति चात्र:-
श्लेष्मा श्र्वेते गुरुः स्निग्धः पिच्छितः शीत एव च।
मधुरस्त्वविदग्धः स्याद्विदग्धो लवणः स्मृतः ॥१५॥

One verse here –
Below mentioned are the properties of Kapha –

• Shweta – white,
• Guru – heavy,
• Snigdha – unctuous
• Pichchila – slimy
• Shita – cold,
• Madhura – sweet when it is normal
• Lavana – salty in taste when improperly cooked (vidagdha kapha)

Sonita (rakta) Sthana: Seats of blood

शोणितस्य स्थानं यकॄत्प्लीहानौ, तच्च,प्रागभिहितं; तत्रस्थमेव शेषाणां शोणितस्थानानामनुग्रहं करोतिः॥१६॥

Below mentioned are the seats of Rakta – blood, which have earlier been said in chapter 14 –

• Yakrit – liver and
• Pliha – spleen
  Being in these seats, Rakta helps and supports the other seats of rakta to render their normal functions.
  अनुष्णशीतं मधुरं स्निग्धं रक्तं च वर्णतः ।
  शोणितं गुरु विस्रं स्याद्विदाहश्चास्य पित्तवत् ॥१७॥
  Properties of Blood are as below mentioned –
• Anushna shita – neither hot nor cold, but is moderate
• Madhura – sweet in taste
• Snigdha – unctuous
• Rakta varna – red in color
• Guru – heavy
• Visra – bad smelling
• Vidahaschasya pittavat – it is like pitta i.e. sour in taste and causes burning sensation, after improper cooking
  

Dosha Sanchaya: Mild accumulation of the Doshas – The first Kriyakakala

एतानि खलु दोषस्थानानि; एषु सम्चीयन्ते दोषाः। प्राक संचयहेतुरुक्तः। तत्र संचितानां खलु दोषाणां स्तब्धपूर्णकोष्ठता पीतावभासता मन्दोष्मता चाङानां गौरवमालस्यं चयकारणविद्वेषश्चेति लिङ्गानि भवन्ति। तत्र प्रथमः क्रियाकालः ॥१८॥

Thus, the seats of all the doshas have been enumerated. Accumulation of doshas following slight increase takes place in these seats of theirs. The causes for accumulation of doshas have already been described earlier in chapter no 6.
The signs and symptoms of accumulation of doshas i.e., sanchaya are –

Sanchaya is the first Kriyakala i.e. first stage of disease activity and first stage of pathogenesis of any disease.
Dosha Prakopa: Aggravation of the Doshas – Further we will describe the causes of Prakopa(great increase/ aggravation) of the Doshas.
Etiological factors for vata aggravation – Vayu (vata) undergoes aggravation by –

• fighting with stronger persons (or animals),
• too much of physical exercise,
• excessive indulgence in copulation and
• studying in excess;
• falling from a height,
• running,
• hurting / sprain,
• injury,
• jumping,
• hopping,
• swimming,
• keeping awake at night,
• carrying heavy load,
• riding (or running with) elephant, horses, chariots in excess,
• walking in excess,
• excessive indulgence in foods which are pungent, astringent and bitter in taste, dry (moisture free), light (quickly digesting) and cold in potency,
• excessive consumption of dried leafy vegetables and dried meat, varaka, Uddalaka, Koradusa, Syamaka, Nivara (these are pulses),
• excessive consumption of mudga, masura, adhaki, harenu, kalaya, nispava,
• fasting / starvation in excess,
• taking food at improper time etc
• overeating (more quantity of food often),
• suppressing the urges of flatus, urine, faeces, semen, vomiting, sneezing, belching and tears and such other causes

स शीताभ्रप्रवातेषु धर्मान्ते च विशेषतः ।
प्रत्यूषस्यपरह्णे च जीर्णेऽन्ने च प्रकुप्यति ॥२०॥

Vata also undergoes prakopa – aggravation in the below mentioned conditions –

• at the time of cold / winter
• when clouds accumulate in the sky
• presence of heavy breeze
• at the end of summer i.e. during rainy season,
• in the afternoon,
• at evenings
• after the digestion of food

Pitta Prakopa karana: Causes for aggravation of Pitta

क्रोधशोकभयायासोपवासविदग्धमैथुनोपगमनकट्वम्ललवणतीक्ष्णोष्णलघुविदाहितिलतैलापिण्याककुलत्थसर्षपातसीहरितकशाकगोधामत्स्याजाविकमांसदधितक्रर्चिकामस्तुसौवीरकसुराविकाराम्लफलकटवरप्रभृतिभिः पित्तं प्रकोपमापद्यते॥२१॥

Etiological factors of pitta aggravation – Pitta undergoes aggravation by –

• anger,
• grief,
• fear,
• exertion,
• fasting,
• ingestion of foods which are spoiled or decomposed / causing burning inside the abdomen during digestion;
• more of copulation,
• excessive strolling / roaming,
• use of foods which are pungent, sour, and salt, penetrating , hot light for digestion, which cause heart- burn / corrosive – in excess,
• excessive consumption of oil of tila (sesame), Pinyaka (oil cake), Kulattha, Sarsapa, Atasi, haritaka Saka,
• excessive consumption of meat of iguana, fish, goat and sheep,
• excessive consumption of curd, buttermilk, cheese,
• excessive consumption of whey, fermented gruel, beer and its bye-products sour fruits, curds devoid of fat and such others

तदुष्णैरुष्णकाले च घनान्ते च विशेषतः ।
मध्याह्ने चार्धरात्रे च जीर्यत्यन्ने च कुप्यति ॥२२॥

Pitta also undergoes prakopa – aggravation in the below mentioned conditions –

• during heat,
• in hot seasons
• after rainy season i.e. autumn season
• during midday
• at midnight
• during the digestion of food

Shleshma prakopa karana: Causes for aggravation of Kapha

दिवास्वप्राव्यायामालस्यमधुराम्ललवणशीतस्निग्धगुरुपिच्छलाभिष्यन्दिहायनकयबकानैषधेत्कटमाषमहामाषगोधूम तिल पिष्ट-विकृतिदधिदुग्धकृशरापायसेक्षुविकारानूपौदहमांसवसाबिसमृणालकसेरुश्रृङ्गाटकमधुर वल्ली फलसमशनाध्यशनप्रभृतिभिः श्लेष्मा प्रकोपमाद्यते॥२३॥

Etiological factors for kapha aggravation – Slesma (kapha) undergoes aggravation by –

• day sleep,
• absence of physical exercise,
• lassitude,
• excessive use of foods of sweet, sour and salt tastes, cold, unctuous (fatty), heavy (hard to digest), slimy, and those increasing the moisture inside the tissues;
• excessive consumption of Hayanaka, Yavaka, Naisadha, itkata (all are cereals),
• excessive consumption of Masa Mahamasa, Godhuma, tila pista vikriti (menu prepared from sesame paste)
• excessive consumption of curd, milk, rice boiled with mudga, milk pudding, products of sugarcane juice, meat and muscle fat of animals of marshy regions and of water,
• excessive consumption of bisa, Mrnala, Kaseruka, Srngataka, fruits of sweet taste and those of creepers;
• excessive intake of mixture of healthy and unhealthy foods,
• overeating and such others

स शीतैः शीतकाले च वसन्ते च विशेषतः ।
पूर्वांह्णे च प्रदोषे च भुक्तमात्रे प्रकुप्यति॥२४॥

Kapha also undergoes prakopa – aggravation in the below mentioned conditions –

• by cold
• in cold / winter season,
• spring season
• at forenoon / morning
• at evening
• immediately after consumption of food

Rakta Prakopa Karana: Causes for aggravation of blood

पित्तप्रकोपणैरेव चाभीक्ष्णं द्रवस्निग्धगुरूभिराहारैर्दिवास्वप्रकोधानलातपश्रमाभिघाताजीर्णविरुद्धाध्यशनादिभिर्विशेषैरसृक प्रकोपमापद्यते ॥२५॥

Etiological factors for aggravation of blood – The prakopa – aggravation of blood takes place by the same etiological factors which cause aggravation of pitta when used frequently. The other causes are as below mentioned –

• foods which are fluid, unctuous, and heavy (hard for digestion);
• sleeping at day,
• anger,
• exposure to fire and sunlight,
• exertion,
• injury,
• indigestion,
• partaking incompatible food etc.

यस्माद्रक्तं विना दोषैर्न कदाचित् प्रकुप्यति ।
तस्मात्तस्य यथादोषं कालं विद्यात् प्रकोपणे ॥२६॥

The blood does not get aggravated without being associated or afflicted by other doshas. Therefore, the time of aggravation of rakta – blood should be considered to be the same as that of doshas.

Dosha prakopa: Aggravation, the second kriyakala

तेषां प्रकोपात् कोष्ठतोदसंचरणम्लीकापिपासापरिदाहन्नद्वेषहृदयोत्क्लेदाश्चजायन्ते। तत्र द्वितीयः क्रियाकालः ॥२७॥
The symptoms of aggravation of doshas are as below mentioned –

Prakopa is the second Kriyakala – i.e. second period of disease activity or second stage of pathogenesis of diseases.

Dosha prasara – Spread of doshas: The third kriyakala

अत ऊर्ध्वं प्रसरं वक्ष्याम:- तेषामेभिरातङ्कविशेषैः प्रकुपितानां किण्वोदकपिष्टसमवाय इवोद्रिक्तानां प्रसरो भवति। तेषां वायुर्गतिमत्त्वात् प्रसरणहेतुः सत्यप्यचैतन्ये। यथा-महानुदकसंचयोऽतिवृद्धः सेतुमवदार्यापरेणोदकेन व्यामिश्रिः सर्वतःप्रधावति, एवं दोषाः कदाचिदेकशो द्विशः समस्ताः शोणितसहिता वाऽनेकधा प्रसरन्ति। तद्यथा-वात्तं ः, पित्तं श्लेष्मा, शोणितं वातपित्ते, वातश्लेष्माणौ, पित्तश्लेष्माणौ, वातशोणिते, पित्तशोणिते, श्लेष्मशोणिते, वातपित्तशोणितानि, वातश्लेष्मशोणितानि, पित्तश्लेष्मशोणितानि, वातपित्तकफाः,वातपित्तकफाः वातपित्तकफशोणितानीति; एवं पञ्चदशधा प्रसरन्ति ॥२८॥
After this, the third stage of pathogenesis i.e. Prasara will be described. Doshas proceed to the third stage by getting further increased, if they are not dealt with during their stage of aggravation. The doshas which have undergone aggravation in their own seats get further excited by the same aggravating causes (as were responsible for their aggravation) would undergo prasara, i.e. overflow from their respective seats and spread to other places just like the mixture of yeast, water and grain flour kept overnight would overflow their vessel.
Vata is the chief cause of prasara i.e. spread of doshas, amongst these tridoshas. This is because vata, in spite of being devoid of sensation (i.e. it is inanimate), has movement owing to its predominance in rajo guna.
Vata is predominant in Rajo Guna. Presence of Rajo Guna enables vata to activate all the things. Thus, vata activates all things due to the predominance of rajo guna in it. This is the basic reason why it causes prasara.
The doshas which have accumulated and undergone aggravation (prakopa) would spread to the other areas by breaking all the barriers i.e. overflowing from their seats wherein they have undergone aggravation, just like a big water body or great accumulation of water, when further increased would overflow the dam by breaking its barriers and joins with the water on the other side and also runs all over the area. This movement or overflow of doshas from its seats to the other places of the body is called prasara. Prasara of doshas can take place either individually or in combination of two doshas, or of all three doshas or with shonita – blood.
Dosha prasara is of fifteen types. They are as below mentioned –
Prasara of single dosha –

• Vata
• Pitta
• Kapha
• Shonita – rakta
  Prasara of two doshas –
• Vata-Pitta
• Vata-Sleshma
• Pitta-Sleshma
• Vata-Sonita
• Pitta-Sonita
• Sleshma-Sonita
  Prasara of three doshas –
• Vata-Pitta-Sonita
• Vata-Kapha-Sonita
• Pitta-Kapha-Sonita
• Vata-Pitta-Kapha
  Prasara of all four doshas
• Vata-Pitta-Kapha-Sonita

कृत्स्नेऽर्धेऽवयवे वाऽपि यत्राङ्गे कुपितो भृशम् ।
दोषो विकारं नभसि मेधवत्तत्र वर्षति॥२९॥
नात्यर्थं कुपितश्चापि लीनो मार्गेषु तिष्ठति।
निष्प्रत्यनीकः कालेन हेतुमासाद्य कुप्यति ॥३०॥

The clouds in the sky cause rain at the place of their accumulation. Similarly, the aggravated dosha, which is undergoing prasara and is spreading either in the entire body or half of the body or any part of the body, would give rise to the diseases therein (where they reach). On the other hand, if the doshas are not severely increased, they remain in their paths, adhering to it. These doshas, when not treated or eliminated, would once again get aggravated in due course of time being excited by suitable causative factors.

तत्र वायोः पित्तस्थानगतस्य पित्तवत् प्रतिकारः पित्तस्य च कफस्थानगतस्यकफ्वत्, कफस्य च वातस्थानगतस्य वातवत्; एष क्रियाविभागः ॥३१॥

In such conditions,

• treatments for Vata, which has spread to the seats of pitta, should be those which mitigate pitta,
• treatments for pitta which has spread to the seats of kapha, should be those which mitigate kapha,
• treatments for kapha which has spread to the seats of Vata, should be those which mitigate vata,
  These are the methods of treatments.

Prasara Kala lakshana: Symptoms during this stage

एवं प्रकृतितानां प्रसरतां वार्यर्विमार्गगमनाटोपौ, ओषचोषपरिदाधूनायनानि पित्तस्य, अरोचकाविपाकाङ्गसादाश्चर्दिश्चेति श्लष्मणो लिङ्गानि भवन्ति; तत्र तृतीयः क्रियाकालः ॥३२॥

Vata Prasara Symptoms – Symptoms of vata which has aggravated and spread to other places are –

• Vimargagamana – movement of doshas / things in wrong direction inside the alimentary tract and
• Atopa – more of gurgling sound in the abdomen;
  Pitta Prasara Symptoms – Symptoms of pitta which has aggravated and spread to other places are –
• Osa – burning sensation felt locally,
• Cosa – sucking type of pain
• Paridaha – burning sensation experience all through the body,
• Dhumayana – feeling as if hot fumes are coming out of the body / stomach

Kapha Prasara Symptoms – Symptoms of kapha which has aggravated and spread to other places are –

• Arocaka – loss of taste / appetite
• Avipaka – indigestion
• Angasada – debility of body or body parts
• Chardi – vomiting
  Prasara – is the third Kriyakala i.e. third stage of disease activity or third stage of pathogenesis.

Sthana Samshraya – Localization of doshas: The fourth Kriyakala

अत ऊर्ध्वं स्थानसंश्रयं वक्ष्यामः । एवं प्रकुपिताः तांस्तान् शरीप्रदेशानागम्यतांस्तान् व्याधीन् जनयन्ति। ते यदोदरसन्निवेशं कुर्वन्ति तदा गुल्मविद्रध्युदराग्रिसंङ्गानाहविसूचिकातीसारप्रभृतीञ्जनयन्ति; बस्तिगताः प्रमेहाश्मरीमूत्राघातमूदोषप्रभृतीन; मेढ्रगता निरुद्धप्रकशोपदंशशूकदोषप्रभृतीन; गुदगता भगन्दरार्शः प्रभृतिन; वृषणगता वृद्धीः ; ऊर्ध्वजत्रुगतास्तूर्ध्वजान्; त्वड्मांसशोणितस्थाः क्षुद्ररोगान् कुष्ठानि विसर्पांश्च्; मेदोगता ग्रन्थ्यपच्यर्बुदगलगण्डालजीप्रभृतीन् ; अस्थिगता कुष्ठानिविसर्पांश्च; मेदोगता ग्रन्थ्यपच्यर्बुदगलगण्डालजीप्रभृतीन्; अस्थिगता विद्रध्यनुशयीप्रभृतीन्; पादगताः श्लीपदवातशोणितवात कण्टकप्रभृतीन् ; सर्वाङ्गगता ज्वरसर्वाङ्गरोगप्रभृतीन्; तेषामेवमभिसंनिविष्टानां पुर्वरुपप्रादुर्भावः ; तं प्रतिरोगं वक्ष्यामः । तत्र पूर्वरुपगतेषु चतुर्थःक्रियाकालः ॥३३॥

From here on, Sthana Samshraya i.e. localization of doshas will be described. After prakopa – aggravation in their own seats and prasara – overflow or spread out, the doshas which are traveling in various paths, towards different places of the body, would now become localized at certain places and produce diseases in such places of localization. This localization of doshas is called as sthana samshraya. Below mentioned are some of the examples of sthana samshraya i.e. lodgment of dosha in particular places of the body and the diseases that they cause therein –

Purvarupas i.e. premonitory symptoms of diseases are produced by these doshas which have become localized. They will be described separately.
Sthana Samshraya, a stage wherein there is lodgment of doshas in the tissues and manifestation of purvarupas is the fourth Kriyakala i.e. fourth stage of disease activity or fourth stage of pathogenesis.

Vyakti (Rupa) – Manifestation of disease: The fifth Kriyakala

अत ऊर्ध्वं व्याधेर्दर्शनं वक्ष्यामः – शोफार्बुदग्रन्थिविद्रधिविसर्पप्रभृतीनां प्रव्यक्तलक्षणता ज्वरातीसारप्रभृतीनां च । तत्र पञ्चमः क्रियाकालः ॥३४॥
Vyakta means manifestation. After this, the vyakta Avastha i.e. stage of manifestation of diseases along with their characteristic signs and symptoms will be described.
This is a stage in which the disease is clearly manifested. The symptoms of the diseases like swelling, malignant tumor, cysts / benign tumor, abscess, erysipelas and such other external diseases and also in fever, diarrhea and such others internal diseases are also clearly manifested.
Vyakta Avastha is the fifth Kriyakala i.e. fifth stage of disease activity or fifth stage of pathogenesis.

Bheda – Chronicity the sixth Kriyakala

अत ऊर्ध्वमेतेषामवदीर्णानां व्रणभावमापन्नानां षष्ठः क्रियाकालः , ज्वरातिसारप्रभृतीनां च दीर्धकालानुबन्धः । तत्राप्रतिक्रियमाणेऽसाध्यतामुपयान्ति ॥३५॥
If the disease is not treated properly in the fifth stage of disease activity i.e. vyakta Avastha, the disease progresses to the sixth stage i.e. bheda Avastha. In this stage, there occurs burning or tearing of the swelling and formation of wounds. Diseases like fever, diarrhea etc. become chronic and complicated in this stage.
Bheda Avastha is the sixth Kriyakala i.e. fifth stage of disease activity or fifth stage of pathogenesis. The diseases become incurable if they are not treated even in this stage.

भवति चात्र:-
संचयं च प्रकोपं च प्रसरं स्तानसंश्रयम् ।
व्यक्तिं भेदं च यो वेति दोषाणां स भवेद्भिषक ॥३६॥
One verse here:-
A physician who understands different stages of dosha disturbances and manifestation of disease (pathogenesis) i.e. Sanchaya, Prakopa, Prasara, Sthana Samshraya, Vyakta and Bheda can only be considered and called as a real physician.

Importance of treating the diseases in the early stages

संचयेऽपहृता दोषा लभन्ते नोत्तरा गतीः ।
ते तूत्तरासु भवन्ति बलवत्तरा ः ॥३७॥

When the doshas are eliminated during the sanchaya stage of pathogenesis itself, they do not undergo further stages i.e. the doshas will not progress into the successive stages of pathogenesis like prakopa, prasara etc. and the disease will not be formed. Otherwise, i.e. if the doshas progress to the successive stages, they become powerful and would cause diseases.

सर्वैर्भावैस्त्रिभिर्वाऽपि द्वाभ्यामेकेन वा पुनः ।
संसर्गे कुपितः क्रुद्धं दोषं दोषोऽनुधावति ॥३८॥

Dosha might get aggravated either in all, any three, any two or even any one of its qualities. When such dosha combines with another dosha, then, the dosha which is less aggravated will follow the dosha which has aggravated severely i.e. the less aggravated dosha becomes secondary to the severely aggravated main dosha.

संसर्गे यो गरीयान् स्यादुपक्रम्यः स वै भवेत् ।
शेषदोषाविरोधेन सन्निपाते तथैव च॥ ३९॥

When such combination of doshas occur, the powerful or greatly aggravated dosha should be treated with utmost importance, without interfering with the remaining dosha. The same principle shall be followed while dealing with sannipata i.e. combination of all the three doshas.

Vrana nirukti – Definition of the wound

वृणोति यस्माद्रूढेऽपि व्रणवस्तु न नश्यति ।
आदेहधारणात्तस्माद्व्रण इत्युच्यते बुधैः ॥४०॥

The wise physician calls this condition as ‘Vrana’ because of the below mentioned reasons –

• it covers the skin or the area of the body and
• the vrana vastu i.e. scar of wound does not go away even after the wound has healed and remains on the body until the person lives
  इति श्रीसुश्रुतसंहितायां सुत्रस्थाने व्रण्प्रश्नाध्यायो नामैकविंशोऽध्यायः ॥२१॥
  Thus ends the Twenty first chapter by name Vranaprasna in Sutra sthana of Susruta Samhita.

Purvarupas i.e., premonitory symptoms of diseases are produced by these doshas which have become localized. They will be described separately.
Sthana Samshraya, a stage wherein there is lodgment of doshas in the tissues and manifestation of purvarupas is the fourth Kriyakala i.e. fourth stage of disease activity or fourth stage of pathogenesis.

Vyakti (Rupa) – Manifestation of disease: The fifth Kriyakala

अत ऊर्ध्वं व्याधेर्दर्शनं वक्ष्यामः – शोफार्बुदग्रन्थिविद्रधिविसर्पप्रभृतीनां प्रव्यक्तलक्षणता ज्वरातीसारप्रभृतीनां च । तत्र पञ्चमः क्रियाकालः ॥३४॥
Vyakta means manifestation. After this, the vyakta Avastha i.e. stage of manifestation of diseases along with their characteristic signs and symptoms will be described.
This is a stage in which the disease is clearly manifested. The symptoms of the diseases like swelling, malignant tumor, cysts / benign tumor, abscess, erysipelas and such other external diseases and also in fever, diarrhea and such others internal diseases are also clearly manifested.
Vyakta Avastha is the fifth Kriyakala i.e. fifth stage of disease activity or fifth stage of pathogenesis.

Bheda – Chronicity the sixth Kriyakala

अत ऊर्ध्वमेतेषामवदीर्णानां व्रणभावमापन्नानां षष्ठः क्रियाकालः , ज्वरातिसारप्रभृतीनां च दीर्धकालानुबन्धः । तत्राप्रतिक्रियमाणेऽसाध्यतामुपयान्ति ॥३५॥
If the disease is not treated properly in the fifth stage of disease activity i.e. vyakta Avastha, the disease progresses to the sixth stage i.e. bheda Avastha. In this stage, there occurs burning or tearing of the swelling and formation of wounds. Diseases like fever, diarrhea etc. become chronic and complicated in this stage.
Bheda Avastha is the sixth Kriyakala i.e. fifth stage of disease activity or fifth stage of pathogenesis. The diseases become incurable if they are not treated even in this stage.

भवति चात्र:-
संचयं च प्रकोपं च प्रसरं स्तानसंश्रयम् ।
व्यक्तिं भेदं च यो वेति दोषाणां स भवेद्भिषक ॥३६॥
One verse here:-
A physician who understands different stages of dosha disturbances and manifestation of disease (pathogenesis) i.e. Sanchaya, Prakopa, Prasara, Sthana Samshraya, Vyakta and Bheda can only be considered and called as a real physician.

Importance of treating the diseases in the early stages

संचयेऽपहृता दोषा लभन्ते नोत्तरा गतीः ।
ते तूत्तरासु भवन्ति बलवत्तरा ः ॥३७॥
When the doshas are eliminated during the sanchaya stage of pathogenesis itself, they do not undergo further stages i.e. the doshas will not progress into the successive stages of pathogenesis like prakopa, prasara etc. and the disease will not be formed. Otherwise, i.e. if the doshas progress to the successive stages, they become powerful and would cause diseases.

सर्वैर्भावैस्त्रिभिर्वाऽपि द्वाभ्यामेकेन वा पुनः ।
संसर्गे कुपितः क्रुद्धं दोषं दोषोऽनुधावति ॥३८॥

Dosha might get aggravated either in all, any three, any two or even any one of its qualities. When such dosha combines with another dosha, then, the dosha which is less aggravated will follow the dosha which has aggravated severely i.e. the less aggravated dosha becomes secondary to the severely aggravated main dosha.

संसर्गे यो गरीयान् स्यादुपक्रम्यः स वै भवेत् ।
शेषदोषाविरोधेन सन्निपाते तथैव च॥ ३९॥

When such combination of doshas occur, the powerful or greatly aggravated dosha should be treated with utmost importance, without interfering with the remaining dosha. The same principle shall be followed while dealing with sannipata i.e. combination of all the three doshas.

Vrana nirukti: Definition of the wound

वृणोति यस्माद्रूढेऽपि व्रणवस्तु न नश्यति ।
आदेहधारणात्तस्माद्व्रण इत्युच्यते बुधैः ॥४०॥

The wise physician calls this condition as ‘Vrana’ because of the below mentioned reasons –

• it covers the skin or the area of the body and
• the vrana vastu i.e. scar of wound does not go away even after the wound has healed and remains on the body until the person lives

इति श्रीसुश्रुतसंहितायां सुत्रस्थाने व्रण्प्रश्नाध्यायो नामैकविंशोऽध्यायः ॥२१॥
Thus ends the Twenty first chapter by name Vranaprasna in Sutra sthana of Susruta Samhita.