Atisara Nidanam – 3rd Chapter of Madhav Nidanam

Abstract

Atisara is an important gastrointestinal disorder described in Ayurveda. It is marked by the repeated elimination of loose or watery stools. Its occurrence is associated with impaired Agni, imbalance of Doshas and altered function of Apana Vayu.Madhava Nidana provides a detailed account of Atisara, covering its causative factors, disease development, and characteristic clinical manifestations. This article discusses Nidana of Atisara. It highlights dietary and lifestyle factors such as incompatible foods, irregular meals and too much fluid intake which can upset the digestive system. It also explains the role of Vata, Pitta and Kapha in understanding the various manifestations of Atisara.

Atisara Nidanam – 3rd Chapter of Madhav Nidanam

Introduction

This disease has been described in detail in classical Ayurvedic text “Madhava Nidana” particularly in context of Nidana (etiology), pathogenesis and clinical features. According to Ayurveda, Atisara is caused by the vitiation of Doshas, impairment of Agni and disturbance in the normal functioning of Apana Vayu. Factors in the diet and in the mode of living such as unwholesome food, improper eating habits and excesses of liquid are said to be contributory factors.Depending upon the predominance of Vata, Pitta, Kapha or their combined involvement Atisara presents with different clinical features. The Nidana of Atisara as given in Madhava Nidana highlights the Ayurvedic concept of disease causation and the importance of identifying the factors responsible for the manifestation of the disease.

Etiological Factors (Nidana) Of Atisara

गुर्वतिस्निग्धरूक्षोष्णद्रवस्थूलातिशीतलैः।
विरुद्धाध्यशनाजीर्णैर्विषमैश्चापि भोजनैः॥ १॥

स्नेहाद्यैरतियुक्तैश्च मिथ्यायुक्तैर्विषैर्भयैः।
शोकाद्दुष्टाम्बुमद्यातीपानैः सात्म्यर्तुपर्ययैः॥ २॥

जलाभिरमणैर्वेगविघातैः कृमिदोषतः।
नृणां भवत्यतीसारो लक्षणं तस्य वक्ष्यते॥ ३॥ (Madhava Nidana, Atisara Nidana, Shlokas1–3. )

According to Madhava Nidana, Atisara may develop due to various ,Aharaja Nidana (Dietary Factors),Viharaja Nidana (Lifestyle Factors), Manasika Nidana (Psychological Factors) and environmental factors that disturb the normal functioning of digestion and the Doshas. The causative dietary factors include excessive consumption of heavy, unctuous, dry, hot, cold, liquid, and bulky foods, along with incompatible food combinations, eating before the previous meal is digested, and irregular eating habits. Excessive or improper use of oleation and other therapeutic measures, exposure to poisons, fear, grief, consumption of contaminated water and excessive alcohol intake are also mentioned as contributing factors. These causes, according to Ayurvedic principles, disturb Dosha equilibrium and contribute to the development of the disease.

Samprapti (Pathogenesis) Of Atisara

संशम्यापां धातुरग्निं प्रवृद्धः शकृन्मिश्रो वायुना अधः प्रणुन्नः।
सरत्यतीवातिसारं तमाहुर्व्याधिं घोरं षड्विधं तं वदन्ति॥
एकैकशः सर्वशश्चापि दोषैः शोकेनान्यः षष्ठ आमेन चोक्तः॥ ४ ॥ (Madhava Nidana Atisara Nidana Shloka 4)

According to Madhava Nidana, Atisara develops when the increased watery component of the body diminishes the digestive fire (Agni), mixes with faecal matter (Shakrit), and is propelled downward by Vayu, resulting in the excessive passage of loose stools.
The text describes six types of Atisara:

Vataja Atisara
Pittaja Atisara
Kaphaja Atisara
Sannipataja Atisara (caused by the combined vitiation of all three Doshas)
Shokaja Atisara (associated with grief)
Amaja Atisara (associated with Ama or incompletely digested material).

Purvarupa (Premonitory Symptoms) Of Atisara

हृन्नाभिपायूदरकुक्षितोदगात्रावसादानिलसन्निरोधाः।
विट्सङ्ग आध्मानमथाविपाको भविष्यतस्तस्य पुरःसराणि॥ ५॥ (Madhava Nidana Atisara Nidana shloka 5)

According to Madhava Nidana, prodromal symptoms of Atisara are pain in the cardiac region, umbilical region, anal region, abdomen and flanks. General weakness of the body. Obstruction of flatus. Constipation or difficulty in passing stools. Abdominal distension (bloating) and indigestion. These may be seen before the full appearance of Atisara and are described in the classical Ayurvedic literature as indicative of the developing disorder.

Symptoms Of Vataja Atisara

अरुणं फेनिलं रूक्षम् अल्पमल्पं मुहुर्मुहुः।
शकृदामं सरुक्शब्दं मारुतेनातिसार्यते॥ ६ ॥ (Madhava Nidana Atisara Nidana shloka 6)

According to Madhava Nidana, Vataja Atisara presents with repeated evacuation of small quantities of stool, accompanied by colicky abdominal pain and increased intestinal sounds. The stools may vary in consistency, appearing dry, frothy, or watery, and may sometimes be passed as hard, compact masses with difficulty. These features reflect the aggravation of Vata Dosha and its influence on normal intestinal motility and defecation.

Symptoms Of Pittaja Atisara

पित्तात् पीतं नीलमालोहितं वा तृष्णामूर्च्छादाहपाकोपपन्नम्। (According to Madhava NidanaAtisara Nidana shloka 7)

Pittaja Atisara is described in Madhava Nidana as a condition characterized by frequent loose stools with abnormal coloration, including yellow, bluish, or reddish hues. Accompanying symptoms Excessive thirst, fainting, burning sensation, inflammatory changes. In Ayurvedic understanding, these clinical features are attributed to the aggravation of Pitta Dosha and are associated with its inherent hot and intense properties.

Symptoms Of Kaphaja Atisara

श्वेतं सान्द्रं गुरु स्निग्धं पिच्छिलं बहुलं तथा।
कफातिसारिणो विट् च शीतं स्याद् रोमहार्षणम्॥ (Madhava Nidana, Atisara Nidana shloka 7)

Kaphaja Atisara is described in Madhava Nidana as a condition with passage of whitish, thick, heavy, oily, slimy stools often with mucus. The stools may be of a cold quality, and the patient may have horripilation. These manifestations are conventionally ascribed to the aggravation of Kapha Dosha representing its nature of heaviness, unctuousness and sliminess.

Symptoms Of Tridosaja Atisara

वराहस्नेहमांसाम्बुसदृशं सर्वरूपिणम् ।
कृच्छ्रसाध्यमतीसारं विद्याद्दोषत्रयोद्भवम् ॥ ८ ॥ (Madhava Nidana Atisara Nidana shloka 8)

Sannipataja Atisara arises due to the simultaneous vitiation of all three doshas -Vata,
Pitta, and Kapha. In this condition, the stool is described as resembling the fat, flesh, and watery substance of a wild boar, indicating its unusual consistency and appearance. It may present with varied clinical features and is considered difficult to treat (Kṛcchrasadhya).

Symptoms Of Amaja Atisara

अन्नाजीर्णात्प्रद्रुताः क्षोभयन्तः कोष्ठं दोषा धातुसङ्घान्मलांश्च ।
नानावर्णं नैकशः सारयन्ति शूलोपेतं षष्ठमेनं वदन्ति ॥ ११ ॥ (Madhava Nidana, Atisara Nidana, Shlokas 11–12)

Amaja Atisara is a condition that develops when improperly digested food disturbs the normal functioning of the doshas and affects the gastrointestinal tract. This leads to repeated evacuation of stools that may vary in colour and is accompanied by abdominal pain. Ama is sticky, has a foul odour, and tends to settle at the bottom when mixed with water.

Ama And Pakva Atisara

संसृष्टमेभिर्दोषैस्तु न्यस्तमप्स्ववसीदति ।
पुरीषं भृशदुर्गन्धि पिच्छिलं चामसंज्ञितम् ॥ १२ ॥
एतान्येव तु लिङ्गानि विपरीतानि यस्य वै ।
लाघवं च विशेषेण तस्य पक्वं विनिर्दिशेत् ॥ १३ ॥ (Madhava Nidana, Atisara Nidana, Shlokas 12-13)

When food remains undigested, the doshas become disturbed and affect the gastrointestinal tract, tissues and waste products. Consequently, stools of different colours are passed repeatedly, accompanied by abdominal pain. The stool is typically heavy, sinks when placed in water, has a foul smell and is slimy due to the presence of Ama.
When the features of Ama described in the preceding verse become reversed, and the patient particularly experiences a feeling of lightness in the body or abdomen, the condition is identified as Pakva Atisara. This indicates that the previously undigested material has undergone further digestion or processing.

Asadhyata (Incurability) Of Atisara

पक्वं जाम्बवसङ्काशं यकृत्पिण्डनिभं तनु ।
घृततैलवसामज्जावेसवारपयोदधि ॥ १४ ॥
मांसधावनतोयाभं कृष्णं नीलारुणप्रभम् ।
मेचकं कर्बुरं स्निग्धं चन्द्रकोपगतं घनम् ॥ १५ ॥
कुणपं मातुलुङ्गाभं दुर्गन्धं कुथितं बहु ।
तृष्णादाहारुचिश्वासहिक्कापा-र्श्वास्थिशूलिनम् ॥ १६ ॥
संमूर्च्छारतिसंमोहयुक्तं पक्ववलीगुदम् ।
प्रलापयुक्तं च भिषग् वर्जयेदातिसारिणम् ॥ १७ ॥
असंवृतगुदं क्षीणं दुराध्मानमुपद्रुतम् ।
गुदे पक्के गतोष्माणमतिसारिणमुत्सृजेत् ॥ १८ ॥
शोथं शूलं ज्वरं तृष्णां श्वासकासमरोचकम् ।
छर्दिं मूर्च्छां च हिक्कां च दृष्ट्वाऽतीसारिणं त्यजेत् ॥ १९ ॥
श्वासशूलपिपासार्त्तं क्षीणं ज्वरनिपीडितम् ।
विशेषेण नरं वृद्धमतिसारो विनाशयेत् ॥ २० ॥ (Madhava Nidana, Atisara Nidana, Shlokas 14-20)

According to Madhava Nidana, certain clinical features of Atisara indicate a severe condition and an unfavourable prognosis. These include stools with unusual colours, consistency or a strong foul odour, along with symptoms such as excessive thirst, burning sensation, loss of appetite, breathlessness, hiccups and pain in the abdominal or costal regions. The presence of fainting, confusion, restlessness, delirium and severe changes affecting the anal region further suggests a critical state. Marked emaciation, abdominal distension, loss of normal body warmth and the development of multiple complications are also described as signs of poor prognosis. The risk is considered particularly grave in elderly individuals who are debilitated and suffer from fever, pain, intense thirst and respiratory distress. These features are discussed as indicators of Asādhyatā (poor prognosis) in Madhava Nidana, Atisara Nidana, Chapter 3, verses 14–20.

Raktatisara

पित्तकृन्ति यदात्यर्थं द्रव्याण्यश्नाति पैत्तिके ।
तदोपजायतेऽभीक्ष्णं रक्तातिसार उल्बणः ॥ २१ ॥ (Madhava Nidana, Atisara Nidana, Shloka 21)

Raktatisara can be caused when someone who has Pittaja Atisara, continues to take foods and substances which increase Pitta excessively. Madhava Nidana says that: This further aggravates the already existing disease condition and leads to involvement of Rakta (blood) causing frequent episodes of diarrhea with blood. The shloka emphasizes the role of improper dietary habits in aggravating Pitta and contributing to the development of Raktatisara.

Pravahika

वायुः प्रवृद्धो निचितं बलासं नुदत्यधस्तादहिताशनस्य ।
प्रवाहतोऽल्पं बहुशो मलाक्तं प्रवाहिकां तां प्रवदन्ति तज्ज्ञाः ॥ (Madhava Nidana, Atisara Nidana, Shloka 22)

When a person eats wrong food, Vata gets aggravated and pushes the accumulated Kapha downwards. Thus, there is repeated straining at stool, often with passage of stool mixed with mucus, sometimes in small amounts. This condition is called Pravahika.

Types Of Pravahika

प्रवाहिका वातकृता सशूला पित्तात् सदाहा सकफा कफाच्च ।
सशोणिता शोणितसम्भवा च ताः स्नेहरूक्षप्रभवा मतास्तु ।
तासामतीसारवदादिशेच्च लिङ्गं क्रमं चामविपक्वताम् ॥ (Madhava Nidana, Atisara Nidana, Shloka 23)

The text describes different kinds of Pravahika depending on the predominant dosha or the involvement of blood. Vata dominant pravahika is associated with pain, Pitta dominant disease is associated with burning sensation. The Kapha involvement has to do with mucus and the Rakta-associated form has blood. It also correlates the condition to the effect of unctuous and dry factors, and recommends the symptoms and stages of Ama and Pakva to be assessed similarly as Atisara.

Atisara Mukti Lakshana

यस्योच्चारं विना मूत्रं सम्यग्वायुश्च गच्छति ।
दीप्ताग्नेर्लघु कोष्ठस्य स्थितस्तस्योदरामयः॥ (Madhava Nidana, Atisara Nidana, Shloka 24)

The shloka clearly states that the signs that signify the end of Atisara are the normal discharge of urine and flatus without the discharge of faeces at the same time. Digestive strength is restored, accompanied by a feeling of lightness in the abdomen.
All of these points seem to show that the bowel movements are slowly coming back to normalcy and the diarrhea is coming to an end. This means that normal evacuation of urine and flatus, digestive power and abdominal lightness are some of the major symptoms of Atisara cessation.

Conclusion

The description of Atisara Nidana in Madhava Nidana provides a systematic understanding of diarrhoeal disorders through the principles of Ayurveda. It explains the role of impaired digestion, vitiation of doshas, and the formation of Ama in the manifestation and progression of Atisara. The text elaborates on its different varieties, characteristic clinical features, associated complications, prognostic indicators, and signs of recovery.The text emphasises the evaluation of stool patterns, digestive function, and the patient’s general health to determine the progression and severity of Atisara. Furthermore, the differentiation between Ama and Pakva stages and the recognition of positive and negative prognostic indicators provide a structured Ayurvedic framework for understanding and assessing this condition.Thus, Madhava Nidana remains an important literary source for studying the Ayurvedic understanding of Atisara, its clinical presentation, and its prognosis.