Chapter 5. Chapter on Kushtha Nidana (Diagnosis of Skin Disorders)

Chapter 5. Chapter on Kushtha Nidana (Diagnosis of Skin Disorders)

अथातः कुष्ठनिदानं व्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||

athātaḥ kuṣṭhanidānaṁ vyākhyāsyāmaḥ||1||
iti ha smāha bhagavānātrēyaḥ||2||

Now I shall expound the chapter on diagnosis of kushtha (dermatosis). As propounded by Lord Atreya.[1-2]

KUSHTA DRAVYAS - Morbid factors that are involved in kushta

सप्त द्रव्याणि कुष्ठानां प्रकृतिर्विकृतिमापन्नानि भवन्ति| 

sapta dravyāṇi kuṣṭhānāṁ prakr̥tirvikr̥timāpannāni [1] bhavanti|

The pathology of skin diseases / kushta origin from the deranged physiology of seven factors / sapta dravyas connected to skin. 

तद्यथा- त्रयो दोषा वातपित्तश्लेष्माणः प्रकोपणविकृताः, 

 tadyathā- trayō dōṣā vātapittaślēṣmāṇaḥ prakōpaṇavikr̥tāḥ,

- They are vata, pitta and kapha doshas in aggravated state and 

1. vata

2. pitta

3. kapha

 दूष्याश्च शरीरधातवस्त्वङ्मांसशोणितलसीकाश्चतुर्धा दोषोपघातविकृता इति| 

 dūṣyāścaśarīradhātavastvaṅmāṁsaśōṇitalasīkāścaturdhā [2] dōṣōpaghātavikr̥tā iti| 

- dhatus, namely, tvak (the word tvak represents skin. 

Since the skin is organ in which rasa dhatu is present, tvak word is used instead of rasa dhatu ), 

mamsa, shonita and lasika that get deranged due to aggravated dosha. 

4. tvak

5. mamsa

6. shonitha

7. lasika

 एतत् सप्तानां सप्तधातुकमेवङ्गतमाजननं कुष्ठानाम्, अतःप्रभवाण्यभिनिर्वर्तमानानि केवलं शरीरमुपतपन्ति||३||

ētat saptānāṁ saptadhātukamēvaṅgatamājananaṁ kuṣṭhānām, ataḥprabhavāṇyabhinirvartamānānikēvalaṁ śarīramupatapanti||3||

- So seven type of kushtha are manifested by these seven morbid factors. 

Thus preliminary and manifested kushtha gradually afflicts the whole body. [3]

Innumerable classification of kushtas

न च किञ्चिदस्ति कुष्ठमेकदोषप्रकोपनिमित्तम्, अस्ति तु खलु समानप्रकृतीनामपि कुष्ठानां दोषांशांशविकल्पानुबन्धस्थानविभागेन वेदनावर्णसंस्थानप्रभावनामचिकित्सितविशेषः| 

na ca kiñcidasti kuṣṭhamēkadōṣaprakōpanimittam, asti tu khalu samānaprakr̥tīnāmapi kuṣṭhānāṁdōṣāṁśāṁśavikalpānubandhasthānavibhāgēna vēdanāvarṇasaṁsthānaprabhāvanāmacikitsitaviśēṣaḥ| 

Variation in single dosha cannot cause kushtha. 

Even in kushtha with similar presentations, the clinical features in terms of 

• sensation in skin / vedana, 

• colour / varna, 

• samsthana / site of skin lesion, 

• names / nama

• other symptoms, and 

• chikitsa / treatment 

स सप्तविधोऽष्टादशविधोऽपरिसङ्ख्येयविधो वा भवति| 

sa saptavidhō'ṣṭādaśavidhō'parisaṅkhyēyavidhō vā bhavati|

- may vary depending on the variation in vitiation of (qualities of) dosha. 

Therefore there are 

1. seven सप्तविधो or 

2. eighteen अष्टादशविधो or 

3. innumerable अपरिसङ्ख्ये types of kushtha. 

दोषा हि विकल्पनैर्विकल्प्यमाना विकल्पयन्ति विकारान्, अन्यत्रासाध्यभावात्| 

dōṣā hi vikalpanairvikalpyamānā vikalpayanti vikārān, anyatrāsādhyabhāvāt| 

The variations in qualities of vitiated dosha lead to further differentiation in types of diseases, except in incurable conditions. 

तेषां विकल्पविकारसङ्ख्यानेऽतिप्रसङ्गमभिसमीक्ष्य सप्तविधमेव कुष्ठविशेषमुपदेक्ष्यामः||४||

 tēṣāṁ vikalpavikārasaṅkhyānē'tiprasaṅgamabhisamīkṣya saptavidhamēvakuṣṭhaviśēṣamupadēkṣyāmaḥ||4||

- As there might be innumerable types of kushtha leading to expansion of text, only seven types of kushtha are described here. [4]

इह वातादिषु त्रिषु प्रकुपितेषु त्वगादींश्चतुरः प्रदूषयत्सु 

वातेऽधिकतरे कपालकुष्ठमभिनिर्वर्तते, 

पित्ते त्वौदुम्बरं, 

श्लेष्मणि मण्डलकुष्ठं, 

वातपित्तयोरृष्यजिह्वं, 

पित्तश्लेष्मणोः पुण्डरीकं, 

श्लेष्ममारुतयोःसिध्मकुष्ठं, 

सर्वदोषाभिवृद्धौ काकणकमभिनिर्वर्तते; 

iha vātādiṣu triṣu prakupitēṣu tvagādīṁścaturaḥ pradūṣayatsu vātē'dhikatarēkapālakuṣṭhamabhinirvartatē, 

pittē tvaudumbaraṁ, 

ślēṣmaṇi maṇḍalakuṣṭhaṁ, 

vātapittayōṟuṣyajihvaṁ,

pittaślēṣmaṇōḥ puṇḍarīkaṁ, 

ślēṣmamārutayōḥ sidhmakuṣṭhaṁ, 

sarvadōṣābhivr̥ddhaukākaṇakamabhinirvartatē; 

When vata and other doshas are aggravated and affect four vitiated dhatus such as twak, mamsa, shonita and lasika and 

1. there is dominance of vata dosha, then the disease is known as kapala kushtha. 

2.  Pitta - Udumbara

3.  Kapha - Mandala

4. Vata-pitta - Rushyajihva

5. Pitta-kapha - Pundarika

6. Kapha-vata - Sidhma

7. all doshas - Kakanaka

एवमेष सप्तविधः कुष्ठविशेषो भवति| स चैष भूयस्तरतमतः प्रकृतौ विकल्प्यमानायां भूयसीं विकारविकल्पसङ्ख्यामापद्यते||५||

ēvamēṣa saptavidhaḥ kuṣṭhaviśēṣō bhavati| sa [1] caiṣa bhūyastaratamataḥ prakr̥tau vikalpyamānāyāṁ bhūyasīṁ vikāravikalpasaṅkhyāmāpadyatē||5||

Thus, there are seven types of specific kushtha, 

however depending on degree of TARA / superior and tama / inferior involvement of etiology, permutation and combinations kushtha may be innumerable. [5]

 

Kushta Nidana / Common etiological factors of kushtha

तत्रेदं सर्वकुष्ठनिदानं समासेनोपदेक्ष्यामः- शीतोष्णव्यत्यासमनानुपूर्व्योपसेवमानस्य तथा सन्तर्पणापतर्पणाभ्यवहार्यव्यत्यासं, मधुफाणितमत्स्यलकुचमूलककाकमाचीः सततमतिमात्रमजीर्णे च समश्नतः,चिलिचिमं च पयसा, हायनकयवकचीनकोद्दालककोरदूषप्रायाणि चान्नानि क्षीरदधितक्रकोलकुलत्थमाषातसीकुसुम्भस्नेहवन्ति, एतैरेवातिमात्रं सुहितस्य च व्यवायव्यायामसन्तापानत्युपसेवमानस्य,भयश्रमसन्तापोपहतस्य च सहसा शीतोदकमवतरतः, विदग्धं चाहारजातमनुल्लिख्य विदाहीन्यभ्यवहरतः, छर्दिं च प्रतिघ्नतः, स्नेहांश्चातिचरतः, त्रयो दोषाः युगपत् प्रकोपमापद्यन्ते; त्वगादयश्चत्वारःशैथिल्यमापद्यन्ते; तेषु शिथिलेषु दोषाः प्रकुपिताः स्थानमधिगम्य सन्तिष्ठमानास्तानेव त्वगादीन् दूषयन्तः कुष्ठान्यभिनिर्वर्तयन्ति||६||

tatrēdaṁ sarvakuṣṭhanidānaṁ samāsēnōpadēkṣyāmaḥ- śītōṣṇavyatyāsamanānupūrvyōpasēvamānasyatathā santarpaṇāpatarpaṇābhyavahāryavyatyāsaṁ, madhuphāṇitamatsyalakucamūlakakākamācīḥsatatamatimātramajīrṇē ca samaśnataḥ, cilicimaṁ ca payasā,hāyanakayavakacīnakōddālakakōradūṣaprāyāṇi cānnānikṣīradadhitakrakōlakulatthamāṣātasīkusumbhasnēhavanti, ētairēvātimātraṁ suhitasya cavyavāyavyāyāmasantāpānatyupasēvamānasya, bhayaśramasantāpōpahatasya ca sahasāśītōdakamavatarataḥ, vidagdhaṁ cāhārajātamanullikhya vidāhīnyabhyavaharataḥ, chardiṁ capratighnataḥ, snēhāṁścāticarataḥ, trayō dōṣāḥ yugapat prakōpamāpadyantē; tvagādayaścatvāraḥśaithilyamāpadyantē; tēṣu śithilēṣu dōṣāḥ prakupitāḥ sthānamadhigamya santiṣṭhamānāstānēva tvagādīndūṣayantaḥ kuṣṭhānyabhinirvartayanti||6||

The common etiological factors for all types of kushtha are briefly described below:

• Continuous exposure to sudden interchange use of cold and hot without following gradual change rule (exposure to sudden change in temperature) / शीतोष्णव्यत्यासमनानुपूर्व्योपसेवमानस्य ,

• Sudden interchange/ alternate consumption of nourishing and depleting diets (change is diet qualities) / सन्तर्पणापतर्पणाभ्यवहार्यव्यत्यासं;

• Continuous and excessive intake of following articles

• Madhu मधु(honey), phanita फाणित (pendium),  मत्स्य matsya (fish), lakucha लकुच(Artocarpus lakooch Roxb), mulaka मूलक(radish) and kakamachi काकमाचीः(Solanum nigrum Linn);

• Continuous over-eating / सततमतिमात्र

• Eating while in state of indigestion

• Eating Chilichima (a type of fish) along with milk  चिलिचिमं च पयसा ;

- Intake of foods mostly consisting of cereals like 

• hayanaka,हायनक  ,

• यवक yavaka(barley), 

• चीनको chinaka, 

• उद्दालक uddalaka, 

• कोरदूष koradusha (Paspalums corbiculatum Linn.) 

- along with 

• क्षीर kshira (milk), 
• दधि dadhi(curd), 
• तक्र takra( butter milk), 
• कोल kola (Indian jujube, zyziphus jujube Lam), 
• कुलत्थ kulattha (Dulicus biflorus Linn), 
• माषाm asha (Black gram,Phaseolus radiates Linn), 
• अतसी atasi(linseed, Linunusit atissimum Linn), 
• कुसुम्भ kusumbha(Carthamustinctorius Linn ) and स्नेहवन्ति unctuous articles 

• Excessive indulgence in sexual intercourse, physical exercise and exposure to heat after consuming the above mentioned food to one’s over-satisfaction.

• A person suffering from fear, exhaustion or grief suddenly enters into the cold water (cold water bath).

• Without vomiting (expelling) out undigested food, if a person consumes food which causes burning sensation(vidahi),

• suppression of vomiting urge,

• indulges in excessive oleation,

Above causative factors lead to simultaneous aggravation of all the tridosha, weakness in the skin etc. four dushyas. Aggravated doshas lodge themselves in these weakened factors and after localization, further vitiate them and manifest kushtha. [6]

Purvarupa / prodromal symptoms
तेषामिमानि पूर्वरूपाणि भवन्ति; तद्यथा- अस्वेदनमतिस्वेदनं पारुष्यमतिश्लक्ष्णता वैवर्ण्यं कण्डूर्निस्तोदः सुप्तता परिदाहः परिहर्षो लोमहर्षः खरत्वमूष्मायणं गौरवं श्वयथुर्वीसर्पागमनमभीक्ष्णं च कायेकायच्छिद्रेषूपदेहः पक्वदग्धदष्टभग्नक्षतोपस्खलितेष्वतिमात्रं वेदना स्वल्पानामपि च व्रणानां दुष्टिरसंरोहणं चेति||७||
tēṣāmimāni pūrvarūpāṇi bhavanti; tadyathā- asvēdanamatisvēdanaṁ pāruṣyamatiślakṣṇatā vaivarṇyaṁkaṇḍūrnistōdaḥ suptatā paridāhaḥ pariharṣō lōmaharṣaḥ kharatvamūṣmāyaṇaṁ gauravaṁśvayathurvīsarpāgamanamabhīkṣṇaṁ ca kāyē kāyacchidrēṣūpadēhaḥpakvadagdhadaṣṭabhagnakṣatōpaskhalitēṣvatimātraṁ vēdanā svalpānāmapi ca vraṇānāṁduṣṭirasaṁrōhaṇaṁ cēti||7||

The clinical manifestations of skin diseases are 

preceded by or associated with loss or excessive sweating (at the site of localization of vitiates doshas), 

• excess rough or excess smooth skin, 

• discoloration, 

• itching, 

• pricking sensation, 

• numbness, 

• severe burning sensation, 

• tingling sensation, 

• goose bumps, 

• xerosis on palpation, 

• hot flashes, 

• heaviness, 

• swelling, 

• if there is tenderness it indicates the possibility of suppurated, burnt, bitten, broken, injured and dislocated parts and 

• even smaller ulcers become chronic, non healing.[7]

Manifestation of Kushta

ततोऽनन्तरं कुष्ठान्यभिनिर्वर्तन्ते, तेषामिदं वेदनावर्णसंस्थानप्रभावनामविशेषविज्ञानं भवति; 

tatō'nantaraṁ kuṣṭhānyabhinirvartantē, tēṣāmidaṁ vēdanāvarṇasaṁsthānaprabhāvanāmaviśēṣavijñānaṁbhavati;

Thereafter (above pathogenesis), kushtha is manifested. 

The specific diagnosis (of types) for nomenclature is based upon 

• vedana / sensation, 

• varna / discoloration, 

• samsthana / site of lesion, 

• prabhava / effect of lesion.

1. Kapala Kushta - vataja

तद्यथा- रूक्षारुणपरुषाणि विषमविसृतानि खरपर्यन्तानि तनून्युद्वृत्तबहिस्तनूनि सुप्तवत्सुप्तानि हृषितलोमाचितानि निस्तोदबहुलान्यल्पकण्डूदाहपूयलसीकान्याशुगतिसमुत्थानान्याशुभेदीनि जन्तुमन्ति कृष्णारुणकपालवर्णानि च कपालकुष्ठानीति विद्यात्(१);
 tadyathā- rūkṣāruṇaparuṣāṇi viṣamavisr̥tāni kharaparyantāni tanūnyudvr̥ttabahistanūni [1]suptavatsuptāni [2] hr̥ṣitalōmācitāninistōdabahulānyalpakaṇḍūdāhapūyalasīkānyāśugatisamutthānānyāśubhēdīni jantumantikr̥ṣṇāruṇakapālavarṇāni ca kapālakuṣṭhānīti vidyāt(1);

Kapala kushtha has the following specific manifestations:

• Ruksha / Dry, 

• Aruna / crimson red in color, 

• Parusha / coarse, 

• vishama visrutha / unevenly spread, 

• khara paryantha / having rough edges, 

• thanu / thin and slightly elevated periphery, 

• severe numbness, 

• covered with bristling hair, 

• afflicted with extreme piercing pain, 

• having mild itching, 

• burning sensation, 

• less serous and pus discharge, 

• having acute manifestation and 

• quick progression, 

• are infested with maggots and 

• appear like a black or blackish red piece of broken earthen pot.(1)

2. audumbara kushta

ताम्राणि ताम्रखररोमराजीभिरवनद्धानिबहलानि बहुबहलपूयरक्तलसीकानि कण्डूक्लेदकोथदाहपाकवन्त्याशुगतिसमुत्थानभेदीनि ससन्तापक्रिमीणि पक्वोदुम्बरफलवर्णान्यौदुम्बरकुष्ठानीति विद्यात् (२); 

tāmrāṇi tāmrakhararōmarājībhiravanaddhānibahalāni bahubahalapūyaraktalasīkāni kaṇḍūklēdakōthadāhapākavantyāśugatisamutthānabhēdīnisasantāpakrimīṇi pakvōdumbaraphalavarṇānyaudumbarakuṣṭhānīti vidyāt(2);

Audumbara kushtha has the following features:

The color of affected part of skin is 

• coppery, covered with coppery / tamra- khara /rough (thick) roma / hair, 

• have plenty of bahu / thick bahala / discharge of puya / pus, rakta / blood and lasika / lymph 

- accompanied with

• kandu / itching, 

• kleda / moistened, 

• kotha / sloughing, 

• burning sensation and 

• suppuration, 

• having acute manifestation and quick progression, 

• associated with rise in temperature and 
• infested with maggots, appear like the ripe fruit of Udumbara (Ficus racemosa Linn) in color.(2)

3. Mandala Kushta

स्निग्धानि गुरूण्युत्सेधवन्तिश्लक्ष्णस्थिरपीतपर्यन्तानि शुक्लरक्तावभासानि शुक्लरोमराजीसन्तानानि बहुबहलशुक्लपिच्छिलस्रावीणि बहुक्लेदकण्डूक्रिमीणि सक्तगतिसमुत्थानभेदीनि परिमण्डलानि मण्डलकुष्ठानिविद्यात्(३);
snigdhānigurūṇyutsēdhavanti ślakṣṇasthirapītaparyantāni [3] śuklaraktāvabhāsāni śuklarōmarājīsantānānibahubahalaśuklapicchilasrāvīṇi [4] bahuklēdakaṇḍūkrimīṇi saktagatisamutthānabhēdīni parimaṇḍalānimaṇḍalakuṣṭhāni vidyāt(3);

Mandala kushtha has following features:
Skin is 

• unctuous, 

• heavy, 

• elevated 

• with smooth, fixed and yellowish margins, 

• white and reddish in appearance, 

• filled with white hairlines associated with 

• copious, thick, white and slimy discharge, 

• excessive oozing and itching, 

• infested with numerous maggots, 

• lesions are slow to spread & progression, 

• round in shape.(3)

4. RISHYAJIHVA KUSHTA

परुषाण्यरुणवर्णानि बहिरन्तःश्यावानि नीलपीतताम्रावभासान्याशुगतिसमुत्थानान्यल्पकण्डूक्लेदक्रिमीणि दाहभेदनिस्तोद(पाक)बहुलानि शूकोपहतोपमवेदनान्युत्सन्नमध्यानि तनुपर्यन्तानिकर्कशपिडकाचितानि दीर्घपरिमण्डलान्यृष्यजिह्वाकृतीनि ऋष्यजिह्वानीति विद्यात् (४);
paruṣāṇyaruṇavarṇāni bahirantaḥśyāvāninīlapītatāmrāvabhāsānyāśugatisamutthānānyalpakaṇḍūklēdakrimīṇi dāhabhēdanistōda(pāka)bahulāniśūkōpahatōpamavēdanānyutsannamadhyāni tanuparyantāni karkaśapiḍakācitānidīrghaparimaṇḍalānyr̥ṣyajihvākr̥tīni r̥ṣyajihvānīti vidyāt (4);

Rishyajihva kushtha has following features:
In this skin is 

• rough, 

• downy red, 

• blackish in the center as well as in the periphery, 

• have the appearance of shades of blue, yellow and coppery tinge 

• associated with acute onset and spreading, 

• with less itching, oozing and maggot infestation, 

• having excessive burning sensation, ulceration, piercing pain (suppuration) as if pierced with bristles, 

• with elevated center and thin margins; 

• surrounded with rough papules and 

• having large circumference and 

• shape like that of the antelope (rishyajihva) tongue. (4);

5. Pundarika Kushta

शुक्लरक्तावभासानि रक्तपर्यन्तानि रक्तराजीसिरासन्ततान्युत्सेधवन्ति बहुबहलरक्तपूयलसीकानिकण्डूक्रिमिदाहपाकवन्त्याशुगतिसमुत्थानभेदीनि पुण्डरीकपलाशसङ्काशानि पुण्डरीकाणीति विद्यात् (५);
śuklaraktāvabhāsāni raktaparyantāniraktarājīsirāsantatānyutsēdhavanti bahubahalaraktapūyalasīkānikaṇḍūkrimidāhapākavantyāśugatisamutthānabhēdīni puṇḍarīkapalāśasaṅkāśāni puṇḍarīkāṇīti vidyāt (5);

Pundarika kushtha has following features: In this type, the skin is 

• white with reddish shade, 

• with red margins covered with red lines and blood vessels, 

• elevated, with copious thick blood, pus and serous discharge, 

• associated with itching, maggots infestation, burning sensation and suppuration, and 

• having acute manifestation and 

• quick progression, 

• appears like the petals of lotus(or Butea monospemum flower). (5);

6. Sidhma kushtha

परुषारुणानि विशीर्णबहिस्तनून्यन्तःस्निग्धानि शुक्लरक्तावभासानिबहून्यल्पवेदनान्यल्पकण्डूदाहपूयलसीकानि लघुसमुत्थानान्यल्पभेदक्रिमीण्यलाबुपुष्पसङ्काशानि सिध्मकुष्ठानीति विद्यात् (६);
paruṣāruṇāni [5] viśīrṇabahistanūnyantaḥsnigdhāni śuklaraktāvabhāsānibahūnyalpavēdanānyalpakaṇḍūdāhapūyalasīkānilaghusamutthānānyalpabhēdakrimīṇyalābupuṣpasaṅkāśāni sidhmakuṣṭhānīti vidyāt (6);

Sidhma kushtha has following features:
In this type, skin is 

• rough and downy red in color, 

• with external margins fissured and 

• thin, unctuous at the center, 

• having white and red shades, 

• numerous lesions, 

• associated with mild pain, itching, burning sensation, purulent and serous discharge, 

• having mild initiation and progression, and 

• less maggots infestation, 

• appear like flower of alabu (Lagenaria siceraria Standi (bottle gourd)) – are to be known as sidhma kushtha(6);

7. Kakanaka Kushta

काकणन्तिकावर्णान्यादौ पश्चात्तु सर्वकुष्ठलिङ्गसमन्वितानि पापीयसा सर्वकुष्ठलिङ्गसम्भवेनानेकवर्णानि काकणानीति विद्यात्| तान्यसाध्यानि, साध्यानि पुनरितराणि||८||
kākaṇantikāvarṇānyādau paścāttu sarvakuṣṭhaliṅgasamanvitāni pāpīyasā [6]sarvakuṣṭhaliṅgasambhavēnānēkavarṇāni kākaṇānīti vidyāt| tānyasādhyāni, sādhyāni punaritarāṇi||8||

Kakanaka kushtha has following features:
In this type, the skin is 

• having color of Gunja (Abrus precatorius) seed in the beginning 

• but later on associated with symptoms of all sinful kushtha subsequently having many colors. 

• This is incurable, 

• while others are curable. [8]

Kushta Sadhya - Asadhyatha / Prognosis of kushta

तत्र यदसाध्यं तदसाध्यतां नातिवर्तते, साध्यं पुनः किञ्चित् साध्यतामतिवर्तते कदाचिदपचारात्| साध्यानि हि षट् काकणकवर्ज्यान्यचिकित्स्यमानान्यपचारतो वा दोषैरभिष्यन्दमानान्यसाध्यतामुपयान्ति||९||
tatra yadasādhyaṁ tadasādhyatāṁ nātivartatē, sādhyaṁ punaḥ kiñcit sādhyatāmativartatēkadācidapacārāt| sādhyāni hi ṣaṭ kākaṇakavarjyānyacikitsyamānānyapacāratō vādōṣairabhiṣyandamānānyasādhyatāmupayānti||9||

 - The incurable / asadhya disease never give up its incurability (never become curable). 

• The curable disease may sometimes become incurable due to misconduct (not following the diet and lifestyle regulations properly). 

The six (types of) kushtha are curable except kakanaka. 

However if not treated properly, they may become incurable due to 

• lack of timely management, 

• improper management and 

• constantly excess aggravation of doshas. [9]

Complications caused by negligence

साध्यानामपि ह्युपेक्ष्यमाणानां त्वङ्मांसशोणितलसीकाकोथक्लेदसंस्वेदजाः क्रिमयोऽभिमूर्च्छन्ति; ते भक्षयन्तस्त्वगादीन् दोषाः पुनर्दूषयन्त इमानुपद्रवान् पृथक् पृथगुत्पादयन्ति- तत्र वातः श्यावारुणवर्णंपरुषतामपि च रौक्ष्यशूलशोषतोदवेपथुहर्षसङ्कोचायासस्तम्भसुप्तिभेदभङ्गान्, पित्तं दाहस्वेदक्लेदकोथस्रावपाकरागान्, श्लेष्मा त्वस्य श्वैत्यशैत्यकण्डूस्थैर्यगौरवोत्सेधोपस्नेहोपलेपान्, क्रिमयस्तु त्वगादींश्चतुरःसिराः स्नायूश्चास्थीन्यपि च तरुणान्याददते ||१०||
sādhyānāmapi hyupēkṣyamāṇānāṁ tvaṅmāṁsaśōṇitalasīkākōthaklēdasaṁsvēdajāḥkrimayō'bhimūrcchanti; tē bhakṣayantastvagādīn dōṣāḥ [1] punardūṣayanta imānupadravān pr̥thakpr̥thagutpādayanti- tatra vātaḥ śyāvāruṇavarṇaṁ paruṣatāmapi caraukṣyaśūlaśōṣatōdavēpathuharṣasaṅkōcāyāsastambhasuptibhēdabhaṅgān, pittaṁdāhasvēdaklēdakōthasrāvapākarāgān, ślēṣmā tvasyaśvaityaśaityakaṇḍūsthairyagauravōtsēdhōpasnēhōpalēpān, krimayastu tvagādīṁścaturaḥ sirāḥsnāyūścāsthīnyapi ca taruṇānyādadatē [2] ||10||

If the curable diseases are neglected (not treated), then they are also afflicted with 

• putrefaction of skin, muscle tissue, blood, lymph and swedaja krimi (maggots or micro-organisms). 

• The krimi get nourishment from the decayed skin etc. and further vitiate doshas leading to variety of complications corresponding to individual doshas as follows:

Due to vata, 

• blackish and downy red discoloration appears, 
• roughness, 
• dryness, 
• piercing pain, 
• emaciation (atrophy), 
• pricking pain, 
• tremors, 
• horripilation, 
• constriction, 
• exhaustion, 
• stiffness, 
• numbness, 
• ulceration and 
• fissures;

Pitta causes 

• burning sensation, 
• sweating, 
• moistening, 
• putrefaction, 
• discharge, 
• suppuration and 
• redness;

Kapha causes 

• whiteness, 
• coldness, 
• itching, 
• immobility, 
• heaviness, 
• protuberance, 
• unctuousness and 
• coating, 
• maggots eat up the skin etc. (skin, flesh, blood, lymph) vessels, ligaments and cartilages. [10]

अस्यां चैवावस्थायामुपद्रवाः कुष्ठिनं स्पृशन्ति; तद्यथा- प्रस्रवणमङ्गभेदः पतनान्यङ्गावयवानां तृष्णाज्वरातीसारदाहदौर्बल्यारोचकाविपाकाश्च, तथाविधमसाध्यं विद्यादिति||११||
asyāṁ caivāvasthāyāmupadravāḥ kuṣṭhinaṁ spr̥śanti; tadyathā- prasravaṇamaṅgabhēdaḥpatanānyaṅgāvayavānāṁ tr̥ṣṇājvarātīsāradāhadaurbalyārōcakāvipākāśca, tathāvidhamasādhyaṁvidyāditi||11||

During this stage, a patient of kushtha afflicts with complications such as- 

• excessive discharge, 

• ulceration of body parts, 

• sequestration of body parts (necrosis of phallenges), 

• thirst, 

• fever, 

• diarrhea, 

• burning sensation, 

• debility, 

• anorexia, 

• indigestion. 

• Such types of kushtha should be known as incurable. [11]

Warning Regarding Treatment
भवन्ति चात्र- साध्योऽयमिति यः पूर्वं नरो रोगमुपेक्षते| स किञ्चित्कालमासाद्य मृत एवावबुध्यते||१२||
यस्तु प्रागेव रोगेभ्यो रोगेषु तरुणेषु वा| भेषजं कुरुते सम्यक् स चिरं सुखमश्नुते||१३||
यथा ह्यल्पेन यत्नेन छिद्यते तरुणस्तरुः| स एवातिप्रवृद्धस्तु छिद्यतेऽतिप्रयत्नतः||१४||
एवमेव विकारोऽपि तरुणः साध्यते सुखम्| विवृद्धः साध्यते कृच्छ्रादसाध्यो वाऽपि जायते||१५||
तत्र श्लोकः- सङ्ख्या द्रव्याणि दोषाश्च हेतवः पूर्वलक्षणम्| रूपाण्युपद्रवाश्चोक्ताः कुष्ठानां कौष्ठिके पृथक्||१६||
bhavanti cātra- sādhyō'yamiti yaḥ pūrvaṁ narō rōgamupēkṣatē| sa kiñcitkālamāsādya mr̥ta ēvāvabudhyatē||12||
yastu prāgēva rōgēbhyō rōgēṣu taruṇēṣu vā| bhēṣajaṁ kurutē samyak sa ciraṁ sukhamaśnutē||13||
yathā hyalpēna yatnēna chidyatē taruṇastaruḥ| sa ēvātipravr̥ddhastu chidyatē'tiprayatnataḥ||14||
ēvamēva vikārō'pi taruṇaḥ sādhyatē sukham| vivr̥ddhaḥ sādhyatē kr̥cchrādasādhyō vā'pi jāyatē||15||
tatra ślōkaḥ- saṅkhyā dravyāṇi dōṣāśca hētavaḥ pūrvalakṣaṇam| rūpāṇyupadravāścōktāḥ kuṣṭhānāṁ kauṣṭhikē pr̥thak||16||

The individual, who neglects the disease in early stage by assuming it as curable,( does not take treatment at early stage) can be regarded as dead after a lapse of time(due to complications). 

• The individual who took treatment properly prior to full manifestation of disease or in its early stage attains happiness for long time. 

• Just as a tender plant is easy to cut down with a little effort, but the same require great effort when fully grown.

 - Likewise, a disease is easily curable in the early stage; it becomes incurable or difficulty to cure as it reaches the advanced stage.[12-15]

इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते निदानस्थाने कुष्ठनिदानं नाम पञ्चमोऽध्यायः||५||
ityagniveshakRutetantrecarakapratisaMskRutenidAnasthAnekuShThanidAnaMnAmapa~jcamo~adhyAyaH||5||
Thus ends the fifth chapter on Kushtha Nidana in Nidana Sthana in the treatise composed by Agnivesha and as redacted by Charaka.