The 5th chapter of Nidanasthana of Sushruta Samhita is named as Kustha Nidanam Adhyaya. This chapter deals with Skin Diseases.

अथातः कुष्ठनिदानं व्याख्यास्यामः ।।१ ।।
यथोवाच भगवान् धन्वन्तरिः ।।२ ।।

We will now expound Kustha Nidāna – diagnosis of Leprosy (and some other diseases of the skin); as revealed by the venerable Dhañvañtari .

Nidāna – Samprāpti: Causes and Pathogenesis

मिथ्याहाराचारस्य विशेषाद्गुरुविरुद्धासात्म्याजीर्णाहिताशिनः स्नेहपीतस्य वान्तस्य वा व्यायामग्राम्यधर्मसेविनो ग्राम्यानूपौदकमांसानि वा पयसाऽभीक्ष्णमश्नतो यो वा मज्जत्यप्सूष्माभितप्तः सहसा छर्दिं वा प्रतिहन्ति, तस्य पित्तश्लेष्माणौ प्रकुपितौ परिगृह्यानिलः प्रवृद्धस्तिर्यग्गाः सिराः सम्प्रपद्य समुद्धूय बाह्यं मार्गं प्रति समन्ताद्विक्षिपति, यत्र यत्र च दोषो विक्षिप्तो निश्चरति तत्र तत्र मण्डलानि प्रादुर्भवन्ति, एवं समुत्पन्नस्त्वचि दोषस्तत्र तत्र च परिवृद्धिं प्राप्याप्रतिक्रियमाणोऽभ्यन्तरं प्रतिपद्यते धातूनभिदूषयन् ||३||

Causative factors of Kustha – Below mentioned are the causative factors of kustha –

• indulgence in unhealthy / improper foods and activities, especially foods which are heavy (hard for digestion), incompatible, unaccustomed, uncooked and unhealthy;
• persons who have consumed fats for oleation therapy,
• persons who have vomited just then,
• persons who indulge more in physical activities and copulation,
• persons who consume meat of animals of domestic and of marshy regions along with milk constantly,
• he who immerses himself in water immediately after getting fatigued by exposure to heat, or
• he who suppresses the bouts of vomiting suddenly

Pathogenesis of Kustha –
Pitta and kapha become aggravated by the above mentioned causative factors. Later, vata gets associated with pitta and kapha and becomes aggravated. These doshas move through the veins (blood vessels) spreading side-wards. Vata conveys pitta and kapha to the exterior i.e. towards the skin, all over the body.

In whichever area (region) of the body these (doshas) get deposited, mandalas (patches) develop on the skin. The regions wherein these patches are formed on the skin, the doshas become increased (and exhibit their symptoms). If not treated (effectively in this stage), the doshas get deep inside, and vitiate the dhatus (tissues).

Purvarūpa: Premonitory symptoms

तस्य पूर्वरूपाणि – त्वक्पारुष्यमकस्माद्रोमहर्षः कण्डूः स्वेदबाहुल्यमस्वेदनं वाऽङ्ग प्रदेशानां स्वापः क्षतविसर्पणमसृजः कृष्णता चेति ।।४ ।।
Its premonitory symptoms are –

• roughness of the skin,
• horripilation without any cause,
• itching,
• either profuse perspiration or absence of perspiration,
• loss of sensation in the skin / certain areas of the body,
• spreading of wound to other areas and
• black coloration of the blood

Kustha bheda: Kinds of kustha

तत्र सप्त महाकुष्ठानि, एकादश क्षुद्रकुष्ठानि, एवमष्टादश कुष्ठानि भवन्ति |
तत्र महाकुष्ठान्यरुणोदुम्बरर्ष्य(र्क्ष)जिह्वकपालकाकणकपुण्डरीकदद्रुकुष्ठानीति |
क्षुद्रकुष्ठान्यपि स्थूलारुष्कं महाकुष्ठमेककुष्ठं चर्मदलं विसर्पः परिसर्पः सिध्मं विचर्चिका किटिभं (मं) पामा रकसा चेति ||५||

Mahā kustha are seven in number. Kshudra Kustha are eleven in number. Altogether, the Kusthas are eighteen types.
Mahakusthas are –

• Aruna,
• Udumbara,
• Rsyajihva,
• Kapāla,
• Kākanaka,
• Pundarika and
• Dadru
  Ksudrakusthas are –
• Sthularuska,
• Mahākustha,
• Ekakustha,
• Carmadala,
• Visarpa,
• Parisarpa,
• Sidhma,
• Vicarcikā,
• Kitibha,
• Pāmā and
• Rakasā

Dosha involvement in all Kusthas

सर्वाणि कुष्ठानि सवातानि सपित्तानि सश्लेष्माणि सक्रिमीणि च भवन्ति , उत्सन्न तस्तु दोषग्रहणमभिभवात् ।।६ ।।
Vata, pitta, kapha and krimi are involved in all types of kustha. They should be recognized at the time of their predominance in kustha.

Mahā kustha

Dosha involvement

तत्र वातेनारुणं , पित्तेनोदुम्बरय॑जिह्वकपालकाकणकानि , श्लेष्मणा पुण्डरीकं दद्रुकुष्ठं चेति । तेषां महत्त्वं क्रियागुरुत्वमुत्तरोत्तरं धात्वनुप्रवेशादसाध्यत्वं चेति ।।७ ।।
Aruņa Kustha is born from Vata. Therefore, Vata and its symptoms are predominant in Aruna type of Kustha.
Below mentioned types of Kustha are born from Pitta and hence pitta is predominant in these kusthas –

• Udumbara,
• Rsyajihva,
• Kapāla and
• Kākaņaka

The Kusthas born from Kapha are Pundarika and Dadru. Kapha is therefore predominant in these two types of Kustha.
Due to the entry (invasion) of these kusthas into the tissues their deep-rootedness, capability to afflict (and produce great changes) and incurability will successively increase (with invasion of every tissue).

Laksanas: Signs and symptoms

तत्र, वातेनारुणाभानि तनूनि विसर्पीणि तोदभेदस्वापयुक्तान्यरुणानि |
पित्तेन पक्वोदुम्बरफलाकृतिवर्णान्यौदुम्बराणि, ऋष्य(क्ष)जिह्वाप्रकाशानि खराणि ऋष्य(क्ष)जिह्वानि, कृष्णकपालिकाप्रकाशानि कपालकुष्ठानि, काकणन्तिकाफलसदृशान्यतीव रक्तकृष्णानि काकणकानि ; तेषां चतुर्णामप्योषचोषपरिदाहधूमायनानि क्षिप्रोत्थानप्रपाकभेदित्वानि क्रिमिजन्म च सामान्यानि लिङ्गानि |
श्लेष्मणा पुण्डरीकपत्रप्रकाशानि पौण्डरीकाणि, अतसीपुष्पवर्णानि ताम्राणि वा विसर्पीणि पिडकावन्ति च दद्रुकुष्ठानि; तयोर्द्वयोरप्युत्सन्नता परिमण्डलता कण्डूश्चिरोत्थानत्वं चेति सामान्यानि रूपाणि ||८||

1. Aruna kustha –
   Causative Dosha – Vata
   Patches are

• light red in color
• thin
• spreading
• associated with pricking and cutting pains
• associated with loss of sensation

1. Audumbara kustha –
   Causative Dosha – Pitta
   Shape and Color – similar to the ripe fruit of Udumbara
2. Rsyajihva kustha –
   Causative Dosha – Pitta
   Patches – resemble the tongue of Rsya – type of deer in appearance, are rough / course.
3. Kapala kustha –
   Causative Dosha – Pitta
   Patches – resemble pieces of Kapala – black mud pot.
4. Kakanantika kustha –
   Causative Dosha – Pitta
   Patches – resemble the fruit of Kakanantika (Gunja – Abrus precatorius).
   Color – bright red and black.

Below mentioned are the symptoms of the above said four types of Kusthas caused by predominant aggravation of pitta (from Audumbara Kustha to Kakanantika Kustha),

• localized burning sensation,
• sucking pain
• burning sensation all over the body,
• feeling as if hot fumes are coming out (of the lesions)
• quick in onset
• quick in ripening,
• quick in progress,
• quick in appearance of krimi – worms

1. Pundarika kustha –
   Causative Dosha – Kapha
   Patches – resemble petals of Pundarika (lotus flower)
2. Dadru kustha —
   Patches – resemble flowers of Atasi in color. They are coppery or purple in color. The lesions / patches spread out and would have eruptions.

General features of Pundarika and Dadru Kustha –

• shape of patches – elevated and circular
• itching
• slow onset of symptoms

Ksudra Kustha

क्षुद्रकुष्ठान्यत ऊर्ध्वं वक्ष्यामः
स्थूलानि सन्धिष्वतिदारुणानि स्थूलारुषि स्युः कठिनान्यरूंषि ।।
त्वक्कोचभेदस्वपनाङ्गसादाः कुष्ठे महत्पूर्वयुते भवन्ति ।।९ ।।
कृष्णारुणं येन भवेच्छरीरं तदेककुष्ठं प्रवदन्ति कुष्ठम् ।।
स्युर्येन कण्डूव्यथनौषचोषास्तलेषु तच्चर्मदलं वदन्ति ।।१० ।।
विसर्पवत् सर्पति सर्वतो यस्त्वग्रक्तमांसान्यभिभूय शीघ्रम् ।।
मूर्छाविदाहारतितोदपाकान् कृत्वा विसर्पः स भवेद्विकारः ।।११ ।।
शनैः शरीरे पिडकाः स्रवन्त्यः सर्पन्ति यास्तं परिसर्पमाहुः ।।
कण्ड्वन्वितं श्वेतमपायि सिध्य विद्यात्तनु प्रायश ऊर्ध्वकाये ।१२ ।।
राज्योऽतिकण्ड्वर्तिरुजः सरूक्षा भवन्ति गात्रेषु विचर्चिकायाम् ।।
कण्डूमती दाहरुजोपपन्ना विपादिका पादगतेयमेव ।।१३ ।।
यत् स्रावि वृत्तं घनमुग्रकण्डु तत् स्निग्धकृष्णं किटिभं वदन्ति ।।
सास्त्रावकण्डूपरिदाहकाभिः पामाऽणुकाभिः पिडकाभिरूह्या ।।१४ ।।
स्फोटैः xÉSÉWæûUÌiÉ सैव कच्छू : स्फिक्रपाणिपादप्रभवनिरूप्या ।।
कण्ड्वन्विता या पिडका शरीरे संस्रावहीना रकसोच्यते सा ।।१५ ।।
Now we will describe Ksudra Kusthas – Minor leprosy

Sthülāruși

• Site of manifestation – near or on the big joints
• Ulcers – are formed, which are thick, immovable and dreadful

Mahat kuştha

• Skin manifestations – constriction and splitting of skin, loss of sensation of the skin
• Weakness of the body

Eka kuştha

• The body becomes blackish red in color in this condition

1. Carmadala kuştha—
   Below mentioned symptoms can be found in the palms and soles –

• Itching
• Pain
• Burning sensation
• Sucking pain

Visarpa kuştha
Nature and similarity with Visarpa – this conditions spreads all over the body just like Visarpa does (herpes, erysipelas). It spreads by invading the skin, blood and muscles very quickly. It is accompanied with the below mentioned symptoms –

• Fainting
• Burning sensation within the body
• Restlessness
• Pricking pain
• Production of ulcers

Parīsarpa kustha
Eruptions having the below mentioned properties appear all over the body slowly,

• Have exudations / discharges
• Spreading in nature

Sidhma kustha
This condition presents with patches of skin with below mentioned features –

• Itching
• White in color
• Thin
• Usually seen in upper parts of the body
• Not troublesome

Vicarcikā kuştha
In this type of Kustha, lines or furrows appear all over the body which presents with –

Vipadika Kustha
In this, lines or furrows are formed in the feet only, which presents with –

• Itching
• Burning sensation
• Pain

Kitibha kustha
In this type of Kshudra Kustha – the skin patch has –

• Exudation
• Round
• Thick
• Has severe itching
• Unctuous
• Black in color

Pāmā kustha
This type of Kustha manifests as eruptions which has the below mentioned symptoms all over –

• Exudation
• Itching
• Burning sensation

Kachchu is a variant of Pama. Kachchu is a condition presenting with vesicles (blebs) which have burning sensation. They appear on the buttock, hands and feet.

Rakasa kustha
This condition presents with eruptions all over the body. There is itching but no exudation.

Dosha involvement in Ksudra Kustha

अरु : ससिध्यं रकसा महच्च यच्चैककुष्ठं कफजान्यमूनि ।।
वायोः प्रकोपात् परिसर्पमेकं शेषाणि पित्तप्रभवाणि विद्यात् ।।१६ ।।

Among the Kshudra Kusthas,
Below mentioned are Kapha Predominant Kusthas –

• Sthūlāru,
• Sidhma,
• Rakasa,
• Mahat Kustha and
• Eka
  Below mentioned are Vata Predominant Kusthas –
• Parisarpa
  The Kusthas other than those mentioned in Kapha and Vata predominant Kshudra Kusthas are the Pitta predominant Kusthas.

According to Acharya Dalhana, Visarpa has quick spreading nature while Visarpa Kustha spreads slowly. This is the difference between these two conditions.

Kilasa: Leucoderma

किलासमपि कुष्ठविकल्प एव ; तत्रिविधं – वातेन , पित्तेन , श्लेष्मणा चेति । कुष्ठ किलासयोरन्तरं – त्वग्गतमेव किलासमपरिस्रावि च । तद्वातेन मण्डलमरुणं परुषं परिध्वंसि च , पित्तेन पद्मपत्रप्रतीकाशं सपरिदाहं च , श्लेष्मणा श्वेतं स्निग्धं बहलं कण्डूमच्च । तेषु संबद्ध मण्डलमन्तेजातं रक्तरोमचासाध्यमग्निदग्धं च ।।१७ ।।
Kilasa (leukoderma, vitiligo) is also a type of Kustha. It is of three kinds. They are produced by Vata, Pitta and Kapha separately.
Kilasa is confined only to the skin and does not have exudations. This is the difference of Kilasa from Kustha.

Symptoms of Kilasa produced by Vata –
The patches are –

• Light red in color
• Rough
• Destroys the skin
  Symptoms of Kilasa produced by Pitta –
  The patches –
• Resembles lotus petals in color i.e. light red in color
• Associated with burning sensation
  Symptoms of Kilasa produced by Kapha –
  The patches –
• Are white in color
• Unctuous
• Thick and
• Are associated with itching
  Kilasa having the below mentioned features are incurable –
• The patches are fused together,
• The patches are localized at the ends of the body i.e. hands, feet, lips and genital organs,
• Has red colored hairs
• Caused by fire burns

Doșa lakṣana in Kustha

कुष्ठेषु तु त्वक्संकोचस्वापस्वेदशोफभेदकौण्यस्वरोपघाता वातेन , पाकावदरणाङ्गुलिप तनकर्णनासाभङ्गाक्षिरागसत्त्वोत्पत्तय : पित्तेन , कण्डूवर्णभेदशोफास्रावगौरवाणि श्लेष्मणा ।।१८ ।।
Symptoms due to Vata – In Kuştha, the below mentioned symptoms are due to vata –

• constriction of the skin,
• loss of sensation,
• sweating,
• swelling,
• splitting (cracking),
• distortion of the arms (loss of fingers) and
• disorders (hoarseness of loss) of voice
  Symptoms due to Pitta – In Kustha, the below mentioned symptoms are due to pitta –
• ripening (ulceration and suppuration),
• cracking,
• loss of fingers and toes,
• distortion of the ears and nose,
• red color of the eyes and appearance of worms (bacteria etc)
  Symptoms due to Kapha – In Kustha, the below mentioned symptoms are due to kapha –
• itching,
• change of color,
• swelling,
• exudation and
• feeling of heaviness

Sādhyāsādhyata: Prognosis

तत्रादिबलप्रवृत्तं पौण्डरीकं काकणं चासाध्यम् ।।१९ ।।
Pundarika and kakana types of Kustha are incurable. They are Adibala Pravritta conditions i.e. they are caused by defect of shukra and sonita and are congenital.

Anology of spread manifestation and spread of kustha

भवन्ति चात्र
यथा वनस्पतिर्जातः प्राप्य कालप्रकर्षणम् ।।
अन्तर्भूमिं विगाहेत मूलैर्वृष्टिविवधितैः ।।२० ।।
एवं कुष्ठं समुत्पन्नं त्वचि कालप्रकर्षतः ।।
क्रमेण धातून व्याप्नोति नरस्याप्रतिकारिणः ।।२१ ।।
Some verses here
When a seed is put in the ground and is nourished by water, its roots come out and it (plant) comes out from the ground in due course of time i.e. at proper time, to become a tree.
Similarly, Kustha too firstly arises in the skin. Later, in due course of time, it invades the other tissues also, especially so, in persons in whom it has not been treated properly and in proper time.

Dhātugata kuștha lakṣaṇa: Symptoms in tissues

स्पर्शहानिः स्वेदनत्वमीषत्कण्डूश्च जायते ।।
वैवयं रूक्षभावश्च कुष्ठे त्वचि समाश्रिते ।।२२ ।।
त्वक्स्वापो रोमहर्षश्च स्वेदस्याभिप्रवर्तनम्||
कण्डूर्विपूयकश्चैव कुष्ठे शोणितसंश्रिते ।।२३ ।।
बाहुल्यं वक्त्रशोषश्च कार्कश्यं पिडकोद्गमः ।।
तोदः स्फोटः स्थिरत्वं च कुष्ठे मांससमाश्रिते ।।२४ ।। be
दौर्गन्ध्यमुपदेहश्च पूयोऽथ क्रिमयस्तथा ।।
गात्राणां भेदनं चापि कुष्ठे मेदःसमाश्रिते ।।२५ ।।
नासाभङ्गोऽक्षिरागश्च क्षते च क्रिमिसंभवः ।।
भवेत् स्वरोपघातश्च ह्यस्थिमज्जसमाश्रिते ।।२६ ।।
कौण्यं गतिक्षयोऽङ्गानां संभेदः क्षतसर्पणम् ।।
शुक्रस्थानगते लिङ्गं प्रागुक्तानि तथैव च ।।२७ ।।
स्त्रीपुंसयो : कुष्ठदोषाढुष्टशोणितशुक्रयोः ।।
यदपत्यं तयोर्जातं ज्ञेयं तदपि कुष्ठितम् ।।२८ ।।
Twakgata Kustha – Below mentioned are the symptoms of kustha invading the skin (rasa dhatu) –

• loss of sensation of touch,
• sweating,
• slight itching,
• discoloration and
• dryness

Raktagata Kustha – The symptoms of kustha invading the blood are –

• loss of sensation,
• horripitations,
• sweating,
• itching,
• formation of pus (bad smell)

Mamsagata Kustha – The symptoms of kustha invading the muscle tissue are –

• thickness of the skin,
• dryness of the mouth,
• roughness of the skin,
• appearance of eruptions,
• pricking and bursting pain and
• stability

Medogata Kustha – The symptoms of kustha invading the fat tissue are –

• bad smell and
• coating of body in excess / formation of wastes in excess
• pus formation,
• appearance of worms (bacteria etc),
• mutilation of body parts

Asthi-Majjagata Kustha – The symptoms of kustha invading the bone and bone marrow tissue are –

• distortion (loss) of the nose,
• red color of the eyes,
• development of worms in the wounds,
• disorders (loss) of voice

Sukragata Kustha – The symptoms of kustha invading the semen tissue are –

• distortion of the arm,
• inability to walk,
• splitting of the body parts,
• spreading of the wounds and
• symptoms described so far

When the doshas producing kustha are present in the sperm and ovum (of parents), the children born to such parents would also suffer from Kustha.

Prognosis of Kustha

कुष्ठमात्मवतः साध्यं त्वग्रक्तपिशिताश्रितम् ।।
मेदोगतं भवेद्याप्यमसाध्यमत उत्तरम् ।।२९ ।।
Kuştha has a favorable prognosis and is curable in

• persons who are self-controlled
• when it is seated in skin, blood and muscle tissues
  Kustha persists for long time without getting cured when it invades and gets seated in fat tissue. It is manageable but cannot be entirely cured.
  On the other hand, when the kustha invades and gets seated in the succeeding tissues i.e. bones, bone marrow and semen, it becomes incurable.

Other causes of Kustha

ब्रह्मस्त्रीसज्जनवधपरस्वहरणादिभिः ।।
कर्मभिः पापरोगस्य प्राहुः कुष्ठस्य संभवम् ।।३० ।।
Below mentioned are the causes of kustha born of sin –

• killing Brahmana, women and pious persons
• robbing other’s wealth
• acts of sin

Reasons for Kustha being the most troublesome disease

म्रियते यदि कुष्ठेन पुनर्जातेऽपि गच्छति ।।
नातः कष्टतरो रोगो यथा कुष्ठं प्रकीर्तितम् ।।३१ ।।
आहाराचारयोः प्रोक्तामास्थाय महतीं क्रियाम् ।।
औषधीनां विशिष्टानां तपसश्च निषेवणात् ।।
यस्तेन मुच्यते जन्तुः स पुण्यां गतिमाप्नुयात् ।।३२ ।।
If the person dies of kustha and is reborn, kustha still follows him and troubles him in the next life too. Therefore it is said that no other disease is as troublesome as Kustha. Only the person who strictly adheres to the advocated foods and activities, puts great efforts to undergo treatments and use of special medicinens and also resorts to penances, would attain a blissful life.

Roga sankramana: Spreading of diseases

प्रसङ्गाद्गात्रसंस्पर्शान्निश्वासात् सहभोजनात् ।।
सहशय्यासनाच्चापि वस्त्रमाल्यानुलेपनात् ।।३३ ।।
कुष्ठं ज्वरश्च शोषश्च नेत्राभिष्यन्द एव च ।।
औपसर्गिकरोगाश्च संक्रामन्ति नरान्नरम् ।।३४ ।।
Diseases like kustha (skin diseases, leprosy), jvara (fever), sosa (consumption), netrabhisyanda (conjunctivitis) and aupasargika rogas (contagious diseases) spread from one person to the other due to the below mentioned causes –

• touching the body of the patient frequently
• inhaling the air expired by the patient
• dining in the same place with the patient or sharing the plates, food and utensils
• sleeping with the patient
• sitting together with the patient
• wearing the dress, garlands and unguents used by the patient

इति श्रीसुश्रुतसंहितायां निदानस्थाने कुष्ठनिदानं नाम पञ्चमोऽध्यायः ।।५ ।।

Thus ends the Fifth chapter by name Kustha nidanam – in Nidānā sthāna of Suśruta saṁhita.