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Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 102-110

Novel Insights into the Concepts of Masurika in Madhava Nidana

Department of Kaya Chikitsa, R. B. Ayurvedic Medical College and Hospital, Agra, Uttar Pradesh, India

Date of Submission16-Nov-2022
Date of Decision10-Dec-2022
Date of Acceptance13-Dec-2022
Date of Web Publication16-May-2023

Correspondence Address:
Dr. Kshama Gupta
Department of Kaya Chikitsa, R. B. Ayurvedic Medical College and Hospital, Agra, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jihs.jihs_15_22

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Madhava Nidana is an authentic and popular Ayurvedic text written by Madhavakara (700–800 AD). Masurika has been well correlated with smallpox, and Madhavakara was the first author to give an independent disease status along with a detailed description of Masurika in Masurika Nidana chapter of the Madhava Nidana. Published literature on Masurika is scarce, and the present review is focused on exploring the contents of Masurika Nidana chapter of Madhava Nidana and its similarity with smallpox. Concepts of nutritional immunology with special reference to the complex interactions between diet, immune status and susceptibility to viral infections can be found in the Masurika Nidana chapter. Krura Grahekshanat Deshe denotes epidemics or pandemics caused by pox viruses. There is a profound similarity between the description of Masurika and smallpox among various domains such as clinical features, types, morphological characteristics of skin lesions, prognosis, and complications. Bhramareneva Viddhani Kurvanti Astheeni (i.e., osteomyelitis variolosa) may denote the findings of postmortem examination or autopsy findings of smallpox patients done by Madhavakara. Although smallpox has been eradicated, the present study findings may provide important information regarding the diagnostic possibilities and management guidelines of other pox virus diseases or other viral epidemics that are associated with skin eruptions.

Keywords: Ayurveda, chickenpox, Masurika, osteomyelitis variolosa, smallpox, viral epidemics

How to cite this article:
Gupta K, Mamidi P. Novel Insights into the Concepts of Masurika in Madhava Nidana. J Integr Health Sci 2022;10:102-10

How to cite this URL:
Gupta K, Mamidi P. Novel Insights into the Concepts of Masurika in Madhava Nidana. J Integr Health Sci [serial online] 2022 [cited 2023 Jun 9];10:102-10. Available from: https://www.jihs.in/text.asp?2022/10/2/102/377145

  Introduction Top

Madhava Nidana or Rogavinishchaya or Rugvinishchaya is an authentic and popular Ayurvedic text written by Madhavakara (700–800 AD). It is the earliest compendium having a detailed description of the diseases based on Nidana Panchakam, i.e., Nidana (etiology), Purva Rupa (premonitory signs and symptoms), Rupa/Lakshana (symptomatology), Upashaya and Anupashaya (aggravating and alleviating factors), and Samprapti (pathogenesis). Madhava Nidana is considered the best in the field of Ayurveda, and it was translated into various regional languages of India and also into the Arabic language. Madhukosha written by Vijayarakhhita and Srikanthadatta and Atanka Darpana written by Vidya Vachaspati are the most popular commentaries on Madhava Nidana. The subject matter is explained in 73 chapters. Unique sequencing of the diseases (or chapters), giving an independent status to some diseases, and description of new diseases are some of the contributions by Madhavakara in Madhava Nidana.[1]

Ancient Indian Sanskrit texts such as Charaka Samhita and Sushruta Samhita refer to a disease called Masurika (having skin lesions that resemble like the size and shape of a lentil, Masura-Lens culinaris), followed by an elaborate description of the disease in Madhava Nidana.[2] Madhavakara has provided a detailed description of Masurika with special reference to its etiology, pathogenesis, symptomatology, types, and prognosis in the 54th chapter (Masurika Nidana) of Madhava Nidana.[3],[4] Masurika has been correlated with various contemporary diseases such as smallpox or variola,[5],[6] chicken pox,[7],[8] and eruptive xanthoma[9] by previous works. Smallpox has been a dreaded epidemic in India for long, and it was associated with a high mortality. In Sanskrit texts, smallpox, as Masurika, is found dating back to over 2000 years. According to Irfan Habib, the disease Masurika appeared in medical literature probably as early as the 7th century. Bhavaprakasha, compiled in the early 16th century by Bhava Mishra, has a full section on Masurika (smallpox) and its treatment. The smallpox goddess Shitala emerged in medical texts from about the beginning of the 16th century.[5] Madhava Nidana is the earliest Ayurvedic text that has provided an independent disease status to Masurika and also its detailed description.[3],[4]

Based on the description provided by Madhavakara in Madhava Nidana, Masurika can be considered smallpox, as it shares the characteristics of being a pandemic, highly contagious viral infection spreading through the respiratory route, similarity in symptomatology and complications, etc.[6] According to the best of the researchers knowledge, there is no prior study exists on Masurika, especially with the intention to explore various concepts such as the rationality of its etiopathogenesis, similarity with smallpox in symptomatology, complications, etc., The present review is focused on exploring the contents of Masurika Nidana chapter of Madhava Nidana and its similarity with smallpox and chicken pox. The present review may provide new insights and may become a torchbearer for future works on Masurika. The present exploratory review of Masurika Nidana chapter may open the doorways for a better understanding and management of epidemic and pandemic viral infections with skin eruptions in Ayurveda.

  Review Methodology Top

Masurika Nidana chapter of Madhava Nidana along with its commentaries Madhukosha (by Vijayarakhhita and Srikanthadatta) and Atanka Darpana (by Vidya Vachaspati), have been referred. Bhava Prakasha text also has been referred. Ayurvedic and relevant contemporary literature has been retrieved from searches of computerized databases such as PubMed, Google Scholar, and AYUSH Portal by using appropriate keywords. Relevant abstracts and open access, full-text articles that are published in the English language were included irrespective of their date of appearance online. Articles of both either contradicting or supportive findings to the present work have been included. Obtained literature has been compiled, critically analyzed, and presented as a narrative review.

  Observations and Discussion Top

References to human viruses in ancient Indian literature could be seen in Rigveda, Charaka Samhita, and other Ayurvedic texts, Puranas, travel accounts of visitors to India, and some British records. The description of Shipada in Rigveda is similar to that of smallpox. Shipa means skin, and Shipada refers to a skin disease (smallpox?) that is believed to occur due to the malevolence of the female demon Simida. Smallpox is known as Sheetala, Visphota, Devi, or Mata. Chickenpox has a specific name Masurika, i.e., pustules resembling lentil grain (Masura). Romantika is a disease that is similar to that measles.[8] In India, the disease smallpox was known as Masurika, meaning lentil in Sanskrit, because the pus-filled pox boils showed a great resemblance in color, shape, and size to Masura (a local variety of lentils). Madhava Nidana, an Ayurvedic text written by Madhavakara, has a separate chapter, “Masurika Nidana” (54th chapter), devoted completely to Masurika which had, evolved into a deadly epidemic by the early 8th century that decimated large scale populations on the Indian subcontinent.[10] The present review explores the contents of Masurika Nidana chapter of Madhava Nidana in the following sections with special reference to its resemblance to smallpox along with its clinical implications.

Etiopathogenesis of Masurika

Excessive and/or regular consumption of food items such as spicy (Katu), sour (Amla), salty (Lavana), alkaline or caustic (Kshara), incompatible diet (Viruddha), high meal frequency/day (Adhyashana), spoilt or contaminated food (Dushta); excessive consumption of common beans or legumes (Nishpava) and green leafy vegetables (Shaaka); contaminated or polluted (Pradushta) air (Pawana) and water (Udaka) and particular cities or states or countries (Deshe) afflicted by maleovelent spirits (Krura Grahekshnat) causes vitiation of bodily humors (Doshas) and blood (Dushta Rakta) that ultimately leads to the manifestation of skin eruptions (Pidaka) similar to that of lentils (Masura) in size, shape, and color (Akriti and Samsthana).[3],[4]

Katu, Amla, Lavana and Kshara Pradhana Ahara

Nutritional immunology focuses on the effects of nutrients on the immune system.[11] An individual's overall nutrition status, the pattern of food intake, and state of nourishment might impact the functioning of the immune system.[12] Katu, Amla, Lavana, and Kshara predominant diet denotes a low-fat and low-calorie diet that is deficient in essential amino acids, fatty acids, and micronutirents. Fat-soluble Vitamins (A, D, E, and K) are absorbed together with dietary fats[13] as Katu, Amla, Lavana, and Kshara predominant diet is a no-fat diet, it may hamper the functioning of the immune system and may increase the susceptibility to infections (Masurika?). Adequate and appropriate nutrition is required for the optimal functioning of the immune system. Undernutrition is a known factor that impairs immune function, and the extent of impairment will depend on the severity of the deficiency. Nutrients may alter the immune function via exerting their effects by changing the gut microbiome.[14] High salt diet (Lavana Ahara) damages the walls of the stomach and increases the expression of cytokines and pro-inflammatory enzymes in gastric mucosa with Helicobacter pylori infection, resulting in inflammation and atrophy. Excessive intake of salty foods (Lavana), spicy foods (Katu), fried foods, along with irregular meal times (Adhyashana?), are known to cause or augment inflammatory changes[15] and may disturb immune functioning by altering the gut microbiome. Katu, Amla, Lavana, Kshara, and Viruddha Ahara come under the category of Rajasika Ahara (food that promotes passion), and they cause disturbance of Agni (digestive fire that maintains metabolic rate, digestion and metabolism), Ojus (immunity), and ultimately leads to the manifestation of various diseases.[16] Undernutrition or malnutrition denotes insufficient intake of energy and nutrients (Katu, Amla, Lavana, and Kshara predominant diet?) to meet an individual's needs to maintain good health. Poor water and sanitation (Pradushta Udaka) are associated with increased frequency of water and sanitation-related morbidity.[17] Nutrition having the potential to effectively treat immune deficiencies related to poor intake and specific nutritional interventions can improve immune function and also prevent infections.[14]

Dushta, Viruddha, and Adhyashana

Viruddha Ahara or incompatible foods may have a bad impact on the immune system and their regular consumption leads to immunosenescence and inflammation at the molecular level.[18] A significant increase in disease risk has been identified with a high meal frequency (≥6 meals/day) (Adhyashana) as compared to a low meal frequency (1–2 meals/day). Diet composition influences gut microbiota. There is a multifaceted relationship between microbiota and food timing. Along with diet composition, meal timings (Adhyashana) also exerts negative effects on the microbiota. Consuming food outside the normal feeding phase (Adhyashana) may disturb normal peripheral and central clocks, and this desynchronization of internal clocks leads to the modification of microbiota that is associated with increased risks of metabolic and cardiovascular diseases. Maintaining a correct eating phase (diurnal for humans) (avoiding Adhyashana) could positively affect the gut microbiome, reducing gut permeability and improving systemic inflammation.[19] Many factors influence gut microbiota composition, such as unhealthy dietary habits, food contamination (Dushta Ahara), gastrointestinal disorders, and infective events. In intestinal dysbiosis, potentially pathogenic microbes (from Dushta Ahara?) take over at the expense of potentially beneficial microbes and leads to a loss of overall microbial diversity as well as a parallel overgrowth of the pathogenic microbiota (from Dushta Ahara?)[20] and will alter the immune functioning.

Nishpava and anti-nutritional factors

Nutritionally, beans (Nishpava) represent a rich and inexpensive source of amino acids, protein, carbohydrates, vitamins, dietary fiber, flavonoids, etc., At the same time, beans also contain antinutrients such as tannins, lectins, phytic acid, and oligosaccharides.[21] Anti-nutritional factors such as tannins, saponins, phytate, polyphenolic compounds, and protease inhibitors interfere with the nutritional value of foods by reducing mineral absorption, and protein digestibility and causing toxicity and health disorders. Anti-nutritional factors reduce the availability or absorption of minerals and lead to the deficiency of nutrients or malnutrition.[22] Excessive dietary fiber (Nishpava and Shaaka) intake can lead to flatulence, diarrhea, and intestinal obstruction in people who do not consume sufficient fluids. A long-term excess of natural dietary fiber (Nishpava and Shaaka) can disrupt the absorption of macro and micronutrients.[23]

Krura Grahekshana and Dushta Rakta

The word Graha may denote a microbe or a virus.[6] The word Krura may denote virulence or infectivity or pathogenicity. The word Ekshana means “looking at” but in the present context, Ekshana could be considered as affliction/implantation of the virus at the portal of entry/contact/adhesion/invasion. The word Deshe indicates population/community/region; in the present context, it represents either an epidemic or pandemic that spreads rapidly, affecting a large number of people. Krura Grahekshanat Deshe could be understood as viral epidemic or pandemic caused by the variola virus (an epidemic of smallpox). Although the usual meaning of Dushta Rakta is vitiation of blood, in the present context (Masurika Nidana), it could be interpreted as viremia. Dushta Rakta is an essential and independent etiological factor in the manifestation of Masurika along with the other dietary factors as explained in Masurika Nidana.[3],[4]

Pradushta Pawana and Udaka

Pradushta Pawana and Udaka denote contaminated air and water, but in the present context, it could be interpreted as viral airborne infectious diseases spreading via droplets (Variola major). True airborne infectious diseases (such as measles and chickenpox) are characterized by long-range aerosol transmission via small droplets (Pradushta Pawana) that specifically have the potential to travel long distances. Smallpox (Variola major) is transmitted via the airborne route (droplet spread) (Pradushta Pawana?). Aerosols are a suspension of solid or liquid particles in a gas, and infectious aerosols contain pathogens (Pradushta Pawana). Replication of some microbes also occurs in water systems, and human infection can occur via infected water aerosols (Pradushta Udaka?), such as fountains and showerheads. Aerosol transmission can be influenced by ventilation factors in outbreaks involving smallpox (Masurika).[24] Concepts of nutritional immunology can be seen in Masurika Nidana. Katu, Amla, Lavana, Kshara predominant diet, Viruddha and Adhyashana and excessive consumption of Nishpava may act as predisposing factors (by causing malnutrition or micronutrient deficiency and making an individual susceptible to viral infection); Pradushta Pawana and Udaka and Krura Grahekshana could be considered as precipitating factors of Masurika. By considering all these facts, it can be stated that there is a profound similarity between the description of Masurika Nidana and the pathogenesis of smallpox and/or chickenpox.

Prodromal phase of Masurika

Jwara (fever), Kandu (itching), Gaatra Bhanga (body pains), Arati (restlessness), Bhrama (giddiness), Twak Shotha (skin inflammation), Vaivarnya (discoloration), and Netra Raaga (conjunctivitis) are the prodromal features of Masurika according to Madhava Nidana.[3],[4] Clinical manifestations of smallpox begin with nonspecific febrile prodrome (Jwara), including high fever (Jwara), chills, abdominal pain, vomiting, headache, and backache (Gaatra Bhanga). The febrile prodrome (Jwara) occurs 1–3 days before the onset of skin lesions (Twak Shotha, Kandu and Vaivarnya). Twak Shotha, Kandu, and Vaivarnya denote the initial onset of rash and the stage of macules that later converted into papules, vesicles, pustules, and crusts.[25] In a few cases of smallpox, painful pustules on the bulbar conjunctiva along with tremendous inflammatory reaction (Netra Raaga) and purulent discharge often extending to the cornea causing inflammation (Netra Raaga), scarring, and perforation with loss of the eye could be seen.[26] The signs and symptoms of Masurika Purva Rupa (prodromal features) documented by Madhavakara in the Masurika Nidana chapter are similar to the prodromal features of smallpox.

Types and clinical features of Masurika

Based on the Doshic predominance Masurika is classified into five types (Vataja, Pittaja, Raktaja, Kaphaja, and Sannipataja) and based on the tissue involved, Masurika is again classified into seven types (Rasagata, Raktagata, Mamsagata, Medogata, Asthigata, Majjagata, and Shukragata). Clinical features of skin lesions, such as their uniformity in surface, distribution, symmetry, structure, content, color, size, shape, texture, etc., varies widely among various types of Masurika [Table 1].[3],[4] A clinical classification is essential to estimate the prognosis and also for the proper planning of treatment. Nine types of smallpox have been explained based on various clinical characteristics [Table 2].[27]
Table 1: Morphological features of the eruptive skin lesions in Masurika

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Table 2: Nine types of smallpox and their characteristic features[27]

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Vataja Masurika

Constitutional symptoms such as Sandhi Bhedha (joint pains), Asthi Bhedha (bone pain), Kasa (cough), Kampa (tremors), Arati (restlessness), Bhrama (vertigo), Taalu Sosha (dry palate), Jihwa Oshtha Sosha (dry tongue and lips), Trishna (excessive thirst), and Aruchi (loss of appetite) are seen in Vataja Masurika.[3],[4] Asthi Sandhi Bhedha, Kasa, Aruchi, Bhrama, and Trishna denote arthralgia, cough seen in upper respiratory tract infection or pneumonia, anorexia due to sepsis or respiratory tract infection, hypotension or reduced cerebral blood flow and dehydration that indicates the need for fluid resuscitation or severe dehydration, respectively.[28] The word Arati may also denote delirium.[29] Vataja Masurika represents toxemia or hypovolemia or hemodynamic instability or sepsis, and septic shock.

Pittaja and Raktaja Masurika

Vidbhedha (diarrhea), Angamarda (body aches), Daha (burning sensation), Trishna, Aruchi, Mukha Paka (sore mouth), Akshi Raaga (conjunctivitis or keratitits) and high fever are the characteristic features of Pittaja and Raktaja Masurika. Rakta, Peeta, and Asita Varna skin lesion of Masurika indicate bleeding into the vesicles (Rakta), those later changes into pustules (Peeta) and scabs (Asita) [Table 1]. It seems that Pittaja and Raktaja types of Masurika represent acute suppurative inflammation predominant smallpox.

Kaphaja Masurika

Praseka (dribbling of saliva), Staimitya (sluggishness), Shiroruk (headache), Gaatra Gauravam (heaviness in the body), Hrullasa (nausea), Aruchi, Nidra (sleepiness), Tandra (fatigue), and Aalasya (feeling lazy) are the clinical features of Kaphaja Masurika.[3],[4]

Skin lesions having Shweta Varna denote pearly appearance of papules or vesicles of smallpox.[27] Kaphaja Masurika seems to be similar to that of benign or discrete or mild varieties of smallpox [Table 3].
Table 3: Similarity between different types of Masurika and smallpox

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Sannipataja Masurika

Constitutional symptoms of Sannipataja Masurika are Kantha Rodha (feeling of obstruction in the throat), Aruchi, Stambha (spastic paralysis), Pralapa (irrelevant speech or delirium), and Arati. Sannipataja Masurika is known for its poor prognosis. Kantha Rodha occurs due to the laryngeal lesions of smallpox or due to tonsillitis; Stambha denotes spasticity that develops due to encephalomyelitis, one of the central nervous system (CNS) complications of smallpox.[27] Pralapa and Arati denote acute psychosis or delirium.[29] Neela skin lesions denote rapidly enlarging ecchymoses having a bluish-purple color especially seen in fulminating type of smallpox. Chipita type of skin lesions are flattened vesicles or papules that are commonly found in fulminating type of smallpox. The word Visteerna denotes a confluent skin lesion in which the individual lesions touch one another, coalesce and forms a network of lesions having small islands of unaffected skin. Madhye Nimna denotes umbilicated skin lesions that are having depression in the middle. Puti Srava denotes excessive suppuration.[27] Neela, Chipita, Visteerna, Madhye Nimna and Puti Srava types of skin lesions are commonly seen in fulminating or malignant confluent type of smallpox and they are associated with high mortality [Table 2] and [Table 3].

Rasagata and Raktagata Masurika

Rasagata Masurika is characterized by water bubble-like skin lesions (Toya Budbuda Samkaasha) that are mild in intensity or not associated with hyperemia (Swalpa Dosha) and contain clear fluid or serum (Bhinne Toya Sravanti). Reddish skin lesions (Lohitakara) associated with suppurative inflammation (Sheeghra Paaka), covered with a thin layer of epithelium (Tanu Tvacha) and contains blood (Bhinna Raktam Sravanti) are seen in Raktagata Masurika.[3],[4] Rasagata Masurkia denotes the vesicular stage of smallpox, whereas Raktagata Masurika denotes hemorrhages into the vesicles or petechial hemorrhages or purpura variolosa [Table 1] and [Table 3].

Mamsagata and Medogata Masurika

Mamsagata Masurika is characterized by hard (Kathina) and velvety (Snigdha) papules devoid of inflammation (Chira Paaka) and covered with thick skin/epithelium (Ghana Tvacha). Constitutional features such as Gaatra Shula (body pains), Trishna, Kandu, Jwara and Arati can also be seen in Mamsagata Masurika. This condition represents papules of smallpox or benign/discrete/mild types of smallpox [Table 1] and [Table 3]. Medogata Masurika is characterized by confluent or semi-confluent (Mandalakara), flattened (Kinchit Unnata), and soft (Mrudu) skin lesions associated with constitutional features such as Jwara, Arati, and Sammoha (disturbance of consciousness) [Table 1] and [Table 3].[3],[4] Medogata Masurika represents benign and malignant confluent types of smallpox, and they are associated with high mortality.[27]

Asthigata and Majjagata Masurika

Both Asthigata and Majjagata Masurika Lakshanas (signs and symptoms) are explained together in the Masurika Nidana chapter of Madhava Nidana. Asthigata and Majjagata Masurika are characterized by skin lesions that are small (Kshudra), flat (Chipita), and skin-colored (Gaatrasama) associated with constitutional features such as Sammoha, Arati, Chindanti Marmadhaamaani (multi-organ dysfunction due to complications of smallpox), Bhramareneva Viddhani Kurvanti Astheeni (make holes in bones, i.e., osteomyelitis variolosa), and Pranani Aashu Haranti (that immediately kills, i.e., having high mortality).[3],[4] Complications such as respiratory (broncho-pneumonia), alimentary (variola dysenterica), eye (blindness), CNS (encephalomyelitis and acute psychosis), joints (suppurative arthritis), and others may lead to death in smallpox patients.[27] Asthigata and Majjagata Masurika denote fulminating or malignant confluent types of smallpox associated with high mortality and also various life-threatening complications of smallpox.

Shukragata Masurika

Pakwaabha Pidaka (ripened skin lesions, i.e., pustules or suppuration), Snigdha, Sukshma type of skin lesions associated with constitutional symptoms such as Staimitya, Arati, Sammoha, Daha (burning sensation), Unmada (acute toxic psychosis or delirium), and Na Jeevitam (death) are the clinical features of Shukragata Masurika.[3],[4] The description of Shukragata Masurika denotes life-threatening complications of smallpox, such as toxemia, septicemia, hemodynamic shock, delirium, acute psychosis, and encephalitis associated with high mortality.[27] Postinfectious encephalomyelitis is a severe demyelinating condition of the brain and spinal cord that occurs as a complication 1–2 weeks after any of the common exanthemata (measles, varicella, rubella), influenza or mumps, or other infections.[30] The word Unmada mentioned in Shukragata Masurika denotes acute toxic psychoses or anxiety or apprehensive mental states or personality changes or delusions or abnormal behavior, etc., CNS complications seen in some of the smallpox patients. Features of mental sequelae of smallpox encephalitis can be seen in Shukragata Masurika.[27]

Prognosis of Masurika

Rasagata, Raktagata, Pittaja, Kaphaja, Kaphapittaja types of Masurika are easily treatable; Vataja, Vatapittaja, Kaphavataja types of Masurika are difficult to treat; Sannipataja Masurika is fatal. It seems that the association of Vata increases the mortality rate. Pravala Sadrusha (looks like a coral reef), Jambu Phalopama (resembling the fruits of Jambu-Syzygium cumini L.), Loha Jaala Sama (looks like iron mesh), and Atasi Phala Sannibha (resembling the fruits of Atasi-Linum usitatissimum) Masurika's are untreatable.[3],[4] Pravala Sadrusha denotes red- or copper-colored skin lesions having a wide variety of clinical presentations, such as scalded appearance or severe sunburn-like appearance or copper-colored scars or a diffuse erythematous base of a lobster-red color or toxemic erythematous rashes or petechial/purpuric rashes or hypertrophic red scars etc., seen in smallpox patients. Jambu Phalopama denotes blue- or purple-colored skin lesions such as ecchymoses of a peculiar bluish-purple color that occurs due to hemorrhage under the mucous membranes in fulminating type of smallpox or bluish-white dead sodden epithelium that appears like a scald and seen in the malignant confluent type of smallpox. Loha Jaala Sama indicates the appearance of skin lesions like a mesh or a net seen in confluent or semi-confluent (individual lesions coalesce and form a network of lesions with small islands of unaffected skin that looks like a mesh) skin lesions of smallpox. Skin lesions that resemble with Atasi Phala (brown colored) can be seen in the malignant confluent type of smallpox.[27] Sannipataja Masurika is characterized by a wide variety of colored skin lesions (Bahuvidha Varna) such as red, brown, black, blue, and purple due to the specific doshic predominance (Dosha Bhedhata).[3],[4]

Complications of Masurika

Kasa (cough), Hikka (hiccup), Pramoha (confusion), Jwara, Pralapa, Arati, Murcha (loss of consciousness), Trishna, Daha, Ati Ghoornata (agitation), Mukhena Prasravet Raktam (hematemesis), Ghranena Prasravet Raktam (epistaxis), Chakshusha Prasaravet Raktam (bleeding in eye-hyphema or subconjunctival/retinal/vitreous/intraocular hemorrhages), Kanthe Ghurghurukam (stridor), Shwasati Atyardha Vedanam (painful respiration), Bhrusham Ghranena Nishwaset (nasal breathing or unable to do mouth breathing), Kurpara Shotha (effusion of elbow joint), Shotha Manibandhake (effusion of wrist joint), and Amsaphalaka Shotha (effusion of shoulder joint) are considered as complications of Masurika [Table 4].[3],[4] Tracheitis, laryngitis, bronchitis, laryngeal edema and obstruction, broncho-pneumonia, empyema, risk of tonsillitis, and secondary infections of the throat are the respiratory complications of smallpox, and they may cause clinical features such as Kasa, Hikka, and Jwara Kanthe Ghurghurukam denotes stridor (high-pitched, abnormal sounds while breathing in and occurs due to blockage in the throat) that may occur due to laryngeal lesions or edema or obstruction in smallpox. Shwasati Atyardha Vedanam denotes painful respiration may be due to pleurisy in smallpox patients. Death may be extremely rapid in smallpox, or there may be extensive hemorrhages (Prasravet Raktam) in the skin and other organs. Hemorrhages may occur in the alimentary canal or into the mouth (hematemesis), eyes (subconjunctival hemorrhages), mucous membranes and also in the respiratory tract (epistaxis) in fulminating and malignant types of smallpox. Prasravet Raktam Mukhena, Ghranena, and Chakshusha denote the hemorrhagic type of smallpox associated with high mortality. Arati, Pralapa, Pramoha, Murcha, and Ati Ghoornata denote restlessness, irrelevant speech, acute confusion or loss of orientation, loss of consciousness, and agitation, respectively, and they are seen in delirium or shock (complications of fulminating or malignant types of smallpox). Bhrusham Ghranena Nishwaset denotes only nasal breathing and unable to perform mouth breathing may be due to obstruction in the mouth due to smallpox lesions or secondary infections.[27]
Table 4: Similarity between the complications of Masurika and smallpox

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Kurpara, Manibandhaka and Amsaphalaka Shotha

Either serous or purulent effusion (Shotha) into the wrists (Manibandhake) and elbow joints (Kurpara) is common in variola major that may cause permanent disability (Upadrava). Elbows (Kurpara) were usually involved first and the affected joints were moderately swollen (Shotha) and not tender. Limitation of movement is the major disability and an interval of often days to 4 weeks (Masurika Ante) occurs before the complication appears (Sudaaruna). Suppurative arthritis (Shotha) and osteomyelitis (Bhramareneva Viddhani Kurvanti Astheeni) as part of a general pyemia undoubtedly do occur. This type of condition is most likely to arise after (Masurika Ante) benign confluent or semi-confluent cases, where there is malnutrition and neglect.[27] Kurpara, Manibandhaka and Amsaphalaka Shotha explained as complications of Masurika denote suppurative arthritis or osteomyelitis of smallpox.

The malignant variant of smallpox, also known as flatpox (Chipita and Visteerna), is characterized by harsh prodromic symptoms (Purva Rupa) with sustained hyperpyrexia (Jwara Teevra and Sudaaruna). Hemorrhagic smallpox is characterized by acute thrombocytopenia compounded by depleted coagulation factors, bleeding (Prasravet Raktam Mukhena, Ghranena and Chakshusha), and hypotension. Liver and concomitant bone marrow failure (Chindanti Marmadhaamaani) augments the hemodynamic instability synergistically. Either variant of smallpox is almost universally fatal (Pranani Aashu Haranti) and associated with predominantly grim outcomes. Smallpox survivors often have debilitating scarring from healed lesions, ocular complications, respiratory failure, pneumonia, cyanosis, sepsis, and hemodynamic shock.[31] There is a similarity between the types of Masurika and smallpox among various domains such as clinical features, types, morphological features of skin lesions, prognosis, and complications [Table 1], [Table 2], [Table 3], [Table 4]. Madhavakara might have performed postmortem examination or autopsy studies on smallpox patients, without which it is not possible to give the statement like Bhramareneva Viddhani Kurvanti Astheeni (i.e., osteomyelitis variolosa). Although smallpox has been eradicated, the present study findings, especially the characteristic morphology of the eruptive lesions such as the size, color, shape and contents described in Masurika Nidana chapter, provide important information regarding the diagnostic possibilities and management guidelines of other pox virus diseases.

Romantika (Measles)

Romantika is caused by aggravated Pitta and Kapha, characterized by the appearance of small eruptions (Roma Kuponnati Sama, i.e., at hair follicles or resembling hair follicles) all over the body and associated with Jwara, Kasa, and Arochaka (anorexia). A brief description of Romantika as an independent disease has been documented in the Masurika Nidana chapter of Madhava Nidana.[3],[4] Romantika is correlated with Measles.[8]

Treatment of Masurika

Masurika treatment is not explained in Madhava Nidana, whereas in Bhava Prakasha (written by Bhava Mishra) management protocol of Masurika has been documented.[32] Masurika should be treated as per the treatment protocol of Kushta (a broad umbrella term for various skin diseases) and Kaphaja and Pittaja Visarpa (Herpes zoster or cellulitis or erysipelas). External application of herbal pastes or ointments mentioned in Kushta and Visarpa needs to be adopted for the management of Masurika also. Various herbal decoctions (Nimbadi Kwatha etc.), dusting powders, eye washes (Aschyotana), pouring of decoctions on skin lesions (Parisheka), gargling with decoctions (Gandusha), and internal medicines are advocated in the management of Masurika. Bloodletting (Rakta Mokshana) needs to be done in Raktaja Masurika.[32]

  Conclusion Top

Madhavakara was the first author to give an independent disease status along with a detailed description of Masurika in the Masurika Nidana chapter of Madhava Nidana. Masurika has been well correlated with smallpox by previous works, and the present study findings support the same. Concepts of nutritional immunology with special reference to the complex interactions between diet, immune status, and susceptibility to viral infections can be found in Masurika Nidana. Krura Grahekshanat Deshe denotes epidemics or pandemics caused by pox viruses. There is a profound similarity between the description of Masurika and smallpox among various domains such as clinical features, types, morphological characteristics of skin lesions, prognosis, and complications. The novel insights provided by the present exploratory study are helpful for a better understanding of other viral epidemics that are associated with skin eruptions.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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