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3. Medium or intermediate (madhya) predominant with [[kapha dosha]] and in [[kapha]] [[prakriti]] individuals. It is also seen in the individuals with equilibrium state of [[dosha]] in [[prakriti.]]
3. Medium or intermediate (madhya) predominant with [[kapha dosha]] and in [[kapha]] [[prakriti]] individuals. It is also seen in the individuals with equilibrium state of [[dosha]] in [[prakriti.]]
==Assessment of koshtha==
The dominant [[dosha]] plays key role in functions of koshtha. The absorption due to dryness (ruksha) property of [[vata dosha]] leads to hard bowel. The slow movement is bowel is due to heaviness (guru), steadiness (sthira), slowness (manda) properties of [[kapha dosha]]. The fast movement in bowel is due to stimulating (sara), sharply acting (tikshna) and fluid (drava) properties of [[pitta dosha]]. The [[dosha]] exert their influence over grahani. Obstruction and stagnation are observed in hard bowels (krura koshtha); whereas the fluidity is the dominating property in soft bowels (mridu koshtha). [Chakrapani commentary on Cha.Sa.[[Sutra Sthana]] 13/65-69]
The consistency of fecal matter is the primary tool for assessment of koshtha. In the context of oleation ([[snehana]]), the fecal consistency is parameter to assess oleation. In subjects who have been properly oleated, the feces are well-formed, evacuated in a smooth, unctuous, unobstructed manner and without stickiness. Whereas in insufficiently oleated subjects, fecal matter is dry and hard (pellet-like). In over-oleated cases, the fecal matter is poorly formed (resulting in sticky feces).[Cha.Sa.[[Sutra Sthana]] 13/57-59]
==Pathways of diseases in koshtha==
Koshtha is one of the disease pathways. It plays vital role in pathogenesis of following diseases: fever ([[jwara]]), diarrhea (atisara), vomiting (chhardi), sluggish bowel (alasaka), acute non-infectious gastroenteritis (visuchika), cough ([[kasa]]), bronchial asthma ([[shwasa]]), hiccups ([[hikka]]), abdominal distension (anaha), ascites ([[udara]]), splenomegaly (pleeha), internal variants of erysipelas ([[visarpa]]), edema ([[shotha]]), abdominal lumps ([[gulma]]), hemorrhoids (arsha), and abscesses (vidradhi). [Cha.Sa.[[Sutra Sthana]] 11/49] Certain diseases are observed more in specific types of koshtha. Udavarta (diseases due to improper or reverse movement of [[vata dosha]]) is a complication of hemorrhoids (arsha). In subjects with [[vata]]-predominant koshtha, the condition may develop without hemorrhoids (arsha). [A.Hr.Nidana Sthana 7/52]<ref name=Hridaya/>
Poor appetite (kshudha-mandya), indigestion (ajirna) and poor digested matter ([[ama]]) are the basic pathological entities related to the koshtha.
The first two stages among six stages of pathogenesis ([[shat-kriya kala]]) i.e. the accumulative stage ([[sanchaya]]) and the provocative stage ([[prakopa]]) are confined to koshtha. The former is characterized by accumulation of [[dosha]] in their sites and the latter by excess aggravation of [[dosha]]. In case of gut, the obstructed bowels leading to pain and abnormal movement of [[vata]], acid reflux, thirst, burning sensation, aversion to food and heartburn can be observed in these stages. The third stage characterized by overflow and migration of [[dosha]]s (prasara) shows signs indicating the involvement of koshtha like abdominal distension, burning sensation, anorexia, indigestion, and vomiting.[Su.Sa.Sutra Sthana 21/18-32]<ref name=Susruta/>
==Factors influencing gut==
Gut is a highly dynamic system characterized by interaction with both intrinsic and extrinsic factors. Among the extrinsic factors, food, regimen, region, and season, and among the internal factors, the physical constitution, age, and psyche are the most crucial ones. All these factors directly or indirectly influence the digestion and metabolism ([[agni]]), both at the gut level and at the tissue level. All these effects culminate at the endpoint called ‘[[ojas]]’ or ‘[[bala]]’ that is the product of the total metabolic activities happening in living body.[Su.Sa.Sutra Sthana 15/19]<ref name=Susruta/> The baseline nature of the gut is decided by the physical constitution of the individual. The grahani of a [[vata]]-dominant individual is also [[vata]]-dominant. Hence the digestive pattern becomes irregular. When the dominance is of [[pitta dosha]], digestive pattern is strong or fast (tikshna). In case of dominance of [[kapha dosha]], the digestive pattern is slow (manda). [Cha.Sa.[[Vimana Sthana]] 6/18] A study conducted to identify the gut microbe diversity among rural population of western India revealed signature microbes that showed [[prakriti]]-specific distribution patterns despite the dominance of firmicutes and Bacteroidetes.<ref>Chauhan NS, Pandey R, Mondal AK, Gupta S, Verma MK, Jain S, et al. Western Indian Rural Gut Microbial Diversity in Extreme Prakriti Endo-Phenotypes Reveals Signature Microbes. Frontiers in Microbiology [Internet]. 2018;9:118. Available from: https://www.frontiersin.org/article/10.3389/fmicb.2018.00118</ref>
==Causes of impairment of [[agni]] and koshtha==
[[Agni]] is impaired by inadequate food intake, indigestion, overeating, irregular eating habits, consumption of unhabituated, heavy, cold, dry, stale food, improper administration of bio-purificatory therapies, emaciation due to diseases, regional and climatic differences, suppression of urges. These are some of the primary causes of diminution of [[agni]] and the cascade of further adverse events in koshtha. [Cha.Sa.[[Chikitsa Sthana]] 15/41-44]
Even if the appropriate food has been ingested in appropriate amounts, if the subject is going through excessive stress, grief, fear, anger, improper diurnal cycle, then the digestion is prone to impairment. [Cha.Sa.[[Vimana Sthana]] 2/9] Gut interacts with brain via metabolic, endocrine, immune, and humoral mechanisms. Hence, gut health and mood, cognition and mental health operate in tandem.<ref>Appleton J. The Gut-Brain Axis: Influence of Microbiota on Mood and Mental Health. Integrative Medicine: A Clinician’s Journal [Internet]. 2018 Aug 1 [cited 2022 Mar 19];17(4):28. Available from: /pmc/articles/PMC6469458/</ref>
==Therapeutic implications of koshtha==
The objective of identification of koshtha are:
i. Diagnosis of the stage of disease (avastha)
ii. Decision of modality, drug, vehicle, and dosage
iii. Prognosis and assessment of therapeutic response
===Diagnosis of stage of diseases===
The stages of the diseases are based on multiple parameters. One of them is either the state of saama (associated with [[ama]]) or niraama (not associated with [[ama]]). Obstruction of channels, diminution of [[bala]], heaviness, improper activity of [[vata]], languor, indigestion, expectoration, difficulty in expelling waste matter, anorexia and tiredness are the cardinal features of saama state. The opposite features indicate niraama state.
Other important stages of diseases are subclinical or latent or dormant (lina dosha avastha) and clinical or manifested phase (vyakta dosha avastha). In former phase, the [[dosha]] stay dormant in the koshtha or in the circulatory channels. They manifest clinical features in favorable season, environment, region, etc. This leads to clinical phase. This stage is important to know, especially in allergy and other autoimmune pathologies, which exhibit seasonal flare-ups. [Su.Sa.Sutra Sthana 21/30]<ref name=Susruta/>, [A.Hr.Sutra Sthana 13/19]<ref name=Hridaya/>
The aggravated state when the [[dosha]] are ready to get expelled out (utklishta) is important state for purification therapies. The other state is when the [[dosha]] are not ready to get expelled out (anutklishta) state. This forms another dyad of disease stages. The former notes “vitiated and inclined to expulsion” and the latter its opposite.[Chakrapani commentary on Cha.Sa.[[Chikitsa Sthana]] 3/146] mobile or unstable (chala) and stable (sthira) states also share similar meanings.
The primary objective of understanding koshtha is the administration of diet, medicines, and therapeutic procedures. [A.Hr.Sutra Sthana 18/15]<ref name=Hridaya/> In general, the guideline for quantity of food that is healthy for everyone has been recommended based on his or her appetite and the capacity of koshtha. The time for food intake is decided based on symptoms indicating digestion of previous meal. The ideal mealtime is when the bowel and bladder has been evacuated, the chest is clear, the [[dosha]]s are optimum, the belching does not reflect any undigested food, sequentially followed by hunger, [[vata]] is in its normal direction, when the [[agni]] is well kindled, the senses are intact and open to perception, and lightness is perceived in the body. [A.Hr.Sutra Sthana 8/55]<ref name=Hridaya/>
In therapeutic purification procedures ([[panchakarma]]), the [[dosha]] are eliminated only when they are located or brought into koshtha. This is observed by the signs like fullness and distension of abdomen after oleation and sudation.[Cha.Sa.[[Sutra Sthana]] 15/11] Koshtha also plays a major role in deciding the dosage of medicines. Soft bowels (mridu koshtha) are easy to oleate and evacuate.[A.Hr.Sutra Sthana 18/35]<ref name=Hridaya/> These individuals usually attain the expected oleation by three days and purgated using mild laxatives like milk, jaggery, buttermilk, juices of sugarcane, grapes, and decoctions like that of Triphala (combination of Terminalia chebula, terminalia bellirica and Phyllanthus emblica). The person with hard bowels takes about seven days to oleate and are also very difficult to purgate.[Cha.Sa.[[Sutra Sthana]] 13/65-69] This is the reason why mild forms of oleation mixed with food and drinks (vicharana) are indicated in soft bowel individuals. [Cha.Sa.[[Sutra Sthana]] 13/82] Medications like oils, marrow, etc. are advised in hard bowel individuals. Some other specific indications with respect to koshtha include that of oil in gut infested with worms (krimi koshtha), and muscle fats (vasa) in gut pains (koshtha ruja).
Sudation ([[swedana]]) is indicated mainly in hard bowel individuals (krura koshtha), especially in abdominal distension. It is not recommended in diseases arising due to [[pitta dosha]] with soft bowels (mridu koshtha). [Cha.Sa.[[Sutra Sthana]] 14/16,21] In koshtha, when [[vata]] afflicts the stomach (amashaya), initially dry sudation is to be done followed by unctuous sudation. When [[kapha dosha]] afflicts the large intestine (pakvashaya), the reverse order is to be followed. [Cha.Sa.[[Sutra Sthana]] 14/9]
Several pharmacological actions mentioned in [[Ayurveda]] revolve mainly around koshtha and its components. The actions that are specifically in relation with gut are: appetite stimulant ([[dipana]]), digestive stimulant ([[pachana]]), the digestion and propelling forward (anulomana), the action of expelling the adhered waste materials without digesting them (sramsana), doing the same function by liquifying (rechana), and by breaking the food items (bhedana).[Sha.Sa.Prathama Khanda/Chapter 4]<ref name= Shargadara> Sharangadhara. Sharangadhara Samhita. Translated from Sanskrit by K.R. Srikantha Murthy. Reprint ed. Varanasi: Chaukhambha orientalia;2016.</ref>
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