The 20th Chapter of Charaka Samhita Sutrasthana is called Maharoga Adhyaya. This is one of the most important chapters. It enlists diseases caused by individual Tridosha – Vata, Pitta and Kapha, qualities of Tridosha, how they cause disease, patho-physiology and their line of treatment.
Table of Contents
General classifications of diseases
There are four types of diseases viz.
Agantuja – due to exogenous causes such as injury, poison etc.
Vatika – Vata imbalance disorders
Paittika – Pitta imbalance disorders
Shlaishmika – Kapha imbalance disorders.
Pain being common to all, diseases are finally of one type (ruk samanyaat).
Diseases are again of two types depending on their nature:
Agantuja – that is exogenous
Nija – endogenous.
They are again of two types
Shareera Adhishtana – somatic
Mano Adhishtana – psychic-depending on the sites of their manifestation viz. body and mind.
Diseases are in fact innumerable in as much as the immediate causes, (like improper diet and regimen) Permutation and combination of various factors of Doshas are innumerable (Aparisankhyeya) . 
General causative factors
The Agantuja Roga – exogenous diseases are caused by
Nakha – nails,
Dashana – teeth,
Patana – fall,
Abhichara – spell,
Shaapa – curse,
Abhishanga – psychic afflictions including demoniac seizure,
Abhighata – injury,
Vyadha – piercing,
Bandhana – bandage,
Veshtana – rapping,
Peedana – application of pressure,
Rajju – binding by rope,
Dahana – fire,
Shastra – weapon,
Ashani – thunderbolt,
Bhuta – demoniac seizure,
Upasarga – natural calamities etc.
The Nija Rogas – endogenous diseases are caused by the imbalance of Tridosha – Vata, Pitta and Kapha. 
Three basic causative features all diseases
Asatmya Indriya Artha Samyoga – Unwholesome contacts between the sense organs and their objects,
Prajnaparadha – intellectual blasphemy, acting against one’s conscience
Parinama – Effects of time constitute the common causative factors for both the exogenous and endogenous types of diseases.
All these four types of diseases when aggravated do share the symptoms of each other. Even then, the distinctive features of each one of them are too clearly manifested avoiding any confusion.
Role of Doshas in disease Pathogenesis
Role of Doshas in the pathogenesis of exogenous and endogenous diseases:
The exogenous diseases (Agantu Roga) begin with pain and then they bring about the disturbance in the Tridosha balance.
The endogenous diseases begin with the disturbance in the Tridosha balance, and then result in pain.
So, in both Njia and Agantu diseases, ultimately Tridosha balance is noted.
Physiological sites of Doshas in the body
Place of Vata Dosha
Basti – Urinary bladder, urinary system
Pureeshaadhaana – rectum,
Sakthi – waist,
Padau – thighs, legs,
Asthi – bones
Pakvashaya – colon are the sites of Vata
Among them, Pakvashaya (colon) is the most important site.
Related: How Vata Dosha dominates different parts of the body?
Place of Pitta Dosha
The important sites of location of these three Doshas are as below:
Swedo – Sweat
Rasa – Rasa dhatu – end product of food digestion, containing all nutrients
Lasika – Lymph
Rudhira – blood
Amashaya – small intestine(lower part of Amashaya) are the sites of pitta
Among them, the small intestine (lower part of Amashaya) is the most important site of Pitta Dosha.
Related: How Pitta influences different body parts?
Place of Kapha Dosha
Ura – Chest,
Shira – head,
Greeva – neck,
Parva – joint,
Amashaya – stomach (upper part of Amashaya)
Meda – fat are the sites of Shleshma (Kapha).
Among them, chest is the most important site of Kapha Dosha. 
Related: How Kapha dominates different body parts?
General functions of balanced Doshas
All the three Doshas are present in all parts of the body. These Doshas, in normal balanced condition, cause good health and in imbalanced condition, they cause illness.
When they are balanced, they cause
Upachaya – body nourishment
Bala – improvement of strength and immunity
Varna Prasada – improvement of skin health and complexion 
Diseases caused by Tridosha imbalance
Endogenous diseases (Nija Roga) again are two types viz:
Samanyaja Vyadhi – diseases caused by Vata, Pitta and Kapha in different combinations
Nanatmaja Vyadhi – specific diseases caused by individual Doshas – Vata, Pitta and Kapha. Samanyaja Vyadhi – Diseases of the combined Doshas are explained in the preceding chapter and diseases caused by individual imbalanced Doshas are being explained here.
Diseases caused by individual Doshas :
Vata when imbalanced alone, causes 80 types of disorders
Pitta when imbalanced alone, causes 40 types of disorders
Kapha, when imbalanced alone, causes 20 types of disorders. 
Vataja Nanatmaja Vyadhi
Eighty diseases caused by Vata alone – Vataja Nanatmaja Vyadhi:
Though Vata imbalance diseases are innumerable, the following eighty diseases are the most commonly manifested ones:
1. Nakhabheda (cracking of nails)
2. Vipadika (cracking of feet)
3. Pada shoola (pain in foot)
4. Pada Bhramsha (foot Drop)
5. Pada Suptata (numbness of foot)
6. Vata khuddata (club foot)
7. Gulpha Graha (stiff ankle)
8. Pindikodveshtana (cramps in calf muscle)
9. Gridhrasi (sciatica)
10. Janu Bheda (Genu varum)- Bow leggedness, bandiness
11. Januvishlesha (Genu valgum) – Knock Knee
12. Urustambha( stiffness of thigh)
13. Urusada (pain in the thigh)
14. Pangulya (paraplegia)
15. Guda Bhramsa (prolapsed rectum)
16. Gudarti (Tenesmus)
17. Vrushanakshepa (pain in scrotum)
18. Shepha Stambha (stiffness of penis)
19. Vankshana anaha (tension of groyne)
20. Shroni Bheda (pain around the pelvic girdle)
21. Vidheda (diarrhoea)
22. Udavarta (bloating)
23. Khanjatva (lameness)
24. Kubjatva (kyphosis)
26. Trikagraha (stiffness of sacro-iliac joint)
27. Prsistagraha (stiffness of back)
28. Parshva Marda (pain in chest)
29. Udaraveshta (Gripping pain in abdomen)
30. Hrit Moha (brabycardia)
31. Hrit Drava (tachycardia)
32. Vaksha- Udgharsha (rubbing pain in chest)
33. Vaksha- Uparodha (impairment of thoracic movement)
34. Vakshastoda (stabbing pain in chest)
35. Bahu Shosha (atrophy of arm)
36. Greeva Stambha (stiffness of the neck)
37. Manyastambha (torticollis)
38. Kanthoddhvamsa(hoarseness of voice)
39. Hanu Bheda (pain in jaw)
40. Ostha Bheda (pain in lips)
41. Akshi Bheda (pain in eye)
42. Danta Bheda (toothache)
43. Danta Shaithilya (looseness of tooth)
44. Mookatva (aphasia / dumbness)
45. Vak Sanga(stalling speech)
46. Kashaya asyata (astringent taste in mouth)
47. Mukha shosha (dryness of mouth)
48. Arasajnata(ageusia) – loss of taste function
49. Ghrana Nasha(anosmia) – loss of smell function
50. Karna Shoola (ear ache)
51. Ashabda Shravana (tinnitus)
52. Ucchaih Shruti (hard hearing)
53. Badhirya (deafness)
54. Vartma Stambha (Ptosis of eyelid)
55. Vartma Samkocha (entropies)
56. Timira(amaurosis) – a type of vision loss
57. Akshi Shoola (pinching pain in eye)
58. Akshi Vyudasa (Ptosis of eye ball)
59. Bhru Vyudasa (ptosis of eye brow)
60. Shankha Bheda (pain in temporal region)
61. Lalata Bheda (pain in frontal region)
62. Shiro Ruk (headache)
63. Kesha bhumi sphutana (dandruff)
64. Ardita(facial paralysis)
65. Ekanga Roga (monoplegia)
66. Sarvanga Roga (polyplegia)
67. Pakshavaha (hemiplegia)
68. Akshepaka (convulsion)
69. Dandaka (tonic convulsion)
70. Tama (fainting)
71. Bhrama (giddiness, dizziness)
72. Vepathu (tremor)
73. Jrumbha (yawning)
74. Hikka (hiccup)
75. Vishaada(asthenia) – weakness, depression
76. Ati Pralapa (delirium) – excessive irrelevant talk
77. Raukshya (dryness)
78. Parushya (hardness)
79. Shyava Arunaava Bhasata (dusky red appearance)
80. Asvapna (sleeplessness)
81. Anavasthita chittatva (unstable mind). [9-11]
Vata dosha qualities
Qualities of Vata Dosha – how it is exhibited in Vata Nanatmaja diseases –
In all the pure Vata diseases, enumerated or implied, the inherent natural qualities and actions of Vata are quite obviously manifested wholly or partially and as such it is not difficult for a competent physician to correctly diagnose the Vatika type of diseases.
Raukshya – Rookshata – roughness,
Shaitya – Sheetata – coolness,
Laaghava – Laghu – lightness
Vaishadya – clarity, non-sliminess,
Gati – movement,
Amoortata – shapelessness,
Anavastitatva – instability- these are the inherent qualities of Vata.
Related: How to understand Tridosha by its qualities?
Vata Dosha symptoms
Vata Dosha while moving from one part of the body if abnormal, exhibits symptoms like –
Sramsa – looseness,
Bhramsa – dislocation,
Vyasa – expansion,
Sangha – obstruction,
Bheda – separation,
Saada – depression,
Harsha – excitation,
Tarsha – thirst,
Kampa – trembling,
Varta – circular movement,
Chaala – motion,
Toda – piercing pain,
Vyatha – aching pain,
Cheshta – action,
Khara – coarseness,
Parusha – harshness,
Vishada – non-sliminess,
Sushira – porousness,
Aruna Varna – reddishness (colour of sunrise),
Kashaya – Astringent taste
Virasa Mukhatva – tastelessness in the mouth,
Shosha – wasting pain,
Shoola – pain,
Supti – numbness,
Samkocha – contraction,
Sthambhana– rigidity and
Khanjata – lameness, etc. These are the actions that help a competent physician to diagnose the pure Vatik type diseases.
Treatment principles of Vata disorders
General principles of treatment of Vata disorders:
Madhura, Amla Lavana Snigdha Ushna Upakrama – The vitiated Vata should be treated by drugs having sweet sour and saline taste and unctuous and hot qualities.
Snehana – oleation,
Sveda – fomentation, sweating treatment
Asthapana – decoction enema
Anuvasana – oil enema
Nasyakarma – nasal instillation of drops,
Bhojana – healthy diet,
Abhyanga – massage,
Utsadana – unction,
Parisheka – sprinkling of oil / liquid containing materials having anti-Vata properties.
This is to be done with due regard to the dosage and the season.
Importance of Basti treatment in Vata disorders
Of all the treatments stated above, the Asthapana (decoction enema) and Anuvasana (oil enema) are the treatment par excellence for the cure of Vatik diseases, because immediately after entering the colon, they strike at the very root of the vitiated Vata and when Vata is overcome in the colon, even the entire vitiated Vata dwelling in other parts of the body is automatically alleviated.
This can be likened to the cutting of the root of a tree which result in the automatic fall of the trunk, branches, sprouts, flowers, fruits, leaves, etc.
Related: How to balance Vata Dosha?
Pittaja Nanatmaja Vyadhi
Forty specific diseases of Pitta – Pittaja Nanatmaja Vyadhi:
Now we shall explain the forty varieties of diseases due to the vitiation of Pitta. Even though the diseases due to the vitiation of Pitta are innumerable, the following forty varieties are the most commonly manifested.
1. Osha (heating)
2. Plosha (scorching)
3. Daha (burning sensation)
4. Davathu (boiling)
5. Dhoomaka (fuming)
6. Amlaka (acid eructation)
7. Vidaaha (pyrosis) – (heartburn)
8. Antar daaha (burning sensation inside the body)
9. Amsa daha ( burning sensation in shoulder)
10. Ushmaadhikya (excessive temperature)
11. Ati Sveda (excessive sweating)
12. Anga gandha (bad odour of thee body)
13. Angaavadarana(cracking pain in the body)
14. Shonita kleda(sloughing of the blood)
15. Mamsa kleda (sloughing of the muscle)
16. Tvak Daaha( burning sensation in the skin)
17. Charma dalana(itching of the skin)
18. Tvagavadarana (cracking of the skin)
19. Rakta kotha (urticaria)
20. Rakta visphota (red vesicle)
21. Rakta Pitta(bleeding tendency)
22. Rakta mandala (red wheals)
23. Haritatva (greenishness)
24. Haaridratva (yellowishness)
25. Neelika (blue moles)
26. Kaksha (herpes)
27. Kaamala (jaundice)
28. Tiktaasyata (bitter taste in month)
29. Lohita Gandhasyata (smell of blood from the mouth)
30. Pooti mukhata(foetid odour of mouth)
31. Trishnaadhikya (excessive thirst)
32. Atrupti (non-satisfaction)
33. Aasya Vipaka (stomatitis)
34. Gala paka(pharyngitis)
35. Akshi paka (conjunctivitis)
36. Guda paka (proctitis)
37. Medhra Paka(inflammation of the penis)
39. Tamah pravesha (fainting)
40. Harita haridra netra mutra varchas (greenish and yellowish coloration of eyes, urine & faeces)
Patho- physiology of Pitta diseases
In all the Paittika types of diseases enumerated or implied, the inherent natural qualities and actions of Pitta are quite obviously manifested wholly or partially and as such it is not difficult for a competent physician to correctly diagnose the Paittika type of diseases.
Qualities of Pitta
The inherent natural qualities of Pitta are:
Aushnya – Ushna – heat,
Taikshnya – Teekshna – sharpness,
Dravatva – liquidity,
Anati Sneha – slight unctuousness, mild oiliness, all colors except white and red,
Visra Gandha – fishy smell,
Katu, Amla – acrid and sour tastes
Saratva – fluidity.
Pitta Imbalance symptoms
Daaha – burning sensation,
Aushnya – ushna – heat,
Paaka – suppuration,
Sveda – perspiration,
Kleda – sloughing,
Kotha – putrefaction,
Kandu – itching,
Srava – discharge,
Raaga – redness and exhibition of its inherent smell, colour and taste.
General principles of treatment for Pitta diseases
Madhura, Tikta Kashaya – Pitta is treated with herbs having sweet, bitter and astringent tastes
Sheeta – cooling qualities
Snehana – oleation
Virechana – purgation,
Pradeha – unction,
Parisheka – effusion,
Abhyanga – massage, etc. procedures done with herbs having anti Pitta qualities.
This is of course to be done with due regard to the dosage and season.
Importance of Virechana in Pitta imbalance
Of all the devices stated above, the purgation is the treatment par excellence for curing the Paittika diseases because, immediately after it is administered, it eliminates the vitiated Pitta from its very root from the level of intestines. When it is overcome in the Amasaya (small intestine), it alleviates the entire vitiated Pitta dwelling in other parts of the body. This can be likened to a hot chamber being cooled by removing the fire from inside it.
Related: How to balance Pitta Dosha?
Kaphaja Nanatmaja Vyadhi
Twenty types of Kaphaja diseases – Kaphaja Nanatmaja Vikara
Now we shall explain the twenty varieties of diseases due to the vitiation of Kapha. Even so, the diseases due to the vitiation of Kapha are innumerable; the following are the twenty varieties which are most commonly manifested.
1. Trupti (anorexia nervosa)
2. Tandra (drowsiness)
3. Nidraadhikya(excessive sleep)
4. Staimitya (timidness)
5. Guru Gatrata (heaviness of the body)
6. Alasya (laziness)
7. Mukha Maadhurya (sweet taste in mouth)
8. Mukha Srava (salivation)
9. Shleshmodgirana (mucus expectoration)
10. Malaadhikya (excessive excretion of excreta)
11. Balasaka (loss of strength)
12. Apakti (indigestion)
13. Hrudayopalepa (feeling as if heart is wrapped up with moisture)
14. Kantopalepa (phlegm adhered to throat)
15. Dhamani Pratichaya (hardening of vessels)
16. Galaganda (goitre)
17. Ati Sthaulya (obesity)
18. Sheetaagnita(suppression of digestive powder)
19. Udarda (urticaria)
20. Shvetaavabhasata (pallor), Shveta Mutra Netra Varchastva (whiteness of urine, eye and faces)
Pathophysiology of Kaphaja diseases
In all the Shlaishmika (Kaphaja) type of diseases enumerated or implied, the inherent natural qualities and actions of Kapha are quite obviously manifested fully or partly and as such it is not difficult for a competent physician to correctly diagnose the shlaishmika type of diseases.
Qualities of Kapha
Sneha – Unctuousness,
Shaitya – coolness,
Shauklya – whiteness,
Gaurava – heaviness,
Maadhurya – sweetness,
Sthairya – steadiness,
Paicchilya – sliminess
Maartsnya – viscosity- three are the inherent qualities of kapha.
Kapha brings about following attributes to the body
Shvaitya – Shveta – whiteness
Shaitya – Sheeta – coolness
Kandu – itching
Sthairya – steadiness, stability
Gaurava – heaviness,
Sneha – unctuousness, oiliness,
Supti – numbness,
Kleda – moistness, stickiness,
Upadeha – sliminess, as if being anointed with oil,
Bandha – binding, obstruction
Madhurya – sweetness,
Chirakaritva – slowness, delay in manifestation- these are the actions that help a competent physician to diagnose diseases caused by kapha.
General principle of treatment for Kaphaja diseases
They (diseases due to vitiated Kapha) should be treated with:
Katu Tikta Kashaya – herbs having pungent, bitter, astringent taste,
Teekshna Ushna Rooksha – treatments and medicines having sharp, hot and dryness qualities
Sveda – fomentation, sweating
Vamana – emesis, vomiting therapy,
Shiro Virechana – elimination of Doshas from the head by Nasya procedure,
Vyayama – exercise etc, which should all contain materials having Anti- Slaismika properties.
This is of course to be done with due regard to the dosage and season. Of all the devices stated above, emetic therapy is the treatment par excellence for the cure of diseases due to Kapha because immediately after entering the Amashaya – stomach, it strikes at the very root cause of the vitiation of Kapha and when it is overcome in the stomach, even the entire vitiated Kapha dwelling in other parts of the body is automatically alleviated. This can be likened to the withering away of paddy, barley, etc. for want of barrier of the cornfield (full of water) being broken.
Related: How to balance Kapha Dosha?
Importance of diagnosis in treatment
Thus it is said:
A physician should first of all diagnose the disease and then he should select proper medicine. Thereafter, he should administer the therapy applying the knowledge of the science of medicine he had already gained.
A physician who initiates treatment without proper diagnosis of the diseases can accomplish the desired object only by chance (he cannot be sure of his success).
The fact that he is well- acquainted with the knowledge of application of medicine does not necessarily guarantee his success. On the other hand, the physician who is well-versed in diagnosing diseases, who is proficient in the administration of medicines and who knows about the dosage of the therapy that varies from place to place and season to season, is sure to accomplish the desired objective.[20-22]
In this chapter – Maha Roga Adhyaya, the enlightened sage has fully dealt with the following subjects: classification, nature, sites of manifestation, specific and general causative factors, interchangeability and specific identity of diseases, sites of Doshas, enumeration of specific diseases due to Doshas, invariable signs and actions of Doshas separately along with their treatment.[23-25]
Thus ends the Twentieth chapter of Charaka Samihta Sutrasthana, of Agnivesa’s work as redacted by Charaka.