Reflection-9

Late afternoon. The clinic is quiet. Kabir, Aarav, and Rohan sit around a wooden desk stacked with papers. Dr. Azad reads through a case sheet. Kabir breaks the silence, turning the old book in his hand.

Kabir: We just finished the chapter on the five fires—Pācaka, Rañjaka, Bhrājaka, Alochaka, and Sādhaka—each linked to its own Pitta. And the teacher is Sushruta, not Charaka.

Dr. Azad (smiling): Yes. And since these subtypes of Agni are discussed and named in Sushruta Samhita for the first time, the chapter had to be his.

Aarav: But the way it was written, he felt more like a clinical teacher than a theorist.

Dr. Azad: That was the author’s design. The cases are imagined, but the reasoning is faithful to the texts.

Rohan: Still, isn’t it a stretch to describe everything as fire? Digestion, blood, skin, vision, even confidence—these are such different things.

Dr. Azad: Do you think Agni here is simply literal fire? Don’t you think it is the principle of change or transformation?

Kabir: I thought so. The ancients must have noticed where transformation was most visible and postulated a “fire” in each place.

Aarav: But why only five? Modern biology recognizes countless transformations! This sounds too simplistic!

Dr. Azad: Well, they selected what they found was most obvious and striking. If Sushruta were alive today, he might add more: perhaps endocrine secretions, immune responses, or neurotransmitters. But in his context, five stood out clearly.

Aarav: And in modern science, what unites these five?

Dr. Azad: They all describe energy conversion and biochemical change. Pācaka through digestive enzymes, Rañjaka through hemoglobin synthesis, Bhrājaka through skin pigmentation, Alochaka through photochemistry in the retina, and Sādhaka through neurochemistry that governs clarity and confidence. Different seats, but one theme: transformation.

Kabir (frowning): But how was this category conceived in the first place? Was it just imagination?

Dr. Azad: No. There is observation component too. Whenever they observed food being digested, blood acquiring red colour, or vision becoming clear, they reasoned: “there must be a subtle fire at work.” Analogical reasoning played a role here. Sun was seen as colouring, heating and illuminating source. This is observation-driven hypothesis.

Kabir: I get it now. Bile was already described as Pitta, a colouring agent. They saw that when Pitta increased, urine and stool turned yellow. From such recurrent patterns, Pitta was linked with both transformation and colouring, and the five forms of Agni were located within it.

Aarav (thoughtfully): Wait. You mentioned change. But isn’t change in location different from change in properties? Was Agni responsible for both?

Dr. Azad: You are right to clarify. Change in location—movement—is Vata’s role. Change in properties—transformation—is Pitta’s role.

Kabir (leaning forward): This is getting interesting. Let’s test the idea against the actual cases. We can start with the cook. What would that condition be called today?

Dr. Azad: Lactose intolerance. His gut digests rice and vegetables, but not milk or curds. Without lactase, the milk sugar ferments, producing bloating, cramps, and loose stools. Sushruta would have described it as weakness of Pācaka Agni.

Aarav: But wait—some people drink milk every day without any trouble. Why can they digest it while others cannot?

Dr. Azad: That is where evolution enters the story. All humans produce lactase as infants, so they can digest their mother’s milk. But in most populations, the enzyme fades after weaning. Only in some groups did genetic mutations arise that allowed lactase to persist into adulthood. This was an evolutionary advantage where dairying became part of life, because milk provided calories, protein, and calcium when other foods were scarce.

Rohan: So Sushruta was partly right—some people’s “fire” handles milk, others’ does not—but the reason is not the fire itself, but genes?

Dr. Azad: Exactly. He explained it as variability in Agni, which was the language of his time. Today we would say it is due to differences in the lactase gene and its regulation.

Kabir: Then does that mean lactose intolerance is the original condition, and tolerance is the exception?

Dr. Azad: Yes. The natural state for most humans is to lose lactase after childhood. Lactase persistence is actually the unusual condition, preserved because it gave an advantage in certain societies. From the Ayurvedic point of view, this explains why some people thrive on milk while others should avoid it—each individual’s Agni, or in modern terms, each individual’s genetic inheritance, differs.

Aarav: And the treatment? Avoiding milk, preferring buttermilk, and taking herbs? Does it make sense?

Dr. Azad: Yes, it does. It reduces the burden and supports digestion. Ayurveda always begins with nidāna parivarjana—avoiding the cause. In this case, restricting milk is not just dietary advice but a therapeutic principle. Herbs like Trikatu then help.

Rohan (curious): But does Trikatu really help? If there is no lactase enzyme, how would it solve the problem?

Dr. Azad: A sharp question. Trikatu does not provide lactase. But in transient lactose intolerance, which can occur after gut infections or inflammation, the brush-border enzymes are transiently suppressed, but may recover. Trikatu stimulates digestive secretions, improves motility, and reduces fermentation. It may promote recovery and make mild intolerance tolerable. But when lactase is permanently absent, as in many adults, the best solution remains avoiding milk.

Kabir (thoughtfully): So the Ayurvedic explanation was weakness of fire, but the real mechanism depends on whether the problem is temporary or genetic.

Dr. Azad: Precisely. The principle of removing the cause and supporting digestion remains valid.

Rohan: What about the potter with pallor?

Dr. Azad: That corresponds to hookworm anaemia. The worms consume nutrients, iron levels fall resulting in anaemia and fatigue follows. Ayurveda described it as weakness of Rañjaka Agni, the fire that colours the blood.

Rohan: Notice also that he ate hurried meals with mud still on his hands. Is there such a description in Ayurveda texts? Do texts discuss worms?

Dr. Azad: Yes, the texts explicitly mention mṛt-bhakṣaṇa janya pāṇḍu—anaemia caused by ingesting mud. They also talk of worms. In his case, both mud contamination and worms are imagined fitting the picture.

Aarav: And Vidanga purgation—was that purgation? Or deworming?

Dr. Azad: Both. Vidanga (Embelia ribes) is a classical remedy. Modern studies show its fruits contain embelin and related compounds with anthelmintic and antimicrobial properties. Expelling the worms restores absorption and strength. The Ayurvedic phrasing was weak Rañjaka Agni, but the therapeutic action was pharmacologically real.

Kabir: So here the remedy worked not just symbolically but biochemically.

Dr. Azad: Correct. The symbolic explanation provided a rationale, but the plant itself had genuine efficacy.

Rohan: Then the goldsmith with white patches must be vitiligo.

Dr. Azad: Correct. Ayurveda identified this as Śvitra, explained as weakness of Bhrājaka Agni, the fire that governs complexion. Charaka mentions Malapū taken with jaggery, followed by sun exposure. Some authors equate Malapū with Bakuchi, though Sushruta explicitly names Bakuchi (Psoralea corylifolia) in this condition.

Rohan: But how exactly would Bakuchi help?

Dr. Azad: Its seeds contain psoralens, light-sensitive compounds. When applied to the skin or taken internally, and then exposed to sunlight, psoralens stimulate pigmentation. Modern dermatology uses psoralens in PUVA therapy—psoralen plus ultraviolet A—on precisely the same principle.

Aarav (seeking clarity): So when they said rekindling Bhrājaka Agni, they were really describing a biological process—stimulating melanocytes through sunlight and plant compounds.

Dr. Azad: Yes, they did not know the detailed biochemistry. Their language was metaphorical, but the therapeutic effect was very real, though not without risks if overused.

Kabir: And the weaver’s son who could not see at dusk?

Dr. Azad: That would be night blindness, which we now know arises from vitamin A deficiency.

Kabir: Do Ayurveda texts describe such a condition?

Dr. Azad: Yes, Ayurveda describes the condition as Naktāndhyā. Sushruta explained it as excess Kapha obstructing vision, not in terms of vitamins.

Aarav: And foods like goat liver? They provide vitamin A, right?

Dr. Azad: Yes. Goat liver is especially rich in vitamin A. Interestingly, in the texts goat liver is recommended for pallor and weakness after blood loss than for eye disease. But the author of this lesson has cleverly used it here as well, to highlight how Alochaka Agni might explain this.

Rohan (probing): But why goat liver? Why not any other food?

Dr. Azad: Good question. In Ayurveda, the idea was that to rekindle Agni or Pitta, you give substances of similar properties. Liver, being red, heavy, and vital, was thought to restore colour and strength. Later history showed this intuition was not misplaced.

Kabir: How do we know?

Dr. Azad: Search for the 1934 Nobel Prize in Physiology or Medicine.

Kabir (typing on his laptop): It says here the Nobel Prize was awarded jointly to George Hoyt Whipple, George Richards Minot, and William Parry Murphy “for their discoveries concerning liver therapy in cases of anaemia.”

Dr. Azad: Yes. They received the Nobel Prize for demonstrating that liver therapy could cure anaemia. They did not know it was due to the presence of vitamin B12, just as Sushruta too was unaware of it. But both traditions discovered liver as a powerful remedy through observation and experimentation.

Kabir (impressed): So Sushruta used liver in cases of blood loss, Whipple used it in anaemia, and in both cases it worked—because of nutrients they could not identify.

Dr. Azad: Precisely. Goat liver, in fact, is rich in both vitamin A and vitamin B12, so it could help in night blindness as well as in anaemia. Two different frameworks, but a striking overlap in practice.

Rohan: And the student who seemed withdrawn and hesitant? Why was he so unsure of himself?

Dr. Azad: In Ayurvedic texts, such a state is linked to weakness of Sādhaka Agni, the fire of intellect, motivation, confidence, and clarity. When strong, it converts effort into achievement. When weak, even simple tasks feel impossible. In modern terms, this resembles low self-esteem, social anxiety, or mild depression.

Aarav: So it was not an illness of the body, but of the mind and emotions?

Dr. Azad: Precisely. He was healthy in every physical sense. His difficulty lay in facing others, speaking in public, and believing in his own ability. Today we might call it a mix of homesickness, social anxiety, and fear of failure.

Kabir: And the remedies? Were they only symbolic?

Dr. Azad: Not at all. Notice Sushruta gave no medicines. Instead, he advised steady breathing at dawn—what we now know calms the autonomic system. He urged patient teaching, encouragement from parents, kindness from peers, even personal intervention with the boy’s guru. These are strategies of psychological support. Small successes kindle self-belief, just as fuel kindles a flame.

Rohan (nodding): So what they described as rekindling Sādhaka Agni, we would describe as rebuilding confidence through gradual exposure and support. So even here the framework was fire, but the methods were real?

Dr. Azad: Exactly. The model differed, but the therapeutic insight was real.

Aarav: But tell us honestly—where was Sushruta right, and where was he wrong?

Dr. Azad: Good. He was right in recognising that health rests on transformations—digestion, blood formation, pigmentation, vision, and confidence. He was right, too, in linking loss of these functions with specific diseases, and in proposing remedies that worked. But he was wrong in some explanations. For example, describing night blindness as due to Kapha obstruction does not fit modern knowledge. We now know it is vitamin A deficiency affecting retinal chemistry. So while his remedy—liver—was correct, the reasoning was not.

Kabir: Then should we keep teaching the old explanations at all?

Dr. Azad: We should teach them, but alongside correction. Students must see both: how observation led to bold theories, and how modern science refined them. To preserve only the poetry of fire and ignore the errors would be misleading. But to dismiss the entire framework as nonsense would be unjust, because many of his remedies were effective.

Rohan: So what do we gain from studying an old and possibly outdated framework?

Dr. Azad: We gain perspective on how knowledge grows. Ancient categories show us how early physicians made sense of illness without microscopes or chemistry. Modern categories reveal the molecular mechanisms. When studied together, you see that Sushruta’s categories were stepping stones, not final answers.

Kabir: Even what we know today may not be final, right?

Dr. Azad: Yes, that is the crux of scientific attitude. All knowledge is fallible.

Kabir: If Sushruta were alive today, how do you think he would adjust his categories in light of modern science?

Dr. Azad: He would probably retain the unifying category of Agni—perhaps under a different name—because it captures the principle of transformation. However, he would not keep Kapha as the explanation for night blindness, nor describe blood as being formed in the liver and spleen alone; he would also recognize the role of bone marrow. He would refine his concepts in light of biochemistry, genetics, and physiology. He would identify enzymes, vitamins, hormones, and neurotransmitters as new forms of fire. His spirit was empirical, and he would adapt his categories to evidence.

Kabir: So the real task is to honour his insights but correct his errors.

Dr. Azad: Exactly. Tradition is not a fossil. It must be studied critically. What is sound—like nidāna parivarjana, or the use of liver in anaemia—should be preserved. What is outdated—like Kapha in night blindness—should be corrected. In this way, ancient teaching remains alive, not as dogma, but as part of a conversation across centuries.

(A phone buzzes. A patient has arrived. The boys rise, still turning their notes, aware that they have witnessed not just the flame of old knowledge but its transformation in new light.)

Aarav (smiling): For a chapter full of fire, this one felt the most grounded.

Dr. Azad: That is how good teaching works. You remember the flame because you saw it alive in the body—and questioned it until it burned brighter!