Endocrinology and the Arts

Kumbhakarna: Did he suffer from the disorder of the hypothalamus?

Om J Lakhani, Jitendra D. Lakhani1 Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, 1Department of Medicine, SBKS Medical College, Pipalia, Vadodara, Gujarat, India

ABSTRACT

Kumbhakarna was brother of the evil Raavana in the mythological tale of Ramayana. According the legend, Kumbhakarna had an insatiable appetite and thirst and used to sleep for great lengths of time. He also had an uncontrollable temper, which was feared by many. It is our assessment that Kumbhakarna possibly suffered from hypothalamic obesity. Hypothalamic obesity can be defined as significant polyphagia and weight gain that occurs because of structural or function involvement of the ventromedial nucleus of the hypothalamus bilaterally. The characteristic features are obesity associated with polyphagia. Somnolence is present in 40% of cases. Sham rage is a characteristic behavioral abnormality seen in these patients. All these symptoms are described in the mythological text while describing Kumbhakarna. The episodic nature of Kumbhakarna’s symptoms can also be explained by another hypothalamic syndrome called Klein–Levine syndrome. This syndrome is characterized by with periodic episodes of somnolence, hyperphagia and hypersexuality along with other behavioral and cognitive difficulties.

Key words: Hypothalamic obesity, Klein–Levine syndrome, Kumbhakarna, Ramayana, somnolence

Art has been a part of medical education in many countries. was granted a boon by the Lord. The “Devas” however Arts and humanities not only broaden the perspective of feared that if Kumbhakarna was given unlimited power then a medical student but also descriptions and pictures of art Raavana would use it to destroy the Devas and their abode. forms in literature, sculpture and performance often helps Hence, they took the help of Goddess Sarawsati. It is said the student navigate through the complex maze of medical that the Goddess made sure that when Kumbhakarna asks learning. A survey conducted amongst medical students in for his wishes his “tongue would be tied”. Hence, when Netherlands concluded that medical students often felt that Kumbhakarna asked for “Indrasaana” (the home of Lord arts teaching enriched the medical curriculum.[1] We report Indra), Brahma heard it as “Nidrasaana” (Bed for sleeping) a story from the Indian mythology, which helped us learn and when he asked for “Nirdevatvam” (destruction of a complex endocrinal condition. Devas), it was misheard as “Nidravatvam” or sleep. As a result, Kumbhakarna was said to sleep for unusually long The story of Kumbhakarna is an important part of periods of time and would be difficult to wake up. When Ramayana. Kumbhakarna was brother of evil Raavana. It is he would wake up, he would have an insatiable appetite said that Kumbhakarna was a devotee of Lord Brahma and and would eat whatever in sight. Eventually, he would be fatigued again and would go back to sleep. He was also Access this article online described to be overweight and possess a terrible rage, Quick Response Code: which many people feared. Website: www.ijem.in Hypothalamic obesity can be defined as significant

DOI: polyphagia and weight gain that occurs because of structural 10.4103/2230-8210.152795 or functional involvement of Ventromedial nucleus of the hypothalamus (VMN) bilaterally.[2] The involvement of

Corresponding Author: Dr. Om J. Lakhani, Room No. 1407, 4th Floor, Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi ‑ 110 060, India. E‑mail: [email protected]

Indian Journal of Endocrinology and Metabolism / May-Jun 2015 / Vol 19 | Issue 3 433 Lakhani and Lakhani: Hypothalamic obesity and Indian mythology

VMN can be because of tumor (e.g.: Craniopharyngioma), episodes have been reported to last from 2 to 80 days. inflammatory conditions (e.g.: Tuberculosis or Sarcoidosis), Another feature from the mythology, which fits into the Neurosurgery, Head injury, Radiotherapy, Aneurysm or description is the inability to articulate what he wanted Genetic conditions (e.g.: Prader Willi syndrome).[3] to say to Lord Brahma. Abnormal speech is reported in 2/3rd of cases of Klein–Levin syndrome.[7] Hypothalamic obesity presents with hyperphagia and obesity associated with (1) constellation of pressure Treatment of hypothalamic obesity is difficult. Lifestyle symptoms in form of headache, vomiting or raised measures have shown little benefit. Anecdotal reports intracranial tension (2) endocrinal features such as impaired and small studies have shown the use of octreotide, reproductive functions, diabetes insipidus and impaired dextroamphetamine, liothyronine and dioxide + metformin. growth and (3) neurological features like Somnolence, Bariatric surgery has also been used successfully in behavioral changes and seizures. Somnolence is present hypothalamic obesity.[3,8] in 40% of patients with hypothalamic obesity. Behavioral abnormalities include antisocial behavior, emotional Use of amphetamine, a CNS stimulant has been deemed lability and sham rage.[4] Patients may have lower to be effective in 70% and 40% cases of Klein–Levin basal metabolic rate and associated growth hormone, syndrome during the episodes. Mood stabilizers like gonadotropins and thyroid hormone dysfunctions are Lithium have been found to reduce the frequency and not uncommon.[5] prolong the duration between the episodes.[7]

Correlating the scientific literature and the mythological In conclusion, disorder of the hypothalamus like story of Kumbhakarna we have come to a conclusion that hypothalamic obesity or could very well explain some of Kumbhakarna was possibly suffering from hypothalamic the symptoms that Kumbhakarna suffered from correlating obesity. The presence of hyperphagia and obesity are the complex hypothalamic disorders with a popular story obvious pointers to the same. A previous publication from Ramayana proved to be an excellent and fruitful way describes him as possibly suffering from Hypothyroidism of teaching and learning. and sleep apnea.[6] We believe hypothyroidism alone cannot explain his predicament since hypothyroidism is References associated with obesity with normal or reduced appetite, however, the legend of Kumbhakarna describes him as 1. De la Croix A, Rose C, Wildig E, Willson S. Arts‑based learning in medical education: The studentsꞌ perspective. Med Educ having an insatiable appetite. The presence of Sham rage 2011;45:1090‑100. in hypothalamic obesity also fits with the description 2. Hochberg I, Hochberg Z. Expanding the definition of hypothalamic of Kumbhakarna. At one point in Valmiki’s Ramayana obesity. Obes Rev 2010;11:709‑21. Kumbhakarna is described to have drunk two thousand 3. Kim JH, Choi JH. Pathophysiology and clinical characteristics of pitchers of water after being woken up from his slumber hypothalamic obesity in children and adolescents. Ann Pediatr Endocrinol Metab 2013;18:161‑7. and summoned by his brother. Polydipsia is a well‑known 4. Bray GA, Gallagher TF Jr. Manifestations of hypothalamic obesity in feature of diabetes insipidus, which in turn is a part of man: A comprehensive investigation of eight patients and a reveiw hypothalamic obesity and is reported in around 30% of of the literature. Medicine (Baltimore) 1975;54:301‑30. patients.[4] The fatigue of Kumbhakarna can be attributed 5. Pinkney J, Wilding J, Williams G, MacFarlane I. Hypothalamic obesity in humans: What do we know and what can be done? Obes Rev to his low metabolic rate and lack of growth hormone, 2002;3:27‑34. thyroid hormone and gonadotropins. 6. Kalra S, Baruah MP, Nagesh VS. The endocrine quiz. Indian J Endocrinol Metab 2014;18:304‑6. Another hypothalamic disorder Klein–Levin syndrome 7. Arnulf I, Zeitzer JM, File J, Farber N, Mignot E. Kleine‑Levin also has certain features, which resemble the story of syndrome: A systematic review of 186 cases in the literature. Brain 2005;128:2763‑76. Kumbhakarna. Klein–Levin syndrome is a rare disorder of 8. Hamilton JK, Conwell LS, Syme C, Ahmet A, Jeffery A, Daneman D. adolescents, which is associated with periodic episodes of Hypothalamic obesity following craniopharyngioma surgery: Results somnolence, hyperphagia and hypersexuality along with of a pilot trial of combined diazoxide and metformin therapy. Int J other behavioral and cognitive difficulties. The etiology Pediatr Endocrinol 2011;2011:417949. of this syndrome is not well defined but often precipitated following trivial infection like flu or head trauma. The Cite this article as: Lakhani OJ, Lakhani JD. Kumbhakarna: Did he suffer episodic nature of Kumbhakarna’s sleep fits conveniently from the disorder of the hypothalamus?. Indian J Endocr Metab 2015;19:433-4. into the episodic nature of this syndrome where the Source of Support: Nil, Conflict of Interest: None declared.

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