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Tuberculosis In Ayurveda- Rajayakshma


Tuberculosis In Ayurveda- Rajayakshma


Rajayakshma is a disease described in all Ayurvedic classics that can be compared with Tuberculosis. Our Acharyas have described all the aspects of the disease very minutely.
Tuberculosis In Ayurveda- Rajayakshma


NIRUKTI
Rajayakshma is composed of two words viz. Raja and Yakshma. The word Raja is derived from Dhatu Raj‘ meaning ‘Deeptau’ which means the person who rules. Yakshma is an adjective of noun Yakshmana derived from Dhatu ‘Yakshm‘ and possessing ‘Manin’ Pratyaya. It indicates the disease, which is to be treated with utmost care by the physicians. Amarkosha has mentioned this as Roga-bheda and Vachaspatyam quotes it as a synonym of Rajayakshma (Bhattacharya, 1962).

VYUTPATTI

The word ‘Rajayakshma’ carries two literary meanings along with it viz. King’s evil and King of the diseases. The prior one is exemplified by the story of Chandra and accordingly termed as the disease of the King. The latter one indicates towards its severity, as it is very difficult to manage so termed as Rajayakshma, the king of the diseases.

PARYAYA

Krodha, Yakshma, Jwara (Ch.Chi.8/1)  Shosha, Kshaya (Su.Ut. 41/4) and Rogarat (As. Hr. Ni.5/1) are the synonyms of Rajayakshma.

PARIBHASHA

Acharya Charaka says that due to obstruction in the Rasavahi srotas the Rasa Dhatu gets accumulated at its own place and this accumulated Rasa Dhatu goes upwards and manifests as Kasa and other clinical symptoms. As a consequence of this Shadrupa and Ekadasharupa are produced and the group of these clinical symptoms as a whole is known as “Rajayakshma”. According to Acharya Sushruta Shosha is a disease that is followed by many diseases as its complications and manifests as a complication of many diseases. It is very difficult to diagnose and treat.

BHEDA(Types)


(A)  On the basis of etiological factors   Chakrapani opines that according to the etiological factors    Rajayakshma can be classified  into 4 types


1. Sahasaja Rajayakshma
2. Sandharanaja Rajayakshma
3. Kshayaja Rajayakshma
4. Vishmashanaja Rajayakshma

(B)  On the basis of Dosha predominance

Almost all Acharyas are of the view that Rajayakshma is Sannipataja i.e. there is dominance of all the three Doshas. But a few Acharyas says that it is of 5 types –

1. Vataja Rajayakshma
2. Pittaja Rajayakshma
3. Shleshmaja Rajayakshma
4. Sannipataja Rajayakshma
5. Urahkshataja Rajayakshma

(C)   On the basis of clinical features

      According to the clinical picture of the disease it has been classified into 3 types viz.

1. Trirupa Rajayakshma
2. Shadrupa Rajayakshma
3. Ekadasharupa Rajayakshma                                            
But Chakrapani opines that these are the three different stages of Rajayakshma.

(D)  On the basis of Pathogenesis

      According to Acharya Charaka and Sushruta, Rajayakshma manifests through two probable ways and these can be considered as two types of Rajayakshma viz.

1. Anuloma Kshaya
2. Pratiloma Kshaya

NIDANA

After going through all the classics, it is found that there
are four major causes of Rajayakshma that can cause the disease singly
or combinedly. These are –

1. Sahasaj
2. Vega Sandharana
3. Kshaya
4. Vishamashana

1.      Sahasaj

     It means excessive and strenuous work or fight or exercise beyond one’s capacity. This can be an etiological factor of Rajayakshma in child labourers. Due to poverty, India has the largest force of child labourers in the world, about 90% of them being in rural areas. Every third house has a working child and every fourth child is employed.Child labour may be defined as employment of children in gainful occupations even at the expense of their physical, emotional and social well being. “Labour” should for the purpose of this definition, be interpreted as “work” which in this case is such as requiring strength or patience rather than skill or training. Child labourers always have lower growth and health status compared to their non-working counterparts, besides exposure to occupational hazards at a very young stage in their lives. Magnitude of ailments say cold, cough, fever, nutritional deficiency states, diarrhoeal disease, accidents etc. is far higher in child labourers, and Tuberculosis is one of them.

2.      Vega Sandharana   This means suppression of natural urges for defaecation, micturition etc. Vijayarakshita has explained that here the Vegas refer to only the urges for flatus, defaecation and micturition and not all other Vegas that are mentioned in “Navegandharniya” chapter of Charaka Samhita. Also while describing the diseases caused due to suppression of 13 urges, Acharya Charaka has not mentioned Rajayakshma as their manifestation. In case of children it is not clear whether this etiological factor has any role in causing Rajayakshma or not.


3.      Kshaya –  Kshaya means depletion or discretion. Acharya Sushruta has described it as the synonym of ‘Shosha’ and explains that the loss of capability of body to do work is called Kshaya (Su.Ut. 41/4). Gangadhar comments that in Rajayakshma it refers to depletion of Rasa Dhatu and Shukra while Yogindranath says that it refers to depletion of Shukra, Oja and Sneha. This may be because Rasa and Oja are taken as synonyms. According to both Acharya Charaka (Ch.Ni.6/8-9) and Acharya Sushruta (Su. Ut. 41/10) this depletion of Dhatus can take place by two ways that can be termed as (i) Anuloma Kshaya and (ii) Pratiloma Kshaya. Anuloma Kshaya means the depletion of Dhatus takes place in the direction of their nourishment i.e. Rasa then Rakta then Mamsa and so on. Pratiloma Kshaya means the depletion of Dhatus takes place in the direction opposite to their nourishment i.e. Shukra then Majja then Asthi and so on. In infants and children only Anuloma Kshaya can take place. The conditions that can lead to Anuloma Kshaya, according to Acharya Charaka, can be divided into 2 categories i.e. Psychological like Bhaya, Shoka, Chinta, Udvega etc. that is not of much significance in case of children and nutritional like intake of Ruksha Ahara i.e. those food articles which when ingested lead to depletion of Dhatus by increasing Vata Dosha, inspite of giving nourishment to the body; intake of less quantity of food, fasting and weak body constitution as in low birth weight babies.


4.      Vishamashana  Vishamashana means intake of food without considering the Ashta Vidhi Vishesha Ayatanani described by Acharya Charaka. The food habits of infants and children depend on their parents. The children of those parents who are ignorant and do not know about child rearing develop faulty food habits. Also the children of working mothers like daily labourers who find little time to take care of child’s feeding are often malnourished. Besides these four major causes many diseases act as Nidanarthakara Roga like Jwara, Raktapitta, Pratishyaya and Kasa (Ch.Ni.8/17-19) that can lead to Rajayakshma as their complication. It is also seen that during the diseases like Prameha (Ch.Chi.6/17), Gulma (Ch.Ni.3/11) and Grahani (Ch. Chi 15/48) the chances of Rajayakshma are increased. The infectious nature of the disease was clearly recognized by Sushruta as he has included it inthe list of Aupsargika Roga (Su. Ni. 5/33). As mentioned earlier Shosha is a synonym of Rajayakshma therefore, the eight causes of Shosha mentioned by Sushruta can also be considered as the causative factors of this disease (Su. Ut. 41/21) – Vyavaya, Shoka, Sthavirya, Vyayam, Adhva, Upvasa, Vrana and Urahkshata but these cannot be found in children except Vyayama, Upvasa, Vrana and Urahkshata which are also not of much significance. Kalyanakaraka has added two more causative factors to the list which are Vighata and Ashana Virasabhavata. Hansaraja Nidana has mentioned Shapa also, as a causative factor. Dalhana while elaborating the Sushruta’s version on Adibala Pravritta Roga (Su.Su. 24/5) has included Rajayakshma under hereditary disorders.

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SAMPRAPTI
Pathology guides medicine. To cure a disease completely, one should know up to the root level of the disease and this is not possible until and unless one is aware of the pathogenesis of the disease. Therefore, to become an eminent physician one should have a deep knowledge regarding pathology behind the occurrence of disease. In case of Rajayakshma Acharya Charaka has mentioned the pathogenesis of all the four types of Rajayakshma in details in Nidana Sthana. A common pathogenesis has been described in Chikitsa Sthana. Further, the pathogenesis of each of Ekadasharupa except Jwara has also been discussed by Acharya Charaka. Other Acharyas have mentioned pathogenesis of two types viz. Anuloma Kshaya and Pratiloma Kshaya.

SAMANYA SAMPRAPTI:

Acharya Charaka has described the Samanya Samprapti of Rajayakshma in a very precise way. He says that when Agni is in its proper form, it leads to proper formation of Dhatus. These Dhatus remain in their respective Srotas and with the help of Agni lead to the formation of subsequent Dhatus. But when there is obstruction in the Srotamsi, it leads to depletion of Dhatus specially Rakta. This results in diminution of Dhatvagni and all these together lead to Rajayakshma (Ch
.Chi. 8/39-40). According to Chakrapani this obstruction in the Srotamsi is due to Dosha responsible for the manifestation of disease. This results in unavailability of Poshaka Rasa to Rakta and other Dhatus. The decrease in supply of Poshaka Rasa also affects the quantum of Dhatvagni, which is further decreased by Dosha Prabhava (Ch.Chi.8/40, Chakrapani. Gangadhar opines that Dhatvagnimandya
takes place due to the depletion of the Adhara i.e. the Dhatu which in turn vitiates the Adheya i.e. Dhatvagni (Ch.Chi. 8/40, Gangadhar). In this way, the Dhatu depletion and Dhatvagnimandya forms a vicious circle leading to further depletion of Dhatus as well as increase in Dhatvagnimandya. The result is incorrect  metabolism of the nutrient leading to more formation of Kitta and less formation of Sararupa Rasa. It is not only the Dhatvagni but Bhutagni also get vitiated (Ch.Chi. 8/40, Yogindranath). While describing the Samprapti of Grahani Roga Acharya Charaka says that due to Nidana sevana, Jatharagni get vitiated and is not able to digest even small quantity of easily digestible food. As a consequence of this, the undigested food starts to ferment and becomes Amavisha. This Amavisha when get associated with different Doshas manifests different diseases. When it get  associated with Kapha Dosha it leads to Yakshma, Pinasa, Prameha and other Kapha dominant diseases (Ch. Chi. 15/48). In this way we see that Ama also act as an important component of Samprapti. Acharya Charaka and Sushruta have mentioned two probable ways of manifestation of the disease viz. Anuloma Kshaya and Pratiloma Kshaya. But here we will only discuss about Anuloma Kshaya
because Pratiloma Kshaya hardly occur in children Indulgence of etiological factors lead to Dosha provocation which get spread all over the body. Out of these Dosha the dominated Kapha Dosha obstructs the Srotamsi specially Rasavaha Srotas leading to malnutrition of further Dhatus and hence Shosha. Acharya Vagbhata has described the process of obstruction in the Srotamsi with some more details. According to him, all the three provoked Doshas get circulated through out the body and when they enter various Sharira Sandhis, they affect the Siras of Sandhis leading to obstruction of the orifices of Srotamsi, resulting in the dilatation of the Srotamsi. Thereafter these Doshas move upwards, downwards and obliquely and produce various symptoms depending upon their localization (As. San. Ni-5/7-8).
Madhava Nidana has followed Acharya Sushruta while describing the Samprapti of Rajayakshma. Vijayarakshita while commenting on these verses says that in addition to depletion of Dhatus the vitiation of Srotamsi is also important,  therwise it may be only Dhatu Kshaya and not Rajayakshma. It is not only the Rasavaha  Srotas but other Srotamsi are also get obstructed by provoked Kapha leading to Anuloma Kshaya. In short, we can say that the two main entities of Samprapti of Rajayakshma are the vitiation of Doshas and vitiation of Agni. As we know that in children all the Dhatus are in their growing phase and not fully mature therefore, if in addition there is Agnimandya due to vitiated Doshas that will affect the growth and development of a child severely leading to high morbidity. Therefore, it  becomes pertinent to arrest the pathology of Rajayakshma in children as soon as possible.

VISHISHTA SAMPRAPTI


1.     Sahasaja Rajayakshma:


Excessive indulgence of various Sahasa Karma beyond one’s capacity leads to injury in the chest including lungs (Ch.Ni.6/4, Gangadhara). The Urastha Vata moves in the injured part of the chestand vitiates the local Kapha (Ch.Ni.6/4, Chakrapani) and Pitta. All these three Doshas together moves in the body upward, downward and obliquely and get localized in various body organs to produce
symptoms accordingly. These symptoms have their own pathogenesis due to the Dosha vitiation on the specific sites viz. the Dosha situated in Sharira sandhi results in Jrimbha, Angamarda and Jwara. Jwara is caused by Vata provocation, Jrimbha occurs when the Dosha get lodged in Hanusandhi and when there is involvement of all Sandhis, Angamarda is observed (Ch. Ni. 6/4, Gangadhara). When Dosha is lodged in Amashaya, it results in Uroroga and Arochaka Uroroga here means the diseases of chest like Hridrava, Shoola etc. The Dosha situated in Amashaya causes diseases of chest because of the vicinity of chest to Amashaya (Ch. Ni. 6/4, Chakrapani). Yogindranath is of the view that Arochaka is caused because of Dosha
situated in Rasana (Ch. Ni. 6/4, Yogindranath) Gangadhara opines that Arochaka is due to Dosha situated in Hridaya (Ch. Ni. 6/4 Gangadhara). When Dosha get situated in Kantha it causes Swarasada and when they get lodged in Pranavaha srotas they results in Shwasa and Pratishyaya. When the Shirah gets occupied by provoked Dosha it causes Shirahshoola. Vata Dosha when get lodged in chest leads to Kanthodhwansa and Kasa. The continuous bouts of Kasa causes Shonitashthivana. Jyotishchandra suggests that it is because of the injury occurred in the Sira of Phuphusa (Ch. Ni. 6/1, Jyotishchandra). The Vata gets vitiated because of Rakta Kshaya leading to Daurbalya and manifest the disease.  Varchobheda has been described as an additional symptom by Gangadhara and Yogindranath. Gangadhara mentions its occurrence because of Dosha situated in Guda (Ch. Ni. 6/4, Gangadhara) while Yogindranath Sen opines that to be because of Dosha vitiation in Amashaya (Ch. Ni. 6/4, Yogindranath).

2.     Sandharanja Rajayakshma :


When any person suppresses the natural urges, it results in Vata provocation. This provoked Vata vitiates Pitta and Kapha. All these three move together through out the body upward, downward and obliquely. These then get settled in various sites. This all lead to manifestation of various symptoms as described earlier in Sahasaja Rajayakshma. Shoola and Purishabheda occur when Vata is vitiated by Ruksha and Chala Guna along with Pitta. Purishabheda leads to Atisara (Ch. Ni. 6/6, Gangadhara and Jyotishchandra). Both the latter symptoms occur due to Dosha anchored in Adhobhaga (Ch. Ni. 6/6, Yogindranath). Vitiated Vata when goes to Parshwa region it causes Atiruja (Ch. Ni. 6/6, Yogindranath), Gangadhara says that Shirahshoola occurs when Kapha Dosha occupy Shirah. Kasa, Jwara, Swarabheda and Pratishyaya are the other symptoms occurring in the disease. All these lead to gradual cachexia of the patient and ultimately Rajayakshma.

3.     Kshayaja Rajayakshma :


The manifestation of Rajayakshma by Kshaya takes place by two different  athways according to the direction in which depletion of Dhatus takes place. These are Anuloma Kshaya and Pratiloma Kshaya as described earlier. Here we will discuss about Anuloma Kshaya only due to its preponderance in childhood.

Anuloma Kshaya


When a Durabala Prakriti person i.e. who is weak since birth (Ch. Ni. 6/8, Gangadhar) indulges in the etiologic factors, it leads to depletion of Rasa residing in Hridaya. According to Gangadhara, Hridaya here refers to Manasa Sthana (Ch. Ni. 6/8, Gangadhar). The Rasa is the Sara of Annarasa and is Taijasa in nature (Ch. Ni. 6/8, Jyotishchandra). It is Dhatu Swaroopa and provides nourishment to other Dhatus (Ch. Ni. 6/8, Chakrapani). According to Chakrapani some other Acharya refers Rasa to be Ojasa (Ch. Ni. 6/8, Chakrapani). Due to its unavailability next Dhatu get depleted (Ch. Ni. 6/8, Gangadhar). This leads to cachexia as a result of depletion of all Dhatus (Ch. Ni. 6/8, Jyotishchandra). If this condition is not treated it ultimately results into Rajayakshma.

4.     Vishamashanaja Rajayakshma :


Vishamashana Sevana leads to imbalance of all the three Doshas i.e. Vata, Pitta and Kapha. These imbalanced Doshas moves in the body and get lodged into the orifices of various Srotamsi. This results in formation of faeces and urine by what so ever is ingested and no other Dhatu is formed. The patient lives only on Upasthambhana of Purisha. The vitiated Doshas mix with malnourished Dhatus (Ch.Ni. 6/10, Yogindranath) and results in various symptoms leading to severe cachexia in the patient. The Vata Dosha causes Shirahshoola, Angamarda,
Kanthodhwansa, Parshwasamrujana, Ansavamarda, Swarabheda and Pratishyaya. Pitta vitiation causes Jwara, Atisara and Antardaha and vitiated Kapha leads to Pratishyaya, Shirogaurav, Arochaka and Kasa. This Kasa leads to injury on chest resulting in Shonitashthivana and due to loss of Rakta Dhatu Daurbalya occurs that ultimately leads to Vishamashanaja Rajayakshma. After going through Samanya and Vishishta Samprapti of Rajayakshma, a brief description of pathogenesis of some symptoms given by Acharya Charaka is mentioned here (Ch. Chi. 8).

1.   Pratishyaya

 The vitiate Vata Dosha residing in the Shirah takes along with it the Kapha, Pitta and Rakta situated at the base of nasal cavity and manifests, a severe form of Pratishyaya.

2.   Kasa

Obstruction in Rasavaha Srotasa causes Vidaha of the stagnant Rasa. It then moves upwards leading to severe cough.

3.   Swarabheda

 Swarabheda is brought about by morbid Vata, Pitta, Kapha or Rakta or by excessive strain during bouts of cough or due to Pratishyaya.

4.   Sarakta Kapha Nishthivana

 In the emaciated patient of Rajayakshma, Vishamashana causes Sarakta Kapha Nishthivana.

5.   Rakta Vamana

Due to obstruction in Raktavaha Srotas the Rakta is not converted into further Dhatus and gets accumulated in Amashaya. This accumulated Rakta Dhatu is vomited through throat.

6.   Shwasa

Vitiated Vata and Kapha Doshas obstruct the Urah region leading to Shwasa.

7.   Atisara

As a consequence of vitiated Dosha, the Agni get impaired resulting in foamy, frequent and loose stools.

8.     Aruchi

Aruchi is caused by vitiation of one or all the three Doshas. These are localized either in tongue or Amashaya. This may be due to psychological aversion to food.

9.   Chhardi

 It may occur due to excessive cough or as a complication of other symptoms.

10.  Jwara

It is manifested when the vitiated Dosha get localized in the Sandhi (Ch. Ni.8). In the patients of Rajayakshma it is of Pralepaka types. This is caused by all the three Dosha but Vata and Kapha are more dominant.

PURVARUPA


As many as 56 Purvarupa of Rajayakshma are quoted in different texts, that can be divided into 4 categories viz. Sharirka, Manasika, Adrishtaja and Swapnaja.

1.      Sharirika

Those prodromal symptoms which occur due to vitiation of Dosha, Dushya, Srotamsi etc. are included in this category. For e.g. Pratishyaya, Kshvathu, Shleshmapraseka etc. These can be further classified according to the Srotasa involved as enlisted in table.

2.     Manasika

 The prodromal symptoms which are produced when there is vitiation of Manasika Dosha are categorized under Manasika Purvarupa. For instance  Bahupramanajignyasa, Nighrunatva etc. These are not found in children. Child may seem irritable due to ailment but specific symptoms described in text are not found.

3.      Adrishtaja

 These prodromal symptoms cannot be explained like ‘Makshika Trinkesha Prayoannapanayoh’. These are also of no significance in case of children.

4.     Swapnaja

 In Ayurveda some specific dreams have been described as Purvarupa of Rajayakshma. In Indriya Sthana also some dreams are mentioned as Purvarupa Arishta of this disease. But these are difficult to assess in case of children because they are not able to explain their dreams but sometimes they get awakened with fear due to some bad dream. The Purvarupas according to various authors are enlisted here.

PURVARUPA OF RAJAYAKSHMA

.

SHARIRIKA

Pranavaha Srotasa

Pratishyaya , Kshavathu , Shwasa ,  Pinasa , Kasa , Murdha gunthanam , Swarabheda  Shiroruja , Shiras, paripurnatvam , Urakshata

Annavaha Srotasa

Shleshma praseka ,  Mukha madhuryama , Anannabhilasha , Bhuktavataschaya Hrillasa , Utkleshanama, ahara antara antara , Chhardi ,  Agnisada ,  Mamsopara ,
Aruchi , Avipaka  

Udakavaha Srotasa

Talu mukha shosha , Rasavaha Srotasa Annakale ayasa , Mukhapada, shopha,
Akshno atimatra, shvetavabhasata , Angasada , Pandu , Nidra , Anidra , Ashnatopibalakshaya , Durbalendriya , Nana srava , Mridu jvara

Raktavaha Srotasa

Mada ,  Murccha , Shonita nishthivana , Mamsavaha Srotas, Hasta pada shosha

Medovaha Srotas

 Uruatisvidyate ,

 Asthivaha Srotas

Nakha kesha roma, ativriddhi

 Shukravaha Srotas

 Strikamata

MANASIKA

Kamottha kopanam , Alpadosheshu, adosheshu doshadarshanam, Panyashya, avikshamana, atyarthama, Bahu pramana, jignyasa , Nighruntva , Kaye bhibhatsa ,
darshanam

 ADRISHTAJA

Makshika, trinakesha prayonnapanayoh, Uchita hriyate chhaya , Madya priyata ,

SWAPNAJA

Darshanam, anudakanama, uddakosthanama, Gram nagar nigam, janapada  shunyate , Pavana dhuma dava ardita taru , Krikalasa, mayura vanara shuka, sarpa, kaka, uluka, shallaki nilamantha, ghridhra sparshanam Varaha ustara khara kasha asthi bhasma tusha angara rashi adhirohanam Jyotirgirinam
patatam , Jvalatam cha mahiruham ,
 Not found in children.

RUPA

Almost all Acharyas have described the cardinal symptoms
of Rajayakshma under three headings viz. Trirupa, Shadrupa and Ekadasharupa Rajayakshma as given in Table –

Trirupa                                      Shadrupa                                Ekadasharupa
1. Ansaparshwa Abhitapa        1. Kasa                                1. Kasa
2. Karapada Santapa               2. Jwara                               2. Ansatapa
3. Jwara                                   3. Parshwashoola                3. Vaiswarya
                                                 4. Swarsada                        4. Jwara
                                                 5. Varchobheda                   5. Parshwaruja
                                                 6. Aruchi                              6. Shiroruja
                                                                                             7. Kapha Nishthivana
                                                                                             8. Rakta Chhardi

However, Chakrapani opined that only Ekadasharupa should be taken as full-fledged syndrome of Rajayakshma (Ch. Chi. 8/31, Chakrapani). The other two i.e. Trirupa and Shadrupa should be considered as the earlier stages of the disease. In Nidana Sthana, Acharya Charaka has described the clinical anifestations  according to the four etiological factors described earlier. They are somewhat similar to the Ekadasharupa but new symptoms are also added as shown in table –

RUPA OF RAJAYAKSHMA ACCORDING TO ETIOLOGICAL FACTORS

1.      Sahasaja

Jwara , Swarasada ,  Pratishyaya ,  Shirahshoola ,  Kasa , Kanthodhwans ,
 Angamarda , Arochaka ,Shwasa ,Shonita, Shthivana, Daurbalya, Varchobheda, Jrimbha, Uroroga


2.      Sandharnaja

Jwara , Swarasada ,  Pratishyaya ,  Shirahshoola ,  Kasa , Kanthodhwans, Shwasa, Varchobheda , Parshwashoola, Ansavamarda, Shoola ,Purishaupashoshanam

             3.  Kshayaja

Jwara , Swarasada ,  Pratishyaya ,  Shirahshoola ,  Kasa , Kanthodhwans, Angamarda ,Arochaka , Shwasa ,Shonita, Shthivana , Daurbalya ,Varchobheda , Parshwashoola ,
Ansavamarda, Avipaka
        

            4. Vishama –Ashanaja

Jwara , Swarasada ,  Pratishyaya ,  Shirahshoola ,  Kasa , Kanthodhwans, Angamarda ,Arochaka , Shonita, Shthivana , Daurbalya ,Varchobheda , Parshwashoola ,Ansavamarda, Antardaha

From the above table, it is found that Jwara, Swarasada, Pratishyaya, Shirahshoola, Kasa and Kanthodhwansa are six common symptoms to all the four etiological factors. Jrimbha and Uroroga are differentiating features of Sahasaja Rajayakshma; Shoola and Purisha Upashoshanam are the differentiating features of Sandharanaja Rajayakshma; Avipaka is of Kshayaja and Antardaha is the differentiating feature of Vishamashanaja Rajayakshma. Acharya Charaka has given an elaborate description of all the Ekadasharupa except Jwara which has been elaborated by Vijayarakshita. These are described as under –

1.     Pratishyaya Pratishyaya appears along with Shirahshoola, Shirogaurav, Ghranaviplava, Jwara, Kasa, Kapha Utklesha, Swarabheda, Aruchi, Klama and Indriya Asamarthya. All these then lead to Rajayakshma.


2.     Kasa The cough is productive and the sputum produced is viscid, white, yellow or green in colour with foul odour.


3.     Swarabheda Swarabheda is brought about by Vata, Pitta, Kapha, Rakta or by Kasa or Pratishyaya. When there is Vata dominance the voice becomes, husky, weak and unstable. There is burning of palate and throat and patient avoids to speak if there is dominance of Pitta and if the voice is affected by Kapha Dosha then it becomes low, chocked and is associated with wheeze. When Rakta get vitiated it creates dysphonia i.e. the voice becomes low and the patient feels difficulty in speech. Due to excessive coughing the throat gets injured as a result the patient feels pain during speech. Due to Pratishyaya the voice is same as that when afflicted by Vata and Kapha.

4.   Parshwashoola – It is not continuous and occurs only during respiratory movements.

5.   Shirahshoola – It is associated with fever and heaviness.

6.   Raktashthivan – When the patient gets emaciated blood stained sputum is expectorated.

7.   Rakta Vamana – When there is obstruction in Srotas the Rakta Dhatu is not converted into Mamsa and starts to accumulate. This excessive Rakta is then vomited.

8.   Shwasa The respiratory passage get obstructed by increased Vata and Kapha due to which there is difficulty in breathing i.e. dyspnoea.

9.    Atisara – Frequent, loose and foamy stools are passed.

10.   Aruchi – It could be due to one Dosha or all the three Doshas combinedly. The three Doshas i.e. Vata, Pitta and Kapha cause astringent, bitter and sweet taste respectively along with anorexia. Sometimes this anorexia may be due to psychological aversion to the food.

11.   Chhardi – This may be due to anorexia cough, vitiated Doshas or fear.

12.   Jwara – The fever comes with the feeling of wrapping up in wet cloth. This could be because of excessive sweating. The fever is of low grade and associated with chills. The patient feels heaviness (Ma. Ni. 2/41, Madhukosha).


UPADRAVA

Even though, it is said that many diseases follow the course
of Rajayakshma but no direct reference of Upadrava of Rajayakshma is seen in any Ayurvedic texts except Basavarajiyam in which some entities are enlisted as Upadravas of Rajayakshma which are given below –
1. Nare Padayoh shopha (oedema on feet in males)
2. Narishu mukha shopha (oedema on face of females)
3. Kukshi Guhya Ubhaya shopha (oedema on flanks and genitalia)
4. Atisara (diarrhoea)
5. Jwara (fever)
6. Mukha Hastapada Shosha (wasting of the facial muscles and
muscles of extremities)
7. Nasagata Raktasrava (epistaxis)
8. Pandu (anaemia)
9. Udara Roga (ascites)
10. Arsha (piles)
11. Gulma (abdominal mass)

SADHYA - ASADHYATA

As many as 25 symptoms can be seen in various texts, which denote the bad prognosis of the disease Rajayakshma and if these symptoms are not present then the disease is said to be curable these are enlisted as –
Parikshina, Mamsashonita , Jatarishta , Sarvalingeupdruta , Daurbalya , Vyadhi Aushadh, Bala Asaha ,Mahashanam, Kshiyamana , Atisara vipiditam , Shuna, Mushkodara , Shuklaksha , Annadveshta , Urdhava Shwasa, Nipiditam ,Kruchhrena Bahumehantam, Striyoabhilashte, Atiartham ,Ucchrito, Upadravam ,Mounama ,Purvarupeabhidrutam, Charana Shopha , Vipuchi Shleshma , Hinangama ,Shoola Shushka, Udara ,Bhinnakansya, Hataswara , Manda Buddhi , Heena Buddhi , Hikka, Vrananga Shosha ,

ARISHTA LAKSHANA
Acharya Charaka has mentioned Arishta Lakshanas of Rajayakshma at different places other than the description of general Arishta. Here only those Arishta Lakshanas are described which can be seen in childhood age. If the patient is continuously losing his Bala and Mamsa then the disease becomes incurable (Ch. Ind. 9/6). Similarly if the patient is suffering from Ansa Abhitapa, Hikka, Shonitachhardi, Anaha and Parshwashoola then the death of the patient is certain (Ch. Ind. 9/7).

CHIKITSA SIDDHANTA

The definition of ‘Chikitsa’ explained by Acharya Charaka (Ch. Su. 16/34) is perfectly applicable in case of Rajayakshma. He says that the treatment of disorders should consist of such operations as to give rise to the concordance of Dhatus. Treatment is given with the objective of ensuring that no discordance will arise in the Dhatus and there is continuance of their concordance. Here the term Dhatu refers to both Doshas and seven Dhatus as per the etymology of word ‘Dhatu’. In Rajayakshma there is vitiation of Doshas that ultimately leads to depletion of Dhatus. Therefore, the prime aim of management of Rajayakshma is concordance of Doshas and Dhatus that can be achieved by implementing the following line of treatment –
(A) Nidana Parivarjana
(B) Yukti Vyapashraya Chikitsa
(a) Bahi Parimarjana (b) Antah Parimarjana
(i) Abhyanga (i) Shodhana
(ii) Utsadana (ii) Shamana
(iii) Snana (iii) Rasayana
(iv) Avgahana
(v) Pradeha - Pralepa etc.
(C) Ahara Chikitsa
(D) Daiva Vyapashraya Chikitsa

 (A) NIDANA PARIVARJANA

Prevention is always better than cure. Acharya Charaka says that by avoiding things that give rise to discordance and practicing those that help concordance, the discordant elements do not persist and the concordant elements are continually brought into existence (Ch. Su. 16/36). Therefore, he has given extra emphasis to Nidana Parivarjana in the management of Rajayakshma (Ch. Ni. 6/5,7,9,11).

(B) YUKTI VYAPASHRAYA CHIKITSA

Yukti Vyapashraya Chikitsa can be divided into 2 types:
Bahi Parimarjana and Antah Parimarjana. Bahiparimarjana Chikitsa includes Abhyanga, Utsadana, Snana, Avgahana, Pralepa, Pradeha etc. as described by Acharya Charaka. While Antah Parimarjana Chikitsa includes Shodhana, Shamana and Rasayana therapy.

(i) ShodhanaAs the Bala of the patient of Rajayakshma is significantly reduced, the Shodhana therapy should be used very cautiously otherwise it may result in disastrous complications (Ch. Chi. 8/88). Also Acharya Charaka has mentioned that extreme care should be taken so that Shodhana should not result in further Karshana (Ch. Chi. 8/87) and for this reason Chakrapani at this place describes the use of Mridu Samshodhana. The Shodhana therapy should be applied only when Doshas are prevalent and proper Snehana and Swedana measures are followed. Acharya Sushruta has also advised that the Shodhana therapy should be of Mridu nature (Su. Ut. 41/34). Charaka has mentioned the use of Vamana and Virechana (Ch. Chi. 8/87) which are mentioned by Vagbhata also (As.Sa.Chi.7/4-5). While Acharya Sushruta has advised the use of all the four Shodhana measures viz. Vamana, Virechana, Asthapana and Shirovirechana in the management of Rajayakshma (Su. Ut. 41/34-35). In Case of children already Shodhana therapy is either contraindicated or if necessary it is advised to be of Mridu nature. Therefore, in case of Rajayakshma where there is already depletion of Dhatus, it is better to avoid Shodhana in this age group.

(ii) ShamanaIn case of Rajayakshma in children, the treatment of choice is Shamana therapy. For this purpose, Acharya Charaka has mentioned the use of various proved regimens for the management of various symptoms of the disease (Ch.Chi. 8/89). The perusal of the properties of various drugs prescribed by Charaka for treatment of Rajayakshma shows that they are mostly Hridya (Ch. Chi. 8/122), Deepana (Ch. Chi. 8/124), Brimhana (Ch. Chi. 8/149), Pachana (Ch. Chi.
8/136), Srotovishodhana (Ch. Chi. 8/166) and Harshakara (Ch. Chi. 8/182). Vagbhata has mentioned the use of Brimhana, Deepana, Hridya, Vataghna and Laghu Dravyas in the management of the disease (As. Sa. Chi. 7/6-7). Acharyas have given much importance to the use of Madya in its management. Acharya Charaka has made a special reference of daily use of Varuni Madya to combat Sandharanaja Rajayakshma (Ch. Chi. 8/164) but it is not applicable in children. It is advised by all Acharyas to keep keen observation on Purisha Samrakshana. As all Dhatus are loosing their potentials, it is only the Avasthambhana Karma of Purisha, which keeps the patient alive. Therefore, it is important to maintain its status in the body and physicians are advised not to give Virechana in excessive quantity in patients suffering from Rajayakshma (Ch. Chi. 8/42).

(iii) Rasayana Therapy - The word ‘Rasayana’ refers to nutrient ‘Rasa’ and its transportation in the body to nourish and replenish the other Dhatus. The process covers the nutrient fraction and its subsequent metabolic transformation and transportation under the influence of different Agnis of the body. Therefore, in Rajayakshma, Rasayana therapy plays an important role. Besides nourishing the Dhatus it prevents further damage by making the tissue strong enough not to
allow any invasion of the disease. Acharya Sushruta has described the use of Rasayana when the disease is approaching at untreatable stage (Su. Ut. 41/56). He has further prescribed the use of Rasona, Nagabala, Pippali and Shilajeet with appropriate method (Su. Ut. 41/59). All these Rasayana drugs except Shilajeet are also mentioned in Kashyapa Samhita along with Aja Rasayana (Ka. Rajayakshma Chikitsa). Vagbhata has also described Rasayana as the best treatment to combat this king of diseases (As. Sa. Chi. 7/108). After the introduction of Parada in the treatment, the term Rasayana was also used for Parada and its preparations. These preparations were also largely used in the management of Rajayakshma in later period.

(C) AHARA CHIKITSA

In the management of Rajayakshma, diet plays an important role, as there is depletion of all the Dhatus especially Mamsa Dhatu of the body. Therefore Acharya Charaka has mentioned various Mamsa preparations for this purpose. The different types of Mamsa are described according to the Dosha predominance viz. Vatashoshi is advised to take the Mamsa of Prasaha, Bhushaya, Anupa, Varija and Varichara while Kapha Pitta Shoshi is advised to take the Mamsa of Pratuda, Vishikara, Dhavaja, Mriga and Dwija (Ch. Chi. 8/160). Besides these Acharya has emphasized to take Kaphaghna Ahara due to dominance of Kapha Dosha in Rajayakshma (Ch. Chi. 8/120).

(D) DAIVA VYAPASHRAYA CHIKITSA

Devata Pujana, Guru Uparjana, Brahamacharya, Dana, Tapa, Mangala, Archana, Ahimsa are the methods implied of Daiva Vyapashraya Chikitsa in the management of Rajayakshma.

PATHYA APATHYA


PATHYA: Madya, Jangal-Pakshi-Mriga-Mamsa, Mudga, Shashtik, Godhnoom, Yava, Shali Dhanya, Madhur Rasa, Amraphala, Panas, Dhatriphala, Kharjura, Narikela, Draksha, Saindhav, Vasapatra, Goghrita, Mahishi Ghrita, Matsyandika etc. (Bh. Rat. 14/319-325).

APATHYA: Virechana, Vegavidharana, Shrama, Swedana, Prajagara, Sahasa, Ruksha Ahara, Vishamashana, Tambool, Kalinda, Kulattha, Masha, Vansha-ankur, Ramath, Amla-Tikta-Kashaya-Katu-Patrashaka, Viruddha Ahara, Kshara Padarth, Vidahi Ahara, Diwa Swap etc. (Bh. Rat. 14/327-329).