We shall now expound Raktapitta and Kasa nidana-diagnosis of bleeding disease and cough; thus said Atreya and other great sages.
अथातो रक्तपित्तकासनिदानं व्याख्यास्यामः ।
इति ह स्माहुरात्रेयादयो महर्षयः ।
Nidana and samprapti of raktapitta – causes and pathogenesis of bleeding disease
भृशोष्णतीक्ष्णकट्वम्ललवणादिविदाहिभिः कोद्रवोद्दालकैश्चान्नैस्तुद्युक्तैरतिसेवितैः कुपितं पित्तलैः पित्तं द्रवं रक्तं च मूर्च्छिते ।॥१॥
ते मिथस्तुल्यरूपत्वमागम्य व्याप्नुतस्तनुम् ॥ २ ॥
पित्तं रक्तस्य विकृतेः संसर्गाद्दूषणादपि । गन्धवर्णानुवृत्तेश्च रक्तेन व्यपदिश्यते ॥ ३ ॥
प्रभवत्यसृजः स्थानात्प्लीहतो यकृतश्च तत् ।
Over-indulgence in materials (of food, drink etc.) which are profoundly hot (heat producing), penetrating deep, pungent, sour, salt and such others which cause burning sensation during digestion, use of kodrava, uddalaka and such others, in more quantity and other causes ( activities) bring about increase of pitta.
By these causes, both pitta which is in liquid form and rakta (blood) which possess closer affinity get vitiated, mix together, assume identical qualities, spread throughout the body, and produce the disease Raktapitta. Pitta being the bye-product of rakta (blood) because of their admixture and property of vitiating each other, and resemblence in smell and colour, it ( pitta ) is reffered to (in the text) as rakta (blood).It (the disease called raktapitta) originates from the seat of rakta (blood) that is the pliha (spleen) and yakrt ( liver). 1-4a.
Notes: Pitta and rakta both being agneya possess similar properties and greater affinity. Both get increased by the same cause, at the same time and give rise to the disease-raktapitta, charactorised by bleeding from different parts of the body. Use of the terms “Pitta in liquid form” is to indicate the pacaka and ranjaka pitta, especially the former, present in the amasaya (stomach), yakrt (liver) and pliha (spleen), which become the sites of origin of the diseases. The blood that comes out is vitiated especially by pitta, associated with kapha and vata to a little extent. It will be having increased heat, liquidity, foul smell, tendency to penetrate the walls of the vessels and tissue cells, flows out continously; the property of clotting being either diminished or lost. Identification of this disease in modern perlance has not so far been satisfactory, disease like polycythemea vera, purpura, haemophilla, etc. Which are primarily haemorrhagic are some of the probables, the first one most likely.
Purvarupa – premonitory symptoms
शिरोगुरुत्वमरुचिः शीतेच्छा धूमकोऽम्लकः ॥ ४॥
छर्दिश्छर्दितबैभत्स्यं कास श्वासो भ्रमः क्लमः ।
नयनादिषु । वर्णानामविवेचनम् ॥ ६॥
स्वप्ने तद्वर्णदर्शित्वं भवत्यस्मिन् भविष्यति ।
Feeling of heaviness of the head, loss of taste (or appetite), desire for cold, feeling of hot fumes coming out (from the stomach through the mouth), (increased) acidity, vomitting, fear from vomitting (by the sight of the vomitted materials) cough, dyspnoea, dizziness, exhaustion, feeling of the smell of iron, blood and raw fish in the mouth, loss of voice, red, termeric (deep yellow) green colour of the eyes etc. (skin, tougue, nails, urine, faeces), inability to recognise blue, red and yellow colours, seeing objects of the same colour (red, deep yellow or green) in dreams-are the symptoms of the forthcoming disease. 4b-7a.
Rupa – clinical features
ऊर्ध्वं कुपितं नासाक्षिकर्णास्यैर्मेढ्रयोनिगुदैरधः ॥ ७ ॥ समस्तैस्तत्प्रवर्तते । रोमकूपैश्च
It (vitiated blood) comes out from the upper parts through the noise, eyes, ears, and mouth; from the lower parts through the penis (urethra), yoni (vagina and genital tract) and rectum; from all the channels, the hair follicles (in the skin) and all other sites (of both upper and lower regions). 7b-8a.
Sadhyasadhyata – prognosis
Notes : The disease is of three types-viz, ordhvagata-bleeding in upward direction, adhogata-bleeding in downward direction and ubhayamargagata or tiryaggata-bleeding from upward, downward and all directions simultaneously. Pitta is the primary causative dosa for all the types, but the secondory or associate dosa is different, kapha for the upward type, vata for the downward type and all the three for the third type.
ऊर्ध्वं साध्यं कफाद्यस्मात्तद्विरेचनसाधनम् ॥ ८ ॥
बह्वौषधं च पित्तस्य विरेको हि वरौषधम् । अनुबन्धी कफो यश्च तत्र तस्यापि शुद्धिकृत् ॥ ९ ॥
कषायाः स्वादवोऽप्यस्य विशुद्धश्लेष्मणो हिताः । किमु तिक्ताः कषाया वा ये निसर्गात्कफापहाः ॥ १० ॥
Urdhvaga (upward direction ) is sadhya (curable) because of kapha (being the associate dosa); for this (the disease ) purgation is the ( ideal) method of treatment, of availablity of large number of drugs; for ( mitigating ) pitta, purgation is the best therapy, and it also clears ( mitigates ) kapha, the associate dosa. Kasayas ( recipes / medicinal forms such as fresh juice, infusion, decoction, powder etc.) though sweet are suitable for the person who has been freed from kapha; then what to say of those recipes which are bitter or astringent, which are by nature mitigaters of kapha. 8-10.
Notes Pratimargaharana-conquering the disease through the opposite direction-is one of the methods of treatment which is applicable to this disease. Diseases having upward and downward directions are controlled by creating movement in the opposite directions respectivelly, eg. severe vomitting is controlled by producing purgations and severe diarrhoea by producing vomitting. Similarly for control of bleeding of upward direction, purgative therapy and of downward directions, emesis therapy are said to be ideal.
अधो याप्यं यलाद्यस्मात्तत्प्रच्छर्दनसाधनम् । अल्पौषधं च पित्तस्य वमनं न वरौषधम् ॥ ११ ॥
अनुबन्धी चलो यश्च शान्तयेऽपि न तस्य तत् । कषायाश्च हितास्तस्य मधुरा एव केवलम् ॥ १२ ॥
Adhoga (downward type ) is yapya (incurable, controllable) because of cala (vata being the associate dosa ), for it (the disease) emesis is the means ( ideal method of treatment) and of availablity of less number of drugs. For (mitigating) pitta, emesis is not the ideal therapy; cala (vata) being the associate dosa, the recipes (which are astringent or bitter ) are incapable (to mitigate ). 11-12.
कफमारुतसंसृष्टमसाध्यमुभयायनम् अशक्यप्रातिलोम्यत्वादभावादौषधस्य च ॥ १३ ॥
न हि संशोधनं किञ्चिदस्त्यस्य प्रतिलोमगम् । शोधनं प्रतिलोमं च रक्तपित्ते भिषग्जितम् ॥ १४ ॥
एवमेवोपशमनं सर्वशो नास्य विद्यते । संसृष्टेषु हि दोषेषु सर्वजिच्छमनं हितम् ॥ १५ ॥
Ubhayayana (both directions simultaneously) type is asadhya (incurable) because of, kapha and maruta (vata) are the associate dosas, of impossibility of administering therapies opposite of the directions ( of bleeding) and of nonavailability of drugs ( in sufficient number), there is no purificatory therapy which is opposite of both the directions, but for raktapitta, the ideal treatment is purifactory therapy opposite to the direction (of bleeding); similarly there is no palliative method for all the dosas; and when all the dosas are mixed together, simultaneous mitigation of all them is 13-15. (most) suitable.
तत्र दोषानुगमनं सिरास्त्र इव लक्षयेत् । उपद्रवांश्च विकृतिज्ञानतस्तेषु चाधिकम् ॥ १६ ॥ आशुकारी यतः कासस्तमेवातः प्रवक्ष्यति ।
If this disease, (raktapitta) recognition of the (vitiating ) dosa is similar to that described in venesection ( chapter 27 of sutrasthana). Its upadrava (secondary diseases, complica tions) are those enumerated in vikrti vijnaniya ( chapter 5 of sarira sthana ). Among them kasa ( cough ) is going to kill the 16-17a. person soon, hence its description further on.
Kasa nidana – diagnosis of cough
पञ्च कासाः स्मृता वातपित्तश्लेष्मक्षतक्षयैः ॥ १७ ॥ क्षयायोपेक्षिताः सर्वे बलिनश्चोत्तरोत्तरम् ।
Kasa ( cough) is said to be of five kinds (one each ) from. vata, pitta, slesman ( kapha); from ksata (injury to the chest ( lungs) and ksaya (consumption ) ; all of them lead on to ksaya if neglected and are strong in the succeeding order (succeeding kind stronger than its preceeding kind ). 17-18a.
Purvarupa – premonitory symptoms
तेषां भविष्यतां रूपं कण्ठे कण्डूररोचकः ॥ १८ ॥ शूकपूर्णाभकण्ठत्वम्
Their premonitory features are-irritation in the throat, loss of taste/appetite, feeling as though the throat is full of thorns. 18b-19a.
Samprapti – pathogenesis
तत्राधो विहतोऽनिलः ।
ऊर्ध्वं प्रवृत्तः प्राप्योरस्तस्मिन् कण्ठे च संसजन् ॥ १९ ॥ शिरः स्त्रोतांसि सम्पूर्य ततोऽङ्गान्युत्क्षिपन्निव । क्षिपन्निवाक्षिणी पृष्ठमुर: पार्श्वे च पीडयन् ॥ २० ॥ प्रवर्तते स वक्त्रेण भिन्नकांस्योपमध्वनिः । हेतुभेदात्प्रतीघातभेदो वायोः सरंहसः ॥ २१ ॥ यद्रुजाशब्दवैषम्यं कासानां जायते ततः।
Anila (vata) obstructed in its downward movement, be ings to move upwards, reaching the chest, invades the throat and then filling the channels of the head, makes for violent upward movement of the body, the eyes, back and chest; pain in the flanks, and comes out of the mouth producing noise resembling the sound of a broken bell-metal.
From the difference in the causes (causative dosa) there is difference in the nature of obstruction of the forceful vata; hence there occurs differences in the pain (symptoms) and the sound of cough. 19b-22a.
Rupa – clinical features
Vataja kasa (features of cough of vata origin)
कुपितो वातलैर्वातः शुष्कोर: कण्ठवक्त्रताम् ॥ २२ ॥
मोहक्षोभस्वरक्षयान् । हृत्पार्श्वोर: शिरःशूलं करोति शुष्कं कासं च महावेगरुजास्वनम् ॥ २३ ॥
सोऽहर्षी कर्फ शुष्कं कृच्छ्रान्मुक्त्वाऽल्पतां व्रजेत् ।
Vata undergoing aggravation (increase ) from aggravating causes, produces dryness of the chest, throat and mouth, pain in the (region of ) heart, flanks and head; delusion, agitation of the mind, loss of voice, gives rise to dry cough accompanied with violent bouts, severe pain and great noise, and horripilations; the person brings out dry sputum with difficulty and after that it ( cough ) gets reduced. 22-24a.
Pittaja kasa (features of cough of pitta origin)
पित्तात्पीताक्षिकफता तिक्तास्यत्वं ज्वरो भ्रमः ॥ २४ ॥
पित्तासृग्वमनं तृष्णा वैस्वर्यं धूमकोऽम्लकः । प्रततं कासवेगेन ज्योतिषामिव दर्शनम् ॥ २५ ॥
From pitta, there is yellow colouration of the eyes and sputum, bitter taste in the mouth, fever, dizziness, vomitting of pitta and asrk (blood), thirst, hoarseness, feeling of hot fumes coming out through the mouth, (increased) acidity, continuous cough keeping the patient gazing at the stars, sitting up with his face turned upward. 24b-25.
Kaphaja kasa (features of cough of kapha origin )
कफादुरोऽल्परूड्मूर्द्धहृदयं स्तिमितं गुरु |
कण्ठोपलेपः सदनं पीनसच्छर्घरोचकाः ॥ २६ ॥ रोमहर्षो घनस्निग्धश्वेतश्लेष्मप्रवर्तनम् ।
From kapha, there is mild pain in the chest, head and (region of) the heart, very little movement (of the chest) and feeling of heaviness, coating of the throat, debility, running in the nose, vomitting, loss of taste/appetite, horripilations; thick, sticky, white sputum is expelled out. 26-27a.
Ksataja kasa (features of cough due to trauma to lungs)
युद्धाद्यैः साहसैस्तैस्तै: सेवितैरयथाबलम् ॥ २७ ॥
उरस्यन्तः क्षते वायुः पित्तेनानुगतो बली | कुपितः कुरुते कासं कफं तेन सशोणितम् ॥ २८ ॥
पीतं श्यावं च शुष्कं च ग्रथितं कुथितं बहु | ष्ठीवेत्कण्ठेन रुजता विभिन्नेनेव चोरसा ॥ २९ ॥
सूचीभिरिव तीक्ष्णाभिस्तुद्यमानेन शूलिना । पर्वभेदज्वरश्वासतृष्णावैस्वर्यकम्पवान् ॥३०॥
पारावत इवाकूजन् पार्श्वशूली ततोऽस्य च । क्रमाद्वीर्यं रुचि: पक्ता बलं वर्णश्च हीयते ।। ३१ ।।
क्षीणस्य सासृड्मूत्रत्वं स्याच्च पृष्ठकटीग्रहः ।
By indulgence in fighting in war, adventerous activities etc., in excess of ones strength, there occurs a wound inside the chest, (lungs); vayu (vata) getting increased and associating with the pitta, produces cough; by these, the patient brings out sputum mixed with blood, yellow or black in colour, dry (non-unctuous), nodular, foul smelling and large in quantity; severe pain in the throat, pain in the chest as though pricked by sharp needles, pain in the joints, fever, dyspnoea, thirst, hoarseness, tremors; cooing sound like that of a pegion comes out of the throat, pain in the flanks also appear; vigour, desire for food, digestion, strength and colour (complexion) get diminished steadity, emaciation, urine is mixed with blood and catching pain in the back and waist develop. 27b-32a.
Ksayaja Kasa (cough due to consumption, pulmonary tuberculosis)
वायुप्रधानाः कुपिता धातवो राजयक्ष्मणः ॥ ३२ ॥
कुर्वन्ति यक्ष्मायतनैः कासं ष्ठीवेत्कफं ततः । पूतिपूयोपमं पीतं विस्त्रं हरितलोहितम् ॥ ३३ ॥
लुच्येत इव पार्श्वे च हृदयं पततीव च । अकस्मादुष्णशीतेच्छा बहाशित्वं बलक्षयः ॥ ३४ ॥
स्निग्धप्रसन्नवक्त्रत्वं श्रीमद्दशननेत्रता ।
ततोऽस्य क्षयरूपाणि सर्वाण्याविर्भवन्ति च ॥ ३५ ॥
All the dhatus (dosas) with the predominance of vata, produce cough in patients of rajayaksma (pulmonary tuberculosis). The patient brings out sputum which is putrified,