Chapter 10 — Rajayakshma – Kshatakshina Nidanam

The 10th chapter of Madhava Nidana deals with Rajayakshma – Kshatakshina Nidana ie., Diagnosis of Pulmonary Tuberculosis or Tuberculosis. Tuberculosis (TB) is a potentially serious infectious disease that mainly affects the lungs. The bacteria that cause tuberculosis are spread from person to person through tiny droplets released into the air via coughs and sneezes.

वेगरोधात् क्षयच्चैव साहसाद्विषमाशनात् |
त्रिदोषो जायते यक्ष्मा गदो हेतुचतुष्टयात् || १ ||

vēgarōdhāt kṣayaccaiva sāhasādviṣamāśanāt |
tridōṣō jāyatē yakṣmā gadō hētucatuṣṭayāt || 1 ||

The four etiological factors that produce the disease of consumption in which tri doshas are involved are –

• Vega Rodha — Suppression of natural urges,
• Kshaya — Emaciation,
• Sahasa — Over – indulgence in daring deeds and
• Vishamashanaat — Irregular eating habits. 1

Pathogenesis of Rajayakshma –

कफ प्रधानैर्दोषैस्तु रुद्धेषु रस वर्त्मसु |
अति व्यव्यायिनो वा अपि क्षीणे रेतस्यनन्तराः |
क्षीयन्ते धातवः सर्वे ततः शुष्यति मानवः || २ ||

kapha pradhānairdōṣaistu ruddhēṣu rasa vartmasu |
ati vyavyāyinō vā api kṣīṇē rētasyanantarāḥ |
kṣīyantē dhātavaḥ sarvē tataḥ śuṣyati mānavaḥ || 2 ||

When the rasavaha srotas (Channels through which rasa dhatu or the blood plasma circulates) gets obstructed by the tridoshas particularly by kapha; or when one indulges in excessive sexual inter course leading to the loss of semen, all the other dhatus of the body undergo deficiency, making the person too much emaciated. 2

Prodromal features of Rajayakshma — 

श्वासाङ्गमर्द – कफसंस्रव – तालुशोष –
वम्याग्निसाद – मद – पीनस – कास – निद्राः |
शोषे भविष्यति भवन्ति स चापि जन्तुः
शुक्लेक्षणो भवति मांसपरो रिरंसुः || ३ ||
स्वप्नेषु काक – शुक – शल्लकि – नीलकण्ठा
गृध्रास्तथैव कपयः कृकलासकाश्च |
तं वाहयन्ति स नदीर्विजलाश्च पश्ये –
च्छुष्कांस्तरून् पवन – धूम – दवार्दितांश्च || ४ ||

śvāsāṅgamarda – kaphasansrava – tāluśōṣa –
vamyāgnisāda – mada – pīnasa – kāsa – nidrāḥ |
śōṣē bhaviṣyati bhavanti sa cāpi jantuḥ
śuklēkṣaṇō bhavati mānsaparō riransuḥ || 3 ||
svapnēṣu kāka – śuka – śallaki – nīlakaṇṭhā
gr̥dhrāstathaiva kapayaḥ kr̥kalāsakāśca |
taṁ vāhayanti sa nadīrvijalāśca paśyē –
cchuṣkānstarūn pavana – dhūma – davārditānśca || 4 ||

These are the prodromal features of Tuberculosis –

• Shvasa — Dyspnea
• Anga marda — Pain in the body
• Kapha srava — Spitting of mucus
• Talu shosha — Dryness of the palate
• Vamya — Vomiting
• Agni sada — Dyspepsia
• Mada — Dizziness
• Pinasa — Running of nose
• Kasa — Cough
• Nidra — Excess sleep
• Shukle Aksha — Eyes turning bright white
• Mamsa Riramsu — Craving for meat
• Sexual intercourse

Such person dreams as if he is being carried away by a crow, parrot, porcupine, peacock, vulture, monkey and chameleon. He also dreams of rivers without water, trees without leaves, and of breeze, smoke, and forest fire. 3 – 4

Symptomatology of Rajayakshma –

अंस – पार्श्वाभितापश्च संतापः करपादयोः |
ज्वरः सर्वाङ्ग च इति लक्षणं राजयक्ष्मणः || ५ ||

ansa – pārśvābhitāpaśca santāpaḥ karapādayōḥ |
jvaraḥ sarvāṅga ca iti lakṣaṇaṁ rājayakṣmaṇaḥ || 5 ||

The features of Rajayakshma are –

• Amsa Parshva Abhitapa — Discomfort (pain) in one shoulder and flanks
• Kara Pada Santapa — Feeling of a mild burning sensation in hands and feet
• Sarvanga Jvara — Fever all over the body

Six features of  Rajayakshma –

(भक्तद्वेषो ज्वरः श्वासः कासः शोणितदर्शनम् |
स्वरभेदश्च जायेत षड् रूपं राज यक्षमणि ||)

(bhaktadvēṣō jvaraḥ śvāsaḥ kāsaḥ śōṇitadarśanam |
svarabhēdaśca jāyēta ṣaḍ rūpaṁ rāja yakṣamaṇi ||)

The six major symptoms of Rajayakshma are –

• Bhakta dvesha — Aversion to eatables
• Jvara — Fever
• Shvasa — Dyspnea
• Kasa — Cough
• Shonita Darshana — Appearance of blood in the sputum
• Svara Bheda — Hoarseness of voice

Eleven features of Rajayakshma and the relationship with doshas –-

स्वरभेदो अनिलाच्छूलं सङ्कोचश्वास पार्श्वयोः |
ज्वरो दाहो अतिसारश्च पित्ताद्रक्तस्य चागमः || ६ ||
शिरसः परिपूर्णत्वभक्तच्छन्द एव च |
कासः कण्ठस्य चोद्ध्वंसो विज्ञेयः कफकोपतः || ७ ||

svarabhēdō anilācchūlaṁ saṅkōcaśvāsa pārśvayōḥ |
jvarō dāhō atisāraśca pittādraktasya cāgamaḥ || 6 ||
śirasaḥ paripūrṇatvabhaktacchanda ēva ca |
kāsaḥ kaṇṭhasya cōddhvansō vijñēyaḥ kaphakōpataḥ || 7 ||

The eleven features of Consumption are –

• Svara Bheda — Hoarseness of voice
• Parshva Sankocha and Shoola — Painfulness and shrinking in the scapular region and flanks
• Jvara — Fever
• Daha — Burning sensation and
• Atisara — Diarrhoea are the symptoms produces due to Vata

When affected by Rajayakshma or tuberculosis the ailment haemorrhage occurs due to provoked pitta while the kapha aggravation leads to

• Shirasa Paripurnatvam — Heaviness in the head
• Bhaktaa cchanda — Lack of desire for taking food
• Kasa — Cough
• Kanthasya dhvansa — Irritation in the throat. 6-7

Prognosis of Rajayakshma —

एकादशभिरेभिर्वा षड्भिर्वा अपि समन्वितम् |
कासातीसार — पार्श्वार्ति – स्वरभेदारुचि – ज्वरैः || ८ ||
त्रिभिर्वा पीडितं लिङ्गैः कास – श्वासासृगामयैः |
जह्याच्छोषार्दितं जन्तुमिच्छन् सुविमलं यशः || ९ ||

ēkādaśabhirēbhirvā ṣaḍbhirvā api samanvitam |
kāsātīsāra — pārśvārti – svarabhēdāruci – jvaraiḥ || 8 ||
tribhirvā pīḍitaṁ liṅgaiḥ kāsa – śvāsāsr̥gāmayaiḥ |
jahyācchōṣārditaṁ jantumicchan suvimalaṁ yaśaḥ || 9 ||

The physicians desiring reputation should avoid cases of tuberculosis that manifests presence of all the eleven features of the disease described above.

Even if there is a case reflecting the six features., viz.,the wise physicians should not take up the case —

• Kasa — Cough
• Atisara — Diarrhoea
• Parshva Arti — Pain in the flanks
• Svara Bheda — Hoarseness of voice
• Aruchi — Anorexia
• Jwara  — Fever

The wise should also discard the cases of tuberculosis that manifest the three features including cough, dyspnoea, and appearance of blood in sputum. 8 – 9

सर्वैरधैर्स्त्रिभिर्वा अपि लिङ्गैर्मांस – बलक्षये |
युक्तो वर्ज्यः चिकित्स्यस्तु सर्वरूपो अप्यतो अन्यथा || १० ||

sarvairadhairstribhirvā api liṅgairmānsa – balakṣayē |
yuktō varjyaḥ cikitsyastu sarvarūpō apyatō anyathā ||10||

Moreover, a patient who suffers from wasting of muscles and strength is also fit for refusal if he manifests all the eleven, six or the three features described above. However, the patient even if he is having all the 11 symptoms described above could be cured if he retains his muscles and strength. 10

महाशनं क्षीयमाणमतीसार निपिडितं |
शूनमुष्कोदरं चैव यक्षिमणं परिवर्जयेत् || ११ ||

mahāśanaṁ kṣīyamāṇamatīsāra nipiḍitaṁ |
śūnamuṣkōdaraṁ caiva yakṣimaṇaṁ parivarjayēt || 11 ||

The patients of yakshma who eat large quantities of eatables but still undergo wasting; who are having diarrhoea, oedema of the scrotum and abdomen are also to be avoided. 11

शुक्लाक्षमन्नद्वेष्टारमूर्ध्वश्वास निपिडितं |
कृच्छ्रेण बहुमेहन्तं यक्ष्मा हन्तीह मानवम् || १२ ||

śuklākṣamannadvēṣṭāramūrdhvaśvāsa nipiḍitaṁ |
kr̥cchrēṇa bahumēhantaṁ yakṣmā hantīha mānavam || 12 ||

Yakshma kills such persons who have developed whiteness of eyes, have aversion to food, have a difficult breathing and urination. 12

Curability of Rajayakshma —

ज्वरानुबन्धरहितं बलवन्तं क्रियासहम् |
उपक्रमेदात्मवन्तं दीप्ताग्निमकृशं नरम् || १३ ||

jvarānubandharahitaṁ balavantaṁ kriyāsaham |
upakramēdātmavantaṁ dīptāgnimakr̥śaṁ naram || 13 ||

Treatment can be given to the patients of Yakshma who do not have fever, who are strong, able to withstand the discomforts of treatments, who are of strong will and proper digestive capacity, and who has not been emaciated. 13

The two types of consumption –

व्यवाय – शोक – वार्धक्य – व्यव्यामाध्वप्रशोषितान् |
व्रणोरःक्षतसंज्ञौ च शोषिणौ लक्षणैः शृणु || १४ ||

vyavāya – śōka – vārdhakya – vyavyāmādhvapraśōṣitān |
vraṇōraḥkṣatasañjñau ca śōṣiṇau lakṣaṇaiḥ śr̥ṇu || 14 ||

Henceforth are described features of the seven types of shosha classified according to their etiological factors:

• Vyavaya — Indulgence in excessive sexual intercourse
• Shoka — Grief
• Vardhakya — Old age
• Vyavyama — Hard work and
• Adhva — Travelling long distances on foot as well as
• Vrana — Chronic ulcers
• Kshata Vrana — Chest lesions 14

Consumption due to over indulgence in sexual act –

व्यवाय शोषी शुक्रस्य क्षयलिङ्गैरूपद्रुतः |
पाण्डुदेहो यथापूर्वं क्षीयन्ते चास्य धातवः || १५ ||

vyavāya śōṣī śukrasya kṣayaliṅgairūpadrutaḥ |
pāṇḍudēhō yathāpūrvaṁ kṣīyantē cāsya dhātavaḥ || 15 ||

Presence of features of deficiency of semen and yellowish white complexion of the body and subsequent wasting of the other tissues of the body are seen in persons who indulge in excessive sexual intercourse. 15

Consumption caused by grief –-

प्रद्यानशीलः स्र्स्ताङ्ग शोक शोष्यपि तादृशः |

pradyānaśīlaḥ srstāṅga śōka śōṣyapi tādr̥śaḥ |

Too much of worry, looseness and weakness of the body are seen in the person who is wasted due to excessive grief.

Consumption caused by senility –-

जराशोषि कृशो मन्दवीर्य – बुद्धि – बलेन्द्रियः || १६ ||
कम्पनो अरुचिमान् भिन्नकांस्यपात्रहतस्वरः |
ष्टिवति श्लेष्मणा हीनं गौरवारति पीडितः || १७ ||
सम्प्रस्त्रुतास्य — नासाक्षिः – शुष्क – रुक्ष – मल – च्छविः |

jarāśōṣi kr̥śō mandavīrya – buddhi – balēndriyaḥ || 16 ||
kampanō arucimān bhinnakānsyapātrahatasvaraḥ |
ṣṭivati ślēṣmaṇā hīnaṁ gauravārati pīḍitaḥ || 17 ||
samprastrutāsya — nāsākṣiḥ – śuṣka – rukṣa – mala – cchaviḥ |

The old age patients suffering from consumption manifest the following symptoms:

• Emaciation
• Low potency
• Mental dullness
• Reduced strength
• And tremor.

Such patients develop anorexia; their voice appears as if it is coming out of a broken bronze vessel. The patients spit small amounts of phlegm, suffer from heaviness, instability, have exudation from mouth, nose, eyes and they develop a dry, rough and pale complexion. 16-17

अध्वशोषि च स्त्रस्ताङ्गः सम्भृष्टपरुषच्छविः ||१८ ||
प्रसुप्तगात्रावयवः शुष्क – क्लोम – गलाननः |

adhvaśōṣi ca strastāṅgaḥ sambhr̥ṣṭaparuṣacchaviḥ ||18 ||
prasuptagātrāvayavaḥ śuṣka – klōma – galānanaḥ |

Patients wasted due to constant and long distance walking manifest the following symptoms:

• Weakness
• Hardness
• And loss of sensation in the body parts
• Dryness of kloma, throat and mouth. 18

Consumption caused by strenuous exercise –

व्यायामशोषि भूयिष्टमेभिरेव समन्वितः |
लिङ्गैरुरःक्षतकृतैः संयुक्तश्च क्षतं विना || १९ ||

vyāyāmaśōṣi bhūyiṣṭamēbhirēva samanvitaḥ |
liṅgairuraḥkṣatakr̥taiḥ sanyuktaśca kṣataṁ vinā || 19 ||

Persons wasted due to excess physical exertion manifest the same symptoms as above. Moreover, he would also reflect features of injury to the chest without a lesion. 19

Incurability of consumption occurring to the wounded –

रक्तक्षयाद् वेदनाभिस्तथैवाहार यन्त्रणात |
व्रणितस्य भवेच्छोषः स चासाध्यतमो मतः || २० ||

raktakṣayād vēdanābhistathaivāhāra yantraṇāt |
vraṇitasya bhavēcchōṣaḥ sa cāsādhyatamō mataḥ || 20 ||

Wasting due to ulcer is generated by loss of blood and the consequent pain as well as due to intake of controlled diet (during the treatment of ulcer). This condition is difficult to treat. 20

Urahkshata (Traumatic chest) –

धनुषा आयस्यतो अत्यर्थं भारमुद्वहतो गुरुम् |
युध्यमानस्य बलिभिः पततो विषमोच्चतः || २१ ||
वृषं हयं वा धावन्तं दम्यं वा अन्यं निगृहणतः |
शिला काष्ठाश्मनिर्घतान् क्षिप्तो निघ्नतः परान् || २२ ||
अधीयानस्य वा अत्युच्चैर्दूरम् वा व्रजतो द्रुतम् |
महानदीर्वा तरतो हयेर्वा सह धावतः || २३ ||
सहसोत्पततो दूरम् तूर्णं वा अपि प्रनृत्यतः |
तथा अन्यैः कर्मभिः क्रुरैर्भ्रुशमभ्याहतस्य वा || २४ ||
विक्षते वक्षसि व्याधिर्बलवान् समुदीर्यते |
स्त्रीषु चातिप्रसक्तस्य रुक्षाल्पप्रमिताशिनः || २५ ||

dhanuṣā āyasyatō atyarthaṁ bhāramudvahatō gurum |
yudhyamānasya balibhiḥ patatō viṣamōccataḥ || 21 ||
vr̥ṣaṁ hayaṁ vā dhāvantaṁ damyaṁ vā anyaṁ nigr̥haṇataḥ |
śilā kāṣṭhāśmanirghatān kṣiptō nighnataḥ parān || 22 ||
adhīyānasya vā atyuccairdūram vā vrajatō drutam |
mahānadīrvā taratō hayērvā saha dhāvataḥ || 23 ||
sahasōtpatatō dūram tūrṇaṁ vā api pranr̥tyataḥ |
tathā anyaiḥ karmabhiḥ krurairbhruśamabhyāhatasya vā || 24 ||
vikṣatē vakṣasi vyādhirbalavān samudīryatē |
strīṣu cātiprasaktasya rukṣālpapramitāśinaḥ || 25 ||

Over indulgence in archery, carrying heavy loads on the head, combating with strong persons, falling from a height recklessly, forcibly stopping a mighty bull on run or horse or taming wild animals, throwing heavy stones, wooden catapults, fighting with enemies (using weapons), reading in a high pitch of sound, running fast long distances, swimming through mighty rivers, running along with horses, sudden jumping, indulging in strenuous dancing and such other acts of violence and excessive sexual intercourse, partaking of dry, scanty and non nutritious eatables generate injury to the chest (or lesion inside the lungs). 21 – 25

उरो विभज्यते अत्यर्थं भिध्यते अथ विरुज्यते |
प्रपिद्यते ततः पार्श्वे शुष्यत्यङ्गं प्रवेपते || २६ ||
क्रमाद्वीर्यं बलं वर्णो रुचिरग्निश्च हीयते |
ज्वरो व्यथा मनोदैन्यं विड्भेदाग्निवधावापि || २७ ||
दुष्टः श्यावः सुदुर्गन्धः पीतो विग्रथितो बहुः |
कासमानस्य चाभिक्ष्णं कफः सासृक् प्रवर्तते || २८ ||
स क्षती क्षीयते अत्यर्थं तथा शुक्रौजसोः क्षयात् |

urō vibhajyatē atyarthaṁ bhidhyatē atha virujyatē |
prapidyatē tataḥ pārśvē śuṣyatyaṅgaṁ pravēpatē || 26 ||
kramādvīryaṁ balaṁ varṇō ruciragniśca hīyatē |
jvarō vyathā manōdainyaṁ viḍbhēdāgnivadhāvāpi || 27 ||
duṣṭaḥ śyāvaḥ sudurgandhaḥ pītō vigrathitō bahuḥ |
kāsamānasya cābhikṣṇaṁ kaphaḥ sāsr̥k pravartatē || 28 ||
sa kṣatī kṣīyatē atyarthaṁ tathā śukraujasōḥ kṣayāt |

As a result the patient will have cutting or pricking pain in the chest and flanks, followed by emaciation. There is trembling of the body and gradually he loses potency, strength, and the natural complexion of body. He is also afflicted by diarrhoea and loss of appetite due to disturbed digestive fire. There is putrefied, black, stinking, yellow and knotty phlegm mixed with blood appearing repeatedly on coughing. The patient suffering from this disease (Urahkshata or traumatic chest) gets emaciated due to trauma and there is loss of semen and essential fluid (ojas) in his body. 26 – 28

Prodromal features of traumatic chest –

अव्यक्तं लक्षणं तस्य पुर्वरुपमिति स्मृतं || २९ ||

avyaktaṁ lakṣaṇaṁ tasya purvarupamiti smr̥taṁ || 29 ||

The features of this disease are seen in a mild form during the premonitory period. 29

The symptomatology of emaciation due to traumatic chest (Kshata kshina) –

उरोरुक् शोणितच्छर्दिः कासो वैशेषिकः क्षते |
क्षीणे सरक्तमूत्रत्वं पार्श्व – पृष्ठ – कटीग्रहः || ३० ||

urōruk śōṇitacchardiḥ kāsō vaiśēṣikaḥ kṣatē |
kṣīṇē saraktamūtratvaṁ pārśva – pr̥ṣṭha – kaṭīgrahaḥ || 30 ||

The cases if Urahkshata or traumatic chest, pain in the chest, vomiting of blood, cough are prominent if trauma is present, while urine mixed with blood, pain in the flanks, back, and waist (hips) are predominant if only emaciation is present. 30

Prognosis of kshata kshina – emaciation due to traumatic chest –

अल्पलिङ्गस्य दीप्ताग्नेः साध्यो बलवतो नवः |
परिसंवत्सरो याप्यः सर्वलिङ्गं तु वर्जयेत् || ३१ ||

alpaliṅgasya dīptāgnēḥ sādhyō balavatō navaḥ |
parisanvatsarō yāpyaḥ sarvaliṅgaṁ tu varjayēt || 31 ||

The condition is curable when the clinical manifestations are mild, appetite is good, general condition of the patient is satisfactory and the disease Is of recent origin. Nevertheless, if the disease has remained over one year, it might persist throughout life. If all the clinical features described above are present in the patient the disease would prove incurable. 31

इति माधवकरविरिचिते माधवनिदाने राजयक्ष्मक्षतक्षीणनिदानं समाप्तं ||10 ||

iti mādhavakaraviricitē mādhavanidānē rājayakṣmakṣatakṣīṇanidānaṁ samāptaṁ ||10 ||

Thus concludes the chapter of Rajayakshma.

Source — 

1. Tuberculosis