An effort to Understand the difference in ‘Guruni-mukhanyasadya-pratirundhyat’ (Ch.Ni.-02/04, Raktapitta) & ‘Guruni-mukhanyasadya-pratirudhyate’(Ch. Ni.-04/08, Prameha)

An effort to Understand the difference in

‘Guruni-mukhanyasadya-pratirundhyat’ (Ch.Ni.-02/04, Raktapitta) 

& ‘Guruni-mukhanyasadya-pratirudhyate’(Ch. Ni.-04/08, Prameha)

S. No.	‘Guruni-mukhanyasadya-pratiryndhyat’  (Ch.Ni.-02/04, Raktapitta)	‘Guruni-mukhanyasadya-pratirudhyate’  (Ch. Ni.-04/08, Prameha)
1. Background	Raktapitta & Prameha, are most important Sampraptis among the 8 basic disease entities in Charak-nidan chapter- 2. There is no any relation superficially in these two diseases because ‘Nidan-panchak’ as well as management etc are totally different from each other, but Samprapti descriptions have similar wordings ‘Guruni-mukhanyasadya’ hence after raising a question by a studious U.G. student, efforts are being made to understand the differences at the level of ‘Srotasas’ as it is related to the Srotas mainly. If  the pathogenesis of Raktapitta & Prameha explored deeply then we find a combined presentations of these two together in 'Vatashonita' disease at some extent where specific Nidanadi/etiological factors are modified & it lead to different disease entity known as 'Vatashonita' having most varied types of  Signs & Symptoms.
2. Basic Reference	A.निष्पावमाषकुलत्थसूपक्षारोपसंहितं, B. दधि दधिमण्डो दश्वित्कट्वराम्लका१ ञ्जिकोपसेकं वा, C. वाराहमाहिषाविक मात्स्यगव्यपिशितं, पिण्याक पिण्डालु शुष्कशाकोपहितं,D.मूलकसर्षप लशुन करञ्जशिग्रु मधु शिग्रु (२खडयूष) भूस्तृणसुमुखसुरस कुठेरकगण्डीर कालमालकपर्णास क्षवकफणिज्झ कोपदंशं,E.सुरासौवीरतुषोदकमैरेय मेदक मधूलकशुक्तकुवल बदराम्ल प्रायानुपानं वा, F. पिष्टान्नोत्तरभूयिष्ठम्; G.उष्णाभितप्तो वाऽतिमात्रमतिवेलं वाऽऽमंपयःपिबति,H. पयसा समश्नाति रौहिणीकं३, काण कपोतं वा सर्षपतैलक्षारसिद्धं, कुलत्थपिण्याक जाम्बवलकुचपक्वैः शौक्तिकैर्वा सह क्षीरं पिब४त्युष्णाभितप्तः I. तस्यैवमाचरतः पित्तं प्रकोपमापद्यते, लोहितं च५ स्वप्रमाणमतिवर्तते । तस्मिन् प्रमाणातिवृत्ते पित्तं प्रकुपितं शरीरमनुसर्प६द्यदेव यकृत्प्लीह प्रभवाणां लोहितवहानां च स्रोतसां लोहिताभिष्यन्दगुरूणि मुखान्यासाद्य प्रतिरुन्ध्यात् तदेव लोहितं दूषयति ॥४॥	त्रयाणामेषां निदानादिविशेषाणां सन्निपाते क्षि प्रं श्लेष्मा प्रकोपमापद्यते, प्रागतिभूयस्त्वात्; स प्रकुपितः क्षिप्रमेव शरीरे विसृप्तिं लभते,  शरीरशैथिल्यात्;  स विसर्पञ् शरीरे मेदसैवादितो मिश्रीभावं गच्छति, मेदसश्चैव बह्वबद्धत्वान्मेदसश्च गुणैः  समानगुणभूयिष्ठत्वात्;  स मेदसा मिश्रीभवन् दूषयत्येनत्, विकृतत्वात्; स विकृतो दुष्टेन मेदसोपहितः  शरीरक्लेदमांसाभ्यां संसर्गं गच्छति,  क्लेदमांसयोरतिप्रमाणाभिवृद्धत्वात्; स मांसे मांसप्रदोषात् पूतिमांसपिडकाः  शराविकाकच्छपिकाद्याः सञ्जनयति,  अप्रकृतिभूतत्वात्; शरीरक्लेदं पुनर्दूषयन् मूत्रत्वेन परिणमयति,  मूत्रवहानां च स्रोतसां वङ्क्षणबस्तिप्रभवाणां मेदःक्लेदोपहितानि गुरूणि मुखान्यासाद्य प्रतिरुध्यते;  ततः प्रमेहांस्तेषां स्थैर्यमसाध्यतां वा जनयति, प्रकृतिविकृतिभूतत्वात् ॥८॥
3. Area of Pathogenesis	Generalised/whole body esp Yakrit/Liver & Pleeha/Spleen being Moola/origine of Raktavah Srotas as per the indulgence of Nidanas.	Generalised/whole body esp Vrikka/Kidneys & Vapavahan/Mysentry  being Moola/origine of Medovah Srotas as per the indulgence of Nidanas.
4. Prakritis/Saar prone to manifest disease	Pitta-dominant, Pitta-vat dominant including mainly Jati-kul-desh-kal-vayah-Pratyatmaniyata concepts along with excellent Ras-rakta-mansa Saar.	Shleshma/Pitta-dominant, Pitta-shleshma dominant mainly including  Jati-kul-desh-kal-vayah-Pratyatmaniyata concepts along with excellent  Ras-rakta-mansa Saar.
5. Dosha dominance	Pitta mainly	Shleshma mainly
6. Gunas dominance	Ushna, Teekshna, Sar, Drav mainly	10 Gunas of Shleshma which present 10 types of Kaphaja-meh.
7. Dushya Dominance	Rakta mainly	Meda mainly
8. Other Dushyas	Ras, Ambu/Kleda, Mansa initially, later in chronicity, there is possibility of involvement of other Dushyas including remaining Dhatus.	10 Dushyas of Prameha. Initially Ras, Rakta, Mansa, Meda & Kleda involvement should be taken,  Later on Dushyas are involved gradually as per chronicity and the individual immunity.
9. Srotas	Ras-rakta, mansa, ambu/ udak, swed, pran or anna or purish or mutra or aartavavah srotas.	Srotasa involved to 10 Dushyas.
10. Srotodushti-prakar	All 4 types are visible at different stages & sites of  Samprapti.	All 4 types are visible at different stages & sites of  Samprapti.
11. Angavayava/Organ involvement mentioned	Yakrit/Liver & Pleeha/Spleen	Vankshan-basti/Urinary system
12. Naidanik effect on Srotasas	Group A to F categorization of Ushna, Amla, Kshar, Katu, Teekshna, Pitta/ Tridoshaprakopak, Vyavayi, Vikasi dietary substances that include Cereals, Soups, meats, curd & its by- products, alcoholic beverages, Viruddha ahar/Dietary incompetence. These Nidanas are not capable to manifest the disease unless there is an exposure to Sun or Heat. These may manifest various other Pittaja disorders as mentioned in Purvarupas of Raktapitta. Dietary causes (Group A-F) lead to Nija types of pitta-prakopa leading from Koshtha to Shakha with Gunas of Pitta & Heat exposure is usually final triggering factor  as mentioned in Group G & H. Collectively above mentioned Nidanas are responsible for the manifestation of Raktapitta where whole body gets affected simultaneously & point of bleeding will be as per individual Prakriti, Sarasamhananadi.	Very well instructed by Punarvasu Aatrey, compiled in S. No. 2. Additionally, it is mentioned…. >तदतिस्थौल्यमतिसम्पूरणाद्गुरुमधुरशीतस्निग्धो पयोगादव्यायामादव्यवायाद्दिवास्वप्नाद्धर्षनित्यत्वाद- चिन्तनाद्बीजस्वभावाच्चोपजायते । तस्य ह्यतिमात्र मेद२स्विनो मेद एवोपचीयते न तथेतरे धातवः, >सन्तर्पयति यः स्निग्धैर्मधुरैर्गुरुपिच्छिलैः । नवान्नैर्नवमद्यैश्च मांसैश्चानूपवारिजैः ॥३॥ गोरसैर्गौडिकैश्चा१न्नैः पैष्टिकैश्चातिमात्रशः । चेष्टाद्वेषी दिवास्वप्नशय्यासनसुखे रतः ॥४॥ रोगास्तस्योपजायन्ते सन्तर्पणनिमित्तजाः । प्रमेहपिडकाकोठकण्डूपाण्ड्वामयज्वराः ॥५॥ In presence of spreading of Shleshmagunas in whole body through various  Rasadi-dhatuvah Srotasa in the absence of appropriate required  physical/mental activities, these shleshmagunas stick to Medodhatu being  similar in properties & lead to ‘Bahu-baddha-abaddha-meda’ condition  (inhibiting nutrition to other dhatus)  that causes the ‘Guruni-mukhanyasadya-pratirudhyate’  condition. This condition may be understood as nearer to hyperlipidaemia & hyperglycaemia  because of Dhatvagni-mandya & this makes hemodynamic changes through various mechanism.   Acharya Sushrut has instructed similarly in Sutrastha- 15/32.
13. Machenism of ‘Guruni-mukhanyasadya’	तैर्हेतुभिः समुत्क्लिष्टं पित्तं रक्तं प्रपद्यते । तद्योनित्वात् प्रपन्नं च वर्धते तत् प्रदूषयत् ॥७॥ तस्योष्मणा द्रवो धातुर्धातोर्धातोः प्रसिच्यते । स्विद्यतस्तेन संवृद्धिं भूयस्तदधिगच्छति ॥८॥ Nidan-seven>Pitta-prakopa with Ushnadi Guna>Pitta+rakta Samyog> Rakta-dushti> Sarva-sharir-swedan>Anya Soumya-dhatu Dravikaran> Rakta dhatu dravyat vriddhi/Hypervolemia> Yakrit/ Pleeha & Sarvasharir Sancharan> Yakrit /Pleeha-kriya-hani….. This is probable mechanism of ‘Guruni-mukhanyasadya’ where whole body is facing the condition of hypervolemia because of presence of mainly superficial vasodilatation and increased hydrostatic pressure in microvasculature & capillary beds. Here Ras, Rakta, Udak, Mansavah Srotas involvement should be considered. As this pathological phenomenon doesn’t subsides itself unless it releases pressure through bleeding or external cold application given, hence term ‘Pratirundhyat’ given that denotes that in the presence of vasodilatation, hypervolemia, increased vascular pressure etc the dravikrita-dhatus/tissue fluid unable to get back their actual site. This is actual description of Pathological event being taken place at the level of Srotasas.	त्रयाणामेषांनिदानादिविशेषाणां..प्रागतिभूयस्त्वात्;..शरीरशैथिल्यात्;  ….समानगुणभूयिष्ठत्वात्;….विकृतत्वात्;..क्लेदमांसयोरतिप्रमाणाभिवृद्धत्वात्; …….अप्रकृतिभूतत्वात्; मूत्रवहानां च स्रोतसां वङ्क्षणबस्तिप्रभवाणां मेदःक्लेदोपहितानि  गुरूणि मुखान्यासाद्य प्रतिरुध्यते; ततः प्रमेहांस्तेषां स्थैर्यमसाध्यतां वा जनयति, प्रकृतिविकृतिभूतत्वात् ॥८॥ Nidan-seven>’Pragatibhuyastvat’- Pre-existing Shleshma-prakriti-anubandha> Whole body distribution of Shleshma/Rasadi-dhatu in the presence of  lethargies in the body because of absence of physical activities/’Sharir-shaithilyat’ that leads to Dhatvagnimandya> Santarpan> Soumya-rasadi-dhatu gets mixed with Medo-dhatu initially because of similar properties leading to adiposity & hyper/dyslipidemia>’Saman-gunabhuyishthatvat’/ Medo-dushti because this overloaded fatty substance interferes the  fat metabolism & acts as a metabolic waste in the body, ‘Aprakritibhutatvat’> body tries to expel it out by generating excessive dhatu-malas (mentioned in Purva-rupas) & Putimansa-pidaka etc. (Importantly G.I.T. functions are intacted here hence Shakha-dushti continues with nutritional overload with the possible presence of Medasavritta-vat.)> Excessive Santarpan where body is unable to excrete metabolic waste through any route then body fluid/Kleda gets affected and body tries to expel it out through urinary system/’Medo-kledopahitani guruni-mukhanyasadya’. This phenomenon takes place in whole-body(10 Dushyas) esp in Mutravah Srotas & Basti/Kidney as it is the Mulasthan of Medovahsrotas. Further it is stated that when Renal function gets affected that it is called sthairya/irreversible stage of the Prameha because the body physiology is permanently altered> ‘Prakriti-vikriti-bhutatvat’. Allopathy science describes ‘Guruni-mukhanyasadya’ as 1. Advance Glycation End-production Formation 2. Increased Increased inflammation & Oxidative stress 3. Extracellular Matrix accumulation 4. Podocyte/GBM dysfunction 5. Glomerular Hyperfiltration/Hypertension leads proteinuria 6. Activation of RAAS & inflammatory cytokines. We can say that hyper/dyslipidemia & hyperglycemia etc metabolic overload represent the ‘Gurunu-mukhanyasadya-pratirudhyate’ phenomenon that inhibit the nutrition of other dhatus/tissues. Regarding mutravasrotas/kidney this mechanism not only obstruct the essential nutrition but also it inhibits renal reuptake of essential nutritional substances.
14. Doshaja             Variations	Raktapitta is mainly Pitta-dominant & Shonit-dushti-janit generalized disorder. There is no Doshaja types are mentioned. Kaphadosha & Vatadosha are associated as ‘Anubandha’ only and manifest the disease according to its doshaja route. All bleeding disorders are not Raktapitta manifestation unless there is generalized involvement of the body that’s why Raktatisar/pravahika etc are described separately where pathogenesis takes place in GIT & Doshas gets expelled out through Anal route, it may be with Raktapitta generalized Samprapti or without it with local GIT response.	Prameha is mainly Shleshma dominant & Medo-dushti-janit generalized disorder. Doshaja types are mentioned, in which ‘Santarpan/Medodushti’ is essential that is seen in Kaphaja/Pittaja-prameha only, While Vatik-prameha/ Madumeha is chronic advanced manifestation of Kapha/Pittaaja- Prameha. Excessive Dhatukshaya may lead to Vatikameha/Madhumeha independently.
15. Santarpan or Apatarpan ?	Usually, Santarpanajanya Tiryak Raktapitta/ITP, DHF etc may be taken as Apatarpanajanya.	Usually, Santarpanajanya Direct manifestation of Vatikameha may be taken as Apatarpanajanya.
16. Physiological State as per Shadupakram	Swinna (Swedan), Brimhit (Brimhan) mainly	Brimhit (Brimhan), Snigdha (Snehan) mainly
17. Therapeutic      applicability as per  Shadupakrama	Stambhan & Langhan (Condition applied)	Langhan(10types)/Guru-atarpan & Rukshan
18. Saan or Niraam ?	Usually, Saam (Ch. Chi.- 04/29)	Usually, Saam (Ch. Chi.- 06/04)
19. Does    ‘Gurunimukhanyasadya'  is focused in Management?	YES ! >अक्षीणबलमांसस्य रक्तपित्तं यदश्नतः । तद्दोषदुष्टमुत्क्लिष्टं नादौ स्तम्भनमर्हति ॥२५॥ If patient is well built & strong enough then bleeding should not be stopped immediately. This indicates the cont. releasing the vascular pressure caused by hypervolemia etc. >प्रायेण हि समुत्क्लिष्टमामदोषाच्छरीरिणाम् । वृद्धिंप्रयातिपित्तासृक्तस्मात्तल्लङ्घ्यमादितः ॥२९॥ मार्गौ दोषानुबन्धं च निदानं प्रसमीक्ष्य च । लङ्घनं रक्तपित्तादौ तर्पणं वा प्रयोजयेत् ॥३०॥ Langhan/very light diet in case of healthy/strong subject and Sheeta Tarpan/cool energy drinks in medium/week subject because of excessive ‘Aam’-condition. >ज्ञात्वा दोषावनुबलौ बलमाहारमेव च । जलं पिपासवे दद्याद्विसर्गादल्पशोऽपि१ वा ॥५२॥ In the condition of hypervolemia & increase vascular pressure (Guruni-mukhanyasadya-pratirudhyat) that doesn’t subside itself, in such condition small amount of liquids/him/Fant/swaras/ kwath etc advised and plenty of external cool application advocated. >वक्ष्यते बहुदोषाणां कार्यं बलवतां च यत् ॥५४॥ अक्षीणबलमांसस्य यस्य सन्तर्पणोत्थितम् । बहुदोषं बलवतो रक्तपित्तं शरीरिणः ॥५५॥ काले संशोधनार्हस्य तद्धरेन्निरुपद्रवम् ।विरेचनेनोर्ध्वभागमधोगं वमनेन च ॥५६॥ Vaman-virechan (Therapeutic Emesis & Purgation) is applicable for strong subject.	YES ! >स्थूलः प्रमेही बलवानिहैकः कृशस्तथैकः परिदुर्बलश्च । सम्बृंहणं तत्र कृशस्य कार्यं संशोधनं दोषबलाधिकस्य ॥१५॥ Constitution is always focused in Ayurveda management. >संशोधनोल्लेखनलङ्घनानि काले प्रयुक्तानि कफप्रमेहान् । जयन्ति पित्तप्रभवान् विरेकः सन्तर्पणः संशमनो विधिश्च ॥२५॥ >सन्तर्पणोत्थेषु गदेषु योगा मेदस्विनां ये च मयोपदिष्टाः । विरूक्षणार्थं कफपित्तजेषु सिद्धाः प्रमेहेष्वपि ते प्रयोज्याः ॥४९॥   Obesity would always be associated with either Kapha or Pitta dominant Prakriti, Mansa-medadi Saar and Atarpan/Rukshan /apatarpan along with Shodhan chikitsa is indicated initially to check nutritional overload or ‘Guruni- mukhanyasadya’.
20. प्रतिरुन्ध्यात् Pratirundhyaat or प्रतिरुध्यते Pratirundhyate	प्रतिरुन्ध्यात् /Pratirudhyaat- Prati+Rudh dhatu, Vidhi-ling Pratham-purush, Kaame /Aavarane refers ought or should to be obstruct, obscure, surround or enclose. There is no certainty here that  something ought to be obstructed essentially. Occurrence of bleeding manifestation is there but it may be minute, very small or moderate or even none being ‘Shonit-dushti’ as per ‘Vidhishonitiya’ pattern.  It may be said that clinical presentation may varied as per subject.	प्रतिरुध्यते / Pratirundhyate – Prati+Rudh dhatu,  Aatmanepade,Lat-lakar, Pratham-purush, Kaame /Aavarane refers ought or should to be obstruct, obscure, surround or enclose. Here it is clearly stated as ‘pratirudhyate’ that refers to obstruction   as an essential/unavoidable phenomenon. Variation in clinical manifestation is possible as per Charak-sutra-sthan - 23 & Sushrut-sutra-sthan – 15/32.
21. Conclusions	It may be concluded that ‘Guruni…’ refers to a condition of raktavriddhi/ hypervolemia caused by liquification of Soumya-dhatus of the body due to heat exposure where displace tissue-fluid doesn’t revert to its original location leading to capillaries rupture. We must not forget that Rakta-dhatu is an 'Uttan'/superficial dhatu so pathogenesis having here is not to be prolonged or persistent in comparison to 'Gambheer'/Deep dhatu. Raktapitta must have Raktasrava/bleeding as a cardinal feature but Raktapitta/Shonit-dushti samprapti may be there without secretary phase leading to other singns & symptoms as per 'Vidhi-shonitiya' pattern.	It may be concluded that ‘Guruni..’ refers to a condition or generalized accumulation of Shleshmagunas in Ras-raktavahadi srotasas affecting the Medodhatu in presence of Dhatvagni-mandya where other dhatus don’t nourish. Vrikka/Kidney, being ‘Mulasthan’ of Meda, gets affected worst where excretory apparatus  not only deprive from nutrition but also renal reabsorption mechanism affected leading to Prabhut-aavil-mutrata.    It must be noted that 'Medo-dhatu' being 'Gambheer' in the dhatu- alignment, any affection here usually leads to prolonged, persistent and irreversible pathology in comparison to 'Uttan'/Superficial Dhatu involvement. Prameha mainly  'Santarpanottha-kapha-pittaja-meha must have prabhut-aavil-mutrata as a cardinal feature but Medo-dushti samprapti may be there without secretary phase leading to other singns & symptoms as per 'Santarpaniya or Medo-dushti' pattern.

 Presented by

Prof. Surendra A. Soni

M.D., Ph.D (Kayachikitsa)

H.O.D.

P.G. Dept. of Kayachikitsa

Govt. Akhandanand Ayurved College,

Bhadra, Ahmedabad, Gujarat, India.

email: surendraasoni@gmail.com