Evaluation of the efficacy of Erandadi Guggulu in Gridhrasi By C.V. RajashekharAs partial fulfillment of post graduation degree M.D.(Ayurveda Vachaspati) Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka Guide Prof. Dr. Ch. Ranga Rao M.D.(Ayu) (Osm) Professor and head of the department Post graduation and research center Kayachikitsa Co-Guide Dr. Siva Rama Prasad Kethamakka M.D. (Ayu) (Osm) Reader in Kayachikitsa Post graduation and research center Kayachikitsa D.G. Melmalagi Ayurvedic Medical College Gadag - 582 103 Post graduation and research center Kayachikitsa 1998-2001
This is to certify that C.V. Rajashekhar (M.D. (Ayurveda) Kayachikitsa) hasworked for his thesis on the topic entitled Evaluation of the efficacy of ErandadiGuggulu in Gridhrasi. Clinical trials are done under my supervision and guidance. This thesis makes adistinct advance on scientific lines in the above subject and the findings are highlysignificant at the statistical evaluation and have considerably contributed to the presentknowledge of the subject. I am fully satisfied with his original work and hereby forward the thesis for theevaluation of adjudicators. Co-Guide Dr. Siva Rama Prasad Kethamakka M.D. (Ayu) (Osm) Reader in Kayachikitsa Postgraduate and Research Center (Kayachikitsa) D.G.M. Ayurvedic Medical College, Gadag.
J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE, & POSTGRADUATE AND RESEARCH CENTER, GADAG, 582 103 Certificate This is to certify that Dr. Rajashekhar C.V. has worked for his thesison the topic entitled Evaluation of the efficacy of Erandadi Guggulu inGridhrasi. He has successfully done the work under the guidance of Prof. Dr. Ch.Ranga Rao M.D. (Ayu) (Osm) and Co-guidance of Dr. Siva Rama PrasadKethamakka M.D. (Ayu) (Osm). This particular study helps in treating the disease Switra (Vitiligo) withpresent scientific approaches. I here with forward this thesis for the evaluation and adjudication. (Dr. G. B. Patil) Principal
ACKNOWLEDGEMENT I take this opportunity to express my profound sense of gratitude andindebtedness to honorable Guide prof. Dr.Ch.Rangarao. M.D (Ay.), Head of theDepartment of Kayachikitsa, D.G.M. Ayurvedic Medical College and Post Graduate andResearch Center, Gadag. For his analytical suggestions and valuable guidance for thecompletion of this work. I sincerely thankful to respected Co-guide, Dr.SivaRama Prasad Kethamakka,M.D. (Ay), Reader in Kayachikitsa, Post Graduate and Research Centre, D.G.M.Ayurvedic Medical College, Gadag. For his guidance and timely advice at every stage ofthis work. I acknowledge my sincer gratitude to Dr. G.B. Patil, Principal D.G.M. AyurvedicMedical College and Post Graduation and Research centre, Gadag, for providing allrequisite facilities for this research work. I extend my immense gratiatude to Dr. V.Varadacharyulu M.D. (Ay.) Professor inKayachikitsa, Dr. M.C. Patil, M.D. (Ay.) Reader in Rasashatra, Dr. Ashok Kumar PandaM.D. (Ay.) and Dr. Shashidhar H. Doddamani, M.D. (Ay.) Lecturers in Kayachikitsa PostGraduate and Research Centre , D.G.M. Ayurvedic Medical College, Gadag, for theirvaluable suggestions and encouragement at all levels of this study. I am very much thank ful to Dr. C.M. Sarangamath, Dr. P.C. Chappanmath,Dr. U.V. Purad, Dr. C.S. Hiremath, Dr. S.S. Avvanni. And Dr. G.S. Hiremath for their kindco-operation during the clinical study. I am thankful to Dr. S.H. Redder, HOD, Panchakarma Department for his kindsupport and providing all facilities to conduct the panchakarma procedures during thisstudy. I wish to expres my thanks to Mr. C.S. Bhat, Professor in sanskrit, who made meto under stand the difficult terms in Sanskri and Iam thankful to all my U.G. teachers ofD.G.M. Ayurvedic Medical College for their advice and encouragement.
I am ever grate ful to Dr. M.Eshwar Reddy, M.D. (Ay.) Dr. S.G. Hiremath,M.D.(Ay.) Dr. A.I. Sanakal M.D. (Ay), Dr. A.S. Prashanth, M.D. (Ay), Dr. Akash Kembhavi, M.D.(Ay) and Dr. Jagadish Yaji for their inspiration and valuable guidance. I am so much thankful to Dr.Venkatesh Karanth, M.D. (RaSdiologist) , Dr. R.T.Pawadashettar, M.D. (Pathologist) and Dr. M.V. Achar, D’Ortho (Orthopaedician) for theirsuggestions regarding modern aspect of this study. I take this oppotunity to thanks Mr. P.M. Nandakumar, Statistician, who helped mein statistical analysis. I would like to express my sincere thank to Mr.V.M. Mundinamani, Librarian. Andthe assistant Mr.S.B. Sureban for providing books intime through out the study. I take this movement to express my thanks to all lmly post Graduate Collegueswho have helped me in one or the other way, Dr. R.V. Shettar, Dr. S.T. Hombal, Dr. Y.S.Mudigoudar, Dr. A.S. Patil, Dr. I.B. Kotturshettar, Dr. S.S. Hiremath, Dr. J.I. Hiremath,Dr. S.K. Tiwari, Dr. R.D. Suresh, Dr. A.J. Shyal Kumar, Dr. Anilkumar, Dr. V.N. Kulkarni,Dr. B.M. Mulkipatil, Dr. G.R.Hadimani, Dr.Srinivas Reddy, Dr. Yasmin and all my friends. I convey my thanks to Management, RMO, Superindent, Receptionist,Lab.Technician, X-Ray technician, Panchakarma assistants, nurses, all non-teachingstaff, all attenders, house surgeons of .D.G.M. Ayurvedic Medical College and Hospital,Gadag for their timely help. I have no words to express my feelings towards my beloved parents, especially myfather, who gave me an opportunity for the higher study and made an effort to get theadmission for P.G. Studies. I also wish to thanks to Dr. S.A. Patil and Family, all his relatives, friends Mr.M.D.Angadi, Mr.Raveendra Koti for their help and moral support.
I take a privilege to express my heartful indebtedness to my Father-in-lawMonther-in-law, Brothers-in law, my cousin brother, and all relatives for their kind supportand encouragement. My sincere gratitudes to Dr.R.K.Gacchinamath, Mr.S.S.Kallanagoudar,Mr.B.G.Menasinkai, Busy Computers, Dharwad for their neat computer typing of my thesisin such an elegant way. My whole-hearted thanks to all my patients for the kind co-operation amidst theirmiseries, their satisfaction was the true achievement of this study through it was beyondmeasures. My sincer thanks to all the persons who have helped me directely and indirectelywith apologies for my inability to identify their names individually. At last I wish to appreciate the inspiration and co-operation of my life partner, thismade me to complete this work successfully in due time. C.V. Rajashekhar
Introduction Ayurveda the ‘Science of life’, or longevity, is the holistic alternative science. Theorigin of this knowledge are already evident in the Atharvaveda. Eventually Ayurveda wasorganized into its own compact system of health and considered a bracnch ofAtharvaveda. Ayurveda deals with the total creation of with special emphasis on the biology life.The chief objects laid down before this science the preservation of health and preventionof disease. The vedas say that all of the creation including humans are made-up ofcombinations of five essential elements. These elements are the subtlest aspects ofhuman life, finer than the molecular. The five basic elemental substances named asAkasa, Vayu, Teja, Jala and Prithvi. A hormonious combination and function of the fiveelements produces the healthy and beautiful body. These five physical elements consitutethe three basic principles Vata, Pitta and Kapha on which the whole philosophy ofmedicine is based. Essential components of the living body which are termed astridoshas (Humours of the body), The tridoshas govern the physico-chemical andphysiological functions of the body. It may be understood that the gross structure of thebody (solid and liquid) is constituded by the kaphaja fraction of the tridosic set-up in thetotal body composition. The entire physico chemical phenomenon including thebiochemical and metabolic activities as well as the endocrine functions are the attributesof pitta, Vata is responsible for the physical activity or the motion in the organism, It isbelieved that the Vata, though not apparently dominant in physical structure very muchdominates in the function and is supposeal to be the leader of the three doshas. Thesethree doshas have contradictory physical charactors and so they are capable orantagonising the activities of each other, than maintaining an equillibrium. A further development of the composition concept of living body is the re-categorisation of the morphophysiological structure of the body into seven dhatus or the
seven basic tissues which are named as Rasa, Rakta, Mamsa, Meda, Asthi, Majja and Sukra. Health is the supreme foundation of virtue, wealth, enjoyment and salvationDiseases are the destropers of health. The Ayurvedic concept of the evoluation of adisease is remarkably wide. According to Ayurveda Vyadhi or disease has been defined asthe state in which both the body and mind are subjected to pain and misery. Whatever maybe the nature of the exciting causes of the disease the actual factors which become excitedand imbalanced are the three doshas. Pain is initiated by asathmyasparsha in the indriyas distributed all over the body. This asathmyasparsa is produced by vitiation of dosha by the provocation of vata dosha. It is said that the reasons for vata kopa is either dhatu kshaya (degenerative changes) or avarana. All the authorities of Ayurveda have been dealt these vata disorders under a separate chapter entitled as Vata Vyadhi. The Vata Vyadhis are a group of diseases caused by the vitiated vata dosha and are generally considered to be 80 in number. Those quantities of food, mind and activity which are in concomitance with those of vata are responsible for the causation of the diseases of vata. Thus the food which is ununctous, cold, etc., the mind which is angered, feared, etc., and the activities like excessive sexual indulgence, night vigil would aggrevate vata to produce vata vyadhi. Both vyadhi and diseases of Vayu have been said to originate from pakwashaya. The dushya are seven dhatus, three malas, kandara, sira, shaya and atma. Vayu is most powerful of all and produce the disease instantaneously. Vata vyadhis are of very serious nature incurable in general and need contradiction approaches for management. Gridhrasi is one among 80 types of vata vyadhi. It is a clinical condition characterised by severe pain starting from the low back region and radiating down along the course of the leg. This is a common entity encountered in clinical practice. The term ‘Gridhrasi’ and `Sciatica’ of modern medicine can be termed Synonymous in as much as
they refer to singular similar presentation - pain along the course of the leg, irrespective ofthe etiological variations. While Ayurveda limits itself to call vata prakopa as the cause ofthis condition, Western medical science highlights further to identify different possiblecauses for such a presentation and also tries to explain the underlying pathology in termsof structural and functional changes. However, the commonest cause for such type ofpain is degenerative changes affected in the lumbar spine. The pain is the most common symptom of Gridhrasi, when it turns to be the majorsymptoms that brings a patient to the physician. Ayurveda still keeps the dignity as aneffective medical sicence, with a strong base of fundamental principles as well as theunique approach towards the disease and diseased one. There is effective line oftreatment for almost all the diseases in the form of sodhana and samana to eradicate theroot cause of the disease and restore normalcy in all respect. It is believed that thedisease cured by sodhana therapy never relapse while the disease cured by samanatherapy may reoccur. The sodhana treatment consists of a number of physico-physiological measuresadvocated in the treatment of the disease. Sodhana chikitsa is the radical treatment ofthe disease and is supposed to eliminate the vitiated doshas, thus completely cures thedisease. Samana chikitsa is the conservative treatment designed for subsiding oralleviating the vitiated doshas. The present study is designed to assess the efficacy of `Erandadi Guggulu’ as asamana therapy alone or along with virechana and vasti sodhana therapies in themanagement of Gridhrasi. Lowback ache and pain radiating down the leg has been termed as LumbagoSciatica syndrome. It is one of the commonest physical problem, stands second aftercommon cold in the present scenario. Multiple causes have been implicated for such acondition. The common etiological factors like discprolapse, sponylosis, stenosis, etc.
degenerative changes, trauma, lifting heavy weights, postural changes, pscychologicalcauses, so on and so fourth. There is no specific etiology mentioned for Gridhrasi in the Ayurveda literatures.But the common etiological factors for Vata Vyadhi have been attributed to this diseasedstate also. Thus vata prakopa due to old age (degenerative changes), ativyayama,visama chesta (poistural changes), besides many vata prakopa causes can produce`Gridhrasi’. Neverthless both Ayurveda and Western medicine agree that the mostcommon cause is vata prakopa in the form of degenerative changes. The disease Gridhrasi is a condition developed because of the excess strainleading to a pressureful state giving rise to restricted movements in the legs. It occursboth in men and women. But those who are on heavy manual work, long travel and alsobad postures seem to be at greater risk. These factors yield pressure over the vertebralcolumn especially over the Lumbar region (L5 & S1). These compression over nerves arebecause of decreased intervertebral disc space. Thus the condition is developed. TheGridhrasi is vividly explained in the Ayurvedic texts under Vata Vyadhi chapters. It ischaracterised by the pain starts from Hip and gradually comes to waiste, back thigh, knee,shank and foot and affects these parts with stiffness, distress and piercing pain and alsofrequently twichings. The ligaments of heel and digits are affected by the vitiated Vatacausing difficulty in lifting the lower limb. The related structures are the posteriorligaments of the lower limb. Parasthesia and later numbness may be felt over the affectedlimb. Two types of Gridhrasi have been explained based on the association of differentsymptoms related to Vata and Kapha doshas viz., suddha Vataja and Vatakaphaja. Thesymptoms of suddha Vataya Gridhrasi are stambha, ruk, toda, spandana, dehavakrataand sula, sparana, stabdata over janu,kati, uru sandhi. The Vatakapaja symptomsincludes tandra, gowrava, arochaka, straimitya pain raditing down the leg is common in
both these varities. Straight Leg Raising (SLR) test is one of the diagnosing criteria incontemparay medical system. In Ayurveda, the general mode of approach in the management of disease isbroadly classified into two the first one is Santarpana and second is Apatarpana.Brihmana (stoutening) and langhana (slimming) are their synonyms respectively,Brihmana for stoutening the body while langhana is for making the body light.Langhana is of two kinds sodhana (purification) and samana (palliative). Of these two,sodhana is advantageous as there is no recurrence or relapse of the pathologicalcondition. Sodhana is that which expells the aggrevated doshas out of the body forcibly.It is of five types, Vamana, Virechana, Anuvasana vasti, Niruha vasti and Nasyakarma.The principles of Vata Vyadhi chikitsa is that suddha Vataja roga and Vata Pittasamsargaja rogas, samsodhana chikitsa which is brimhana in nature is to be done. InVatakapha samsargaja rogas - sodhana chikitsa which is langhana in nature is to bedone. Bhavamisra, the author of Bhavaprakasha Nighantu, sepcially ascribed that theperson who got Gridhrasi should be purified. He has advocated Vamana, Virechana andVasti commonly as purifying measures. In further he has mentioned the treatment withoutsodhana therapy will go waste, one out of the Bhavamisra yogas, `Erandadi Kwatha’along with Guggulu, hypothetically has a good value of reversal of pathogenic state inGridhrasi patient. Thus to evaluate the efficacy of `Erandadi Guggulu’ after sodhana(virechana and vasti) therapy and also a palliative therapy (Samana) is undertaken for thepresent trial. The objectives of the study are 1. To evaluate the efficacy of the `Erandadi Guggulu’ in Gridhrasi. 2. To evaluate the efficacy of the `Erandadi Guggulu’ in increasing the Intervertebral disc spaces.
BIBLIOGRAPHY• Amarakosha with Sudha Saukritha- Hindi Commentary By Vishwanath, Zha, Motilal Bandrasidas , Varanasi .• Ayurveda Formulary of India 2nd Edition. 1979.• Bhavaprakasha Nighantu of Bhavamisra, published by Chowkhambha Sanskrit Sansthan, Varanasi, 5th Edition, 1988.• Astanga Hridaya Vidyothini Hindi Commentary By Atrideva Gupta, Chowkhambha Sankrit Samsthan, Varanasi, 5th Edition 1975• Astanga Sangraha of Vagbhata - English translation by A Board of scholars, Sri. Satgaru Publications. A division of Indian Books Centre, Delhi, First Edition 1999.• Brihat Nighantu Ratnakara with Hindi Commentory 5 part, Teekakara, Sri.Dattaram, Sri.Krishnadas Prakashan, Bombay. 1996.• A text book of Surgical Pathalogy, By Sir Charles Illingworth and Bruce M.Dick. ELBS 12th Edition 1979.• Brain’s Diseases of the Nervous System By. John walton 10th Edition, Oxford Medical Publications, 1993.• Basavarajeeyam. By Vaidya Basavaraju, 1959, Published by konda shankaraiah, Vani press, secundarabad.• Bhela Samhita, Edited by Girija Payal Shukla, 1959. Published Chaukhambha Publication, Varanasi.• Charaka Samhit Poorvardha and Uttarardha, Jaikrishnadas Ayurveda Series No.16. published by Chowkhambha Orientatlia, Varanasi, 1992.• Charaka Samhita with ayurveda dipika Commentaries of chakrapanidatta and Jalpakalpataru Explanatory Notes and annotations of M. Gangadhar. Edited by Narendra nath and Balaichandra sengupta. Chawkhamba Orientalia, Varanasi, 1991.• Campbell’s operative ortnopaedics by campbell, Vol.5, Eight Edition.
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Historical Review History the study of past events about Ayurveda start from the Vedas whichare considered as the earliest available records. The historical revew is classified in2 divisions 1. Vedic period. 2. Samhita period.1. Vedic Period There is no reference about the diseases Gridhrasias as such either inAtharva veda or in Rugveda but there are references about Vatavikaras such aspippali is mentioned as a medicine in Kshipta roga (Vatakritasya Bheshajeekshiptasya bheshajam)1. In Gridhrasi kshepana is a feature according to itsderivation . Hence we assume that in Atharva Veda the word Kshipta may be usedfor Gridhrasi . Similarly Vishanakaj - a herb is also mentioned for vata (Vishanaka mamavaasi vatee kritna nashanee)2. In purana there are some reference aboutvatavyadhi. Agnipurana : There are some references about Vataroga, Astigata vata andSarvangavata3. Garuda Purana: The name of Vatavyadhi its Nidhana and few useful tailas are mentioned4.2.Samhita Period : In this period Ayurveda attained its glory. All the three main Samhitas writtenin this period were discussed the disease Gridhrasi and its management. Charakahas included Gridhrasi in both nanatmaja and samanyaja type of vyadhi. It meansone among the Aseeta vatavyadhis5. But there is no separate Nidhana, Samprapti
about Gridhrasi in Charaka Samhita. Charaka has advised shiravyadha, vasti karmaand agni karma as the remedies for the Gridhrasi6. Susruta and Vagbhata have mentioned Gridhrasi one among the vatavyadhisand it is a Snayugata vatavikara. Sushruta has mentioned shirovyadha as the maintreatment where as Vagbhata suggested snehana, dahana and upanaha are useful7. In Bhavaprakasha also described the disease Gridhrasi and its managementindetail he specifically ascribed that the person who got Gridhrasi should be purifiedhe has instructed vamana and virechana should be done before the administration ofvasti chikitsa8. Chakradatta the book which deals with the treatment aspect includesthe management of Gridhrasi. He gave much importance to the yogas whichcontains Eranda among shamana yogas . He also mentioned vasti, shiravyadha asthe shodhana chikitsa. At last he suggested to burn the little finger of the affectedlimb if the Gridhrasi is not subsided by any of the above treatment9. Yogaratnakara also mentioned the symptoms and management for Gridhrasiin general for Vatavyadhi like previous books were mentioned10. Hareeta describedthe signs and symptoms of Raktavataja dosha as severe pain in the region betweenkati, ooru and janu. Further he named it as Gridhrasi11. In Kashyapa samhita Gridhrasi is considered as one among the Aseetivatavikaras12. In Madhavanidhana there are some additional symptoms apart fromthe symptoms earlier mentioned in Charaka samhita like Charaka he has alsofollowed the general nidhana and samprapti for all the vata vyadhis13. InSharangadhara samhita, Gridhrasi is considered one among the Aseeti vatavikarasand some specific yogas are mentioned for its management. Aseeti vatavikaras andsome specific yogas are mentioned for it management14. Chakrapani, Dalhana ,Arunadatta the main commentators of Brihatrayeeopine that Gridhrasi is a shoola pradhana vatavyadhi kandaras and snayus are
affected impairment in lifting the lower limbs is the main feature . Gridhrasi is of twotypes Vataja and Vatakaphaja. In Basavarjeeyam Gridhrasi is mentioned as Gridhra vata one among theAseeti Vata Rogas. He has mentioned some strange symptome like sweda, murcha,brama, trisna, vidaha which indicates the involvement of pitta. Apart from this he hasmentioned that both lower and upper limbs are involved. In the treatment aspect hehas mentioned Chintamani rasa, Poornachanrodaya rasa and Drakshadi gutika15.Definition The word Gridhrasi is derived from the noun Gridhras, with the grammaticalsuffix word Mnip. The meaning of word Gridhra is the vulture. The word Gridhrasimeans a vata vyadhi16. Gridhras + Mnip = Gridhrasi The word Gridhrasi is of Feminine gender. Gridhramapi sati, Ouru sandhu vata roga. According to the above stanzas the meaning of “Syati” is taken as kshepana,which mens throwing or an action similar to throwing. Taking this into considerationalong with the commenary of Amarasudha18, it could be detected the movemen ofthe leg resumbles a throwing action which is similar to the gait of the vulture.Gridhrasi – f – Rheumatism affecting the loins19.Sciatica (Si – at’t – ka) [L] – Severe pain in the leg along the course of the sciaticnere felt at back of the thigh running down the inside of the leg20.
Paribhasha The condition where the pain is felt first in buttock (spik) then the posterioraspect of waist (kati) and radiates downwards in the posterior aspects of the thing(ooru), knee (janu), claf (Jangha) and foot (pada), along with stiffness (stambha)piercing sensation (toda). Associated with fequent twitchings (spandana) is called asGridhrasi21. According to sushruta and vagbhata, Gridhrasi is a condition where theligaments (Kandaras) of heel and digits (parshnee and anguless) are affected by thevitiated vayu causing difficulty in lifting the lower limb. The related structures are theposterior ligaments of the lower limb22. Chakrapani opine that Gridhrasi means Gridhrasi shula, i.e. pain which issimilar to the pain in Gridhrasi mentioned under vatavyadhi. 23Paryaya (Synonyms) Thw word Gridhrasi has 3 synonyms used by various authors. They arementioned as below. 1. Ringhinee – Cause to creep or crawling. Go slowly24. 2. Ranghinee25 3. Radhina26
The word shareera comparises both structural and functional aspects of thebody. In Gridhrasi disease the body parts affected are katiprishta pradesha(Lumbosacral region), spik (buttock), jangha (thigh), janu (knee) and pada (leg &foot) which results in the impariment of the movement of lower extremity. Though there is no direct descriptions in Ayurveda about Anatomical parts,responsible in the manifestation of Gridhrasi disease. The anatomical parts in andaround the katiprishta pradesha and the marmas (vital parts) are considered in thepathophysiology of Gridhrasi disease.Ayurvedic Insight of Shareera1. Katiprishta pradesha (Lumbo scaral region) There are 24 asthi sandhis (joints) in prishta vamsha (vertebral column). Theyare movable joints which have limited movements (prathara sandhis) 27. The bonesof katipristha pradesha are firmly united by mamsa rajjus28 (ligaments). There are 60muscles are situated in the prishta bhaga and each 5 muscles are situated in thebuttocks29. The sleshaka sleshma which does the function of sandhi samsleshana issituated in these joints providing smooth movements of the joints. Trika (sacram) theunion of 5 sacral vertebra is also the seat of Avalabaka kapha.2. Katikataruna Marma30 The term kati means waist (iliac) and Taruna refers to cartilaginous or softbones. However, Katikataruna Marma lies in the shroni (Pelvis) which is an AssthiMarma lying on either side of the spine. The measure of this marma is half fingerwidth (approx 1 cm). It is suitable to consider the marma near the upper margin ofpelvic bone which form the kati and few centimeters away from the lumboscral joint.Underneath are the iliac bone, the iliac artery and sacro iliac joint ligaments.3. Kukundara Marma30a
The term denotes the kukundara Asthi, Kukundara literally means one whodwell or supports the cavity. Thus the Kukundara marma falls within the pelviccavity. It is a sandhi marma measuring a length of approx 1 cm. This marma islying few centimeters diagonally below the katikataruna. Just under neath this, thefibres of Sciatic nerves emerge out of the spinal chord. The structure of sacroiliacjoint also fall beneath this marma. Sushruta says that an injury to this marmacauses sensory and motor disability of lower extremities.4. Nitamba Maram30b This is an Asthi marma measuring a length of approx. 1 cm. Nitamba literallyrefers to the region of hips. It is found upon the two pelvic bone on either side. TheNitamba Marma lies on half the distance between sacral bone and the femoralgreater trochantor. It falls just above the line diagonally drawn from sacrum to the femoral joint.This marma almost refers to the Sciatic nerve chord before entering the femoralregion. In obese person, it may be difficult to located this Marma due to excessadiposity in this region. Many scholars opined that Nitamba Marma lying above the pelvis on theback. This is apparently due to the translation of Sushruta’s sloka as ‘above’ theshroni insted of ‘upon’ the shroni palaka. Nitamba literally refers to hips and thelatter is more appropriate as on injury to this Marma causes atropy of legs due to theinjury to Sciatic nerves.5. Indrabasti Marma31 This is a Mamsa Marma found on all the four limbs located in the forelegsand forearms. Some scholars stated the lenght of this marma as 2 fingers width andsome other as half finger width. Locating Indrabasti is easier on the legs. It is exactlyon the tip of the calf muscle body (Gastrocnemious) from where two of its tendons,emerge forming a ‘V’ angle. It is better palpable with patient sitting straight and
semiflexed legs. The great Sciatic nerve and the Tibial artery can be found belowMarma in lower limbs.Modern Insight of Shareera1 Vertbral Column The total number of bones present in the body are together called as skeleton.The main division of skeleton is into Axial and Appendicular. The axial skeletonincludes vertebral column, Sternum, Ribs and Skull. The appendicular skeletonincludes the bones of the upper and lower limbs and girdle bones. The vertebralcolumn extends from the base of the skull through the hole length of the neck & trunkit consists of 33 separate irregular bones called vertebrae placed in series andconnected together by ligaments and discs of fibrocartilage to form a flexible curvedsupport for the trunk. The vertebral column varies in length but is about 70 cm in man and 60 cm inwoman. The vertebra are named according to region in which their lie. They are 7cervical, 12 thoracic, 5 lumbar, 5 sacral and 5 coccygeal. In adults 5 sacralvertebrae fuse together to form sacrum and the 4 coccygeal vertebrae fuse to formcoccyx.Common Feature of Vertebral Column.. With the exception of the first two cervical vertebrae all vertebrae consists ofa large anterior weight bearing body and a posterior placed vertebral arch. The archsprings from the posterolateral aspects of the body and with it surrounds a large holethe vertebral foremina when the vertebrae are placed in series these foraminatogether with the ligamenta flava that unite the adjacent laminae form the vertebralcanal which lodges the spinal cord with its meninges and blood vessels.
The Body This is approximately cylendrical but its flat superior and inferior surfaces areslightly flared so that the anterior and lateral surfaces are concave from abovedownwards. The surfaces are perforated by many small vascular foramina and is flator concave from side to side. Each superior and inferior surface is rough for theattachment of the fibro cartilagenous intervertebral discs. The vertebral bodiesincrease in size from the skull down to the pointwhere the weight of the body ispassed from the sacrum to the pelvic girdle and then diminish rapidly.The Spinous Process These posterior projections act as attachments for the interspinous andsupraspinous ligaments which strengthen the vertebral column posteriorly and giveattachments to many muscles. They are thickest and strongest where theseattachments are maximal, particularly in the lumbar region.Transverse Process These act as attachments for muscles helping to increase their leaverag overthe vertebral column. They form one articulation for most of the ribs thus supportingthem and controlling their movements. In regions other than thoracic the rib elementsare fused with the transverse process.Lumbar Vertebrae The fine lumber vertibrae lie in the loins. These are distinguished by largesize and absence of coastal facets and transversal foramina. The bodies are about3cm in depth and nearly 5cm in width, the upper and lower surfaces are kidneyshaped in outline. The vertebral foramen is triangular, larger than thoracic butsmaller than at cervical levels the pedicles are short. The spinous process is almost horizontal quadrangular and thickened only itsposterior and inferior borders. The superior articular processes bear vertical concave
articular facets facing posteromedially with a rough maxillary process on theirposterior borders. The inferior articular processes have vertical convex articularfacets facing antero laterally. The transverse processes are thin and large except themore substantial fifth pair. The rectangular spine of a lumbar vertebrae projectsalmost horizontally back but owing to the slope of the laminae is level with the lowerhalf of the body. The fifth lumbar vertebra has a massive transverse process continuous withthe whole of pedicle and encroaching on the body. The body is usually the largestand markedly deeper in front. Contributing thus to the sacrovertebral angle. Upperand lower borders of lumbar bodies give attachment to the anterior and posteriorlongitudinal ligaments. Posteriolaterally, psoas major is attached to the upper andlower margins of all lumbar bodies.Sacrum It is a large triangular base formed by fusion of five sacral vertebrae. Thesacral vertebrae provide strength and stability to pelvis and transmit the weight of thebody to the pelvic girdle through the sacroiliac joints. The joint involves the upperthree vertebrae and the bone tapers below that level to a blunt apex formed by thebody of the 5th sacral vertebrae. This sacrum is roughly wedge shaped from base to apex and from pelvic todorsal surface as the base is directed more forwards from upwards. The base of thesacrum is the antero-posterior surface of the first sacral vertebrae. The sacrum isbent so that the pelvic surface of the anterior part of the bone makes an angle ofabout 10 degrees with the horizontal when the body is erect. While the posterior partlies at right angles to it an each side the costal elements are fused with the bodypedicle and transverse processes and are enlarged to form the lateral part of thesacrum which is wing shaped on its abdominal aspect. Posteriorly the pedicle andtransverse process are incorporated in the lateral part but a pit or a foramen may bepresent between them and the enlarged rib element. The vertebral foramen so
formed is triangular and is the upper end of the sacral canal. On each side lateral tothe sacral canal on each side, lateral to the inter vertebral discs lies a row of fourpelvic sacral foramina which transmit the ventral rami of the sacral nerves, branchesof the arteries and veins. These foramina are larger than the dorsal ones and leadfrom the sacral canal grooving the lateral part of the sacrum.Anatomy of Intervetebral Joint Lumbo Sacral Joint All vertebrae from 2nd cervical to 1st sacral articulate by cartilaginous jointsbetween their bodies, synovial joints between their articular process (zygapophysial)and fiì¥Á G ¿ 6
bjbj Ù Ù " ì³ ì³ 2 ÿÿ ÿÿ ÿÿ ] 4 nts. Thefifth lumbar vertebra is attached to ileum and sacrum by the iliolumbar ligament.These joints vary much in geometry.Inter Vertebral Disc It is a fibrocartilagenous disc which binds the two adjacent vertebral bodies,from axis to sacrum. Morphologically it is a segmental structure as opposed to thevertebral body which is intersegmental.Shape The shape of the intervertebral disc corresponds to that of the vertebralbodies between which it is placed.Thickness It varies in different regions of the column and in different parts of the samedisc. In cervical and Lumber regions the discs are thicker in front than behind, whilein the thoracic region they are of uniform thickness. The discs are thinnest in theupper thoracic and thickest in the lumbar region. The discs excluding the first twovertebrae form a fifth of the post axial vertebral column. This contribution is greaterin cervical and lumbar regions than in thoracic region.Structure of Intervertebral disc Each disc is made up of three parts viz., nucleus pulposus, annulusfibrousus, cartilaginous plate. The individual description is as follows, Nucleus Pulposus It is the central part of the disc which is soft and gelatinous at birth. Its watercontent is 90% in newborn and 70% in old age. It is kept under tension and acts as a
hydraulic shock-absorber. It represents the remains of the notochord and contains afew multinucleated notochordal cells during the first decade of life, after which thereis a gradual replacement of the mucoid material by fibrocartilage derived mainlyfrom the cells of annulus fibrosus and partly from the cartilagenous plates coveringthe upper and lower surfaces of the vertebrae. Thus with advancing age the discbecomes amorphous and difficult to differentiate from the annulus. Its water bindingcapacity and the elasticity are reduced. Annulus Fibrousus It is the peripheral part of the disc made up of a narrower outer zone ofcollagenous fibres and a wider inner zone of fibrocartilage. The laminae formincomplete collars which are convex downwards and re connected by strong fibrousbands. They overlap into one another at obtuse angles. The outer collagenous fibresbend with anterior and posterior longitudinal ligaments.Cartilagenous Plate Two cartilagenous plates lie one above the other below the nucleus pulposus.Disc gains its nourishment from the vertebrae by diffusion through these plates.Functions of Intervertebral discs 1. Intervertebral discs give shape to the vertbral column. 2. They act as a vertebral series of shock-absorbers or buffers. Each discs may be linked to a coiled up spring.Movements of the Vertebral Column Range of movement between vertebrae is restricted by the limiteddeformation of intervertebral discs. Whose greater thickness at cervical and lumbarlevels increases individual range. It is also limited by the topography of theZygapophysial joints and by concomitant changes in tension of the ligamentoussyndesmoses. Thus the total range of vertebral movement includes flexion,extension, lateral flexion, rotation and circumduction
Flexion In flexion the anterior longitudinal ligaments become relaxed and the anteriorparts of intervertebral discs are compressed. While at its limit the posteriorlongitudinal ligaments, ligamenta flava, interspinous and supraspinous ligaments andposterior fibres of intervertebral discs are tensed.Extension In extension the opposite events of flexion occurs. It is limited by tension ofthe anterior longitudinal ligament, anterior discal fibres and approximation of spines,Zygapophyses and compression of posterior discal fibres.Lateral Flexion Here the intervertebral discs are laterally compressed and contralaterallytensed and lengthened motion being limited by tension of antagonist muscles andligaments. It is always combined with rotation. Lateral movements occur in any partof the column but are greatest in cervical and lumbar regions.Rotation Rotation involves twisting of vertebrae relative to each other, with torsionaldeformation of intervening discs. Movement is slight at cervical level, greater in theupper thoracic and least in the lumbar region.Neuro Anatomy Lumbar Plexus The lumbar plexus is formed by the ventral rami of the first three lumbarspinal nerves and part of the fourth, with a small branch from the subcostal nerve inhalf the cases. The nerve emerge from the intervertebral foramina and their ventralrami communicate with the sympathetic trunk. They then divide and recombine inthe substance of the psoas muscle anterior to the plane of the transverse processesof the lumbar vertebrae.
The first two lumbar ventral rami divide into superior and inferior branches.The superior branch of the first, with or without a branch from the subcostal nerve(Branch of T12), divides into the iliohypogastric and ilioinguinal nerves. The inferiorbranch unites with the superior branch of the second to form the genitofemoralnerve. The inferior branch of 2nd, 3rd and the upper part of the 4th all divide intosmaller ventral and larger dorsal divisions. The ventral divisions combine to form theobturator nerve. The dorsal divisions unite to form the Femoral nerve and the lateralcutaneous nerve of the thigh which arises from the 2nd and 3rd only. Irregularmuscular branches pass to the psoas and quadratus lumborum muscles. Sacral Plexus This plexus is formed from the ventral rami of the 4th lumbar to the 4th sacralspinal nerves. The plexus lies on the dorsal walk of the pelvis, mainly betweenpiriformis muscle and its fascia. The nerves entering the plexus converge to form a broad triangular band.Which passes through the inferior part of the greater Sciatic foramen, belowpiriformis and enters the gluteal region as the sciatic nerve. The sciatic nerve dividesinto tibial and common peroneal nerves at a variable point in the thigh. Formation The lumbosacral trunk comprises part of the 4th and all the 5th lumbar ventralrami, it appears at the medial margin of the psoas major, descending over the pelvicbrim anterior to the sacro-iliac joint to join the first sacral ramis. These rami convergeto the greater sciatic foramen and unite with little intermingling to form upper andlower bands.Branches Anterior 1.Nerve to quadratus femoris and Inferior gemellus (L4, 5, S1). 2.Nerve to obturator internus and superior gemellus (L5, S 1,2). 3.Pelvic splanchnic nerves (S2, 3, 4).
4.Posterior femoral cutaneous nerve (S2,3). 5.Pudendal nerve (S 1,2,3,4,5).Posterior Branch 1. Muscular twigs to piriformis (S 1,2) and to coccygeus and levator ani (S 3,4) 2. Superior gluteal nerve (L4, 5: S1). Inferior gluteal nerve (L5,S1,2), posterior femoral cutaneous nerve (S, 1, 2). 3. Perforating cutaneous nerve (S 2, 3). 4. Perineal branch of S4.Both Anterior And Posterior Branch 1.Sciatic nerve (L4, 5, S 1, 2, 3). 2.Posterior cutaneous nerve of thigh dorsal divisions of S1, 2 and ventral divisions of S2, 3.Sciatic Nerve The sciatic nerve is 2cm broad at its origin and the broadest in the body. It isthe continuation of the upper band of the sacral plexus. It leaves the pelvis via thegreater sciatic foramen below the piriformis and descends between the greatertrochanter and ischial tuberosity along the back of the thigh, dividing into the tibialand common peroneal nerves. Proximal to the knee Superiorly it is deep to thegluteus maximus, resting first on the posterior ischial surface with the nerve toquadratus femoris between them, it then crosses posterior to the obturator internusand the gemelli. Then on to the quadratus femoris, separated by it from obturatorexternus and the hip joint. More distally it is behind the adductor magnus and iscrossed posteriorly by the long head of the biceps femoris.
Branches 1. Articular branches; Arise proximally in the gluteal region to supply the hip joint. 2. Muscular branches; May arise in the lower part of gluteal region or upper part of the thigh. The tibial part of sciatic nerve supplies semetendinosus, semimembranosus, long head of biceps femoris and ischial head of biceps femoris.The Tibial Nerve The tibial nerve, the larger sciatic divisions arised from the branches of the4th and 5th lumbar and 1st to 3rd sacral ventral rami. It descends along the back of thethigh and popliteal fossa with the popliteal artery and continuing into the leg. In thethigh it is overlapped proximally by the hamstring muscles, but it is more superficialin the popliteal fossa. In the leg the tibial nerve descends with the posterior tibial vessels. It liesbetween the heel and the medial malleous, dividing into medial and lateral plantarnerves. Its branches are articular, muscular, sacral, medial calcanean and medianand lateral plantar.
Nidana is ascribed to form the causative factors of a disease. For propertreatment of a disease, it is essential to determine the exact nature of the diseasewith special reference to the doshas, dhatus, malas, srotas and agni involved in itsmanifestation. Gridhrsi is a vata disorder and is included among the eighty types of vatadisorders32. There is no much difference in the causative factors (Nidana) of vatadiseases33. Only due to samprapti visesha of vitiated vata will leads to variety of vatadisorder34 like Gridhrasi35, Ardita, etc36. The factors which causes vitiation of vata areclassified under the fallowing subheadings. 1.Swaprakopaka nidana 2.Margavarodhaka nidana 3.Marmaghatakara nidana 4.Dhatukshayakaraka nidana The aetiological factors having same properties of vata causes increase ofvata, according to samanya vishesha siddanta. The principle of the doctrine is thatthe combination of similar (samanya) brings about vriddi and the combination ofdissimilar (visesha) brings out kshaya37. Further excessive and constantconsumption of the same aetiological factors results in the provacation of the someaetiological factors rresults in the provacation of vata and the factors which favoursthe provacation of vata are also considered here. These aetiological factors areclassified as fallowes;1.Swaprakopaka nidana a.Ahara (Dietic factors) Excessive and continous intake of diet possessing the properties of ruksha,laghu, sheeta and rasas like katu, tikta, kashaya. Irregular food habits, insufficientdiet, exclusive diet, fasting repeated intake of diet.Intake of dried leafy vegetables,
dried food articles, cereals like varaka, kodrava, nispava, pulses like syamaka,mudga, kalaya, chanaka, harenu. b.Vihara Ratri jagarana, excessive walking, excessive swimming, excessive riding onHorses and vehicles, ativyavaya, prapatana (falling), adhyasana ,bharavahana(weight lifting), ativyayama, (excessive exercise)38 Balavat vigraha(fighting with person of superior strength). c.Climatic and seasonal factors and age Climatic : Excessive exposure to air, cloudy atmosphere. Seasonal : Rainy seasjon, end part of the summer season. End part of the day, night, digestion. Age : Vata dosha is dominent in old age due to dhatu kshaya (degenerative changes) d.Factors due to improper elimination therapies39 Improper purification methods like vamana, virechana, vasti…etc40., This is termed as mithyopachara. The term denotes has excessw of action as well as insufficient action due to accessive or insufficient dose of purification respectively. Wrongly carried out methods causes vitiation of vatadosha. e.Pscychological factors Excessive emaciation due to worry, grief, anger, fear, anxiety, timidity are the mental factors. Direction senses is one of the functions of manas and vata is said to be the controller and conductor of mind41. So the impairement of mind due to these factors causes vata prakopa42.2.Margavarodhaka Nidana The aetiological factors which causes obstruction in the normal movement ofvata results in the provacation of vata. The factors which are responsibleformargavarodha are as fallowes;
a.Veghadharana and Udheerana Suppression of natural urges and inducing the urges forcefully causesprovocation of vata by margavarana. In Gridhrasi these factors causes provacationof Apanavayu, a stanika dosa may aggrevate the condition43. b.Ama Dosha Due to hypo functioning of ushma (kayagni), the food which is not completelydigested, yields immature rasa in amasaya and due to the retention (in amasaya)undergoes formentation. This state of rasas is spoken as ama. When ama collectsand obstructs the flow of vata in vatavahasrothas which gets vitiated and movesaround in different directions producing vata vyadhis. c.Anya Dosha Gridhrasi is classified into two vataja and vatakaphaja. In vatakaphajaGridhrasi, kapha vitiating factors plays a role. The kapha is provoked by the fallowingfactors causes obstruction in the normal movement of vata causing its provocation.Kapha Provocating Factors Ahara Excessive and continuous usage of food predominant of sweet, acidic, salty,cold, unctous, heavy, shiny. Intake of food in excessive quantity food articles likeyavaka, saishadha, blackgram, wheat, rice cakes, curd, milk, payasa, cane sugerpreparations. Flesh of aquatic animals, heavyfood, rawmilk. Product of milk, banana,tender coconut and intake of water stored for one night44. Vihara Day sleep, sedentary habits, laziness, excessive sleep non indulgence ofphysical and mental work, suppression of vomiting.Other factors Harsha, non adoption of purificatory processes like vamana, virechana andvasti, ajeerna, agnimandya, early age, Vasantaritu.
Climate Cold climate causes margavarana hence produces vata vyadhi.3.Marmaghatakara Nidana Injury to the marma causes vataprakopa resulting in untolerable pain45.marmas, sira, snayu, asthi and sandhis. But the presence of all these are notneeded46. Hence injury to the katiprishtavamsha and injury to the kukundaramarmaresults in loss of function of lower limbs47. The following aetiological factors which cause marmagata in the Lumbosacral region are considered. Lifting of heavyweight, carrying heavy materials,habitual use of uncomfortable bed and seat, Fighting with persons of superiorstrength. Fall from a moving vehicle or animal or from a height. 3. Dhatuksayakaraka Nidana The diminution of dhatus owing to various aetiological factors are alsoconsidered. The dhatukshaya causes increase of rookshata thus provoking vata. Italso causes lack of nutrition to the cells. In old age due to the degeneration of thedisc causes pressure on nerve roots by the structures causing Gridhrasi emaciationdue to prolonged illness, exessive haemorrhage, atikarshana are the otherdhatukshayakaraka nidhanas. Exessive indulgence in exercise, sex causesdhatukshaya causes vata prakopa.Aetilogical Factors According To Modern A. In the Back I. Developmental anomalies a) Spina Bifida b) Spondylolisthesis c) Hemivetebra (When one of the two centers of ossification for the vertebral body is to develop)
d) Abnonrality in the articular processes articular facets of the 5th lumbar vertebra may take the form like that of articular processes of the thracic vertebra. e) Besides lack of fusion between the two walves of the neural arch which produces the condition of spina bifida. The lamina may fail to fuse with the body of vertebra. f) Split vertebra (When there is a definite gap between the two centres of ossification) g) SacralizationII. Traumatic a. Lumbo sacral strain. b. Injuries to the intervertebral joints. c. Spondylolisthesis d. Compression fracture e. Vertebral process fracture f. Ruptured discIII. Functional Defects a) Anterio – posterior imbalance pregnancy. b) Lataral imbalances ( Scoliosis.)IV. Inflammatory a) Pyogenic osteomelitis. b) Rheumotoid arthritis c) Ankylosing spondylitisV. Spinal Infections a) Tuberculosis b) Brucellosis c) Spinal epidural abscess
VI. Neoplasm 1. Spinal Tumours and Intraspinal Tumours a) Tumours of the vertebral column b) Although almost any tumour can metastasise to bone the 6 most common are • Thyroid • Breast • Lung • G I tract • Renal • Prostate Primary bone tumours do occur in the spine. The most common are 2. Benign • Haemangioma • Osteoid Osteoma • Osteoblastoma • Aneurysmal bone cyst • Giant cell tumour 3. Malignant • Myeloma • LymphomaVII Degenerative Disease of the Spine • Disc prolapse • Spinal stenosis • Spondylolisthesis • Osteoarthritis (Spondylosis)
• Senile osteoporosisB. Reffered Pain From Visceral Disease 1. Abdominal disorders • Pancreatitis • Cholecystitis • Biliary calculus • Peptic ulcer 2. Pelvic disorders • Salphingitis • Intrapelvic tumour 3. Genito Urinary causes • Renal infection • Renal calculus • ProstitisC Other Causes • Postural back pain • Psychiatric diseasePoorvarupa Poorva rupa are the premonitory symptoms which occur before the completemanifestation of a disease. Commonly all diseases will show same premonitorysymptoms before the disease develops. But there are no such premonitorysymptoms of Gridhrasi are mentioned in the classics. But in general beforemanifestation of Gridhrasi vitiated vata will show its symptoms in the body. Theseincludes mild pain in the kati and pada, Karshya, Ushnakamitwa, Shakrutgraha(Constipation) and Balahani48.Samprapti The samprapti of Gridhrasi has not dealt seperatly. The saprapti ofVatavyadhis in general also helps to explain the samprapti of Gridhrasi. Thus the
aetiological factors results in the vitiation of Vata which occupy in the body channelswhere degraded points is present produces49 various kinds of disorders. Whichaffects the whole body or get localised in a particular region. By the observation of the aetiological factors mentioned in Vatavyadis thereare 4 sets of nidanas which gives the separate mode of samprapti in themanifestation of Gridhrasi. Hence the samprapti of Gridhrasi is explained in 4different mannor as follows.1. Samprapti of Swaprakopaka Hetujanya Gridhrasi The aetiological factors mentioned under this heading in nidana part causeschaya of vata dosha in its main seat, Pakvashaya. Further intake of the sameaetiological factors are causing vata prakopa. In this stage the vitiated vata doshatravels to the kati pradesha, spic and lower limb where the Gridhrasi nadi originatesand situated in that place either in kati prista vamsha or in the course of the Gridhrasinadi the vitiated vata gots lodged causing rukshata depleting sneha gun a which isessential for the nourishment of Gridhrasi nadi and corresponding snayu or kandara.This results in the manifestation of Gridhrasi disease and exhibition of signs andsymptoms of vataja Gridhrasi disease.2. Samprapti of Margavarodhaka Hetu Janya Gridhasi Suppressing natural urges and inducing the natural urges forcefully causesprovocation of vata. Here provocation of Apanavayu situated in katipradesha whichfurther causes obstruction to the normal movement of vata by Gridhrasi nadiresulting in the manifestation of Gridhrasi. The vitiation of Kaphadosha from its own aetiological factors causesobstruction to Gridhrasi nadi in its origin i.e. in the lumbo sacral joints resulting in theexhibition of signs and symptoms of vata-kaphaja Gridhrasi. Amadosha which issimilar to the kapha also causes obstruction in the above manner resulting in themanifestation of disease.
The presence of Gridhrasi in the origin and course of the Gridhrasi nadicauses obstruction to the normal function of Gridhrasi nadi thus resulting in theGridhrasi vyadhi.3. Samprapti of Marmaghatajanya Gridhrasi Injury to the marma present in the lumbosacral region or in theKukundaramarma region causes injury to the roots of Gridhrasi nadi thus resulting inthe impaired function of Gridhrasi nadi due to the provocation of vata. It exhibits thesigns and symptoms of Gridhrasi wuth sever pain.4. Samprapti of Dhatu Kshayajanya Gridhrasi Dhatukshaya results in the provocation of vata and increase in its propertieslike rookshata in katiprista vamsha sandhis which further causes diminution ofshleshaka kapha as a result the movement of kati prista vamsha sandhis areimpaired. The roots of Gridhrasi nadi are campressed due to the pressure on it bythe surrounding structures results in the disease. Gridhrasi.This occurs usually in theold age. It can be understood that the vata gets that aggrevated in pakwashaya due tovarious aetiological factors , seated in kati pradesha results in pain and stiffness . Itis mentioned that the main seats of vata are pakwashaya, kati, sakti. Herepakwashaya can be considered as not only the large intestine, but also visceralorgans of the pelvic cavity. Kati pradesha is the region where the vertebral columnjoins the hip bones on either sides and that includes the lumbar, sacral and sacroiliacjoints and its related structures like lumbar and sacral plexus . The vitiation of vata inthese location vitiates the Gridhrasi nadi. This leads to Gridhrasi vyadhicharacterised by the pain starts from hip and gradually comes down to waist, backthigh, knee, shank and foot, affects these parts with stiffness, distress, piercing painand also frequent quiverings. Hence it is considered that Gridhrasi is a shoola pradhana vyadhi. AsGridhrasi nadi is responsible for the locomotion of the lower limbs, difficulty in lifting
the lower limb is observed. Thest features can be considered as the pratyatma lingaof Gridhrasi (Cardinal symptoms of Gridhrasi)Samprapti Ghataka Dosha Vata * Prana vata * Vyana vata *Apana vata Kapha * Sleshaka * Avalambaka Dooshya Asthi Snayu • Khandara • Asti sandi Srotas * Vata vaha srotus Srotodusti prakara * Sanga Ama * Jatharagni janita Agni * Jatharagni Roga marga * Madyama Udbhavastana * Pakwashaya
Adhistana Gridhrasi nadi. Vyaktastana * Kati. • Prista • Ooru • Janu • Jangha • PadaBheda (Classification) Two types of Gridhrasi have been explained based on the association ofdifferent symptoms related to vata and kapha dosha viz., suddha vataja andvatakaphaja. Gridhrasi is mentioned among vata Nanatmaja vyadhis, andinvolvement of kapha, naturally needs clarification. Nanatmaja—‘Na-Anatmaja’means involvement of a singular dosha. More than the involvement, it is thelevel/stage at which ‘involvement,’ takes place, is the one which distinguishes aNanatmaja Vyadhi from a Samanyaja Vyadhi. For a disease to be called Nanatmajait should satisfy two basic conditions. 1. Only one dosha should be involved in the genesis of the disease. 2. No dosha, other than that particular dosha, should be able to cause that particular disease.
Sometimes during the course of a Nanatmaja disease of a particular dosha,symtoms of other doshas are also seen. The symptoms that appear during thecourse of a disease, are termed Anubandha lakshanas and can be seen in any kindof a disease. Thus classification of Gridhrasi into suddhavataja and vatakaphaja isjustified.Roopa The roopa is the lakshana or characterstic features of a disease. Thisappearance of the exact signs and symptoms commences in the vyaktavasta the 5thstage of kriyakala. The signs and symptoms of vataja and vatakaphaja Gridhrasi are asfallowes,Vataja Gridhrasi Stamba (stiffness), ruk (pain), toda (piercing pain) associated with frequentspandana(twitchings) starting from spik(buttock) then kati (Lumbosacral region) andgradually in the posterior aspects of ooru (thigh), janu (knee), jangha (Calf) and pada(foot)50. According to Sushruta and Vagbhata, the kandaras (ligaments) of parshnee(heel) and angulis51 (digits) are affected by the vitiated vata causing in lifting thelower limb52. According to Madhavakara and Bhavamishra, the symptoms mentioned byCaraka have been accepted along with dehasyapi pravakrata53 (bending of the body)Stambha (rigidity), spurana in katisandhi (Lumbosacral intervertebral joints) oorusandhi and janusandhi (knee joint) are observed54. In Yogaratnakara all the signsand symptoms mentioned in Madhava nidana are accepted except stabdhata insteadhe has mentioned suptata (loss of sensation) 55.Vatakaphaja Gridhras Here along with the above symptoms addition of few symptoms like Gowrava(heavines), Aruchi (anorexia) and Tandra (drowsiness) are mentioned56.
Madhavakara added Vahni Mardhana (loss of appetite) Mukha praseka(excessive salivation) along with the symptoms of vataja Gridhrasi57.Lakshana (Symptomatology) Symptoms mentioned in different texts are anumarated as bellow, Suddhavataja lakshanas- • Sthmba • Ruja • Toda • Spandana • Dehavakrata • Janu Kati,Uru Sandhigata- Soola , Spurana, Stabdata. Vatakaphaja lakshana – • Tandra • Gowrava • Arochaka • Agnimardhava • Mukhaprasheka • Bhaktadvesha • Athaimitya Pain radiating down the leg is common in both of these verities. Sushrutadoes not classify the disease, but says along with the pain “Sakthi-kshepa” Nasawould be present. Vagbhata follows Sushruta, but uses “Sakti–Utkshepa“ Nasa.These two terms need further eloboration as it leads to a very interesting situation. “Kshepa” means prasarana (Dalhana) meaning extension. “Utkshepa” meanselevation /raising. Thus in Gridhrasi, there would be difficulty/ inability in raising theleg as well as extending the leg. Very interestingly, raising/ elevation (Utkshepa) andextention (Kshepa) have been considered as two important parameters for arriving at
the diagnosis and measuring the progress of the disease by the Western MedicalScience while S.L.R.-Straight Leg Raising test measures elevation, Lesegues signtests the extension. Thus it appears, the seedlings had long been sprouted for thedevelopment of S.L.R.and Lesegues. SYMPTOMATOLOGY IN VARIOUS TEXTS________________________________________________________________Texts Charaka Sushruta Vagbhata Bhava Gadanigraha Prakasha and Vaidya Chintamani__Kati, Prishta,Uru, Janu,Jangha,Pada Ruk + + + + + Toda + - - + + Sthamba + - - + +Saktikshepa - + - - -Saktyutkshepa - - + - -Deha Vakrata - - - + +Arocaka + - - +Agnimandya - - - + +Bhakta Dwesh - - - + +Mukha Praseka - - - + +Gourav + - - + +Staimitya - - - + +Tandra + - - + +________________________________________________________________
Sapeksha Nidana Sapeksha nidana or differential diagnosis is the determination andestablishment of a disease condition took into consideration of various other similardisorders. Gridhrasi can be differentiated from the fallowing similar diseases where inthe Anotomical structures in between kati (Lumbosacral region) and lower limb areinvolved.1. Kalli According to Arunadatta kalli is considered as the severe painful state of bothGridhrasi and vishwachi at the same time. Both upper and lower limbs are affectedsimultaneously. The thigh, calf, foot and hands are crooked (shrunken) towards itsbase. In Gridhrasi avamotana (crookedness) is not present and need not besimultaneously with vishwachi.2. Khanja The vitiated vayu settles in kati region and the kandaras (ligaments) of lowerlimbs gets affected with akshepana (clonus) of ligaments is a feature resulting in theimpairment in walking. In Gridhrasi the word kati means lumbo sacral region. Buttoda and stambha are present in buttock, posterior aspect of kati, thigh, knee, calfand foot. The affected anatomical region is specifically mentioned. Akshepana isabsent and impairement in walking resembles the gait of a vulture.3. Pangu The same features mentioned in khanja are applicable here, but in panguboth the lower limbs are affected resulting in the total immobilisation of the lowerlimbs i.e., the person can’t walk whereas in Gridhrasi the affected person can walkresembling the gait of a Vulture.4. Kalaya Khanja The person affected by this disease starts walking with kampana. He iskeeping his steps in a cris-crossed manner. i.e., the sandhibandana (alignment of
ligaments) in joints are weakened. It is believed that consumption of kalaya, (Triputa,Lathyrus satium) a variety of cereal causes lathyrism as a result of a neurotoxiareleased by the kalaya spastic paraplegia is a feature of it which we can’t observe inGridhrasi.5. Oorustambha The vitiated kapha dosha along with meda obstructs the vata and pitta in oorupradesha producing immobilisation of the thigh and calf. The movement of the lowerlimb is completely stopped due to the severe pain. The patient feels that his limb is ofothers. He is unable to percieve the cold sensation in the affected limb. Burningsensation, fever, bodyache are the other features of oorustambha. Where as inGridhrasi, the posterior aspects of thigh, calf along with kati, buttock, knee and footare involved. The movement of the limb is possible, daha, jvara are not found.6. Gudagatavata The vitiated vayu situatd in the guda checks the normal expulsion of faecesand urine with pain in abdomen. Urinary calculi are the resultants. The other featuresare pain and emaciation in back, sacral region, thigh, calf and foot. Though the pain in thigh, calf, foot are present in Gridhrasi, the specificanatomical region is mentioned the other symptoms which are necessary todiagnose the gudagata vata are absent in case of Gridhrasi.Sadhyasadhyata The sadhyasadhyata of a disease depends upon many factors such asstrength of the vyadhihetu, the strength of the dosha prakopa, severity of symptoms,duration of disease and importance of seat of the disease. It also depends upon age,sex of the patient, rogamarga and dhatu dusti….etc. Gridhrasi is a vatavyadhi andthe nature of vata is also plays an important role. Acharya Sushruta considered vatavyadhi as one of the mahagada which is cured with difficulty58. Caraka advocatedthat those which are astigata or majjagata are usually cured with difficulty or evenincurable on account of seriousness of the stanadusti present in the disease. Caraka
also added that vatavyadhi does not respond to any treatment when there isdiminution of mamsa and bala. However, when they are treated in their early stage,when the patient has got sufficient strength and with the absence of any upadravasare curable. The same principles are also applicable to Gridhrasi. The vitiation of vatadosha occurs in prista, kati and spik regions with theinvolvement of the sandhi and sandhi bandhas. These in further give rise to thevitiation of the Gridhrasi nadi. If the patient suffering from Gridhrasi approaches tophysician earlier the treatment and if he had proper treatment in time is likely to becured. In case the changes in the spinal joint are of an advanced condition or if theGridhrasi nadi get vitiated intensevely, then even the test treatment is likely to resultin relief only partial at times. When Gridhrasi of vatakaphaja type, i.e., associatedwith kapha dosha, the rate of cure is more and easier to cure than it is having onlyvata dosha59.
Chikitsa Restoration of dosha, dhatu and mala to a state of equalibrium is the mainaim of chikitsa in Ayurveda60. All the vata vyadhis are treated with the aid ofmedicines and diet that are madhura, amla, lavana and snigdha61. Considaring thenature and state of vyadhi the following measures are also adopted viz., Snehana,Swedana, Vamana, Virechana, Nirooha and Anuvasanavasti62. Charaka says that vatavyadhi should be treated according to the particularstana i.e.Pakwashaya and dooshya affected63. Gridhrasi is a vata vyadhi, themeasures adopted for vatavyadhis have to be considered. But Charaka, Sushrutaand few other Acharyas have specified certain measure of treatment. Some of themare ascribed as below.Snehana Acharya Bhela has specifically mentioned snehapana in Gridhrasi. He furtherrecommends that Bala taila is beneficial but Mulaka tail and Sahachara tail are thebest Snehas64. Sushruta and Vagbhata included Gridhrasi in snayugata vatavikara.So both of them advocated snehana in snayugata vatavikara65. Dhallanarecommended both bahya and abyantara snehana, where Vrudda Vagbhata hasstressed over abyanga. Both Charaka and Vagbhata have the openion that if there isprovocation of vata alone without any avarna then abyntara sneha like gruta, taila,vasa and majja are to be administered66.Swedana Charaka, Sushruta and Vagbhata have suggested swedana karma invatavyadhis67. The piercing pain, rigidity, stiffness are quickly relived and softness ofthe part restored by means of swedana68. The rigid, crooked pain full parts can bebent or moved accordingly by means of snehana and swedana69. Repeatedsnehana and swedana will not allow vata to vitiate in its place. The swedas can beadopted are nadi, sankara and prastara70. The snigda swedas are helpful in vatajaGridhrasi where as both snigda and rooksha swedas are useful in vatakaphaja
Gridhrasi. Swedana can be administered in Gridhrasi of other than dhatuksaya andswaprakopaka origin. Swedana is done before the administration of shodhana.Upanaha Though it is one kind of swedana, it is specifically indicated in Gridhrasi apartfrom swedana71. Upanaha or poultice relieves stiffness, piercing pain, odema,spasticity of the limbs etc. upanaha mixed with mamsa in grita,taila, amla and lavanaitems is used (It is indicated in loss of sensation of a particular part). Sandhisuptatais a feature of Gridhrasi.Unmardana It is beneficial in cases of vitiation of vata and kapha dosha. After unmardanaseka is indicated. This procedure is advanced by Sushruta, Bhela, Vagbhata. Thisis said to be relieve the pain of injuries.Sodhana Chikitsa Bhavaprakasha specifically ascribed that the person who got Gridhrasishould be purified. He has instructed vamana, virechana and vasti one after theother as purifying methods. In further he has mentioned treatment without sodhanatherapy will go waste73.Vamana Vamana therapy will be beneficial for vata kaphaja Gridhrasi to alleviate thekapha dosha.Virechana If the disease is not relieved by means of snehana and swedana owing to theinvolvement of other doshas, here Caraka advocates sodhana by means ofvirechana using snehayukta ousadha i.e., Tilvaka grita, Eranda taila with milk74. Majority of authorities prefer Eranda taila with milk, or with Gomutra. All are ofthe openion to give it in daily doses upto a period of one month75. Eranda taila issaid to be the beneficiall in both vata and kapha involvement. Hence it is useful inboth variety of Gridhrasi76. In vatakaphaja Gridhrasi, Eranda taila with pippali is
indicated77. This purificatory method can be adopted in margavaranajanya Gridhrasias well as in marmaghatajanya Gridhrasi. Virechana is administered before theadministration of vasti karma.Siravyadha Siravyadhais suggested by Sushruta and Charaka78. Dalhana comments, thatwhen the Gridhrasi is originated due to sonitavarana, fails to treat the disease by allmeans, then siravyadha has to be done79. Charaka advocates siravyadha betweenthe kandara and gulpha80 while Sushruta says in the sankuchitajanya position81 andgives the location as four fingers above and below the janusandhi82. It is clear thatsiravyadha should not be done in cases of dhatukshaya, swaprakopakajanyaGridhrasi. It can be done in margavaranajanya Gridhrasi where rakta is avarana.Agnikarma Agnikarma or chemical cauterization is indicated in disease due to vitiation ofmamsa and where vata gives rise severe pain in the twak, sira, snayu, sandhi andasthi83. Charaka stated Agnikarma but he has not explained the procedure84.Chakradatta advocated Agnikarma on the kanistikanguli only after the failure of allvarieties of treatment85. Vridda Vagbhata says that different methods of Agnikarmaby madhu, sneha etc. has to be done86.Bandhana This is indicated in snayu, sandhi, siragata vata by Sushruta and Vagbhata87.Though Sushruta has mentioned Bandhana in asthi, snayu sira chinna. Keeping inview that in Gridhrasi of marmaghata origin, there may be sandhichyuti (discprolapse) or injury to the snayu which binds the Lumbosacral vertebra. He has alsomentioned that Bandhana gives support to the asthi. In further he has indicatedMandala Bandhana in kati (Lumbo sacral region ) by using hard materials like leatheror metal. Similarly Lumbo sacral belt is adviced in contemporary medicine, if the disclesion and lumbo sacral spondylosis, lumbar spondylosis are the cause.
Virechana Karma Virechana therapy is very useful for the elimination of vitiated pitta dosha, andprevention as well as cure of diseases caused by pitta. Virechana also helps in theelimination of kapha dosha which is situated in pittasthana. It is also preferable forthe elimination of vata dosha which is mentioned in vata vyadhi.Definition of Virechana Virechana is a process by which the elimination of doshas throughadhomarga (Guda) willl takes place88. Removal of the doshas from the body throughadhomarga is called as virechana.Properties of virechana dravyas Virechana dravyas will have all the properties of vamana dravyas. I.e.ushna,teekshna, sukshma, vyavayi and vikasi gunas. They posssess prithvi and jalamahabhutas which show the tendency of adhobhaga pravritti89. However, the following virechana drugs described by charaka90 have beengiven preference for different degrees of virechana karmas. i. Sukha virechana - Trivrit root ii.Mridu virechana - Aragwadha iii.Tikshna virechana - Snuhi kseera Sushruta described the following drugs with priority for virechana91. i. Mula virechana - Syama Trivrit ii.Twak virechana - Tilwaka iii.Phala virechana - Haritaki iv.Taila virechana - Eranda v.Swarasa virechana - Karavellaka vi.Kseera virechana - Snuhi Sharangadhara mentioned the following classification of virechana drugs92 inreference to 4 types of adhobhagahara karmas. i. Anulomana - Haritaki
ii.Sransana - Katuki iii.Bhedana - Katuka iv.Rechana - Trivrit The virechana may be of following two types depending upon its physicalcharacteristics. i.Snigdha virechana ii.Ruksha virechanaProcedure of virechana Karma The procedure of virechana karma is followed by 3 stages as follows, 1. Poorva karma (pre-operative procedure) 2. Pradhana Karma (operative procedure). 3. Paschat karma (post operative procedure)Poorva Karma Atura Pareeksha : The patients undergoing virechana karma should be examined by astavidhaand dashavidha pareeksha. There by deciding whether the patient is fit for snehana,swedana and virechana karma. Atura Siddata : After proper examination of the patients, proper drug has been selected foramapachana depending upon the predominance of the samadoshas till theniramavasta. After the confirmation of niramavastam, snehana and swedanaprocedures should be done. Sambhara Sangraha (Collection of Drugs) ; Drugs which are required for virechana karma and to treat the upadravashould be collectd and kept ready. According to dosha predominance virechanadrugs mentioned by Vagbhata93 are as below, 1. Vatadosha - Snigdha, Ushna, Lavana 2. Pitta dosha - Kashaya and Madhura
3. Kapha dosha - KatuPradhana Karma This includes the administration of virechana yoga, atura paricharya andnireekshana. The detail procedure has discussed in Material and Method section.Atura Paricharya and Nireekshana After administration of the virechana dravya, physician must observe thesigns and symptoms of Hridhosha, Jeernoushadha, ajeernoushadha. Hridhosha Lakshana Whenever there is proper purgation then the patient will pass the following inthe order of mala, pitta and kapha. Jeernoushadha Lakshana Vatanulomana, swasthya, agnideepti, thrishna, manaprasada, indriya laghutaand shuddha udgara, etc. are existing. Ajeerna Virechanoushadha Lakshana Dourbalya, daha, angasada, bhrama, moorcha, sirashoola, etc. are ajeernavirechanoushadha lakshanas. Vega Nirnaya After the administration of virechana dravya, don’t consider the first 2-3vegas which are associated with mala, count the Vegas after 2-3 vegas.Samyaka Virechana Lakshana Table showing the samyaka virechana lakshanas according to BrihatrayiSl.No. Lakshanas Charaka Sushruta Vagbhata 1. Srotovishuddi + - - 2. Indriya prasada + + - 3. Laghuta + + - 4. Agni vriddi + - -
5. Anamayatva + + - 6. Vit pitta kapha + + - Vata nissarana 7. Vatanulomana + + - 8. Ayoga lakshana abhava - - +Paschat Karma Samsarjana Karma After Virechana, the patient may not be allowed to take normal diet.So thepatient should be given peyadi ahara for 3 to 7 days according to shuddi. Forpradhana, madhyama and avara shuddi patients, peya, vilepi, akrita yusha,kritayusha, akrita mamsarasa and kritamamsa rasa should be given for 3, 2, and 1annakala. The normal diet is adviced for avara, madhyama and pradhana shuddipatients after 3rd, 5th and 7th day evening respectively. The diminished agni will cometo normal after this samsarjana karma. Pariharya Vishaya 94 Some instructions are to be followed after Virechana karma. The contraindicated diet and regimens. • Loud speaking • Excessive meals • Silling in one position for long time • Excessive walking • Anger and sarrow • Excessive use of cold items • Vehicle riding • Sexual intercourse • Sleeplessness • Day sleep
• Unwholesome food • Inducing natural urges.Virechanotthara karma After virechana, if not shodhana is to be done, the shamanoushadha may beadvised or vasti karma can be followed on 9th day onwards 95.Vasti Chikitsa Vasti is the procedure of introducing medical recepies in the form of enematathrough rectal, vaginal or urethral route and evacuating it to produce the effect ofrectally introduced medicaments. The term vasti is derived from the apparatus(Urinary bladder of an animal) used for the introduction of the medicaments. As it isintroduced into the vasti region and as it is retained there for a short period. Vasti has most importance in sodhana therapy. It is said to be half of thewhole treatment or some times a complete treatment because it corporates all thetreatment aspects of Ayurveda into it. Vasti is the principle and specific treatment forvata vyadhis. Because vayu is the motive force behind all physiological andpathological states of the body. Acharya Sushruta described that whether it issarvanga or ekanga vata vikara, vasti is the single and most effective method ofsodhana therapy. According to Vagbhata vasti is the foremost among all treatments and isindicated in the disorders, having predominance of vata or vata alone. Vasti bringsback the deranged vata, either by vriddhi or kshaya to a state of equallibrium96. Vastithough administered locally into lower abdomen, have wide systemic action. It islikened to the cutting of root of a tree results in the automatic destruction of the trunk,branches, sprouts, flowers, fruits, leaves etc97. Vasti is of three kinds, Niruha, Anuvasana and Uttara vasti98. The term Niruhaliterally means that whose effect can’t be guessed. It is also known as Asthapanavasti, administered through the rectum making use of decoction of drugs mainly.
Anuvasana means that which remains in the body for some time without causing anyharm. It is also known as snehavasti. It is alsso administered through the rectum,making use of medicated oil to alleviate vata and to nourish. Uttaravasti is the enema of upper tract administered through vaginal andurethral passages, but not of the rectal passage. Decoction of drugs and medicatedoil both are used for this. Panchakarma is an ancient Indian method of medical management whichhas now abruptly drawn the attention of physicians far and wide. It comprises ofvamana, virechana, anuvasana, niruha and nasya. Generally in practice niruha andanuvasana are included under the head of vasti and raktamokshana is added as thefifth99. Vasti karma the method of administration of medical recipes into pakwashayafinds a top place among the panchakarmas. Since it produces sodhana of doshas,samsamana of diseases, samgrahana of malas and so many other karmas at onestroke. As vasti is composed of various kinds of medicinal drugs including sneha,kashaya etc. it eliminates the provoked doshas and it stabilizes the achayaja doshawhich increased in its own site100. Vata is the motive force behind the functions like elimination or retention ofpureesha, mootra, pitta and other malas in their respective sites and vata is the mainaetiological factor in the manifestation of diseases pertaining to sakha, kosta, marmaurdvanga, various organs of the whole body. There is no better remedy other thanthe vasti in alleviation of vata which vitiated excessively. So that Acharya Carakapraises vasti chikitsa to be half of the chikitsa while others hold it to be whole of thechikitsa101. Definition of Vasti ‘ Vasu nivase ’ means residence102 ‘ Vasu acchadane’ means that which gives covering. ‘ Vasu avrunoti mootram‘, means that which covers the urine.
Vasti-Nabheradhobhaga stana, means that which lies just below umbelicusand is the collecting organ of urine, the urinary bladder103. In the context of panchakarma the term vasti is used in a different meaning.The term vasti means, the bladder of an animal used as a device to administer themedicinal recipes hence the term vasti is used as a name of panchakarma therapy todesignate the process104. It is also said that the medicine administered rectallyreaches the vasti region. Where it is retained for some time. The term vasti alsosignifies the covering material such as the leather bag. Generally vasti karma is correlated to enema of contemporary medicine, theenema is given to remove the faeces. But in Ayurveda the vasti idea underlying thevasti is entirely different from enemal Acharya Charaka enumarated the beneficialaspects of vasti as it helps rejuvenation and it will provide happiness, andcomplexion. It is good for old as well as young. Obvious hazards in this therapy105.According to Sushruta, vasti will cure all diseases caused by vata, pitta, kapha, rakta,samsarga and sannipata of doshas. It will be beneficial in the treatment of everydisease and in healthy persons also106.Classification of Vasti Since vasti is an important treament processes in Ayurveda, having variedtherapeutic applications and effects, it may be classified in different ways and onecan’t find any uniformity in the classification of vasti among the authors of classicaltexts. Generally the term vasti has been used for all types of vasti karma whichinclude niruha, anuvasana, uttaravasti etc. But Charaka used the term vastiexclusively for niruha. Similarly the term vasti also been reffered to the process ofsirovasti, vranavasti, etc. Considering various aspects the fallowing classification are brought about, 1. Adhistana Bheda ( site of application ) 2. Dravya Bheda ( the medicinal preparation used ) 3. Sankhya Bheda (number of vastis given )
4. Matra Bheda (quantity of medicine used ) 5. Karma Bheda ( according to action ).i. Adhistana Bheda According to site of application vasti is mainly classified into Internal andExternal1) Internal (Abhyantara) a) Pakwashayagata vasti – Administration of drug by ano-rectal route (Gudamarga) and its adhistana is pakwashay. b) Uttaravasti – The term uttara vasti is used to designate both mootrashayagata and garbhashayagata vasti by ancient scholars as their routes of administration are superior to the anal orifice in human body. c) Vranagata vasti – This vasti is indicated for shoshana and roopana process of vranas. The drug is administratered through vranamukha by process of vasti karma.2) External (Bahya) In certain diseases medicated oil is kept over the part of the body by making a brim with the paste of black gram powder for prescribed period of time. It is named after the site of application of oil such as a) Shirovasti – Over the scalp107 b) Urovasti -- Over the chest c) Kativasti -- Over the lumbor sacral region.ii. Dravya Bheda It is based on the major ingredient kwatha or sneha is used as vasti dravya .It is classified into Nirooha and Anuvasana. 1) Nirooha vasti – When vasti is given with more of kwata , then it is calledas Nirooha vasti. It is the important type of vasti karma having varied therapeticeffects. Nirooha vasti is so called because it is able to eliminate the doshas from thebody and its action in the body is beyond the perception of physician. The effect of