Pravahika kc019 gdg


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The evaluation of efficacy of Nagaradi Churna in Pravahika with special reference to Amoebic dysentery, Basavaraj G. swami, 2000-03, Department of Kayachikitsa,Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG

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Pravahika kc019 gdg

  1. 1. “The evaluation of efficacy of NagaradiChurna in Pravahika with special reference to Amoebic dysentery” By Basavaraj G. swami As partial fulfillment of post graduation degree Ayurveda Vachaspati M.D. (Kayachikitsa) Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka Guide Dr. Vangipuram Varadacharyulu M.D. (Ayu) (Osm – Gold Medallist Professor H.O.D. Kayachikitsa Postgraduate studies and research center, Kayachikitsa Co-Guide Dr. Shashidhar H. Doddamani, M.D. (Ayu) Asst. Professor in Kayachikitsa Postgraduate studies and research center, KayachikitsaD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE Gadag - 582 103 Post graduate studies and research center Department of Kayachikitsa 2000-2003
  2. 2. This is to certify that the contents of this thesis entitled “The evaluation of efficacyof Nagaradi Churna in Pravahika with special reference to Amoebic dysentery” is hasbeen worked out by BASAVARAJ. G. SWAMI, under my supervision with close guidance. Even though this disease, Pravahika has been mentioned in Ayurvedic texts, theaetiology, pathogenesis etc., needs further evaluation and research. It is as developed andexplained by BASAVARAJ. G. SWAMI is unique and scientific and will definitely help inelucidation of this disease in Ayurvedic and Modern scientific parlance and further planningwith the management. This work is applied, scientific and an original contribution in the field of research inAyurveda. I am fully satisfied with the work and recommend the dissertation to be put before theM.D. (Ayurveda Vachaspathi) Kayachikitsa panel of Rajiv Gandhi University of HealthSciences, Bangalore for adjudication. Guide Dr. V.Varadacharyulu M.D.(K.C)(Osm), Professor & H.O.D DEPT. KAYACHIKITSA DGMAMC, PGS&RC, Gadag
  3. 3. J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER DEPARTMENT OF KAYACHIKITSA GADAG, 582 103 Certificate This is to certify that BASAVARAJ. G. SWAMI has worked for his thesis on the topicentitled “The evaluation of efficacy of Nagaradi Churna in Pravahika with specialreference to Amoebic dysentery”. He has successfully done the work under the guidance Dr. V. Varadacharyulu, M.D.(Ayu) (Osm), and Co-guidance of Dr. Shashidhar H. Doddamani, M.D (Ayu). We here with forward this thesis for the evaluation and adjudication. (Dr. V. Varada charyulu) (Dr. G. B. Patil)
  4. 4. Certificate This is to certify that BASAVARAJ. G. SWAMI has worked for his thesis on the topicentitled “The evaluation of efficacy of Nagaradi Churna in Pravahika with specialreference to Amoebic dysentery”. 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 highly significantat the statistical evaluation and have considerably contributed to the present knowledge ofthe subject. Co-Guide Dr. Sashidhar H. Doddamani, M.D. (Ayu) Asst. Professor in Kayachikitsa Postgraduate studies and research center
  5. 5. “The evaluation of Nagaradi Churna in Pravahika with special reference to Amoebic dysentery”.Index Chapter-1 1 to 6Introduction to Pravahika Chapter-2 7 to 77Conceptual study – includes Shareera, Nidana, and Chikitsa in detailwith respect to the disease in comparison to contemporary medicine. Chapter-3 78 to 89Drug review – Nagaradi churna composition is discussed with itspharmacological and pharmaco-dynamics. Chapter-4 90 to 97Material and methods Chapter-5 98 to 112Observation and results Chapter-6 113 to 123Discussion and conclusion Annexes Summary References Bibliography
  6. 6. List of tablesPravahika Nidana 46Correlative Aetiology of Pravahika and Amoebic dysentery 47Signs and symptoms of Pravahika mentioned in various Ayurveda 55textsSamprapti ghatakas of Pravahika can be deduced as follows 58Differences between the three Atisara, Pravahika and Grahani 66Differences between amathisara and Pravahika. 67Table-1 Depicting the frequency at the disease in the different Age 99groupsTable –2 Depicting the Sex ratio of the study 100Table–3 Depicting the frequency of the disease according to Religion 101Table–4 Depicting the frequency of the disease according to economic 102statusTable-5 Depicting the frequency of the disease according to Regional 103DistributionTable-6 Depicting the frequency of the disease According to 104OccupationTable-7 Depicting the frequency of the disease according to Diet 105Table-8 Data related to presenting complaints 106Table-9 Tests of significance - Statistical Data related to parameters 107Table-10 Showing results 109Difference of assessment criteria – Baseline to final 110The assessment criteria - individual patients 111
  7. 7. List of graphsGraph-1 Depicting the frequency at the disease in the different Age 99groupsGraph –2 Depicting the Sex ratio of the study 100Graph–3 Depicting the frequency of the disease according to Religion 101Graph–4 Depicting the frequency of the disease according to 102economic statusGraph-5 Depicting the frequency of the disease according to Regional 103DistributionGraph-6 Depicting the frequency of the disease According to 104OccupationGraph-7 Depicting the frequency of the disease according to Diet 105Graph-8 Data related to presenting complaints 107Graph-9 Showing results 112
  8. 8. AcknowledgementI am deeply indebted to several people who have helped me during my study.I acknowledge my sincere gratitude to my guide Dr. V. Varadacharyulu, H.O.D.Post-Graduate studies and Research Center in Kayachikitsa, D.G.M.A.M.C, Gadag,for his expert comments, critical analysis and affectionate encouragement,throughout my study.I am grateful to my Co-guide Dr. Shashidhar H. Doddamani, Asst. Professor, Post-Graduate studies and Research Center in Kayachikitsa, D.G.M.A.M.C, Gadag forinspiring me to take up this dissertation subject and supporting me with timelyguidance and encouragementWords are poor substitutes for my immense feelings of gratitude to Dr. G. B. Patil,Principal, DGMAMC, Gadag. I thank him for his ever-inspiring encouragement,facilities provided and personal interest in overall supervision of this study.With a deep sense of gratitude, I thank my teacher Dr. K. Shiva Rama Prasad,Reader/ Asst. Professor, Post-Graduate studies and Research Center inKayachikitsa, D.G.M.A.M.C, Gadag for his much-valued guidance, constant supportand encouragement throughout my study.It is my prime duty to remember Late Sri Danappa Gurushiddhappa Melmalagi,founder chairman of this esteemed Ayurvedic institution, which made manygraduates to serve the ailing in and around Gadag district. I am taking with respectthe name of Mrs. Girijamma Melmalagi who became mother for many in thisinstitution.I extend my immense gratitude to Dr. M.C. Patil, Dr. Raghavadra Shetter and Dr.Kuber Shank, faculties of Post-Graduate studies and Research Center inKayachikitsa, D.G.M.A.M.C, Gadag.
  9. 9. I am very grateful to my parents late Sri Gangadhara Swami, Smt. SiddhalingammaBhoosanurmath and late Prof. S.A. Hiremath, S.A. College, Naregal for theircooperation since my birth to study medicine.I can never forget the encouragement of Late Dr. C M Sarangamath, learnedcolleague friend and philosopher who inspired me to take-up postgraduate studies.The cooperation of my wife Smt Vidya, my children Avinash, Anusha and Abhilashain the process of my post-graduation is unique.I sincerely remember the co-operation and guidance extended to me by Dr. G.S.Hiremath, Dr.S.B.Govindappanavar, Dr. V.M. Sajjan, Dr. C.S. Kudarikhannur, Dr. U.V. Purad, Dr. Gireesh Danappagoudar and all the staff of D.G.M. Ayurvedic MedicalCollege, U.G and P.G. I thank all my P.G. colleagues and Heads of the Departmentsof Dravyaguna, Rasashastra and Panchakarma for their timely support and co-operation.I genuinely remember the co-operation and support extended in the clinical trail byR.M.O. Dr. S.D. Yarageri, Dr.N.S. Hadli, and hospital staff for their constant help andco-operation.I honestly remember the co-operation and support of Dr.G.S.Hadimani, Dr.Shankaragouda, Dr. Srinivasa Reddy, Dr. A.P.Yasmin, Dr. C.S. Hanamanthagoudarand all the scholars of DGMAMC – PG branches. I thank all my P.G. colleagues fortheir constant help and co-operation.I candidly thank Mr. P.M. Nandakumar, statistician, for the statistical analysis of theresults, librarian V.M. Mundinamani for his timely assistance and thank ShankarBelawadi for his constant co-operation in my career.With deep sense of gratitude I thank all the subjects who participated in this study. (Basavaraj G. swami)
  10. 10. Food, water and air in order of increasing priority are the main for survival of humanbeing. One way intake of these are not sufficient to withstand, but also the expulsion of theexcessive or the unwanted is to be pushed out, therefore the mechanism of formation offecal matter, urine and expiration of carbon dioxide have been developed in the body. Thequantity, quality of the above three play an important role in the life, thus it is clearly said inthe Samhitas as, That the life not only depends upon the food but also on the fecal matterpassed out with reference to Rajyakshma management. Out of many diseases in thegastrointestinal tract, the important are Pravahika, Athisara, and Grahani. The diagnosis of Grahani as per the present systems other than Ayurveda is difficultbut where as the other two which may manifest individually or as well as related with one toanother have been identified by the Acharyas centuries ago. It is still followed by thephysicians of all systems even today. Susruta and Madhavakara have first identifiedPravahika as distinctive disease and Charaka as a symptom in kaphaja athisara. Pravahika the disease coined after the word pravahana or kunthana which is definedas the sound made by a person when to strains down to pass the stools, seems to be theappropriate definition, even though many have defined it as Atisara or Grahani associatedwith pain. But the cardinal symptoms is that even after straining the person passes smallamount Mala or fecal matter associated with large quantity of Kapha or mucous or pus orblood. Basically unhygienic conditions are the causes of spread of the disease. It ismanifested via the oral cavity along with food and water. Urbanization where the sewageand the drinking water supply are near gets inter-linked to cause the epidemics. The irony ofthe same is that it does not manifest in the persons and may be sub clinical, but still theycan contaminate the others too. This is augmented by the habit of eating food and drinkingat places with poor hygiene, and the mechanical life of the city in particular supporting this Pravahika – Introduction 1
  11. 11. habit, and also drinking water at different places. The cause of not manifesting after invasioncould be the resistance of the person. And if the food taken is unwholesome or virudha inquantity, quality and timing may help in the formation of Ama and reduce resistance of theperson thereby manifesting the Pravahika. Even though the line of treatment is with goodprognosis but the rate of recurrence is high. The number of fatalities is low with the help ofpresent drug therapy, but it was high earlier, especially during the wars where epidemics arecommon. The disease is the result of the vitiation of Samanavata, Kledakakapha andApanavata. Even though the above Doshas are vitiated to smaller extent the disease will notmanifest unless it is associated with the Ama, which is the result of the agnimandya. As aresult of the vitiation of the Kledakakapha and the Samanavata, or if the doshic vitiation issevere and the involvement of the Pachakapitta/ Agni is not there then the disease willmanifest without the formation of the Ama also. Thus the disease may manifest with theassociation of Ama or even without. This disease is the equivalent with the contemporarydisease dysentery is said to be due to the infection of Entemoeba histolitica or E. coli orBacteria. Susruta also affirmed krimi as the cause with out specifying the type or name.Here we observe that in all cases of positive infestation the signs and symptoms may not beseen. Probably in these cases of Pravahika, once the person takes more of virrudha aharaor Ama kara ahara for the formation of Ama. Ama is the undigested food getting fermentedin the stomach. By which the resistance of the person will decrease thereby the sub clinicalsigns and symptoms may become clinical.Need and significance of the study:- Generally using contemporary system management relives the signs and symptomsin the patients, but the hard luck of the same is that the patients are prone for malignancy if Pravahika – Introduction 2
  12. 12. the systemic drugs are used indiscriminately. Especially in India the diagnosis is basedmostly on the signs and symptoms rather than by investigation. Keeping in view the above points when we search for an alternative system for thetreatment of Pravahika. Ayurveda gives a good answer because of the herbal drugs beingwith out side effects and the wholesome treatment of the disease. This not only takes outthe disease but also the resistance and immune capacity of patient is increased. So that therecurrence rate may be low compared to the other groups of medicament usage. Even though Ayurveda has advocated many a number of medicines for Pravahika,the selection of Nagaradi churna has been undertaken based on the following points. The Chakradatta has given a best combination of drugs, which are appropriatehaving the krimighna effect over the Entamoeba Histalitica. E. Coli, and other variousbacteria. And also having the property of regulating the bowel habits, along with deepana,pachana shoola hara raktha sthambaka and ropana gunas. The pathology for the passage of blood and mucous is due to the inflammation of thelarge intestine mucosa due to the exo-toxins of the bacteria and the irritation of the cysts ofEntamoeba hystolitica as explained by the contemporary medicine. Though Ayurveda couldnot explain it for the lack of postmortem facilities to locate the krimi in the dead body thesigns and symptoms enunciated is exactly same and krimi has been pointed under the limelight of Tridosha theory.Objectives of the study: - 1) To study literary search on Pravahika vis-a-vis amoebic dysentery 2) To study the efficacy of Nagaradi Churna on Pravahika with reference to subjective and objective parameters 3) To evaluate the efficacy of Nagaradi Churna in improving the clinical status of Pravahika with special reference to E.Coli infection Pravahika – Introduction 3
  13. 13. Historical glimpses of Pravahika The sage physicians of ancient India have recognised the disease Pravahika as aproblem of all ages and sex. To begin with an inquiry into the etymological begins of theword Pravahika. The word Pravahika it self is a combination of two identical units as pra and vahik.Vahika is derived from the root vaha with the suffix-nvul of kridanta. For the pra upasarga,vaha dhatu, nvul pratyaya and tap are combining lead to an origin of the word Pravahika. According to shabda stoma mahanidhi pravahana indicates mala pravahana. Hencemore fecal matter when expelled out with tenesmus can be defined as Pravahika. Furtherwhen there is urge for defecation but expulsion of stool is not much can be termed asPravahika. Susruta suggested Pravahika, as it originates from the vadhri vilodane or vahadhatu. Which means prayatna (initiation) for expulsion of fecal matter with tenesmus.Kaviraja gananath sen has lucidly clarified that the word pravahana means kunthan(tenesmus) "pravahanam nama kunthanama" which means in a disease where there ismore kunthana, the said disease can be termed as Pravahika. The word Pravahika is a term of female gender, which means "pravahyati malambahulam" or "pravahyati muhurmuhu sakapha malam pravar tayati iti Pravahika". InPravahika the vitiated Vata tries to excrete the Kapha which is accumulated due to intake ofahita Ahara in the kosthas of the patient. The accumulated Kapha along with mala comesout by pressing force from the anus in small quantity. This clinical condition is known asPravahika in Ayurveda1. Charaka described the signs and symptoms of Pravahika2, however the remedialskills are found noted in the Chikitsa chapter of Charaka Samhita3. In Susruta Samhita it isdescribed specifically under Atisara chapter and the treatment and symptoms are vividly Pravahika – Introduction 4
  14. 14. described4. Vagbhata accepted the views of Charaka. Most of other collections likeParashara Samhita, Sharngadhar Samhita. Bhavaprakash, Madhvanidana and BhaishajyaRatnavali etc. enumerated the disease in detail paying it the status of a disease. With the advent of scientific knowledge and thought, the medical science reached itspeak during 19th century and the disease Pravahika has a simulation with amoebic colitis.The roman physician Galen (130-205 A.D.) also identified the disease and mentionedinfection of the liver and intestine. Therefore keeping all the above points in view the combination of Nagaradi churnahas been under taken for the trial and also they are, supporting for the above properties.The combination of Nagaradi churna5 is as follows: Nagara Zingiber officinale Ativisha Aconitum heterophylum Mustaka Cyperus rotandis Dhataki Woodflorida fruticosa Rasanjan Berberis aristata (modified form) Vatsaka Holarrhena antidysentrica Twak phala Cinnomnmn zeylanicum Bilwa Aegle marimelos Pata Cissampelos pareira Katuki Latilopicrorhiza kurroaroyleHypothesis: - Nagaradi Churna in Pravahika with special reference to Amoebic dysentery is moreeffective in controlling the condition and to eliminate the causative organism. Pravahika – Introduction 5
  15. 15. Materials and methods: - 30 cases with cardinal symptoms of Pravahika would be undertaken for the trial aftergetting the stool examined from DGM Ayurvedic Medical College, Gadag. All the positivecases would be considered for the trial as out patients, as the disease is not that acuteneeding the admission to wards and requires close observation. The efficacy and the resultsin detail has been recorded and discussed separately in the concerned chapters. Pravahika – Introduction 6
  16. 16. 1 Charaka Chikitsa 19/72 Charaka Chikitsa 19/303 Charaka Chikitsa 19/344 Susruta Uttara 40/140-1415 Sahasra Yoga Churna Prakarana – 83,84 Pravahika – Introduction 7
  17. 17. Historical review History of any subject starts either or around the birth of Christ as accepted by thehistorians. Time being divided as pre Christ and post Christ that is the birth and death ofChrist from when an approximate chronological information is recorded and available. Thisseems to be also effected the identification of various books and their time period. But whilenot pointing the specific year or century. Indian philosophy in general and history inparticular searches itself in the Apourusheya vedas and the great grammarian’s work ofpanini grammar being the earliest. So also Ayurveda which is accepted to have its rootsfrom this period even though many changes and editions have come across. Thus we startour search from the Vedas. Regarding the present topic of Pravahika as a disease, we donot see any references in Vedas 6. But an approximation of its coining could be assessed tobe in the 8th century BC, with reference to the Baudhika vangmaya where its mention anddiscussion is clearly seen. Its reference in Ayurvedic texts should be definitely present sinceit is seen in the contemporary literature of that time 7. The line of treatment of both Grahani and Pravahika are similar, therefore basing onthis principle, it might have been though to be paryaya of Grahani. Such a discussion isseen in garuda puraana. It is believed according to some that Buddha had suffered from blood motions whichresulted in his nirvana and these bloody motions being different from Atisara, have beenidentified as pakkanddika or praskhanddika, whose symptoms and signs are similar to thatof Pravahika. The characters mentioned in the above reference seem to be similar to that of 8Pravahika. Mention of prakkandhika or praskhandhika in books of angutharanikaaya anddhighanikaaya 9, jathaka 10 etc.,. It is also seen in milindapahaana 11. 12 13 In another bauddhika literature, majjminikaaya and jathak mention of lohithapakkandhika is seen which is equivalent ot rakthaja Pravahika. Pravahika – Conceptual Study 7
  18. 18. Here we even get references of the isolated causative factors for the said disease,which is similar to that of Pravahika. Eating vitiated bath, a type of food preparation. Inmilindapahaano, where in a short story mentions that eating pig meat causes it, due to theinability of the pachakagni to digest it. Where as the treatment reference is seen in keshabjathak. Where it says that due to anidhra results into ajeerna, and it causes theevra vedanaand pravahana with blood motions, when the treatment of the doctor failed, on an advise ofa friend dhahi, madhu, ghrita and guda was tried which gave good relief. In milindapahaanoalso reference of rakthaja Pravahika is seen. The characters or the signs and symptoms mentioned in the baudhika saahityawhich they have called as praskhandhika or Pravahika is similar to those mentioned in thesavil’s system of medicine under the heading of dysentery. That is the patient complaints offrequency of motions with blood, mucus and perhaps with pus in stools. Associated withtenesmus, and abdominal pain, must be known to be suffering from dysentery. Thus from the above references keeping in view, the bauddhika period as around800 B.C., and since we do not have authentic Ayurvedic texts of this period we assume thatwithout the availability I the prevailing medical system such references may not be positivelymentioned in other literature. 14 Charaka used the word Pravahika and also uses the word pravaahana while 15mentioning the kaphaja athisara lakshanas. Again in the siddhi sthaana while describingthe upadravas in the series with other diseases Pravahika mention is seen. But he has notgiven any definition of the word or the explanation of the same. 16 The definition and specificity of the disease is seen in Susruta after explainingAtisara, where even the lines of treatment and drugs have been mentioned. From then on allthe classics have given the description of the disease, like Vagbhata, Madhavakara,Bhavaprakasha, Sarangadhara etc., but significant material is not to be seen. In the recent Pravahika – Conceptual Study 8
  19. 19. literature too except for commenting upon the above classics and explaining the same in abetter way much work has not been done in this regard, and only improvises the thoughts ofthe older classics. After a wide gap we find that the so-called disease which is having similar signs andsymptoms of Pravahika is dysentery. As in Ayurvedic literature, even in the present medicalhistory, written information is only available in a proper way from 1700 to 1800 years A.D.,and the earlier information is not clearly available. The start of the importance and theprominence of this disease are associated with wars. The initial description of the disease isas dysentery, later on we sees the development of the classification of the disease and lateron the development of these sub groups but still in general practice treatment is given fordysentery in general. The accountable history starts from 1752 when sir. John Pringle has givendescription of dysentery from the army in Flanders. In 1788 John Hunter compared with thesigns and symptoms of the disease as seen by him in the Army in Jamica with thosementioned by Sydenham and others in 1779-80 prevalent in London. In India the modernliterature of dysentery in a written form is from Amesley in 1828 in his book researches onthe diseases of India, where he reports of dysentery and abscess of liver as seen in Madraspresidency. Twinning in 1835 dealt fully with dysentery in his book clinical illustrations of themore important diseases of Bengal. A concise paper on dysentery for the first time waswritten Edmund Parkes in 1846. Kenneth Mackinnon reported remarks on dysentery andhepatitis in India and fatal cases in 1848 in his treatise on the prevailing diseases of Bengaland northwest provinces. While in London it was seen in Millbank prison by William Baly.With relation to be time period of the year between august to November, in algeria wasmentioned by Haspel in 1847. In 1849 bleker recognised dysentery in batavia. Then on in1860 james morehed in his diseases of Indians in Bombay. Woodward in medical and Pravahika – Conceptual Study 9
  20. 20. surgical history of the war of the rebellion published in 1880 deals with diarrhea anddysentery together, Fayer in 1881 has mentioned the treatment of the same withJpecacuanha in India Dysentery which was assumed to have been caused by an organism living in thehuman intestine, it was doubted whether these caused the disease or only associated with itbecause its presence in normal cases and absence in the positive cases. Early breakthrough available for this problem by shiga in 1898 discovered bascillus dysenteriae andother closely allied strains of coli. In 1859 at prague lambl has discovered living amoebae ininfantile diarrhea and demonstrated I other cases of diarrhoea and dysentery. In 1870 D.D.gunningham and lewis have seen amoebae in cholera stools but have not given anyimportance. Loesch at St. Petersburgh in 1875 found amoebae in stools and in the ulcers oflarge intestines of a postmortem case. In 1876 and 1881 sonsino grassi, perroncito foundamoebae in-patients and Grassi and Leuckart also discovered in healthy people. In 1890 Councilman and Lafleur of USA published a classical description of thedisease together with a fully review of earlier literature and was supported by Lutz in 1891has identified amoebae in the case of dysentery. Lock at the same period reported findingsof amoebae in dysentery cases at Texas. Rogers in 1901 recorded occurrence of amoebicdysentery in India. Schandium published his observations on the life history of thepathogenic and saprophytic forms of amoeba. All (Klebs in 1887, Chantemesse, and Widalin 1889, Grigorieff and Ogata in 1892)opinioned that the dysentery was due to a single bacillus. Majjcora in 1892 suggestedbacillus Coli of exalted virulence to be the cause of dysentery and by Arand in 1894. Bacilluspyocyaneus by calmette (1893) and Bertrand (1897), streptococci by Durham & Mott (1896)Ciechanowski & Nowack (1898) were found. Other organisms found were bacillus coli, B.Proteus vulgaris, B. subtilis and vucrococci shiga in 1898. Clearly established in Japan the Pravahika – Conceptual Study 10
  21. 21. bacillus, and were seen in serum of the cases and was confirmed by Kruse in 1900 andFlexner and in 1902 by Rogers in India thus they have established a difference of bacillarydysentery and amoebic dysentery. Thus what basically described on the basis of signs and symptoms as Pravahikasome where between 3rd century BC, and 3rd century AD in Ayurveda further probed andwhat has been mentioned as causative factors are reestablished in the recent ages. Theseare further classified on the basis of the organisms as bacillary and amoebic even thoughSusruta and Vagbhata had doubted that some organisms to be one of the causes of thedisease, some centuries ago. The history of dissecting a human body for the knowledge has started in the age ofSusruta it self but being ruru sishya parampara. Except the important points and thoserequired were written, where as the rest did the teacher only explain. Therefore the basicpoints and detailed explanations of various organs have not been available. Secondly onlyanatomy as individual subject was not considered but with relation to the physiology.Coming to the anatomy with relation to Pravahika, we find in the texts mention of koshta andits organs, which are related, with the process of digestion of food, excretion of excrete andurine 17. When we observe Charaka comments we see that the organs comprising of thekoshta are nabhi, Hridaya, kloma, yakruth, pleeha, vrukka, vasthi, malaashaya, pakwasaya,Uttara and adho guda, kshudhrantra and sthoola anthras, vahanam totally 15 in number 18. 19 Susruta has explained the shape, size and mode of formation of these organs too .He also classified these organs according to the functions and shapes of these organs asclassifying all the ashayas or those, which store and later on pass out the contents.Therefore he has mentioned Amashaya and Pakwashaya in ashayas. Explaining theanthras he has clearly given that the length of the same differs from Male and female in the Pravahika – Conceptual Study 11
  22. 22. ratio of 31/2 to 3 vyamaanyanthraam. Where as guda is included in the orifices along withthe other openings.DEFINITION AND SYNONYMS The original word as seen in the earliest text of Ayurveda is Pravahika by Charaka 20while giving the lakshanas of kaphaja Atisara . It was considered as part of Atisara butlater on it has gained its own importance never the less both are inter linked. The wordPravahika is derived from ‘vaha’ dhatu succeeding the ‘pra’ upasarga and both related with 21 22‘lyut’ prathyaya giving the word Pravahika . Kaikaseya is of opinion that it is masculine . 23Where as raja radha kantha deva in the shabda kalpa druama says that Pravahika isfeminine. Rravathi muhur muhur pravarthathe meaning passing very frequently and laterputs as Grahani Roga. Further mentions that it is a rakshasa and as the one which isresponsible for movement, it has also been given here itself the lakshans and treatment forPravahika at another place. Shabda ratna karam is of opinion that it is Atisara Roga and the pravahana means 24 25flowing or waves or pravruthi . According to vachaspathyam Pravahika is a disease and 26Amarakosha has defined it as Grahani , and further says that pravahikathaha is that which 27is responsible to cause movement or gathi. Rajanighantu says that it is valluka .Amarakosha mani prabha teeka has given two synonyms for Grahani. First one is 28sangrahani and the other is Pravahika, which means Grahani ruk or Grahani ruja . Whereas in Namalinganusasana he mentions ruk as ruja and Pravahika and mentions rukh as rujaand Pravahika. Pravahika, Grahani are synonyms of samgrahani, earlier it is said asGrahani ruk here only Grahani is Pravahika. Vaijayanithi nighantu opines that Pravahika and Grahani are similar to that of Atisara29 . Shabdasthoma mahanidhi says that the reference relates jala srotases and Pravahika is 30related to movement of malam and is Grahani Roga . Shabdardha chandrika says it as Pravahika – Conceptual Study 12
  23. 23. 31 32Atisara . Shabdartha parijatha says that Pravahika is ahisara vyadi . Vaidyakeeyashabda sinduram mentions that Pravahika is Grahani Roga according to raja nighantu but 33he says that it is Atisara bedha, and for the word pravahanam it means kunthaanam . Theword meaning of kunthanam means the sound, which is made when one effort downward toincrease the intra-abdominal pressures to pass the stool out. Dalhana seems to give the meaning of pravahana as preryamanasya that is forcingthe faecal matter out without bothering the exact definition of the individual word. Pravahikadisease is defined as a problem in which the patient has to put effort to pass stools, which isassociated with Kapha, the quantity of the faecal matter passed is small, but the frequencyof the defecation is raised associated with abdominal pain 34. Almost all the authors have mentioned Pravahika, at different places different wordsequivalent to Pravahika are used. Following are the synonyms used by various Acharyasapart from Pravahika. 1. Nihssarak: Sri gathou dhatu presided by Nis upasarga and confined with lyut prathgyaya forming Nihssarak. This word is used because in Pravahika only small amount of mala is passed. Sru dhatu denotes movement, Nis upasarga denotes reduced or less that is relects on the small quantity of Kapha or mala. Susruta and Hareetha have used this word 35. 2. Nihscarak: Nis upasarga followed by char means movement again with lyut prathyaya is the way in which the word is formed. The meaning is explained to similar to that of Nihssrak. This word was also used y Susruta and Hareetha 36. 3. Visramsi: Sramsi sarpane dhatu preceded by vi upasrga forming visramsi meaning excessive passage via guda. This is seen in the Ama avastha in Pravahika. This word is used by bhoja alone. Pravahika – Conceptual Study 13
  24. 24. 4. Bimbisi: Ashtanga sangraha kara basing upon the bleeding given the word for Pravahika as bimbisi. He alone has given the name, whose mala is red being in association with raktha like bimbiraktha varna phala and further it is said that this is due to vrana in bruhadantras and also ulcer in sleshma kala of anthra. (could be the Pureesha dhara kala) 5. Praskhandika: Pra upasarga followed by skandhir gathi shoshanamo dhatu and being combined with lyut prathyaya as above forms praskhandhika, meaning large quantity of blood being passed. Some others have used the word prakkhandhika. 6. Anthra granthi: Due to vrana or ulcer in the gastrointestinal tract or bruhadanthras, the seepage is blocked and a swelling is seen like granthi. This word is used by parashara. 7. Annagranthi: This is also similar to that of anthra granthi, the cause of obstruction to the seepage in the capillaries is due to the blockage by small particles of food and small granthis are formed like food particles in size.Anatomical description Apart from the above the anatomy of the anthras and amapakwasayaa, a detailedinformation regarding some of these were explained as required, in the disease. Forexample in case guda, the explanation is give in the Arshas relation it is described as theend part of stoolantras, and is about 4 ½ inches in length and formed by the saramsa ofraktha and Kapha, digested by the Pitta with the involvement of Vata. Susruta has given aplace in Marmas and included in the mamsa Marma and says that any trauma may cause 37instant death or sadyopranahara category . Charaka has explained that the gudacomprises of the Uttara and adho guda gananatha sen in prathyaksha sareera explains it ashaving 3 parts. Pravahika – Conceptual Study 14
  25. 25. 1. Gudoshta (anus) 2. Guda nalika (anal canal) 3. Malasaya (rectum). The last part of the rectum is lower 1 inch is also considered as guda.Valis of guda:- The valis of guda consists of 3 number and from above downwards it is pravahani,Visargini and samvarni. These are lining involved indentures of a conch shell, situated one 38above the other, coloured like the palate of the elephant . The circumferences of these are4 inches 39. What is explained as the anal sphincter and the muscles of the rectum and anushelping in the closure and opening of the anal orifices and helping in the expulsion of thefecal matter, similarly there valis are thought to help in the above said manner.PRAVAHINI It is the first one from the above and is in the upper part of the guda and is about11/2 inch above the second. Dalhana defines that the one which helps in the passage ofMala. “pravaha yati iti pravahani”. Ghanekar says “Malasya peedanaath pradhnmaapravahani”. Vaghbhatta pravahani. As it presses the faecal matter down it is called aspravahini.VISARJINI It is the second one between pravahani and amavarani and is about 1 ½ inch abovethe 3rd. Dalhana says that which helps in the expulsion of faecal matter is vissargini,“visrujateethi visaargini”. “guda visparaneni Mala visarjanat dwiteeya visargini” by ghanakar.“thaasan antharaniadya visarjini” by Vagbhata, that which expands guda and helps inpassage of Mala. Pravahika – Conceptual Study 15
  26. 26. SAMVARANI 40 The last vali and in 1 inch above the gudoshta . Balhana says that which helps theclosure of the guda. “samrunateethi samvarani” valistu samvarani name. Gudasamkoochanaakya peshi dweya, kruthi” Chakraa aakara valisthu samvarani name”ghanekar. Vaghbhata “baahya samvarani”. The guda samkoochana is with the help of 2peshis, which are round in shape and are called as samvarani, and is external.Gudoshta :- It is below the samvarani, and is the terminal part of the guda consisting about 1 ½ 41yava pramana . Bhoja says it is only about ½ anguls and outside there are hairs arepresent. Dalhana explains vali as folds of twak. Ghanekar in his commentary has comparedthese valis with Houston vales. Which are transverse folds of mucous membrane. Situatedin rectum but extend up to anal verge. Therefore not only the Houston valves, anal columnsand valves are considered as these valis, Ayurveda has based it explanation on the basis ofphysiology than anatomy therefore pravahani and visargini could be the ampulla of rectum,internal and external sphincter, whose functions can be considered as pravahani, visarginiand sambarani 42. From the above references we find that the Uttara gudha consists of the rectum orthe malashaya as per ghananatha sen and adho gudha being the gudoshta and gudanalika. With the help of the above organs, the ingested food is digested and the undigestedforms as kitta. From this water is separated and the solid forms as the Pureesha in thepureeshavaha Srotas with its moola or controlling points being in the Pakwashaya andguda, helps in the excretion of the pureesha. Both Susruta and Charaka have mentionedthis pureeshavaha Srotas 43. The large intestine extends from the end of the ileum to the anus, and is about 1.5meters long. Its caliber is largest at its commencement at the caecum, and gradually Pravahika – Conceptual Study 16
  27. 27. diminishes as far as the rectum where there is a dilation of considerable size just above theanal canal. It differs from small intestines by 1. Greater caliber, 2. Most of the part is fixed 3. Colon is puckered and saculated and the longitudinal fibers or teeniae coli are shorter that the circular. 4. Little peritoneal covering with fatty projections termed appendices epiploicae except over the colon vermiform appendix and rectum. The large intestine describes an arch and encloses the convolutions of the small intestines. Commences in right lumbar and hypochondriac region to below the liver, bends to right (right colic flexure) to the left, and curving downward and forward as convexity passes as transverse colon, to the left hypochondrium, then bends (left colic flexure), and descends via the lumbar and iliac regions to pelvis, and forms a loop called pelvic colon, and continues along lower part of posterior wall of pelvis to the anus.Caecum The caecum, which is the commencement of the large intestine, lies in the right iliacfossa. Its surface projection occupies the triangular area bounded by the right lateral plane,the transtubercular plane and the fold of the groin. It is a large sac which has a blind lowerand but is continuous above with the ascending colon, and at the point where the onepasses into the other the ileum opens into the large intestine from the medial side. Itsaverage length is about 6cm. And its breadth about 7.5cm. It is situated in the right iliacfossa above the katerak lateral half of the inguinal ligament; it rests on the iliacus and on thepsoas major, being separated from both muscles by their covering fasciae and theperitoneum, and the caecal recess of the peritoneum which frequently contains the Pravahika – Conceptual Study 17
  28. 28. vermiform appendix. In addition,the lateral cutaneous nerve of the thigh intervenes betweenit and the iliacus. In front it is usually in contact with the anterior abdominal wall, but thegreater omentum, and it the caecum is empty, some coils of small intestine, may lie in frontof it. As a rule, it is entirely enveloped by peritoneum, but in about 5 percent of cases theperitoneal covering is incomplete, the upper part of the posterior surface being in coveredand connected to the iliac fascia by areolartissue. The caedum enjoys a considerableamount of movement, so that it may become herniated down the right inguinal canal, and ithas occasionally been found in an inguinal hernia on the left side. The caecum varies in shape, but, according to treves, it may be classified under oneof four types. In early foetal life it is short, conical, and broad at the base, with its apexturned upwards and medically towards the ileocolic junction. It then resembles the caecumof the mangabey monkey. As the foetus grows, the caecum increases in length more than inbreadth, so that it forms a longer tube and lacks the broad base, but still has the sameinclination of the apex towards the ileocolic junction. This form is seen in the spider monkey.As development goes on, the lower part of the tube ceases to grow and the upper partbecomes greatly increased, so that at birth the narrow vermiform appendix hangs from theapex of a conical caecum. This is the infantile form ad as it persists throughout life in about2 percent of subjects, it was regarded by treves as the first of his four types of human caeca.The three taeniae coli start from the appendix and equidistant from each other. In thesecond type, the conical caecum has become quadrate by the outgrowth of a saccule oneach side of the anterior taenia. These saccules are of equal size, and the appendix arisesfrom the depression between them, instead of from the apex of a cone. This type is found inabout 3 percent of subjects. The third type is the normal type for man. Here the twosaccules, which in the second type were uniform, have grown at unequal rates; the right withgreater rapidity than the left. In consequence of this an apparently new apex has been Pravahika – Conceptual Study 18
  29. 29. formed by the downward growth of the right saccule, and the original apex, with theappendix attached, is pushed over to the left towards the ileocolic junction. The threetaeniae still start from the base of the vermiform appendix, but they are now no longerequidistant from each other, because the right saccule has grown between the anterior andpostero lateral taeniae, pushing then over to the left. This type occurs in about 90 percent ofsubjects. The fourth type is merely an exaggregated condition of the third; the right sacculeis still larger, andat the same time the left saccule has become atrophied, so that the originalapex of the caecum, with the vermiform appendix, is close to the ileccolic junction, and theanterior taenia courses medially to the same situation. This type is present in about 4percent of subjects.The ileocolic valve;- The lower end of the ileum opens into the medial and posterior aspect of the largeintestine, at the point of junction of the caecum with the colon. The ileocolic orifice isrepresented on the surface at the point of intersection of the right lateral and transtubercularplanes; about 2 cm. Below this point the vermiform appendix opens into the caecum. Theopening is provided with a valve consisting of two seqments or lips, which project into thelumen of the large intestine. If the intestine has been inflated and dried the lips are ofsemilunar shape. The upper lip, nearly horizontal in direction, is attached to the line ofjunction of the ileum with the colon; the lower lip, the longer and more concave, is attachedto the line of junction of the ileum with the caecum. At the ends of the aperture the twosegments of the valve coalesce, and are continued as narrow membranous ridges for ashort distance, forming the frenula of the valve. The left or anterior end of the aperture isrounded; the right or posterior is narrow and pointed. In the fresh condition, or in specimens,which have been hardened in situ, the lips of the valve project as which folds into the lumenof the caecum, and the opening may present the appearance of a slit or may be somewhat Pravahika – Conceptual Study 19
  30. 30. oval in shape. The circular muscle coat of the terminal part of the ileum is thickened to forma sphincter. Each lip of the valve is formed by reduplication of the mucous membrane and of thecircular muscular fibers of the intestine, the longitudinal fibers and peritoneum beingcontinued uninterruptedly from the small to the large intestine. The surfaces of the valve directed towards the ileum are covered with villi andpresent the characteristic structure of the mucous membrane of the small intestine aredestitute of villi and marked with the orifices of the numerous tubular glands peculiar to themucous membrane of the large intestine. It was formerly maintained that this valveprevented reflex from the caecum into the ileum, but in all probability it acts as a sphincterround the end of the ileum and prevents the contents of the ileum from passing too quicklyinto the caecum; the valve is kept in a condition of tonic contraction by impulses which reachit through the sympathetic nerves. The taking of food into the stomach initiates contraction ofthe ileum and the passage of ileal contents into the large intestine through the ileocolicopening. • The colon is divided into four parts: • The ascending • Transverse • Descending and • PelvicAscending colon The ascending colon, about 15 cm. Long, is smaller in caliber than the caecum. Itbegins at the caecum, and ascends to the under surface of the right lobe of the liver, whereit is lodged in a shallow depression, termed the colic impression, here it bends abruptlyforwards and to the left, forming the right colic flexure. In surface projection it runs upwards Pravahika – Conceptual Study 20
  31. 31. immediately to the right of the right lateral plane, from the tranbstubercular plane to midwaybetween the subcostal and transpyloric planes. It is covered with peritoneum on its front andsides. Its posterior surface is connected by areolar tissue to the fascia over the iliacus.Iliolumbarligament, ouadratus lumborum and the aponeurotic origin of the transversusabdominis, and to the perirenal fascia in front of the lower and lateral part of the right kidney.The lateral cutaneous nerve of the thigh, the fourth lumbar artery (as a rule) and,sometimes, the ilio-inguinal and iliohypogastric nerves cross behind it. Sometimes, it iscompletely invested with peritoneum, and it then possesses a distinct but narrowmesocolon. It is in relation, in front, with the convolutions of the ileum, the right edge of thegreater omentum and the abdominal wall.Right colic flexure The right colic flexure comprises the terminal part of the ascending colon and thecommencement of the transverse colon. Which turns downwards, forwards and to the left.Behind it is in relation with the lower and lateral part of the anterior surface of the right lobeof the liver; anteromedially, to the second part of the duodenum and the fundus of the gall-bladder. It is not covered by peritoneum on its posterior surface, asorenal fascis. The flexureis not so acute as the left colic flexure.Transverse colon The transverse colon about 50 cm. Long begins at the right colic flexure, in the righthypochondriac region, and passing across the abdomen into the left hypochondriac region,curves sharply on itself, downwards and backwards, beneath the lower end of the spleen,forming the left colic flexure. In its course across the abdomen it describes an arch, theconvavity of which is usually6 directed backwards and upwards; towards its splenic endthere is often an abrupt U-shaped curve which may descend lower than the main curve. Itssurface projection is drawn from a point, situated immediately lateral to the right lateral plane Pravahika – Conceptual Study 21
  32. 32. and midway between the subcostal and transpyloric planes, to the umbilicus, above andlateral to the intersection of the left lateral and transpyloric planes. The precise positionoccupied by the transverse colon is difficult to define, for it not only shows variations fromindividual to individual but its position varies in the same individual from time to time. Verycommonly it lies in the lower umbilical or upper hypogastric region, but it is often found at ahigher level, especially in formal in hardened subjects. It frequently descends in a V-shapedmanner, the apex of the V reaching well below the level of the ilia crests. The posteriorsurface of its right extremity is devoid of peritoneum, and is attached areolar tissue to thefront of the second part of the duodenum and the head of the pancreas. Between the headof the pancreas and the left colic flexure, the transverse colon is almost completely investedby peritonum, and is connected to the the anterior border of the pancreas by the transversemesocolon. It is in relation, by its upper surface, with the liver and gall-bladder, the greatercurvature of the stomach, and the lateral end of the spleen; by its under surface, with thesmall intestine; by its anterior surface with the posterior layers of the greater omentum, itsposterior surface is in relation with the second portion of the duodenum, the head of thepancreas, the upper end of the mesentery, the duodenojejunal flexure and some of the coilsof the jejunum and ileum.Left colic flexure The left colic flexure is situated at the junction of the transverse and descendingparts of the colon in the left hypochondriac region, and is in relation with the lateral end ofthe spleen and the tail of the pancreas, above, and with the anterior aspect of the leftkidney, medially the flexure is so acute that the end of the transverse colon usually lies incontact with the front of the descending colon. The left colic flexure lies at a higher levelthan, and on a plane posterior to, the right colic flexure and is attached to the diaphragm, Pravahika – Conceptual Study 22
  33. 33. opposite the tenth and eleventh ribs, by a peritoneal fold, named the phrenicocolic ligament,which lies below the lateral end of the spleen.Descending colon The descending colon about 25 cm. Long passes downwards through the lefthypochondriac and lumbar regions. At first it follows the lower part of the lateral border ofthe left kidney and then, at the lower pole of that organ, it descends, in the angle betweenpsoas major and quadratus lumborum, to the crest of the ilium, it then curves downwardsand medially in front of the iliacus and psoas major, and ends in the pelvic colon at the inletof the true pelvis. In surface projection it passes downwards, just lateral to the left lateralplane, from a point situated a little above and to the left of the intersection of the transpyloiricand left lateral planes, as far as the fold of the groin. The peritoneum covers its anteriorsurface and sides, while its posterior surface is connected by areolar tissue with the fasciaover the lower and lateral part of the left kidney, the aponeurotic origin of the transversusabdominis, the quadratus lumborum, the iliacus and the psoas major. Numerous structurescross behind it. They include; the subcostal vessels and nerve, the iliohypogastric and ilio-inguinal nerves, the fourth lumbar artery (as a rule), the lateral femoral cutaneous, femoraland genitofemoral nerves, the testicular (or ovarian) vessels and the external iliac artery, allof the left side. The descending colon is smaller in calibre, more deeply placed, and morefrequently covered with peritoneum on its posterior surface, than the ascending colon.Anteriorly it is related to coils of the jejunum, except in its lower part, which can be feltthrough the anterior abdominal wall when, the abdominal muscles are relaxed.Pelvic colon The pelvic colon begins at the inlet of the true pelvis. Where it is continuous with thedescending colon, it forms a loop, which varies greatly in length, but averages about 40 cm.And normally lies within the pelvis. The loop consists of three parts, the first part descends in Pravahika – Conceptual Study 23
  34. 34. contact with the left pelvic wall, the second crosses the pelvic cavity, between the rectumand bladder I the male, and the rectum and uterus in the female, and may come into contactwith the right pelvic wall, the third arches backwards and reaches the median plane at thelevel of the third piece of the sacrum, where it bends downwards and ends in the rectum.The pelvic colon is completely surrounded by peritonaum, which forms a mesenbtery,termed the pelvic mesocolon; this diminishes in length from the centre towards the ends ofthe loop, where it disappears so that the loop fixed at its junctions with the descending colonand rectum, but enjoys a considerable range of movement in its central portion. Its relationsare therefore subject to considerable variation. Laterally, it is related to the external iliacvessels, the obturator nerve, the ovary (in the female), the vas deferens (in the male) andthe lateral pelvic wall. Posteriorly it is related to the internal iliac vessels, the ureter, thepiriformis and the ascral plexus, all of the left side. In seriorly it rests on the bladder, in themale, and on the uterus and bladder, I the female. Above and on its right side, it is in contactwith the terminal coil of the ileum.Rectum The rectum is continuous above with the pelvic colon, whilst below it ends I the analcanal. From its origin at the level of the third sacral vertabra it passes downwards. Lying inthe sacrococcygeal curve, and extends for 2 or 3cm. In front of, and a little below the tip ofthe coccyt. As far as the apear of the prostate. It then bends sharply backwards into the analcanal. It therefore presents two anteroposterior flexures; an upper or sacral flexure with itsconvexity backwards, and a lower or perineal flexure with its convexity forwards. Threelateral curves arealso described, the upper one covex to the right, opposite the junction ofthe third and forth sacral vertebra, a middle one convex to the left. Opposite thesacrococcygeal articulation, and a lower convex to the right in front of the tip of the coccyx. Pravahika – Conceptual Study 24
  35. 35. As a result of these lateral curves the rectum is not exactly in the median plane, except at itsupper and lower ends; the middle part bulges to the left. The rectum is about 12 cm. Long. And its commencement its calibre is similar to thatof the pelvic colon, but near its termination it is dilated to form the rectal ampulle. It has nosacculations comparable to those of the colon, but when the lower part of it is contracts itsmucous membrane is thrown into a number of folds, which are longitudinal in direction andare effected by the distension of the gut. Besides these there are certain permanenthorizontal folds of a semi lunar shape. There are usually three of these horizontal folds. Butsometimes four or five and frequently only two, are present. One is situated near thecommencement of the rectum, on the right side; a second extends inwards from the left sideof the tube at a slightly lower level, a third, the largest and most constant, projectsbackwards from the fore part of the rectum, opposite the fundus of the urinary bladder.When a fourth is present, it is situated on the left and posterior wall near the lower end of thetube. These folds are about 12 mm. In width and contain some of the circular fibers of thegut. In the empty states of the intestines they overlap each other. Their use seems to be“support the weight of faecal matter, and prevent its urging towards the anus, where itspresence always excites a sensation demanding its discharge”. The peritoneum is related only to the upper two-thirds of the rectum, covering at firstits fronts and sides, but lower down its front only, from the latter it is reflected on to thebladder in the male and the posterior vaginal wall in the female. The level at which the peritoneum is reflected from the rectum to the viscus in front ofit is higher in the male than in the female. In the former the height of the recto-vesical pouchis about 7.5 cm (i.e., the height to which an ordinary index finger can reach) from anus. Inthe female the height of recto-uterine pouch is about 5.5 cm from the anal orifice. In themale foetus the peritoneum extends downwards on the front of the rectum as far as the Pravahika – Conceptual Study 25
  36. 36. apex of the prostate. The lower part of the rectum is surrounded by a dense tube of fascia,which consists of a localized thickening, and compression of the extra-peritoneal tissue, thisfacial tube is loosely attached to the rectal wall by areolar tissue, in order to allow ofdistension of the viscus.Anal canal The anal canal begins at the level of the apex of the prostate, is directed downwardsand backwards through the pelvic floor, and ends at the anus. It forms an angle with thelower part of the rectum, and is from 2 to 3 cm long. It has no peritoneal covering, but isinvested by the sphincter ani internus, supported by the levatores ani, and surrounded bythe sphincter ani externus. In the empty condition it presents the appearance of ananterposterior longitudinal slit. Behind, it is in contact with a mass of musclular and fibroustissue, termed the anococcygeal body; in front it is seperated by the perineal body from themembranous part of the urethra and the bulf of the penis in the male, and from the lowerend of the vegina in the female. The upper half of the anal canal is lined by mucous membrane which presents fromsix to ten vertical folds know as the anal columns. These columns are usually well marked inthe newborn child but are often ill defined in the adult. They are produced by in folding of themucous membrane and of some of the longitudinal muscular tissue, end each contains asmall artery and vein which are the terminus radicals of the superior rectal vessels. They areseparated from one another by furrows, and end below in small crescentic valve-like folds,termed anal valves; these valves join together the lower ends of the anal columns, and eachforms the inner wall of a small pouch or anal sinus. The lower half of the anal canal is lined with skin and exhibits a series of foldextending upwards from the anus towards the anal columns. A white line indicates thejunction of the skin and mucous membrane, which is somewhat wavy owing to the Pravahika – Conceptual Study 26
  37. 37. interlocking of the cutaneous and mucous folds. The part of the anal canal below the analvalves is developed from the ectodermal proctodaeum while the part above them is fromentodermal cloaca. In correlation with this dual mode of development the following facts maybeenoted. In the lower half, the epithelium is of the startified squamous type, the skin issupplied by cerebrospinal nerves (inferior haemorrhoidal nerve), the arterial blood supply isfrom the inferior rectal artery, the venous drainage is by the inferior rectal vein, which passesto the internal pudendal vein, and the lymphatics drain with those of the perinal skin into thesuperficial inguinal lymph glands. In the uper half, the epithelium is simple columnar in type,the mucous membrane is supplied by sympathetic nerves, the arterial blood supply is fromthe superior rectal artery, the venous drainage is the superior rectal vein route, and thelymphatics drain with those of the rectum. At the junctional zone portal and systemic venouscirculatios anastomose; and the vein passes between the internal and external sphincters.The different types of nerve supply of the two parts of the anal canal connote a response todifferent types of stimuli; the lower part is very sensitive and responds to stimuli like the skinin general; and the upper part, like the gut is insensitive to stimulation apart from increase intension.Anus or anal orifice The anus or anal orifice is the lower aperture of the anal canal and is situated about4 cms below and in front of the apex of the coccyx in the cleft between the buttocks. Theskin surrounding it is thrown into a series of folds which converge towards the orifice and arecontinued upwards into the lower part of the anal canal. After puberty, hairs are developedin this skin I the male only. Guda has been divided into the uttara and the andhra by chraka on which thechakrapani comments that the part of guda, which stores is the uttara and passes out viathe adhara. These two could be the rectum and the anus. Susruta in his reference says that Pravahika – Conceptual Study 27
  38. 38. which passes the vayu (flatulence) and mala is the guda, probably it is the nearest to therelation to the function of control of the movement of the feacal matter, similar to that of thesphincters. This could be one of the reasons why it is also considered as one of the moolasof the Pureesha vaha srotas. Vegadharana, athyashana, ajeerna, agnimandya and the alpa Pureesha will vitiatethe Pureesha vaha srotas. The lakshanas manifested by the Pureesha vaha srotas aftervitiation are difficulty in passing stools, or stolls are passed in small quantities with pain andsound or the stools are hard or watery, and the frequency of the passage may increase, orassociated with foul smell.MICRO ANATOMY OF THE LARGE INTESTINE The large intestine has four coats; serous, muscular, submucous and mucous. Theserous coat is peritoneum, which invests the different portions of the large intestine to avariable extent. In the course of the colon the peritoneal coat is thrown into a number ofsmall pouches filled with fat called appendices epiploicaem more in transverse colon andthe pelvic colon and not present in the rectum. The muscular coat consists of an external longitudinal and an internal circular layerof unstriped muscular fibers. The longitudinal fibers form a continuous layer over the surfaceof the large intestine, but in certain situations this layer is thickened to form conspicuouslongitudinal bands, taeniae coli and in the intervals between them the longitudinal coat islees than half the thickness of the circular conat. In the caecum and colong three taeniaeare present, ranging from 6 to 12 mm in width in different individuals. On is placed anteriorlyon the caecum, ascending, descending and pelvic colon but posteriorly on the transversemesocolon, the third is placed posterolaterally in the caecum, ascending and descendingcolon and pelvic colon, but is situated on the anterosuperior surface of the transverse colonat the site where the posterior layers of the greater omentum meet this part of the large Pravahika – Conceptual Study 28
  39. 39. intestine. In the pelvic colon the longitudinal fibers become more scattered, and round therectum they spread out and form a layer which completely encircles this portion of the gut,but is thicker on the anterior and posterior surfaces, so that an anterior and posterior broadband is seen. At the rectal ampulla few strands of the anterior longitudial fibers passforwards to the perineal body to form the rectourethralis muscle. In addition, two fasciculi ofthe plain muscles arise from the front of the second and third coccygeal vertebrae, and passdownwards and forwards toblend with longitudinal muscular fibers on the posterior wall ofthe anal canal. These are known as rectococcygeal muscles. The circular fibers form a thinlayer over the caecum and colon, being especially accumulated in the intervals between thesacculi, in rectum they form a thick layer, and in the anal canal they become numerous, andconstitute the shinter ani internus. This sphincter ani internus surrounds the upper 2.5cms ofthe anal canal below it is in contact with the subcutaneous part of the sphincter ani externusand posteriorly and on each side it is covered by the pubo rectalis part of levator ani. The submucous coat connects the muscular and mucous layers closely together.The mucous membrane of caecum and colon is pale, smooth, and destitute of villi. Andraised into numerous crescentic folds, which correspond with intervals between sacculi,those of rectum are thicker, darker and more vascular and more loosely connected withmuscular coat. The glands of large intestine are minute tubular prolongatios of mucousmembrane arranged perpendicularlyVessels and nerves The arteries which supply the part of the large intestine developed from the midgut(caecum, appendix, ascending colon, right two thirds of transverse colon) are derived fromthe colic branches of the superior mesenteric artery, those supplying the left part of thetransverse colon, descending colon, pelvic colon, rectum and upper half of the anal canal(hind gut derivatives) are the inferior mesenteric artery (and its terminal branch, the superior Pravahika – Conceptual Study 29
  40. 40. rectal) and the middle rectal artery. The rectum is supplied by the superior, rectal branch ofthe inferior mesentric, and anal canal by the superior, middle and inferior rectal arteries. Thesuperior rectal artery is continuation of the inferior mesenteric artery. The veins of the rectum commence in a plexus of vessels which surrounds the analcanal. From the plexus about six vessels of considerable size are given off. These ascendbetween the muscular and mucous coats running parallel to one another at about the middleof the rectum they pierce the muscular coat, and by their union, form a single trunk thesuperior rectal vein. This arrangement is termed the rectal plesux. It communicates with thetributeries of the middle and inferior rectal veins, at its commencement, and thus acommunications is established between the systemic and portal circulations. The nerve supply of the large intestine (exclusive of the lower half of the anal canal)is derived from the sympathetic and parasymathetic systems. The caecum, appendix,ascending colon and the right two thirds of the transverse colon all derivatives of the mid guthave their sympathetic supply from the coeliac and superior mesenteric ganglia, and theirparasympathetic supply from the vagus, the left third of the transverse colon, descendingcolon, pelvic colon, rectum and upper half of the anal canal derive their sympathetic supplyfrom lumbar part of the trunk and hypgastic plexus by means of the plexuses on thebranches of the inferior mescenteric artery. The parasympatheitic supply to this part of thegut is derived from the pelvic splanchnic nerves. From these latter fibers pass to the pelvicplexuxes to supply the rectum and upper half of the anal canal. Further branches from thepelvic splanchnic nerves pass upon the posterior abdominal wall behind the peritoneum,independently of inferior mesenteric artery, to be distributed directly to the left colic flexureand descending colon 44. Pravahika – Conceptual Study 30
  41. 41. Physiological description Apart from this the whole koshta especially the gastrointestinal tract is covered by amembrane called mucous membrane according to modern even though the nature of thisalmost similar throughout, the functions differ at various places.Pureeshadharakala There by basing on the function Ayurveda pin points some places and called itaccordingly as Pureeshadharakala where the faecal matter is formed by the absorption ofthe water content by the membrane present, there. This Pureeshadharakala is situated inthe Pakwashaya. The boundaries of this are below the yakruth, koshta that is Amashaya,Pakwashaya madyastham, anthras and unduka 45. In the kala sequence the pureeshadhara or the mala dhara kala is the fifth one. It issituated in the sthoolanthras, but also extends into kshudranthras, yakruth, pleeha too. Thewaste products of the digestion pass through the unduka and then on the differentiationtakes place by the kala into mootra, mala and vayu, this is the so-called maladhara kala 46. The moola or the controlling points of the pureeshavahasrotas are two that ispakwashaya and guda (anal sphincters and the nerves of sciatic plexus). The Pakwashayaaccording to the later thoughts has been further divided into a) Undhuka or pureeshundk, 47this seems to be a refference to the caecum , it is a bag like stricture which is 4 incheslong, therefore generally it is reffered as pottlak, by dalhana that which Susruta callas 48unduka , Charaka has called it as pureeshadhara. The kshudhranthras, and thesthoolanthras are joined by a valve or kapatika, this will allow the forward movement only,and on the top of it is the unduka 49.Pittadharakala Coming to the Pittadharakala it is the 6th one in sequence and is situated in theAmashaya and Pakwashaya and will digest 4 types of food taken by the person. Some Pravahika – Conceptual Study 31
  42. 42. explain it is that which is situated between Amashaya and Pakwashaya and cover the partof anthras called Grahani 50.Pakwashaya The digestion of the food is completed in the kshudhranthras, and the digestedmaterial is absorbed via the rasa dhamanis and the rasayanees will distribute the samethroughout the body. The rest of the waste or the kitta part of the food is pushed in to thesthoolantras. And the water content of the kitta is absorbed in the sthoolanthras, the kala ofthe sthoolanthras will such the water, this process Charaka mentions as the action of Agni,therefore the liquid kitta will solidify as the water content is absorbed. This is called as thepureesha. The rasa of this Pureesha being katu, dushitha vayu will be produced in thePakwashaya. Therefore three products are produced in the sthoolanthras that is pureesha,mootra, and the mala bhootha vayu 51. Chakrapani on the above says that by the term paripindita Pakwashaya is thechange of form in the kitta to form solid or lumps of stools and vaayusyaat katu bhavathah isduring the above process of solidification pungent vayu is produced 52.LARGE BOWEL MOTILITY: Colon receives the mixed residues remaining after completion of intestinal digestionand absorption that digested and undigested food residues and remains of the digestivesecretions including considerable quantities of water and fluids swallowed or secreted andhas escaped absorption in the small intestines, and are converted into faecal matter which islater evacuated. The motor activities are divided into a) those that appear to designedprimarily to absorb and b) to propels the matter down. Colon agitates itself to segmenting contraction as of small intestines, Haustralcontractions in which clonic walls roll back and forth, kneading movements in large Pravahika – Conceptual Study 32
  43. 43. segments for contraction and relaxation, by alternate peristalsis and anti-peristalsis. Antiperistalsis are rare in human colon.ACT OF DEFECATION: Due to mass movement of the intestines and the entry of the faeces into the rectumcauses a desire to defecate and when the intra luminal pressure of 20 to 25 cm of water inrectum will generally create the desire to defecate, this desire could be induced by strainingto pass stools. The receptors of the rectal wall not only detect the increase in the pressurevariations (presso-receptors) but can also differentiate accurately whether the pressureincrease is due to gas, liquid or solid. The act of defecation is preceded usually by voluntaryeffort consisting of assumption of appropriate posture, voluntary relaxation of the externalanal sphincter and the compression of the abdominal contents by means of straining. Thesemovements in turn probably give rise to stimuli which augment the visceral reflexes althoughthese originate in the distal ends of rectum with the result that, the reflexes cause a masscontraction involving the entire colon and the internal anal sphincter relaxes. Therefore theact of defecation is under control of involuntary as well as the voluntary to certain extent.Reflex centers for defection are situated I the hypothalsmus, lower lumbar and upper sacralsegments of the spinal cord and in the ganglionic plexus of the gut.SOURCE OF PUREESHA: Apart from the one that is the undigested and unabsorbed food material, the secondsource is the dhatu kitta, which is the resultant of dhatu paka of all the dhatus. The same isin the modern too said as, the carbohydrates and protein are totally absorbed by the timethey reach the caecum along with fats, and those which are undigested as cellulose, and thefaeces is made up of the above and the bacterial secretions etc., this the ahara part of it,where as regarding the dhatu kitta, it is seen in the experiments that even during stravationsstools are formed, and does not change in composition, in an isolated intestines after some Pravahika – Conceptual Study 33
  44. 44. time formation of stools was seen and it constituted more of faecal fat, which is present evenif the fatty foods are not ingested. It differs from the dietary fat but resembles the blood lipidshaving lecithin and coporosterol which is derived from the action of bacteria (reducing thecholesterol and other substances like calcium, phosphate, magnesium and inorganicmaterials), these are the products of the dhatu kitta, probably. In Pravahika we observe that the kledhaka Kapha pachaka Pitta, samana Vata andapana Vata are involved in the disease pathogenesis. When we observe their functions andthe sthaanas.PUREESHA SWAROOPA: A person passes about 100 to 150 grams of faecal matter per day constuting 25% ofdead and living micro organisms of the large intestines, 75% is water, small amount of fat, ofendo genous origin. Ash 15% calcium, phosphates, iron, magnesium. Ether solublesubstances – 15%, fats, fatty, acids, lecithin, cholic acid and coprosterol. Nitrogen 5%derived from purine base, about 0.11 gms/day. Desquamated epithelial cells, bacteria,mucus, undigested and unabsorbed food.FUNCTIONS PUREESHA: Pureesha will support deha or the body and also controls Agni and vayu, apart fromshukra on which the streangth of the body depends and the jeevana on mala. In rajyakshmaas the Agni is in manda state the food is undigested and is passed with mala, therefore thequantity and the components of the mala has to be protected.PUREESHA KSHAYA LAKSHANAS: If the quantity of the mala visarjana is more than the patient suffers from shoola,anthra koojana, shareera gurutwa and adhmana 53. Pravahika – Conceptual Study 34
  45. 45. Kledakakapha: It is situated in Amashaya and moistens the food, brought to it and disintegrates orbreaks and liquefies it, Susruta has qualified the Amashaya as the organ which is above thepittasaya, according to Chakrapani, the part of Amashaya which is the seat of kledaka 54Kapha is the urdwa Amashaya . The additional function is it acts as chandra for tejas ofpita that is it protects the Amashaya from being digested by the Pitta also located there,here inthis not it is supported by the malaroopa Kapha of the dhatu parinama, which is resultof kittta paka of rasagni of rasadhatu and poured into Amashaya. Gastric mucous (mucin) islike kledaka Kapha it is thick, viscous fluid, it is rich in mucoproteins, which is a glycoprotein,particularly one in which the sugar component is chondropointen sulfuric or muco proteinsulphuric acid as seen in vitreous humour, synovial fluid etc., glycoproteins are not digestedby the enzymes of the gastric mucosa. The actions are 1) Buffer the strong acid 2) Inhibitsthe action of pepsin and moistens the food and loosens the molecules especially of theprotein molecules. Similarly in Ayurveda too it is believed, that the gastric juice is secretedby the cells throughout the lining of stomach and mucin by the gastric glands, which forms aprotective layer from pepsin. Much of the water of gastric mucous is reabsorbed andbecomes extra-cellular fluid.Samanavata: The digestion of the food and separation of the required part from waste are with thehelp of Samanavata. Charaka states it is located near Agni, the word Agni denotes theantharagni or the pachakagni or the Pachakapitta. The Pachakapitta is located in Amashayaand Pakwashaya. Susruta says it is in between Amashaya and Pakwashaya ashtangasangraha says that it is near the Agni and moves in Amashaya and Pakwashaya and also inthe channels carrying doshas, malas, sukra, artawa and water. Ashtanga Hridaya says onlyin the koshta as the range of movements. Charaka says it stimulates the pachakagni, Pravahika – Conceptual Study 35
  46. 46. regulates the channels carrying sweda, Dosha, ambu. It helps the antargni to digest the foodtaken in time and quantity and also helps in the seperation of saara and kitta. Ashtangasangraha and Hridaya are of the opinion that it receives and retains till digested and laterseperates the sara and the kitta 55. Receive food, retain and digest either in Amashaya or Pakwashaya and makesSeparation of saara and kitta, absorption from Pakwashaya the acchabhaga from kitta.Propulsion of kitta or food residue downs to pureeshadhara kala, and later out of the body.Samanavata will stimulate production of Pitta in two regions. Gastric secretion, on ingestionof a meal, gastric secretion is initiated prior to the food arriving into the stomach by theafferent impulses arising in head via vegas nucleus, and efferent stimuli are sent to gastricmucosa via vagi. The cephalic or initial stimulation is due to sight, smell or taste of food orfrom the act of mastication. Stimulation of vegus causes the increase in the concentration ofthe hydrochloric acid and pepsin. In gastric phase both neural and humoral control is seen.Gastrin is released from the pyloric mucosa by local, mechanical and chemical stimulationvia cholineargic nervous mechanism comprising of meisser’s flexus and its local and centralconnections. Stimuli of vagi facilitated the nervous mechanism involved in release of gastrinand may release small amount even in absence of specific local stimuli. Neither of gastrin orvegal will produce the maximal stimulation, but both simultaneously will produce abundantsecretion. Pancreatic secretion is also under both central nervous system and humoral.Nervous is by sympathetic and parasympathetic division of autonomic nervous system. Inaddition there is evidence that a local cholinergic mechanism, independent of vagalinnervation may play a role. Stimulation of vegas or parasympathetic innervation ofpancreas results to secretion of enzymes but not bicarbonate. Secretion of brumer’s glands is increased on stimulation of vegas neural andhumoral mechanism of small intestines stimulation is poorly known. Local, chemical and Pravahika – Conceptual Study 36
  47. 47. mechanical stimulation cn evoke secretion few are of that only parasympathetic will controlthe axons of these cells lying in the central nervous system in mid brain, medula oblongataand sacral region and are connected with ganglonic cells within or in close relation toinnervated organs. Vagal fibers to esophagus and stomach and small intestine synapseswith ganglion cells of the myenteric plexux of auerbach and submucous plexus of meissner. Motor effect of Samanavata is due to intrinsic nerves of stomach and intestines,gastero intestinal tract has abundant nerves from authonomic nerves, and contain within itswall an elaborate plexus of interconnected ganglia of two plexus, • Myenteric plexus of auerbach and • Sub mucous plexus of meissner, Those are considered as artificial but act as one unit. The entaric plexus should beregarded as a separate division of autonomic nervous system and that said as entericnervous system. Parasympathetic fibers of G.I.T., smooth muscles from vegas does not endin smooth muscles but synapse with cells of enteric plexus. These will increase or decreasethe excitability of reflex centres and not to initiate muscular activity directly. Sympatheticsupply from splanchnic nerves mostly vasomotor sypply, gastero intestinal tracthas its owncapability on the basis of local nervous mechanism and properties of smooth muscle, as therhythemic functions as gastric antral peristalsis and segmental contractions of small andlarge intestines are dependent on smooth muscle, and the highly co-ordinated function asforward peristalsis in small intestines and mass movement of colon etc., depend upon themyenteric plexus. Both neurogenic and myogenic function are regulated by central nervoussystem via autonomic nerves. Thus even if intrinsic nerves are severed the intestines cancarry its functions. The rhythmic contraction is together to agitate the intestinal contents and facilitatesseveral processes, it ends to increase the degree of sub division of food particles with Pravahika – Conceptual Study 37
  48. 48. mixing with digestive fluids and change the layers which are in contact with mucosa helpingin absorption, also the changes in pressure helps in absorption. Peristaltic and rhythmicsegmentation are super imposed and are independent. The peristaltic contraction manifestas a rise of the tone level of the intestinal muscles, with out interruption to segmentationcontraction. This has the effect of narrowing the lumen of intestines at the point at which theincrease to tonus occur and it may obliterate it. As the waves of contraction and tones traveldown they sweep the contents forward to the distal end. The villi of the small intestinesincrease the surface of absorption, the activity is for two types. • Lashing and • Rhythmic shortening and lengthening The absorption depends upon its activity and are under the nervous control, theyincrease in activity is due to spalanchnic but not the Vegas.Apanavata: According to Charaka the seat of Apanavata is the testis, urinary bladder, penis,umbilicus, thighs, groin, rectum and the anthras, the definition is that the one which tends tomove downwards. Where as Susruta states that the Apanavata is situated in thepakwadhana that is the receptacle of the fully digested food, and also the Pakwashaya,there is no separate receptacle for the fully digested and the partly digested food, and thedigestion is completed in this region and the nutrients are absorbed simultaneouslytherefore the pakwadhana is that region where the kitta bagha is left and later transformedinto Pureesha by pureeshadhara kala of koshta. It is interpreted by some as colon andrectum. Vagbhata also says that Apanavata resides in the pakwadhana and moves via theurinary bladder, hips, penis, testis, groin and thighs. Apanavata also denotes the lower mostends and the Vata associated with this region 56. Pravahika – Conceptual Study 38
  49. 49. All accept the same action that is • Vegapravarthana that excretion of mala and mootra • Ejection of semen • Bring down menstrual blood • Passage of the foetus during delivery that is it consists of action of defecation, micturation erection of penis, and ejaculating, free menstrual flow and normal delivery and cause premature delivery of the ill formed foetus.Pachakapitta: The digestion of the ingested food is the basic function of Pachakapitta. TheAyurvedic scholars, stating that every disease is due to the vitiation of this Pachakapittaemphasize the importance of the same. Chakrapani says that ‘ Antharagni Chikitsa isKayachikitsa it also controls the other pittas of the body, as they are originating from it. Theirwaxing and waning depend upon the increase and decrease of the Pachakapitta. Agni issynonymies as kayaagni, pachakagni, koshtagni antaragni and jatharagni etc., thisPachakapitta is stated to be situated in the Amashaya and Pakwashaya together called asthe koshta, and here the food is digested. The interior of these asayas is covered by amembrane or kala called as Pittadharakala which produces Pachakapitta. The part wherethis Pittadharakala is situated is also called as Grahani as it stores the food till it iscompletely digested 57. Charaka quotes that the koshtagni leads all other factors with relation to digestion inthe body, the seat of which is grahani, which stores the undigested, digests and pushes intothe Pakwashaya. The life spans, vitality, health. Complexion, luster, heats, enthusiasm,plumpness are dependent upon the dehagni and when this is extinguished the man dies,when it is deranged, it causes illness 58. Pravahika – Conceptual Study 39
  50. 50. Therefore the main stay of life is this antharagni and if it is functioning appropriatelythen one will not fall ill. Where as Susruta says that by a dispensation which is unseen andhidden a cause which cannot be perceived or explained in terms of known fact thePachakapitta or antharagni is responsible for the digestion of food and drinks. Even though located in the Amashaya and Pakwashaya, by the inherent powers itcontributes and augments the actions of other pittas present else where in the performanceof metabolic functions of the body. The kala or membrane (mucous) situated in between theAmashaya and Pakwashaya is the Pitta dhara kala and that part of the koshta is called asgrahani, it gives support to the Pachakapitta for the digestion of food y this part of the koshtaon its way to Pakvashaya 59. Susruta further says that this Grahani and the Agni depend on the integrity of eachother. Where as Vagbhata in the sangraha states that this Pitta in between the Amashayaand Pakwashaya consists of all the five bhootas, but the tejas and the soma guna is moreand less respectively and with help of Samanavata it digests the food, even in the Hridayathe some points have been mentioned, and with reference to Pittadharakala Susruta wasfollowed 60. Pravahika – Conceptual Study 40
  51. 51. Nidana of Pravahika Any disease should have a sequence of pathogenesis that is the process in whichthe disease causing factors should be triggered resulting in vitiation of these factorsfunctions and end in diseases with specific or general signs and symptoms. The triggeringcauses should be present in all diseases. These factors will change from one disease to theother and also will change from period to period in specific, but the basic factors will be thesame in one way or the other. With ensuing changes in the periods varying from decades tocenturies the virility of the causes undergo changes. Apart from the above the reaction orthe response of the human being is also changing to these causative factors for example heis loosing the thresh hold of pain and the resistance to the changing climates andatmospheres is decreasing when compared with those mentioned in the Samhita andNighantus. Etiological factors for Pravahika and Atisara are similar as prescribed by all authorsconsidering both as a dual disease, diarrhea and dysentery which the Acharyas haveaccepted and included, Pravahika and Atisara together some hundreds of years backstanding same till now. Having been the oldest one according to the availability of the cases Pravahika – Conceptual Study 41