CLINICAL EVALUATION OF VIRECHANA THERAPY IN THE MANAGEMENT OF PANDUROGA, Shaila Gurappa Borannavar. Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103.
Clinical Evaluation of Virechana Therapy In The Management of Panduroga By Shaila Gurappa Borannavar. Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. (PANCHAKARMA) In PANCHAKARMA Under the guidance of Dr. Shivaramudu P. M.D. (Ayu) And co-guidance of Dr. Shashidhar.H. Doddamani. M.D. (Ayu) Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2006.
Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled“Clinical Evaluation Of Virechana Therapy In TheManagement Of Panduroga” is a bonafide and genuineresearch work carried out by me under the guidance ofDr.Shivaramudu P. M.D. (Ayu), Professor, Post-graduate department ofPanchakarma and co-guidance of Dr. Shashidhar. H. Doddamani.M.D.(Ayu) , Assistant Professor, Post graduate department ofPanchakarma.Date: Shaila Gurappa BorannavarPlace: Gadag.
CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “ClinicalEvaluation Of Virechana Therapy In The Management OfPanduroga” is a bonafide research work done by Shaila GurappaBorannavar. in partial fulfillment of the requirement for the degreeof Ayurveda Vachaspathi. M.D. (Panchakarma).Date:Place: Gadag Dr. Shivaramudu P. M.D. (Ayu). Professor
ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “ClinicalEvaluation Of Virechana Therapy In The Management OfPanduroga” is a bonafide research work done by Shaila GurappaBorannavar. under the guidance of Dr. Shivaramudu P. M.D. (Ayu), Prof.Postgraduate department of Panchakarma and co-guidance ofDr. Shashidhar. H. Doddamani, M.D. (Ayu), Assistant Professor, Post-graduate department of Panchakarma.Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Panchakarma.
CERTIFICATE BY THE CO- GUIDE This is to certify that the dissertation entitled “ClinicalEvaluation Of Virechana Therapy In The Management OfPanduroga” is a bonafide research work done by Shaila GurappaBorannavar in partial fulfillment of the requirement for the degreeof Ayurveda Vachaspathi. M.D. (Panchakarma).Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).Place: Gadag. Assistant Professor, Post graduate Department of Panchakarma.
I Acknowledgement I deserve my respectful greetings in the lotus feet of Jagadguru Shri. AbhinavaShivanandmahaswamiji to his holiness and divine blessings. I am highly indebted to honorable H.O.D. Dr. G. Purushottamacharyulu M.D.(Ayu), PG Dept. of Panchakarma, for his valuable suggestions in the completion of thiswork. I express my obligation to respectful guide Dr. P. Shivaramudu Prof. Dept. ofPanchakarma P.G.S.&R.S. Gadag for his critical suggestions and expert guidance, whichmade me to complete this work. I am extremely greatful and obliged to my co-guide Dr. Shashidhar H.Doddamani M.D. (Ayu), Dept. of Panchakarma, P.G.S.&R.S., Gadag for his guidanceand encouragement at every step of this work. With profound sense of gratitude I express my sincere thanks to Dr. G.B. Patil,the Principal, D.G.M.A.M.C., Gadag for his timely encouragement as well as providingall necessary facilities for this research work. I am extremely obliged to Dr. Santosh Belawadi M.D. (Ayu) Lecturer, PGDepartment of Panchakarma, for his remarkable suggestions and support throughout thisstudy. I express my sincere gratitude to Dr. V. Varadacharyulu, Dr. M.C. Patil, Dr.Mulgund, Dr. K.S.R. Prasad, Dr. Dilip Kumar, Dr. R.V. Shettar, Dr. Kuber Sankh,Dr. Girish Danappagoudar, Dr. Jagadish Mitti, Dr. Nidagundi for their constantencouragement. My modest gratitude to Dr. S.D.Yerageri, R.M.O. D.G.M.A.M.C.&H, Gadag,Dr. U.V. Purad, Dr. K. S. Paraddi, Dr. S.H. Redder, Dr. S. A. Patil and otherundergraduate teachers for the their support in the clinical work.
II My sincere gratitude to Shri. V. M. Mundinmani (Librarian), Shri. Surrebanfor providing book facilities, and to Smt. Belawadi other office and hospital staff fortheir kind support in my study. I am thankful to Dr. P.S. Khona and Shri. B.S Tippanagouda (Lab. Tech.), whoextended their co-operation in the investigations and I also extend my sincere thanks toShri. Nandakumar for statistical analysis of the study. My deep gratitude to all my college and friends Dr. Jairaj, Dr. Hugar, Dr.Kendadmath, Dr. Chandramouleeswaran, Dr. Santosh, Dr. Varsha, Dr. Subin, Dr.Febin, Dr. Sateesh, Dr. Akki, Dr. Vijay, Dr. Biradar, Dr. Hakkandi, Dr. Ashwindev,Dr. Madhushri, Dr. Devendrappa, Dr. Kalmesh, Dr. Shibaprasad, Dr. Prasanna,Dr. Veena, Dr. Bani, Dr. Mangala, Dr. Bhingi, Dr. Sunita, Dr. Sajjanar, Dr.Kalmath, Dr. Venkareddy, Dr. Meenakshi, Dr. Kumbar, Dr. Udaykumar Dr.Ratnakumar, Dr. Shakuntala Dr. Sobagin, Dr. Shivaleela, Dr. Anitha, Dr. Suvarna,Dr. Jayashree, Dr. Ashwini and other PG scholars for their timely help. I extend my gratefulness and sincere obligations to my friends Dr. Pradeep A.,Dr. B. Ganti, Dr. Nikhila and Dr. Seema P., in spite of their busy schedule they havegiven me kind suggestions and support to complete this work. My heartfelt gratitude to all my sisters and their families, especially Shri. B.Mulawad (Lecturer) and Mr. Mahantesh for their constant support and encouragementthroughout my currier. I acknowledge my patients for their constant participation in this clinical trial andI extend my thanks to all persons who ever helped me directly or indirectly withapologies for my inability to identify them individually. Finally, I dedicate this work whole to my respected parents Mr. GurappaBorannavar & Mrs. Ningamma B., for their wholehearted inspiration and support tofulfill this dream.Date : Shaila G. Borannavar.Place : Gadag.
III AbbreviationsAh – Ashtanga Hridaya.As – Ashtanga Sangraha.AT – After treatment.AV – After Virechana.BT – Before Treatment.BV – Bhavaprakasha.Ch – Charaka.GIT – Gastrointestinal tract.GR – Good response.Ha – Harita Samhita.IDA – Iron deficiency Anaemia.MN – Madhava Nidana.MR – Moderate Response.NR – Not responded.PR – Poor responded.SS – Sharangadhara Samhita.Su – Sushruta Samhita.Va – Vagbhata.VG – Vyoshadi Gutika.Yr – Yoga Ratnakara.
IV AbstractBackground Panchakarma is popular term used for shodhana Chikitsa, which can givesatisfactory results in chronic diseases (Chirakari vyadhis) adopted in bahudoshavastha.Virechana is one among them, which eliminates vitiated doshas through adhomarga i.e.Guda. In this especially ama pakwashayagata doshas are eliminating. Globally, 30% oftotal populations are anaemic and half of these some 600 million people have irondeficiency. Panduroga is a santarpanajanya vyadhi, where pittadosha plays major role inpathogenesis. Hence, Virechana is most appropriate shodhana therapy. Vyoshadi Gutikais upakalpa of Trivrit indicated in Panduroga and can be considered as Sukha Virechaka.Objective The present study was planned with following aims and objectives – 01. To evaluate the effect of Virechana therapy in Panduroga. 02. To evaluate the effect of Virechana karma with Vyoshadi Gutika in Panduroga.Methods It is single group “An observational study” where the patients having symptomsof Panduroga were selected and classical Virechana therapy was administered – The treatment contains the following steps – 01. Deepana pachana with Trikatu churna 3-6 gms thrice daily before food, till the appearance of Nirama lakshanas. 02. Snehapana with “Dadima Ghrita” in arohana vidhi, till the samyak snigdha lakshanas are seen. 03. Abhyanga with murchita tile taila followed by mridu sweda (Ushna jala snana). 04. Virechana with “Vyoshadi Gutika” 35-45 gms along with sheetajala as anupana.
V 05. Samsarjana karma was followed for 3-5 days depending upon the shuddhi achieved. 06. Follow up study was done for 15 days. During these period patients were advised to follow the pathya apathya mentioned in Panduroga.Assessment criteriaSubjective parameter – The classical symptoms of Panduroga i.e. “Panduta”, “Arohanayasa”, “Dourbalya”, “Bhrama” and Agnimandya.Objective parameter – Haematological study, i.e. Hb is taken as main criteria, along with that PCV, MCV, MCHC and Smear study was also assessed.Results: As a result of the proper administration of Virechana karma, it was noted that, itgives long-lasting effect, which includes extraneous variable too. This can be appreciatedby comparing both subjective and subjective parameter taken before and after thetreatment. Among 30 patient who were taken for this study 9 patients (30%) wereresponded good, 15 patients (50%) were moderately responded, whereas 6 patients (20%)shown mild response.Interpretation and ConclusionVirechana is the most appropriate shodhana therapy in Panduroga. It alone can showsignificant result if the Pathya apathya is followed properly.Key words – Shodhana karma; Virechana therapy; Panduroga; Anaemia; Iron deficiencyAnaemia; Haemoglobin; Trikatu churna; Dadima Ghrita; Vyoshadi Gutika.
VI TABLE OF CONTENTSChapters Page No.1. Introduction 1-32. Objectives 4-53. Review of literature 6-674. Methodology 68-815. Results 82-1146. Discussion 115-1277. Conclusion 128-1298. Summary 130-1319. Bibliography 132-14710. Annexure
VIIList of TablesTable No. Table showing the Page No. 01. Virechana yogyas 12 02. Virechana ayogyas 13 03. Samyak snigdha lakshanas 15 04. Virechana matra 16 05. Oushadha jeernajeerana lakshanas 17 06. Virechana vega nirnaya 18 07. Samyak virchana lakshanas 19 08. Virechana ayoga lakshanas 19 09. Virechana atiyoga lakshanas 20 10. Aharaja Nidana of Panduroga 29 11. Viharaja Nidana of Panduroga 30 12. Poorvarupa of Panduroga 31 13. Samanya lakshnas of Panduroga 32 14. Classification of Panduroga 33 15. Lakshanas of vataja Panduroga 33 16. Lakshanas of pittaja Panduroga 34 17. Lakshanas of kaphaja Panduroga 34 18. Lakshanas of Mrit bhakshanajanya Panduroga 36 19. Properties and ingredients of Trikatu churna 69 20. Properties and ingredients of Tila taila 69 21. Properties and ingredients of Dadima ghrita 70 22. Properties and ingredients of Vyoshadi gutika 71-72 23. Status of the patients of present study 82 24. Distribution of patients by age and response 82 25. Distribution of patients by sex and response 84 26. Distribution of patients by religion and response 85 27. Distribution of patients by occupation and response 86 28. Distribution of patients by socio-economical status and response 87 29. Distribution of patients by marital status and response 88 30. Distribution of patients by food habits and response 89 31. Distribution of patients by treatment history and response 90 32. Distribution of patients by prakriti and response 91 33. Distribution of patients by vyasana and response 92 34. Distribution of patients by koshta and response 93 35. Distribution of patients by agni and response 94 36. Distribution of patients by Nidana and response 95 37. Distribution of patients by incidence of lakshanas and response 99 38. Distribution of patients by type of Panduroga and response 100 39. Distribution of patients by snehapana and response 101 40. Distribution of patients by samyak snigdha lakshanas & response 102 41. Distribution of patients by number of Vegas and response 104 42. Distribution of patients by incidence of Maniki and response 105 43. Distribution of patients by incidence of Antaki and response 106
VIII 44. Distribution of patients by laingiki shuddhi and response 107 45. Distribution of patients by type of shuddhi and response 108 46. Overall assessment 109 47. The subjective parameters 110 48. The objective parameters 111 49. Distribution of patients by treatment protocol and observations 112-113 50. The statistical results 114List of GraphsGraph No. Graph showing the Page No. 01. Age incidence and response 83 02. Sex incidence and response 84 03. Religion incidence and response 85 04. Occupation incidence and response 86 05. Socio-economical status incidence and response 87 06. Marital status and response 88 07. Food habits and response 89 08. Treatment history and response 90 09. Prakriti and response 91 10. Vyasana and response 92 11. Koshta and response 93 12. Agni and response 94 13. Aharaja Nidana and response 96 14. Viharaja Nidana and response 97 15. Manasika Nidana and response 98 16. Lakshana of Panduroga and response 99 17. Type of Panduroga and response 100 18. Snehapana and response 101 19. Samyak snigdha lakshana and response 103 20. Incidence of vegiki and response 104 21. Incidence of manaki and response 105 22. Incidence of antaki and response 106 23. Incidence of laingiki and response 107 24. Type of shuddhi and response 108 25. Overall assessment 109List of photographsPhoto No. Photographs Showing the Page No.01. Drugs used in the study 6902. Ingredients of Dadima Ghrita 6903. Vyoshadi Gutika and its ingredients 71 List of flow charts.Chart No. Charts Showing the Page No01. Samprapti of Panduroga 3702. Erythropoiesis 62
INTRODUCTION Ayurveda the cultural heritage of Indian civilization is not only a medicinal sciencebut also a full-fledged science consisting of social, spiritual, environmental,psychological well-being and allied branches essential to lead healthy and happy life. Ayurveda believes in supreme power (Atma). This concept is essential to knowthe limitations of human efforts and to accept the existence of things beyond theperception of our sence. “Ayu” means life, which is proper combination of Shareera, Indriya, Satwa andAtma. Veda means knowledge. Ayurveda provides not only curative measures but alsopreventive principals for healthy and long life. Restoration of dhosha, dhatu and mala to astate of equilibrium is the main aim of chikitsa in Ayurveda and it also gives equalimportance to Prasanna, Atma, Indriya and Manas i.e. Manasika Swasthya. The brimhana and langhana are the two types of treatment modalities mentionedin the classics1 and this langhana classified into shodhana and shamana, where shodhanacan be considered as Panchakarma therapies2. The procedure by which the vitiated doshas are get eliminated from the body iscalled shodhana3. It is five in number viz. Vamana, Virechana, Vasti, Nasya andRaktamokshana4. This purification may be either transmuscosal or transdermal.Panchakarma can adopt as a part of Chikitsa, prior measures for Rasayana chikitsa andfor Swasthavritta palana as well. Virechana is specially indicated for pitta dosha, pitta dosha associated with kaphadosha and also pitta sthanshrita kapha doshajanita conditions. Along with this virechanais beneficial in vataja and raktaja disorders too. 1 Introduction
“Na Tesham Punarudbhavaha” indicates importance of Panchakarma i.e.diseases treated with Panchakarma are having less chances of reoccurrence by prohibitingthe aggravation of doshas5. Panduroga is mentioned in Brihattrayi, Laghutrayi, and other classical texts. Thisis a pitta pradhana tridoshaja vyadhi in which rasa and rakta are mainly affected. Charaka opines that due to excess intake of pitta prakopaka tridosha prakopakaahara, viahara the vitiated doshas assumes sthanasamshraya in between tawk and mamsaresulting in pandu, harita, and haridra varna to the skin. Hence, the disease is named asPanduroga. Panduroga can be correlated with “Anaemia” in modern medicine. It refers to astate in which the level of haemoglobin in the blood is below the normal range(M-14.0g/dl F-12.3g/dl) appropriate for the age and sex. It may occur as primary diseaseor as associated condition with other diseases.Incidence And Prevalence Globally, 30% of the total world population are Anaemic and half these, some 600million people have iron deficiency. Iron deficiency Anaemia (IDA) is most prevalent nutritional problem in the worldtoday. Young children and women of reproductive age group especially pregnant andlactating women are at greatest risk. Though prevalent in all countries, IDA is mostwidespread in developing countries where prevalent of this disease may be as high as 60-70% in pre-school children and 60-80% in pregnant women. 2 Introduction
Need for the study The modern management of Anaemia is mainly oral therapy and parental therapyfor correcting iron deficiency. These are inspite of many advantages still remainsunsatisfactory. Oral therapy can cause nausea, abdominal discomfort, diarrhoea, andconstipation as side effects and it almost turns stool black, which is harmless side effect.The adverse effect of parental therapy includes hypersensitive reactions, haemolysis,hypotension, and circulatory collapse, vomiting and muscle pain. Blood transfusion,which is said as emergency treatment, can rise in Hb up to 1gm with a single unit. But itcan also cause some complication like acute intravascular hemolytic reactions, febrilenon-hemolytic reactions and allergic reactions. Thus it is important to search to moresafe, cost effective therapy, which could be explored from the Auyrveda. Virechana isone such therapy, which can give wonderful results in many diseases includingPanduroga. As pitta dosha plays a great role in samprapti of Panduroga. Virechana is thebest and most acceptable shodhana therapy. Charaka has praised the importance of Vyoshadi Gutika in Kalpasthana which isindicated in many disorders including Panduroga6 as it is a yoga of Trivirt, it can beconsidered as best for Sukhavirechana. In this study the patient suffering with lakshanas of Panduroga were administeredclassical virechana therapy, with specially indicated Dadima Ghrita7 for Snehapana andVyoshadi Gutika8 for Virechana karma. 3 Introduction
OBJECTIVES Even though many research works have been conducted on the effect of someindigenous drugs on “Panduroga.” This study is intended to observe the beneficial effectsof Virechana in Panduroga as Panduroga. Panduroga is pittapradhana tridoshaj vyadhi where rasa and rakta are mainlyaffected. Virechana is main line of treatment for pittadosha and it is not viruddha Chikitsafor kapha and vata dosha, which are associated in this disease. Panduroga issantarpanajanya vyadhi where virechana a kind of apatarpana Chikitsa could givebenefical effects. Veirechana mainly acts on Pittadharakala, as Pittadharakala andMajjadharakala are one and the same according acahrya Dalhana. So Virechana maystimulates triggering points of the production the raktadhatu i.e. Haemopoietic system. Vyoshadi Gutika is a upakalpa of Trivirtt can be considered as Sukhavirechakaand is indicated in Panduroga. Its ingredients are easily available, method of preparationis very easy and it is palatable too. Its ingredients contains properties like Rechaka,Bhedana, Srotoshodhaka, Agnideepaka, Raktashodhaka, Krimighna, Yakrit uttejaka andVatanulomaka, which could be helpful in treating the pathogenesis of Panduroga. So the objective of this study is – 01. To evaluate the effect of Virechana Therapy in Panduroga. 02. To evaluate the effect of Virechana karma with Vyoshadi Gutika. (Charka Kalpasthana) in Panduroga. 4 Objectives
Research works done on Panduroga 01. Deshapande Swati S. – Clinical study of Panduroga and its Management with Mandoora bhasma. 02. Pandey Shashi – Effect of Pathya ghrita in cases of Pandu. 03. Kottarshetti Irranna – The effect of Guda Nagaradi Vati in Panduroga. 04. Basavaraj R. – A Comparative study on the effect of Dhattriavaleha and Kaseesa bhasma in Panduroaga w.s.r.t. to Iron deficiency Anaemia. 05. Loba Zenica – Evaluation of the effect of shuddha Kaseesa and Loha Bhasma in Panduroga w.s.r.t. Iron deficiency Anaemia – A comparative study. 06. Jaiswal Vipal – Efficacy of Ashta Dashanga lepa in the management of Panduroga. 07. Raka Shital F. – To Study the effect of Rasnapanchaka kashaya in Amavastha of various diseases w.s.r.t. to Pandu. 08. Purani D. A. – A clinical study on the Management of Panduroga with Yogaraja Rasayana. 5 Objectives
HISTORICAL REVIEW Ayurveda, the most indigenous system of medicine has propagated treatment formany diseases. The principles of treatment described in our ancient Auyrvedic texts stillhold good since ages. Panduroga is a dreadful disease, which sticks all the age groups. It is thereforeessential to find out effective and harmless treatment of Panduroga and for that it isnecessary to look at ex-post factor where Panduroga has been described in minute details. In a systemic enquire into the state of medical science in India. It may be pointedout that the Brihattrayee’s earliest of medical literatures, which furnish us with detaildescription of the disease Panduroga and Virechana therapy. For the sake of conveniencethe history of Ayurveda can be derived as follows – 01. Vedic Period 02. Pauranika Period 03. Samhita Period 04. Sangraha Period 05. Modern PeriodA. VEDIC PERIOD In Vedic literature especially in Rigveda and “Atharvana veda we found the term“Halima” and “Harita” which are observed to be correlative with Panduroga. Thetreatment of the disease is also mentioned in both Vedas.B. PURANA KALA The word “Pandu” is available in Mahabharata when sage “Vyasa” intercoursewith “Ambilika” the windows of “Vichitra veerya”, she becomes pale with fear. That’swhy her son who born becomes pale (Pandu) colour and named as “Pandu”. 6 Historical review
In Garuda Purana there is a reference that Takra mixed with loha churna wasadvocated in the treatment of Panduroga. Besides the above description, Pandu is alsoavailable in Agnipurana, Valmiki Ramayana and Yogavasistha.C. SAMHITA PERIOD Charaka Samhita – In Charaka Smahita sutrasthana, it is mentioned aboutVirechana dravya sangraha, Virechana yogas and its procedure9-11. In kalpasthana variousvirechana kalpas have been explained12 where as in Siddhisthana, Virechana samyakyoga, ayoga, atiyoga, Virechana yogyayogya, Virechana vyapat and their respectivetreatment are mentioned.13-15 Panduroga is well elaborated in Charaka samhita Chikitsasthana 16th chapter16. Sushruta Samhita – In sutrasthana different virechana dravyas including thevarious preparations of Trivrit are mentioned17-18. In chikitsasthana, the procedure ofVirechana karma, samyak ayoga, atiyoga, vyapat and their treatment is mentioned19-20. Panduroga is described in Sushruta samhita Uttaratantra 44th chapter.21 Ashtanga Hridaya – In Sutrasthana Virechana vidhi is explained22. InKalpasthana, Virechana yogas and vyapatas are mentioned.23-24 Panduroga Nidana is explained in Ashtanga Hridaya Nidanasthana 13th chapter25and its management in chikitsasthana 16th chapter.26D. SANGRAHA PERIOD Virechana well explained in Ashtanga sangraha Sutrastana27, Kasyapa samhitaSiddisthana,28 Bhavaprakasha Purvakhanda29, Yogaratnakar Virechanaadhikara30 andChakradatta Virechanaadhikara.31 7 Historical review
Panduroga is described in Ashtanga sangraha Nidanasthana32 and Chikitsasthana,33Kasyapa samhita Sutrasthana,34 Yogaratnakar Pandurogaadhikara,35 BhavaprakahsaMadyamakhanda,36 Madhavanidana,37 Chakradutta Pandurogaadhikara.38E. MODERN PERIOD Cathartics are used in modern medicine for the treatment. Different types of drugsand their action are mentioned in Satuskar pharmacology.39 In this period so many commentators have discussed about Panduroga and theycorrelated it with Anaemia. The word Anaemia was first appeared for medical use in1824 and in 1849 it began to have specific medical meaning (which is much moresimilarly with Panduroga). 8 Historical review
VIRECHANA KARMANIRUKTI AND PARIBHASHA Virechana is described from the root –Rich dhatu, Vi upasarga, Nich and Lout pratyaya are also take part in the derivation. “Visheshena Rechayateeti” 1 It means “Mala Nissarana” i.e. elimination of malas through any of the route inthe body. But in Ayurveda the word virechana is used for indication of only theelimination of malas through adhobhaga i.e. Guda (Anal route). Even in case ofNiruhavasti Malas are eliminating through Guda, but adhobhagaharana type of shodhanais not producing here i.e. elimination of Aama pakwashayagata malas. Certain specificterminology is used in Ayurveda to indicate the elimination of malas other than Guda eg.Vamana, Shirovirechana. “Tatradoshaharanam Adhobhagam Virechanam Sanjnyakam |” 2 The act of expelling vitiated doshas (malas) through adhobhaga is known asvirechana. Here Chakrapani commented adhobhaga means “Guda” 3. “Vireko Mukhapeetam Gudamargenanta: sthetastha | Doshasya Nirasaaranam Pittasya Paramaushadham ||”4 Virechana is the process in which the orally administered drug can bring thevitiated doshas through adhomarga and it is special treatment for pittadosha. “Virechanam Pittaharanam Shreshtam |”5“Pitta Tu Virekam Shleshma Samsrushte Vaa Tatsthanagate Vaa Shleshmaneeti |” 6 9 Virechana Karma
Virechana is a specially indicated for pitta dosha, Pitta dosha associated withkapha dosha and kapha dosha which is situated in pittasthana. Mridu Virechana is the line of treatment for avarana vata vyadhies7. As we know“Pittam Tu Swedaraktayo|”8 i.e. Pitta and rakta have got ashraya, ashrayee bhavarelation, thus Virechana can be employed as a treatment in vitiated rakta and its disorders.PARYAYAThe synonyms are9 • Rechana • Praskandana. According to the Sanskrit – English dictionary purgative, cuthartic. Evacuant andApercent are the different meanings of Virechana10.VIRECHANA DRAVYAS Virechana dravyas will have all the properties of vamana dravyas i.e. Ushna,Teekshna, Sukshma, Vyavayi, Vikashi, except Urdhobagahara in case of vamana andAdhobagahar in Virechana. But unlike vamana, the Virechana dravyas consistpredominance of prithvi and jala mahabuthas, which show specific property of removingthe doshas through adhobhaga. i.e. Guda marga11. 10 Virechana Karma
TYPES OF ADHOBHAGAHARA KARMA Acharya Sharangadhara has classified according to the action of the virechanadravyas – 01. Anulomana12 – The drugs, which will digest (paka) the apakwa malas and bring them to adhomarga by removing the bandhana. eg. Haritaki. 02. Sramsana13 – The drugs which expel the slishta malas (malas adhere to the lumen of intestines) with out doing the paka. eg. Aragwadha. 03. Bhedana14 – The drugs, which disintegrates the Abaddha or Baddha or Pindita forms of malas and then evacuating through adhomarga. eg Kutaki. 04. Rechana15 – The drugs which eliminates pakwa and apakwa malas by making them in drava form through adhomarga. eg Trivritta. There are certain drugs, which will help, in proper Virechana or which willsynergies the action of Virechana dravyas is known as Virechanopaga. The drugsdisciebed are Draksha, Kashmarya, Parushaka, Abhaya, Amalaki, Vibhitaki, Kuvala,Badara, Karkandhu and Pilu16.VIRECHANA YOGYA AND AYOGYA As a first step in Virechana vidhi, one has to observe whether the patient is fit forVirechana karma or not. For this Virechana yogyas and Virechana ayogya criteria isgiven in the classics. Those who are fit for virechana should only be given withvirechana, otherwise it will leads to complications. 11 Virechana Karma
PROCEDURE OF VIRECHANA Procedure of Virechana can be classified under three headings Purvakarma Pradhanakarma PaschatakarmaPurva karma: Sambar sangraha Atura pariksha Atura siddhata Matra vinischaya Sambar sangraha: The medicines and instruments useful for Snehana, Swedana,Virechana and the treatment of Virechana vyapat must be collected prior to theadministration of Virechana therapy. Atura pariksha: Examiniation of the petient for yogya ayogya. Deciding the Virechana matra depending on the Dosha, Atura bala, Bheshaja, Kaala, Desha, Agni, Koshta, Shareera, Ahara, Satmya, Satwa, Prakriti, Vaya, Saama avastha and Vikara23 Deciding the type of Sneha and Virechana yoga by considering vyadhyanukulata and vyadhyanurupataSpecific drugs for Virechana.24(a)Vata Pradhana - Trivrit + Saidhava + Shunthi + Kanji or MamsarasaPitta Pradhana - Trivrit Choorna + Draksha KwathaKapha Pradhana - Triphala Kwatha, Gomutra, TrikatuChildren between the - Draksha Rasa + Aragvadha Phala Majja 24(b)(Age group of 4-12 years) 14 Virechana Karma
Atura siddhata: Prior to Virechana Karma the patients can be administered with Pachana, Snehanaand Swedana procedures as a purvakarma Pachana can be administered in the condition of Ama, till the appearance of Nirama lakshanas Snehapana should be followed in arohana vidhi, till the appearance of samyak snigdha lakshanas, maximum duration will be 3 to 7 days.25Samyak Snigdha Lakshanas26-28Table No. 03. Showing the Samyak Snigdha Lakshanas.Sl. Lakshanas Ch Su Va Sl. Lakshanas Ch Su Va01. Vatanulomana + - + 07. Anga laghavata - + -02. Agnideepti + + + 08. Twak snigdhata - + -03. Purisha snigdhata + + + 09. Adhomarga sneha srava - + -04. Asamhata varcha + + + 10. Klama - + +05. Gatra mardavata + + - 11. Shaithilya - + -06. Gatra snigdhata + + + 12. Snehodvega - - + Snehaat Praskandanam Jantuhu Triratroparata Pibet |29 In case of Virechana, 3 days rest is mentioned after Snehapana. During these daysAbyanga, Swedana and Snigdha, Drava, Ushna bojana, Mamsarasa, Odana, AmlarsaPhala is recommended.30 i.e. the food must not produce kaphavruddhi “Manda Kapha”is the condition described for proper Virechana Karma.31 Matra vinischaya Matra of Virechana drug should be in such a quantity that the desired effect ofShodhana must be achieved with out causing ayoga and atiyoga lakshanas 15 Virechana Karma
Table No. 04. Showing the dosage of Virechana according to sharangadhara.32 Kalpana Heena Matra Madhyama Matra Uttama Matra Kwatha 8 tolas 4 tolas 2 tolas Kalka, Choorna 4 tolas 2 tolas 1 tolas ModakaNature of Koshta and Virechana Mrudvi Matra Mrudu koshte cha madhyama | Krure Tikshana Mata Dravyair Mrudu Madhyama Tikshanakaihi ||Acharya Sharandhra opiens that the dravya matra should be alpa, madhyama, uttama forthe person of Mrudu, Madhyama and Krura Koshta respectively.33 Sushruta also opinsthe same. 34 Pradhana Karma: Pradhana karma starts with administration of virechana dravyas till the stoppageof virechana Vegas i.e. – 01. Virechana yoga sevana. 02. Atura paricharya and Nirikshana. 03. Vega nirnaya. 04. Observation of samyak yoga, ayoga and atiyoga lakshanas. 05. Virechana vyapat and Pratikara.Virechana yoga sevana: Before the administration of virechana yoga the physician must examine thepatients physical and mental health once again. Patient must have digested, the foodtaken on previous day and must got sound sleep on the previous night. 16 Virechana Karma
Shleshma kaale Gate Jnyatwa Koshta Samyak Virechayeet |35 According to Vagbhata, the patient has to take virechana karma just aftershlesmakala. It can be understood as the time is so adjusted that the virechana should bestarted during pittakala. The pittakala falls between 10.00 am to 2.00 pm. Hence, the timeand dose of the virechana dravya should be decided depending upon the koshta andagnibalabala of the patient. Ushna or sheeta jala can be used as anupana in accordancewith Virechana yoga.Atura paricharya and Nirikshana: The vaidya must observe the lakshans of Jeernoushadha, Ajeernaoushadha, Hritdosha and vyapat.Aushadha Jeernaajeerna Lakshana36-37Table No. 05. Showing Aushadha jeernaajeerna lakshanas. Sl. Aushadha jeerna lakshana Aushadha ajeerna lakshana 01. Vatanulomana Dourbalya 02. Swasthya Daha 03. Kshut Angasada 04. Pipasa Bhrama 05. Mana prasannata Moorchha 06. Indriya prasannata 07. Shuddha udgar In case of ajeernaoushadha lakshanas, the Virechana drugs should not be givenimmediately, as the drug may produce severe purgation i.e. Atiyoga. But in some cases ifthe drug is digested, and there is no hrit dosha lakshanas, he should be given food, againvirechana oushadhi should be administered on the next day. Even then if the virechanadoes not occur then the patient must be given proper snehana swedana once again andthen Virechana oushadhi can be administered after 10 days38. 17 Virechana Karma
Apart form the above lakshanas the hrit dosha lakshanas should also be taken intoconsideration. In proper virechana there will be expulsion of mala, pitta and kapha Vatain sequence, “Kaphantam Virechana” and appearance of daurbalyata and laghutaindicates that doshas have properly eliminated.39 If virechana persists even after manifestation of Hrit dosha lakshanas then vamanashould be performed.40 If the Virechana Vega does not occur then instantaneously theushna jala pana, and swedana must be performed on pani, pada and udara.41Vega Vinirnaya For the purpose of observation of pravara, madhyama and avara shuddhi,Chakrapni has given four types of criteria i.e. Laingiki, Antiki, Vegiki and Maniki, butimportance should be given to Laingiki shuddhi. For vega vinirnaya the physician have toleave the first two-three malayukta Vegas, then counting should be done till kaphantam.Table No. 06. Showing the Virechana vega vinirnaya.42 Sl. Vega vishaya Pravara Madhyama Avara 01. Vegiki 30 Vegas 20 Vegas 10 Vegas 02. Maniki 4 Prastha 3 Prastha 2 Prastha 03. Antaki Kaphantam 04. Laingiki Samyak Virechana Lakshanas 18 Virechana Karma
OBSERVATION OF SAMYAK YOGA, AYOGA AND ATIYOGA LAKSHANAS Laingiki shuddhi lakshanas are given in the table. Thereafter the Ayoga andAtiyoga lakshanas mentioned in the classics have been presented in tabular form.Table No. 07. Showing the Samyak Lakshana of Virechana karma.43 Sl. Virechana Samyak Lakshana Ch Su Va 01. Srotovishuddhi + - - 02. Indriya prasada + + - 03. Laghuta + + - 04. Agnideepiti + - - 05. Anamayatwa + - - 06. Kramat Vit, Pitta, Kapha and Vata Nissarana + + - 07. Vatanulomana - + - 08. Absence of Ayoga, Atiyoga lakshanas - - +Virechana Ayoga and Atiyoga LakshanasTable No. 08. Showing the Ayoga lakshanas of Virechana.44 Sl. Lakshana Ch Su Va Sl. Lakshana Ch Su Va 01. Kapha prakopa + + + 10. Vata pratilomata + - - 02. Pitta prakopa + + + 11. Daha - + + 03. Vata prakopa + - - 12. Hridaya ashuddhi - + + 04. Agnimandya + + - 13. Kukshi ashuddhi - + + 05. Gourava + + - 14. Kandu - + + 06. Pratishyaya + - + 15. Vitsanga - + + 07. Tandra + - - 16. Mutrasanga - + - 08. Chhardi + - - 17. Pidaka - - + 09. Aruchi + + + 19 Virechana Karma
Table No. 09. Showing the Atiyoga lakshanas of Virechana.45Sl. Lakshana Ch Su Va Sl. Lakshana Ch Su Va01. Kapha kshayaja + + - 12. Hikka + - - vikara02. Pittakshayaja + - - 13. Moorchha - - - vikara03. Vata kshayaja + - - 14. Gudabhrimsha - - - vikara04. Supti + - - 15. Shoola - + -05. Angamarda + - - 16. Kapha, Pitta rahita Sweta, - - + lohita udaka nissaranam06. Klama + - - 17. Mamsa dhavanavat - - + Udakasrava07. Vepathu + - - 18. Medakhandavat - - +08. Nidra + - - 19. Trishna - - +09. Dourbalya + - - 20. Bhrama - - +10. Tamapravesh + - - 21. Netra Praveshanam - - +11. Unmad + - - 22. Raktakshayaja vikara + - - Ahridya, durgandhita, adhika matra yukta virechana oushadhi and in kaphotkleshaajeernavastha the administered Virechana oushadha may produce vamana.46Paschat Karma Regimens to be adopted after virechana karma till the patient is able to takenormal diet are known as paschat karma. Soon after the samyak virechana karma the agnibecomes imbalance state. Hence, the patient is not allowed to take normal diet, which cancause further vitiation of agni. Hence, the peyadi samsarjana krama should be followed inorder to bring back the equilibrium in the state of agni.47 20 Virechana Karma
Three to seven days samsarjana krama is followed by administrating peya, vilepi, akrita krita yusha and akrita krita mamsarasa depending upon the shuddhi achieved. But in following conditions Tarpana should be administered instead of samsarjana viz.48 – 01. Pitta kapha parisrava. 02. Madatyaya. 03. Vatapitta prakriti. In Tarpna, Swaccha Tarpana, in place of Peya and Ghana Tarpana in place of Vilepi should be used according to Chakrapani.49 VIRECHANA VYAPAT Improper conduction of Virechana leads to vyapats like50 – 01. Adhmana 06. Jeevadana Guda bhramsha 02. Parikartika 07. Vibhrimsha51 Sajnyanasha 03. Parisrava 08. Stambhana Kandu 04. Hridgraha 09. Klama 05. AngagrahaSushruta has given 15 vyapats of virechana52 – 01. Vamana occurs with virechana 08. Atiyoga dravyas (Urdhwagati). 09. Jeevadana 02. Virechana occurs with Vamana 10. Adhmana dravyas(Adhogati) 11. Parikartika 03. Shesha oushadhitwam 12. Parisrava 04. Jeerna oushadhitwam 13. Pravahika 05. Heena dosha apahritatwam 14. Hridyopasarana 06. Vata shoola 15. Vibandha 07. Ayoga 21 Virechana Karma
As seen above, acharyas have clearly metioned the ayoga and atiyoga vyapat indetail and their respective treatment.VIRECHANA OUSHADHA KARMUKATA The vamana and virechana dravyas posses similar properties like ushna, teekshna,sukhma, vyavayi and vikashi gunas. Drugs will reach the hridaya by its veerya thereby itenters into dhamanis, sthula and anu srotas of the body. The Vikashi guna is responsiblefor quick absorption, due to ushna guna vishyanadana will be produced. Teekshna gunadoes chhedana of samhata doshas and brings back them to koshta. Form there due toprithwi and jala mahabhoota gunas and adhobhagahara prabhava the doshas geteliminated through gudamarga. Both Virechana and Vaman oushadhas are having thesimiler propereties exept Urdwabhagahara in Vamana, adhobhagahara in case ofVirechana dravyas and it is only because of Prabhava the Virechana drugs producesVirechana karma.53 Sushruta added sara guna along with the ushnadi gunas and this sara guna act asanulomana.54 Acharya charaka says, the drugs act not only due to its prabhava but also due toits dravyatwa prabhava gunatwa prabhava and both dravyatwa and gunatwa prabhava.And the factors mentioned here may change based on the different conditions. The effectproduced is karma. The factor responsible for manifestation of effect is veerya.55 22 Virechana Karma
MODERN CONCEPT OF LAXATIVES: 56 Laxatives are act through multiple mechanisms affecting the epithelial transfer,directly or indirectly, leading to decreased sodium absorption and increase in chloridesecretion by intestinal epithelial cells. These drugs are sometimes classified according to intensity of action as mild,moderate or drastic. Laxative effect suggests the elimination of soft-formed stool withoutgripping and without much loss of water. In large doses many laxatives promotecatharsis, which means purgation and passage of more fluid stools. Laxatives can beclassified according to their mechanism of action as follows:I. Stimulant or Irritant Laxatives: Antroquinone group – This acts by stimulation of large bowel and also probably by inhibiting NaCl water absorption in the colon. eg. Cascara sagrada and senna.Pharmacological actions: As these drugs act mainly on large bowel evacuation occurs 6to 8 hours after their ingestion. Stools are usually semisolid in consistency and incidenceof griping is low. Irritant oils – eg. Castor oil. It is fixed oil obtained by expression of the seeds of Ricinus communis Linn.Chemically, it is triglyceride of ricinoleic acid, an unsaturated hydroxy fatty acid. Castoroil itself is nonirritant. When ingested, it is hydrolysed in the intestine by pancreaticlipase to glycerol and ricinoleic acid. Ricinoleic acid acts as an irritant and producespurgation. Pharmacological actions : As ricinoleic acid acts on small intestine, it producescopius liquid stools, with associated fluid loss. Colonic emptying may be so completethat patient may not pass the stool for several days. The action is quicker than that of theanthroquinone and is evident within two to tnree hours. It causes griping. 23 Virechana Karma
Miscallaneous – eg. Phenolphthalein bisacodyl, sodium picosufate. Pharmacological actions : Mechanism of action is not known but the drug actsas stimulant mainly on the large bowel after 6 to 8 hours and produces soft, semisolidstools associated with a little griping. An interesting aspect of phenopthaline is that about15% of the dose is absorbed, some of which is re-excreted in the bile. This enterohepaticcirculation of the drug causes prolongation of its laxative effects.II. Osmotic laxatives Certain salts when given orally are not much absorbed and are retained in thegastrointestinal tract. Such preparations exert an osmotic effect and therefore holdconsiderable amount of water, thus increasing the intestinal bulk. This acts as amechanical stimulus causing an increase in the intestinal motor activity and evacuation. Pharmacological actions : these compounds act in the small as well as largeintestines and therefore produces a watery evacuation within 3 to 6 hours. Because oftheir quick onset of action they are given early in the morning before breakfast. They donot cause irritation and there is very little griping. Patients should be instructed to takeplenty of water along with these drugs since administration of hypertonic solution mayproduce dehydration due to water extraction from the circulation.III. Bulk laxatives – eg. Methyl cellulose, Agar agar, Ptantago seeds, Bran. These are various natural or semisynthetic polysaccharides and cellulosederivatives, which when orally are not absorbed and increase the indigestible residue.These agents absorb water and swell up, thus providing the stimulus of mechanicaldistention for evacuation. 24 Virechana Karma
Pharmacological actions: These agents act purely because of their physicalproperty. Their action is mild and is usually seen 12 to 36 hours after ingestion. Theyproduce evacuation of solid or semisolid stools without any irritation or griping. Someagents also have lubricating properties. Usually, these drugs are administered at bed time.IV. Emollient laxatives: eg: Liquid paraffin and Dioctyl sodium sulfosuccinate. Liquid paraffin mineral oil most widely used emollient laxative. It consists of amixture of hydrocarbons obtained from petroleum given orally. It is not significantlyabsorbed and exerts a softening and lubricating effect on faeces. Pharmacological actions: It is mild in action and itself does not initiateperistalsis. Because of its lubricant action, the straining during defaecation can beavoided. It is usually given at bed time, but can be taken at any time of the day. 25 Virechana Karma
DISEASE REVIEWNIRUKTI AND PARIBHASHA In Ayurveda, different diseases are named on the basis of signs and symptoms,the origin of the disease, location of exhibiting its symptoms. Here the disease Pandu isnamed on the basis of “Varna.” The word “Pandu” is derived form “Padi–Nashne” dhatu by adding “Ku”Pratyaya to it. For Pandu specifically the Nashana will be of the Varna i.e. the colour,which is said by acharya Charaka as “Vaivarnya.”1 Thus the derivation of the word“Pandu” indicates the abnormal colouration of the body. Pandustu Peetabhagardhaha Ketaki Dhuli Sannibham |2 Pandu is a mixture of shweta and peeta varna in equal proportions, whichresembles the colour of pollen grains of Ketaki flower. Pandu Haridra haritaan Varnancha Vividham Stwachi | Sa Pandurogaha Ityuktaha || Pandu Haridra Haritan Pandutwam Tesham Chaadhikam | The disease in which, twacha becomes Pandu, Haridra, Harita varna is known asPanduroga.3 Padutwenopalakshitaha Rogaha Pandurogaha | The disease in which Pandubhava, Pandutwa or Panduvarna is more is known asPanduroga.4 26 Disease Review
RELATION BETWEEN RAKTA, PITTA AND PANDU. In describing the rupas of Panduroga, acharya charaka has described symptomslike Vaivarnya, Ojogunakshayam, hataprabha, Alparakta nissara. Hence, it is necessary toknow the role of Raktadhatu and Pittadosha which play a predominant role in themaintenance of the complexion of the body. Rakta has been considered as a key factor forthe Jeevana, and Poshanakarma of the body. According to Maharshi Sushruta, Raktam Jeevam Iti Sthiti:|5 But, the proper functions of rakta can be expected only in its pure form as said byacharya charaka. Tadvishuddham Hi Rudhiram Balavarnasukhayusha | Yunakti Pranianam Prana: Shonitam Hyunuvartate ||6 As per the classics, raktadhatu is derived from rasadhatu. Rasa is an aqueousfluid. It is a transparent and colourless substance due to the predominance ofJalamahabhoota and due to predominance of Teja mahabhoota it is reddish in colour. Rasadhatu is sara of Shadrasayukta ahara called Poshya dhatu. When this poshyadhatu undergoes pachana by agni derived from pitta, it transforms into raktadhatu. Due tothe action of ranjaka pitta on rasa, it gets transformed into reddish colour substance i.e.Rakta. Acharya Sushruta has mentioned the main site of rakta is Yakrit and Pleeha.7Ranjaka pitta is located in Yakrit and Pleeha, plays a major role in ranjana karma ofRasadhatu. According to Vagbhata site of Rajaka pitta is amashaya.8 On the bases of above description it can be deducted that rakta depends on pitta,which transforms rasa into rakta, and bala, varna, ayu depends on rakta. 27 Disease Review
Pandu is said as Pitta pradhana vyadhi.9 In all types of paittika disordersobviously there will be impairment of pitta i.e. in either vriddhi or kshaya stage. It can be said that pitta plays an important role in the formation of rasaraktadidhatus as agni is represented by pitta in body which brings about good and bad effectsaccording to its normal or abnormal state.10 When pachaka pitta gets vitiated and due to its adverse effect, the digestiveprocess gets disturbed thereby dhatu formation. Ranjaka pitta also plays vital role information of rakta, hence its vitiation also affect the formation of rakta. The vitiation ofsadhaka pitta disturbs the functions of hridaya and rakta parisanchalana. Hence, the sthayidhatus are poorly nourished. As a result, due to rakta kshaya, Bhrajaka and Alochakapitta also becomes durbala in performing their normal functions. Hence, varioussymptoms of pitta are observed in Panduroga. Thus it can be inferred that pitta plays a vital role in manifestation of diseasePandu. 28 Disease Review
NIDANA PANCHAKA Disease can be diagnosed by the study of Nidana, Purvaroopa, Roopa, Upashayaand Samprapti.NIDANA11, 12.13 The different authors have explained many nidanas for manifestation of thedisease Pandu. For the sake of convenience it can be categorized under different groups.A. Aharaja NidanaTable No. 10. Showing the Aharaja Nidana of Panduroga.Sl. Nidana Ch Su Va Sl. Nidana Ch Su Va01. Amlarasa sevana + + + 08. Tilataila sevana + + -02. Kshara seavnaa + - - 09. Madya sevana + - -03. Lavana rasa sevana + + + 10. Mrit bhakshana + + -04. Ati ushna bhojana + - - 11. Teeskhnahara sevana - + -05. Viruddha bhojana + - - 12. Atikatu sevana - - +06. Nishapava sevana + - - 13. Ati kashaya sevana - - +07. Masha sevana + + - Charaka mentioned Pandu in Santarpanajanya vyadhi.14 Above said nidanas arecauses for pitta pradhana tridoshas prakopa and Mandagni. Acharya Madhavakar,Bhavaprakash, Yogaratnakar have followed the Susrutha’s version.15 These types ofahara may lead to disturb in digestive and assimilative process, leading to Panduroga. 29 Disease Review
B. Viharaja NidanaTable No. 11. Showing the Viharaja Nidana of Panduroga.Sl. Nidana Ch Su Va Sl. Nidana Ch Su Va01. Amlarasa + + + Manasika factors sevana02. Kshara seavnaa + - - 11. Bhaya + - -03. Lavana rasa + + + 12. Krodha + - + sevana04. Ati ushna + - - 13. Kama + - + bhojana05. Viruddha + - - Pratikarma Vaishamya bhojana06. Nishapava + - - 14. Snehatiyoga + - - sevana07. Masha sevana + + - 15. Vegavidharana in vamana + - - karma Manasika factors 16. Amatisara sangaha + + -08. Chinta + - - 17. Dushtaraktanigraha in + - - Raktarsha09. Shoka + - - 18. Snehavibhrama + - - Causes related to vihara deals with both physical and mental activities as well asiatrogenic cause i.e. Pratikarma vaishamya.C. Nidanarthakara Roga Panduroga can manifest as secondary to some other disorders like – Raktarbuda16 Raktarsha20 Asrgdhara17 Pleehodara21 Raktapitta18 Yakrutodara22 Yakrit-pleeha roga19 Pittaja Prameha23 All leads to either rakta kshaya due to bleeding or vikrita doshas which results inPanduroga. 30 Disease Review
POORVAROOPA24, 25, 26 The Panduroga manifests with following prodromal signs and symptoms –Table No. 12. Showing the Purvaroopa of Panduroga.Sl. Purvaroopa Ch Su Va Sl. Purvaroopa Ch Su Va lakshana lakshana01. Hritspandana + - + 08. Mritbhakshaneccha - + -02. Rukshya + - + 09. Akshi kuta shotha - + -03. Swedabhava + - + 10. Avipaka - + -04. Shrama + - + 11. Aruchi - - +05. Twacha sphutana - + - 12. Peetamutrata - + +06. Sthivana - + - 13. Peeta purisha - + -07. Gatrasada - + + 14. Alpa vanhita - - + Madhavakara, Bhavaprakasha and Yogaratnakara have followed Sushruta’sversion.27ROOPA The term roopa implies to both the signs and symptoms by which a disease isidentified. These can be classified as – 01. Pratyatma lakshana (Cardinal sign & Symptom) 02. Samanya lakshana (General sign & Symptom) 03. Vishesha lakshana (Distinguisheing features of doshanubandha)Pratyatma Lakshana: Pandurvarna is considered as Pratyatma lakshana of Panduroga. This colour isalmost similar to pollens of Ketaki flower. 31 Disease Review
Samanya lakshana: The Samanya lakshanas of Panduroga mentioned in the classics other than Pandutacan be considered as below –Table No. 13. Showing the Samanya lakshanas of Panduroga.28,29 Sl. Roopa Ch Su Va Sl. Roopa Ch Su Va 01. Panduta + + + 13. Shwasa + - + 02. Karna kshweda + - + 14. Gaurava + - + 03. Hatanala + - + 15. Gatra peeda + - - 04. Daurbalya + - + 16. Shunakshikuta + - + 05. Sadana + - + 17. Harita varna + - - 06. Annadwesha + - + 18. Hataprabha + - + 07. Shrama + - + 19. Kopanatwa + - - 08. Bhrama + - + 20. Shishira dwesha + - + 09. Gatrashoola + - + 21. Nidralu + - - 10. Jwara + - + 22. Pindikodweshtana + - - 11. Aruchi + - + 23 Sheerna lomata + - - 12. Gatramadata + - -Vishishta Rupa The lakshanas which are specifying the involvement of particular doshas andthere by helpful in differential diagnosis of Panduroga. The classification of Panduroga is made with reference to samanya samprapti.Though the classification is made on the bases of involvement of particular dosha, theprime factor involved is pitta dosha.30 32 Disease Review
Classification of Panduroga:31,32,33,34Table No. 14. Showing the classification of Panduroga. Sl. Prakara Ch Su Ah As BP YR MN 01. Vataja + + + + + + + 02. Pittaja + + + + + + + 03. Kaphaja + + + + + + + 04. Tridoshaja + + + + + + + 05. Mridbhakshnanajanya + - + + + + + The description of vishishta rupa according to classification of Panduroga ispresented as follows –Vataja Panduroga Lakshana:35Table No. 15. Showing the Samanya lakshanas of Vataja Panduroga. Sl. Lakshana Ch Su Va Sl. Lakshana Ch Su Va 01. Krishna angata + - - 09. Toda + - + 02. Krishna nakhatwa - + - 10. Kampa + - + 03. Krishnekshanatwa - + - 11. Parshwaruk + - + 04. Krishna sira - + - 12. Shiroruk + - + 05. Krishna ananatwa - + - 13. Shopha + - + 06. Ruksha netrata - + - 14. Anaha + - + 07. Rukshangata + - - 15. Asya vairasya + - + 08. Angamarda + - - 16. Balakshaya + - + 33 Disease Review
Tridoshasja Panduroga lakshana Vitiation of all the doshas causes severe degree of dhatushaithilya and dhatu gauravata leading to dhatu and Oja kshaya. The features of sannipataja pandu are explained only in Hareeta samhita. All other authors have stated that it manifests due to the vitiation of all the doshas and considered as asadhya type of Panduroga. Hareeta Samhita38 01. Tandra 06. Hrillasa 11. Moha 02. Alasya 07. Shosha 12. Trishna 03. Shotha 08. Vitbheda 13. Klama 04. Vamana 09. Jwara 05. Kasa 10. Kshudartata As per the opinion of Brihattrayee’s the lakshanas of Vataja, Pittaja and KaphajaPanduroga were seen severely in Tridoshaja Panduroga depending on their degree ofvitiation.39Mridbhakshanajanya Pandu – Acharya charaka40 and Vagbhata41 have explained Mridbhakshanajanya pandu.Further, Madhavakara, Yogaratnakara and Bhavaprakashakar have also followed theCharaka’s version.42 But Sushruta has not considered it separately. Here Mridbhakshanais considered as a Nidana for Panduroga rather than an individual type. The person who is addicted to consuming Mrid like Kashaya, Ushara(Ksharanurasa), Madhura rasa will vitiates Vata, Pitta and Kapha dosha respectively. TheMrid moreover, produces srotovarodha without undergoing pachana leading to Indriyabalahani and Teja, Veerya and Ojas kshaya. Thus manifesting Panduroga, which cancause Bala, Varna and Agni nasha. 35 Disease Review
Mridbhakshanajanya Panduroga lakshanaTable No. 18. Showing the Samanya lakshanas of Mridbhakshanajanya Panduroga. Sl. Lakshana Ch Va MN BP Yo 01. Shoonaganda + - + + + 02. Shoonakshikoota + - + + + 03. Shoona bhru + - + + + 04. Shoona pada + + + + + 05. Shoona nabhi + + + + + 06. Shoona mehana + + + + + 07. Krimikoshta + - + + + 08. Atisara + + + + + 09. Sasrik Mala Pravritti + + + + + 10. Kaphayukta malapravritti + + + + +SAMPRAPTI The causes of Panduroga that are explained under the heading of Nidana leads tovitiation of Tridosha but however, pitta is dominating dosha irrespective of type ofPandu. Acharya Charaka and Vagbhata mention the detailed Samprapti of Panduroga.The intake of pitta pradhana ahara in excess, pitta situated in hridaya aggravates, it ispropelled by aggravated (balina) vayu through dashadhamani that spreads all over thebody. The vitiated pitta affects in between twak and mamsa leads to vitiation of twak,mamsa, vata, asrik, thereby produces various varna like Pandu, Haridra and Hareeta, dueto Panduvarna pradhanata it is called as “Panduroga”. 43,44 According to acharya Sushruta, indulgence of Nidana leads rakta pradushana thatcauses vitiation in Twak causes the Pandubhava therefore it is called as “Panduroga”.45 36 Disease Review
Samprapti of PandurogaDhatu Dourbalya Nidana Sevana AgnidushtiPradushya Raktam Prakopa of Pitta pradhana doshas Agnimandya Hridaya Samvasthita Amavisha Utpatti Vimarga gamana of pitta by vitiated by vayu Twak Mamsantarashrita. Kapha, Vata, Rakta, Twak, Mamsa dushti. Rakta kshaya Bala, varna, oja kshaya. Vaivarnya P a n d u r o g a 37 Disease Revuew
UPADRAVA If the patient continues to indulge in ahara and vihara, which are said to be theNidana of Panduroga– the doshas get further aggravation and thus produces upadrava.Only Sushruta has mentioned complication of Panduroga.46. Viz, Aruchi Pipasa Jwara Chhardi Shiro ruja Agnisada Shopha Abalatwa Murchha Klama Hridaya peedana Swarabheda DahaSADHYASADHYATA47 For the prognosis of Panduroga authors have mentioned asadhya Pandurogalakshanas are as follows – Panduroga of long duration with excessive rukshata is not treatable. If the patient has developed shotha after long duration and is having vision of objects in yellow is not treatable. If the patient passes Baddha and Alpamala with kapha and Hareeta varna is not curable. If the patient suffering from Atisara. If the patient is deena, Shwetangayukta (Shwetavarna leepatanga). If the patient is suffering from Chhardi, Moorchha, Trishna. If the patient is having Panduvarna of Danta, Nakha and Netra. Whose anta bhaga i.e, bahu, janga, shira are shothayukta and madhyabhaga is durbala and vice versa. Patients whose guda, sheeshna and muska are shothayukta. Patient having recurrent attacks of Sangnya nasha. 38 Disease Review
CHIKITSA SUTRA The first line of treatment in Panduroga is snehana followed with samshodhana bymeans of teekshna vamana and virechana. After kostha shuddhi the patient shoud beadopted with pathya ahara and vihara.48 According to acharya Sushruta the Chikitsa sutra for Panduroga is snehanafollowed by vamana and virechana. For this acharya Dalhana opines that thoughUrdhwashodhana (vamana) is contra-indicated, Mrudu vamana can be administered inaccordance with Ritu, Desha, Prakruti, Kaala, Shareera.49 Snehairupakramya snigdamatva virechayet | First snehana should be specified with indicated snehas and there after virechanashould be followed.50 For Mrutbhakshanajanya Pandu the line of treatment is précised as Teekshnashodhana in accordance with balabala, followed by snehapana to restore the strength.51 Dosha vishesha Chikitsa in Panduroga52 1. Vataja pandu – Sneha bhooyistha 2. Pittaja Pandu – Tikta sheetala prayoga. 3. Shleshmaja Pandu – Katu, Tikta, Ushna dravya prayoga. 4. Sannipataja Pandu – Vimishra Chikitsa prayoga. 5. Mritbhakshanajanya Pandu – Nidana parivarjana along with the doshika chikitsa. 39 Disease Review
SHAMANAUSHADHIS In Pandurogadhikara a variety of Ghrita, Churna, Vati, Kashaya, Avaleha,Asavaarishta Bhasma and other single drug preparations are described for themanagement of all types of Panduroga. Ghrita: Panchagavya ghrita, Kalyanaka ghrita, Mahatiktaka ghrita, Dadimaghrita, Katukadya ghrita, Pathya ghrita, Danti ghrita, Draksha ghrita, Haridradi ghrita,and Vyoshadi ghrita. Churna: Navayasa churna, Tapyadi churna, Trivyushanadi churna, Triphalachurna, and Shunthi churna. Vati: Mandura vataka, Punarnava mandura, Bibitakadi vataka, and Shilajatuvataka. Kashaya: Negrodadivarga kashaya, Triphala kashaya, Vishaladi phanta, Guduchikashaya. Avaleha: Vidangadyaavaleha, Darvyadileha, Dhatraavaleha, Triphaladyaavaleha,Yogaraj rasa, Pravaladyavaleha, Abhayavaleha and Ayorajovyoshadyavaleha. Asavaarishta: Dhatryarishta, Goudarishta, Beejakarishta, Manduradyorishta,Abhayarishta, Phalarishta, Bibhitakasava, and Lodhrasava. Bhasma: Lohabhasma, Mandurabhasma, and Swarnamakshikabhasma. Others: Suddha kasisa, Shuddha shilajatu, Shuddha gairika, Mandura, Pravala,Mukta, Amalaki, Yashtimadhu, Chitrakamula, Guduchi Daruharidra, Nimba,Swarnakhiri, Ikshu, Goghrita, and Takra. 40 Disease Review
PATHYAPATHYA53 Pathya Generally for Pana and Bhojana Shali, Yavagu, Yusha, Godhuma, Madya,Mamsarasa, Dugdha, Ghrita, Patola, Shaka, Draksha, Dadima, Kharjura, Amalaki andIkshurasa should be adviced.Specially, for – Vata - Laghupanchamula siddha Jala. Pitta - Hribera, Shunthi sadhita ghrita. Kapha - Arishta, Sidhu, Asava. Tridosha - Takra. Apathya Agni, Aatapa, Aayasa, Pittakaraka annapana, Maithuna, Krodha, Adwa and otherfactors, which are said to be the causes for Panduroga, should be avoided. 41 Disease Review
ANAEMIA1,2 Anaemia can be defined as a haemoglobin concentration in blood below thenormal range appropriate for the age and sex of the individuals. In adults, the lowerextreme of normal haemoglobin is taken as 14.0g/dl for males and 12.0g/dl for females. A decrease in the oxygen carrying capacity of the blood is termed as “Anaemia.”The haemoglobin content of the erythrocytes determines the oxygen carrying capacity.Hence, a reduction in the blood haemoglobin level and in the number of circulatingerythrocytes are characteristics of Anaemia, Although haemoglobin value is employed as the major parameter for determiningvalue is employed as the major parameter for determining whether or not Anaemia ispresent, the red cell count, haematocrit (PCV) and absolute values of MCV, MCH, andMCHC provide alternate means of assessing Anaemia.Patho-physiology of Anaemia Subnormal level of haemoglobin causes lowered oxygen carrying capacity of theblood. This in turn initiates compensatory physiologic adaptations such as – 01. Increased release of oxygen from haemoglobin. 02. Increased blood flow to the tissues. 03. Maintenance of the blood volume. 04. Redistribution of blood flow to maintain the cerebral blood supply. Tissues with high oxygen requirement such as the Heart, CVS, and the skeletalmuscles during exercise, bear the brunt of clinical effects of Anaemia. 42 Disease Review
Clinical features of Anaemia The haemoglobin level at which symptoms and signs of anaemia develop dependsupon following factors – 01. The spread of onset of Anaemia – Rapidly progressive Anaemia causes more symptoms than Anaemia of slow onset, as there is less time for physiological adaptation. 02. The severity of Anaemia – Mild Anaemia produces no symptoms or signs but a rapidly developing severe Anaemia may produce significant clinical features. 03. The age of the patient – The young patients due to good cardiovascular compensation tolerate Anaemia quite well as compared to the elderly.Symptoms In symptomatic cases of Anaemia, the presenting features are tiredness, easyfatiguability, generealised muscular weakness, lethargy and headache. In older patientsthere may be symptoms of cardiac failure, angina pectoris, intermittent claudication,confusion and visual disturbances.Signs A few general signs common to all types of Anaemia are as follows – 01. Pallor – Pallor is the most common and characteristic sign, which may be seen in the mucous membranes, conjunctiva and skin. 02. Cardiovascular System – A hyperdynamic circulation may be present with tachycardia, collapsing pulse, cardiomegaly, midsystolic flow murmur, dyspnoea on exertion and in case of elderly congestive heart failure. 43 Disease Review
03. Central nervous system – The older patients may develop symptoms like attacks of faintness, giddiness, headache, Tinnitus, drowsiness, numbness and tingling sensation of the hands and feet. 04. Occular manifestations – Retenal haemorrhages may occur if there is associated vascular disease or bleeding diathesis. 05. Reproductive system – Menstrual distribances such as amenorrhoea and menorrhagia and loss of libido are some of the manifestations involving the reproductive system in Anaemia subjects. 06. Renal System – Mild proteinuria and impaired concentrating capacity of the kidney may occur in severe Anaemia. 07. Gastrointestinal system – Anorexia, flatulence, nausea, constipation and weight loss may occur.Investigations of the Anaemia subject After obtaining the full medical history pertaining to different general and specificsigns and symptoms in order to confirm the presence of anaemia its type and its cause thefollowing plan of investigations is generally followed. A. Haemoglobin estimation – The first and foremost investigation in any suspected case of Anaemia is to carry out haemoglobin estimation. Several methods are available, but most reliable and accurate is Cyanmethaemoglobin (HiCN) method Drabkin soultionj and spectrophotometer. If the haemoglobin value is below the lower limit of the normal range for particular age and sex, the patient is said to be anaemic. 44 Disease Review
B. Peripheral blood film estimation – The haemoglobin estimation in invariably followed by examination of peripheral blood film for morphologic features after staining it with Romanowsky dyes (Leishman’s Staining). The following abnormalities we can look for in the smear study. a. Variation in size – Microcytosis (Iron deficiency anaemia) Macrocytosis (Megaloblastic Anaemia) Dimophic b. Variation in shape – Poikilocytes. c. Inadequate haemoglobin formulation – Hypochromasia. d. Compensatory erythropoiesis e. Miscellaneous changesC. Red cell indices – An alternative method to diagnose and detect the severity of anaemia is by measuring the red cell indices – a. In iron deficiency and thalassaemia MCV, MCH and MCHC are reduced. b. In Anaemia due to acute blood loss and haemolytic Anaemia MCH, MCV and MCHC are all within normal limits. c. In Megaloblastic Anaemias, MCV is raised above the normal value.D. Leucocytes and platelet count – Measuring of Leucocytes and platelet count helps to distinguish pure anaemia form pancytopenia in which red cells, granulocytes and platelet counts are often elevated.E. Reticulocyte count – reticulocyte count is done in each case of anaemia to assess the marrow erythropoietic activity. In acute haemorrhage and in haemolysis, the reticulocyte response is indicative of impaired marrow function. 45 Disease Review
F. Erythrocyte sedimentation Rate – The ESR is non-specific test used as a screening test for anaemia. It usually gives a clue to the underlying organic disease but Anaemia itself may also cause to rise in ESR. G. Bone marrow examination – Bone marrow aspiration is done in cases where the cause for anaemia is not obvious. In addition to these general tests, certain specific tests are done in different types of anaemias.Classification of Anaemia A. Pathophysiologic I. Anaemia due to impaired red cell production. a. Acute post-haemorrhagic Anaemia. b. Chronic blood loss. II. Anaemia due to impaired red cell production. a. Cytoplasmic maturation defects – i. Deficient haem synthesis – Iron deficiency anaemia. ii. Deficient globin synthesis – Thalassaemic syndromes. b. Nuclear maturation defects – Vitamin B12 or folic acid deficiency and Megaloblastic Anaemia. c. Defect in stem cell proliferation and differentiation – i. Aplastic Anaemia. ii. Pure red cell aplasia. d. Anaemia of chronic disorders. e. Bone marrow infiltration. f. Congenital Anaemia. III. Anaemia due to increased red cell destruction (Haemolytic Anaemia) 46 Disease Review
B. Morphologic I. Microcytic, hypochromic. II. Normocytic, Normochromic. III. Macrocytic, Normochromic.Iron deficiency Anaemia The commonest deficiency disorder present throughout the world is irondeficiency, but its prevalence is higher in developing countries. The factors responsiblefor iron deficiency in different populations are variable and are best understood in thecontext of normal iron metabolism.Iron metabolism The amount of iron obtained form the diet should replace the losses form skin,bowel and genitourinary tract. These losses together are about 1 mg daily in an adult maleor in non-menstruating female. While in menstruating woman there is an additional ironloss of 0.5-1 mg daily. The iron loss required for haemoglobin synthesis is derived form two primarysources –01. Ingestion of foods containing iron (e.g. Leafy vegetables, Beans, Meats, Liver, etc.)02. Recycling of iron form senescent red cells.Absorption 01. The average western diet contains 10-15 mg of iron out of which only 5-10% is normally absorbed. 02. In pregnancy and in iron deficiency, the proportion of absorption is raised to 20- 30%. 47 Disease Review
03. The iron is absorbed mainly in the duodenum and proximal jejunum. 04. Iron from diet containing haem is better absorbed than non-haem iron. 05. Absorption of non-haem is enhanced by factors such as ascorbic acid (Vitamin C), Citric acids, Sugar, Gastric secretions and Hydrochloric acid. 06. Iron absorption is impaired by factors like medicinal antacids, milk, pancreatic secretions, phytates, phosphates, ethylene diamine tetra acetic acid (EDTA) and tannates contained in tea. 07. Non-haem iron is released as ferrous or ferric form but is absorbed exclusively as ferrous form. The iron balance in the body is maintained largely by regulating the absorptive intake by intestinal mucosal cells, so called Mucosal block. 08. The factors, which determine this mucosal intelligence, are unknown. When the demand for iron is increased there is increased iron absorption, while excessive body stores of iron causes reduced intestinal iron absorption.Distribution In an adult iron is distributed in the body as under – 01. Haemoglobin – Present in the red cells, contains most of the body iron (65%). 02. Myoglobin – Comprises a small amount of iron in the muscles (35%). 03. Haem and Non-haem enzymes – eg. Cytochrome, Cutalase, peroxidase, succinic dehydrogenase and falvoproteins constitute a fraction of total body iron (0.05%). 04. Transferrin bound iron – Circulates in the plasma and constitutes another fraction of total body iron (0.5%). All these forms of iron are in functional forms. 05. Ferritin and haemosiderin – These are the storage forms of excess iron (30%). Thus, are stored in the mononuclear phagocytic cells of the spleen, liver and bone marrow and in the parenchymal cells of the liver. 48 Disease Review
Iron transport and utilization After absorption, iron circulates in the blood bound to beta globulin fraction,siderophilin or transferrin. Transferrin is present almost exclusively in the plasma andextra vascular space and serves to transport iron from the site of absorption and storage tothe areas of its utilization. The liver parenchymal cells are the major site of transferrinsynthesis. The labile iron pool (mainly ferritin) is that part of the body iron which is readilyavailable for utilization of haemoglobin synthesis. Iron quickly enters this pool 01. After absorption form the intestines 02. After release form the RBC breakdown 03. Following parental injections. If the amount entering this labile pool is in excess of needs, then it is transferredinto storage pool. The daily iron turnover has been estimated to be approximately 35 mg. The major contribution to this 21 mg comes form the normal red cellsdestruction. About 3 million red cells are destroyed every second. Iron released formdestroyed red cells is thus reutilized. About 11 mg of iron is contributed by that fraction which is not used forhaemoglobin production during its stay in the marrow. While remaining 2-3 mg comesform the storage sites, intestinal absorption and the extra cellular fluid. Form these 35 mg of iron about 32 mg, enters the erthropoietic labile pool, apoorly defined compartment, primarily in the bone, for erythropoiesis. Approximately1mg of iron goes for storage and into extra cellular fluid each and about 1 mg is excreted,mainly in urine and sweat. 49 Disease Review