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Atisara Chikitsa (view source)

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|title=Atisara Chikitsa

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|keywords=atisara, diarrhea, ama, nirama, sangrahi treatment, pichcha basti

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|keywords=atisara, diarrhea, ama, nirama, sangrahi treatment, pichcha basti,Ayurveda, Indian system of medicine, charak samhita.

|description=Chikitsa Sthana Chapter 19. Management of Atisara (diarrhea and associated disorders)

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|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg

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|image_alt=charak samhita

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|type=article

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<big>'''[[Chikitsa Sthana]] Chapter 19. Management of Atisara (diarrhea and associated disorders)</big>'''

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~~<big>''' Abstract </big>'''~~

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The chapter on [[Atisara Chikitsa]] (management of diarrhea) traces the historical origin of the disorder since the Vedic period and attributes it to eating of heavy and hot foods specially meat products. There are six types of diarrhea, three of which are caused by single ''dosha'' (''vataja, pittaja'' and ''kaphaja'') while a fourth is caused by the combination of all the three ''doshas''. The fifth and sixth types are caused due to psychological factors such as fear and grief. Some of these variants could be further classified based on their constituents, e.g., ''vataja atisara'' (diarrhea caused due to ''vata dosha'') is further divided into ''ama'' and ''nirama atisara'' (with or without mucoid substances diarrhea) and it has been emphasized not to stop the lose motions in initial or ''ama'' stage.

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The etiology, pathology, signs and symptoms of each of these six types of diarrhea, along with their prognosis have been detailed here.The principles of treatment and complications associated with diarrhea, such as bleeding, suppuration, ulceration and prolapsed anus are also described along with various measures to tackle the problems effectively.

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''Sangrahi'' (astringent or anti-diarrheals) therapies are not advisable in the initial stage of the disease because of presence of ''ama'' inside the body. Instead, mild laxative should be given to eliminate the accumulated ''doshas''. Diarrhea should be allowed to continue and should not be stopped by constipating or bowel binding drugs. The patients shall be managed with light to digest, nutritive and liquid diet regimen which enhances power of ''agni'' as well as it helps to stop diarrhea.

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~~'''Keywords''': ''atisara, diarrhea, ama, nirama, sangrahi'' treatment, ''pichcha basti''.~~

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{{Infobox

|title = Atisara Chikitsa

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|label5 = Other Sections

|data5 = [[Sutra Sthana]], [[Nidana Sthana]], [[Vimana Sthana]], [[Sharira Sthana]], [[Indriya Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]

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|label6 = Translator and commentator

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|data6 = Byadgi P.S.,Dube N.

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|label7 = Reviewer

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|data7 = Prasad B.S.

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|label8 = Editors

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|data8 = Singh G., Goyal M., Deole Y.S., Basisht G.

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|label9 = Year of publication

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|data9 = 2020

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|label10 = Publisher

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|data10 = [[Charak Samhita Research, Training and Skill Development Centre]]

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|label11 = DOI

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|data11 = [https://doi.org/10.47468/CSNE.2020.e01.s06.020 10.47468/CSNE.2020.e01.s06.020]

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}}

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~~|header3~~ =

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<big>''' Abstract </big>'''

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The chapter on [[Atisara Chikitsa]] (management of diarrhea) traces the historical origin of the disorder since the Vedic period and attributes it to eating of heavy and hot foods specially meat products. There are six types of diarrhea, three of which are caused by single ''dosha'' (''vataja, pittaja'' and ''kaphaja'') while a fourth is caused by the combination of all the three ''doshas''. The fifth and sixth types are caused due to psychological factors such as fear and grief. Some of these variants could be further classified based on their constituents, e.g., ''vataja atisara'' (diarrhea caused due to ''vata dosha'') is further divided into ''ama'' and ''nirama atisara'' (with or without mucoid substances diarrhea) and it has been emphasized not to stop the lose motions in initial or ''ama'' stage.

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The etiology, pathology, signs and symptoms of each of these six types of diarrhea, along with their prognosis have been detailed here.The principles of treatment and complications associated with diarrhea, such as bleeding, suppuration, ulceration and prolapsed anus are also described along with various measures to tackle the problems effectively.

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''Sangrahi'' (astringent or anti-diarrheals) therapies are not advisable in the initial stage of the disease because of presence of ''ama'' inside the body. Instead, mild laxative should be given to eliminate the accumulated ''doshas''. Diarrhea should be allowed to continue and should not be stopped by constipating or bowel binding drugs. The patients shall be managed with light to digest, nutritive and liquid diet regimen which enhances power of ''agni'' as well as it helps to stop diarrhea. </div>

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}}

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'''Keywords''': ''atisara, diarrhea, ama, nirama, sangrahi'' treatment, ''pichcha basti''.

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~~=== Introduction ===~~

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== Introduction ==

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''Grahani'' and ''atisara'' - both manifest due to the vitiation of ''agni'' and share common features of impairment of digestion resulting in indigestion and loose motions. Therefore, this chapter should logically precede or succeed the chapter on ''grahani''. But it is described three chapters after that on ''grahani''. The reason for this unusual sequencing of these topics is that since ''pandu'' is a common symptom and sequelae of the malabsorption syndrome (''grahani''), the chapter on ''pandu'' follows ''grahani''. Now, dyspnea (''shwasa'') is a major symptom of ''pandu,'' and thus, follows the chapter on ''pandu''. Similarly, chapter on ''kasa'' (cough) follows ''shwasa'' because of their relationship. That explains the sequencing of ''grahani'' and ''atisara'' in [[Charak Samhita]].

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''Atisara'' leads to the depletion of water and beneficial salts, causing dehydration in the body. This provokes ''vata'', and therefore requires taking special care of ''vata'', particularly if, the ''atisara'' is caused by all the three ''doshas''. Hydration of the body by means of oral administration of milk, buttermilk and various liquid preparations is advised. Goat’s milk is very useful in bloody diarrhea.The treatment of cholera and other dehydrating diarrheal diseases was revolutionized by the promotion of oral rehydration solution (ORS), the efficacy of which depends on the fact that glucose-facilitated absorption of sodium and water in the small intestine remains intact in the presence of cholera toxin. Where indicated, appropriate antimicrobial agents can shorten the duration of illness from 3–4 days to 24–36 h, hence it should be started depending on the course of illness. Adequate prophylaxis measures should be taken to prevent the infectious diarrhoea.

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</div>

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=== Sanskrit Text, Transliteration and English Translation ===

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== Sanskrit Text, Transliteration and English Translation ==

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iti ha smAha bhagavAnAtreyaH||2||

</div></div>

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We shall ~~now illustrate~~ the chapter ~~on the management~~ of ~~''atisara'' (~~diarrhea). Thus, said ~~lord~~ Atreya [1-2]

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Now we shall expound the chapter "Atisara chikitsa" (Management of diarrhea and associated disorders). Thus said Lord Atreya. [1-2]

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</div>

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==== Query by Agnivesha ====

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=== Query by Agnivesha ===

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bhagavan! atIsArasyaprAgutpattinimittalakShaNopashamanAni prajAnugrahArthamAkhyAtumarhasIti||3||

</div></div>

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On one occasion, when Lord Atreya was sitting on the northern slope of the Himalayas surrounded by the sages after completing his daily worship and oblations to the fire, Agnivesha approached him, offered his humble salutations to him, and requested him to expound the origin, etiology, signs and symptoms, and treatment of ''atisara'' (diarrhea) for the well-being of humanity [3]

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</div>

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==== Historical origins of ''atisara'' ====

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=== Historical origins of ''atisara'' ===

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taM dRuShTvA pravyathitA bhUtagaNAH, teShAM copayogAdupAkRutAnAM gavAMgauravAdauShNyAdasAtmyatvAdashastopayogAccopahatAgnInAmupahatamanasAM [1] cAtIsAraHpUrvamutpannaH pRuShadhrayaj~je||4|| <br />

</div></div>

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After consideration of the above submission of Agnivesha, Lord Punarvasu said, “O Agnivesha, listen to me. I shall give a detailed response to your question.

In the Vedic age/ancient times, sacrificial animals used to get released in the wild soon after the recitation of the sacrificial mantras, and these animals were not killed during the course of the sacrifice (''yajna''). However, in the subsequent periods following the reign of Daksha Prajapati, the sons of Manu named Narishyana, Nabhag, Ikshvaku, Nriga, and Sharyati, sacrifice of these animals became a part of the ''yajna'' (sacrificial ritual) at their instinctive acquiescence. After that, during the sacrifice over a long course of time performed by Prushadra (name of a king), as goats were not obtainable, even the sacred cows were also offered up for sacrifice. This deviation bewildered (or disturbed) all of humanity leading to grief. When the flesh of these sanctified cows were eaten, by the heavy, hot and incompatible to human nature properties of their flesh, as well as the use of what was not prescribed by the scriptures, the people started suffering from the loss of their ability to digest and losing their mental equilibrium, resulting in ''atisara'' (diarrhea). Thus, diarrhea originated from the ''yajna'' performed by Prushadhra [4]

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</div>

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==== ''Vataja atisara'' ====

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=== ''Vataja atisara'' ===

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pakvaM vA vibaddhamalpAlpaM sashabdaM sashUlaphenapicchAparikartikaM hRuShTaromA viniHshvasa~jshuShkamukhaH kaTyUrutrikajAnupRuShThapArshvashUlI bhraShTagudomuhurmuhurvigrathitamupaveshyate purIShaM vAtAt; tamAhuranugrathitamityeke,vAtAnugrathitavarcastvAt||5|| <br />

</div></div>

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*''Vata'' dominant ''atisara'' occurs if a person with ''vata'' dominant constitution indulges in following: Exposure to strong wind, excess sunlight, and physical exercise;

*Indulgence in dry and rough or less quantities of food (''pramitashana'') or irregular meals or strong alcoholic drinks or excessive sexual intercourse; and

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According to some physicians, this type of diarrhea is also called ''anugrathita-atisara'' because of evacuation the scybalous stool. [5]

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</div>

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==== ''Pittaja atisara'' ====

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=== ''Pittaja atisara'' ===

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kRuShNaM raktapittopahitamatidurgandhamatisAryate [1] purIShaM,tRuShNAdAhasvedamUrcchAshUlabradhnasantApapAkaparIta iti pittAtisAraH||6|| <br />

</div></div>

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A person of ''pittaja'' constitution, by indulging in the following etiological factors, gets afflicted by ''pittaja atisara'':

*Excessive intake of sour, saline, pungent, alkaline (''kshara''), hot and sharp (''teekshna'') ingredients;

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*The patient suffers from morbid thirst, burning sensation, excessive sweating, fainting, colic pain and hot sensation; and

*There is suppuration of the anus [6]

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</div>

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==== ''Kaphaja atisara'' ====

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=== ''Kaphaja atisara'' ===

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tasya rUpANi- snigdhaM shvetaM picchilaM tantumadAmaM guru durgandhaMshleShmopahitamanubaddhashUlamalpAlpamabhIkShNamatisAryate sapravAhikaM,gurUdaragudabastiva~gkShaNadeshaH kRute~apyakRutasa~jj~jaH salomaharShaH sotkleshonidrAlasyaparItaH sadano~annadveShI ceti shleShmAtisAraH||7|| <br />

</div></div>

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A person of ''kaphaja'' type of constitution indulging in the following factors experiences the manifestation of ''kaphaja atisara'':

*Consumption of heavy, sweet, cold and unctuous ingredients in excess;

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These are the specific features of ''kaphaja atisara''. [7]

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</div>

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==== ''Sannipataja atisara'' ====

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=== ''Sannipataja atisara'' ===

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अतिशीतस्निग्धरूक्षोष्णगुरुखरकठिनविषमविरुद्धासात्म्यभोजनादभोजनात्कालातीतभोजनाद्यत्किञ्चिदभ्यवहरणात्प्रदुष्टमद्यपानीयपानादतिमद्यपानादसंशोधनात्प्रतिकर्मणांविषमगमनादनुपचाराज्ज्वलनादित्यपवनसलिलातिसेवनादस्वप्ना- दतिस्वप्नाद्वेगविधारणादृतुविपर्ययादयथाबलमारम्भाद्भयशोकचित्तोद्वेगातियोगात्कृमिशोषज्वरार्शोविकारातिकर्षणाद्वाव्यापन्नाग्नेस्त्रयोदोषाःप्रकुपिताभूयएवाग्निमुपहत्यपक्वाशयमनुप्रविश्यातीसारंसर्वदोषलिङ्गंजनयन्ति ||८||

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atishItasnigdharUkShoShNagurukharakaThinaviShamaviruddhAsAtmyabhojanAdabhojanAtkAlAtItabhojanAd yatki~jcidabhyavaharaNAtpraduShTamadyapAnIyapAnAdatimadyapAnAdasaMshodhanAt pratikarmaNAMviShamagamanAdanupacArAjjvalanAdityapavanasalilAtisevanAdasvapnA-datisvapnAdvegavidhAraNAdRutuviparyayAdayathAbalamArambhAdbhayashokacittodvegAtiyogAtkRumishoShajvarArshovikArAtikarShaNAdvA vyApannAgnestrayo doShAH prakupitA bhUyaevAgnimupahatya pakvAshayamanupravishyAtIsAraM sarvadoShali~ggaM janayanti||8||

</div></div>

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The causative factors of ''sannipataja atisara'' (diarrhea caused by the simultaneous vitiation of all the three ''doshas'') are as follows:

*Intake of excessively cold, unctuous, ununctuous, hot, heavy, coarse and hard ingredients;

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Because of the above mentioned causative factors, ''agni'' (power of digestion) gets vitiated as a result of which all the three ''doshas'' get aggravated. These aggravated ''doshas'' in turn further afflict the ''agni'', and having entered into ''pakvashaya'' (colon) cause ''sannipataja atisara''. [8]

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</div>

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==== Signs and symptoms of ''sannipataja atisara'' ====

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=== Signs and symptoms of ''sannipataja atisara'' ===

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ebhirvarNairatisAryamANaM sopadravamAturamasAdhyo~ayamiti pratyAcakShIta; tadyathA-pakvashoNitAbhaM [2] yakRutkhaNDopamaM medomAMsodakasannikAshaMdadhighRutamajjatailavasAkShIravesavArAbhamatinIlamatiraktamatikRuShNamudakamivAcchaMpunarmecakAbhamatisnigdhaM haritanIlakaShAyavarNaM karburamAvilaM picchilaM tantumadAmaMcandrakopagatamatikuNapapUtipUyagandhyAmAmamatsyagandhi makShikAkAntaM [3]kuthitabahudhAtusrAvamalpapurIShamapurIShaM vA~atisAryamANaMtRuShNAdAhajvarabhramatamakahikkAshvAsAnubandhamativedanamavedanaM vA srastapakvagudaMpatitagudavaliM muktanAlamatikShINabalamAMsashoNitaMsarvaparvAsthishUlinamarocakAratipralApasammohaparItaM sahasoparatavikAramatisAriNamacikitsyaMvidyAt; iti sannipAtAtisAraH||9||

</div></div>

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The three aggravated ''doshas'' cause excessive vitiation of ''dhatus'' (tissue elements, e.g., ''rakta'' (blood)), resulting in the appearance of different colors (in the stool). The nature of these colors depends upon the nature of the vitiated ''dhatus'' and ''doshas''.

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Such a patient should be rejected for the treatment (as it is incurable). [9]

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</div>

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==== Guidelines for starting treatment ====

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=== Guidelines for starting treatment ===

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tamasAdhyatAmasamprAptaM cikitsed yathApradhAnopakrameNa hetUpashayadoShavisheShaparIkShayAceti||10||

</div></div>

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The patient who has not yet reached the stage of absolute incurability should be properly treated after the examination of causative factors, ''upashaya'' (pacifying factors) and nature of the aggravation of specific ''dosha''. In this condition, the most aggravated ''dosha'' should be treated in the beginning followed by the treatment of the other less aggravated ''doshas''. [10]

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</div>

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==== Exogenous (psychological) diarrhea ====

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=== Exogenous (psychological) diarrhea ===

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tattayorlakShaNaM vAyoryadatIsAralakShaNam||11||<br />

</div></div>

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The exogenous type of ''atisara'' (diarrhea) is of mental origin and is of two types. One of these is caused by fear and the other is caused by grief. Their signs and symptoms are similar to those of the ''vatika'' type of ''atisara''. Thus ''atisara'' or diarrhea is of two types, viz., ''nija'' or endogenous (like ''vataja, pittaja, kaphaja'' and ''sannipataja atisara'' and ''agantuja/manasa'' or exogenous [11]

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</div>

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==== Management of exogenous (psychological) diarrhea ====

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=== Management of exogenous (psychological) diarrhea ===

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pravakShyAmyanupUrveNa yathAvattannibodhata||13|| <br />

</div></div>

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The following therapies help to cure ''agantuja/manasa'' or exogenous:

Both fear and grief causes aggravation of ''vata'' instantaneously. ''Vata'' alleviating drugs and therapies should be administered for the treatment of exogenous ''atisara''. The patient suffering from diarrhea caused by fear (''bhayaja'') should be exhilarated. The patient suffering from diarrhea caused by ''shoka'' (grief) should be consoled [12-13]

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</div>

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==== Principles of treatment ====

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=== Principles of treatment ===

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la~gghanaM cAlpadoShANAM prashastamatisAriNAm||19|| <br />

</div></div>

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The following principles of treatment are used in management of ''atisara'':

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*Moderately aggravated ''dosha'' should be managed by ''pramathya'' (a type of decoction of drugs) which stimulates the power of digestion (''dipana'') and which is carminative (''pachana'') should be administered. Slightly aggravated ''dosha'' should be managed by ''langhana'' (fasting therapy) [14-19].

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==== Recipes of ''pramathya'' ====

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=== Recipes of ''pramathya'' ===

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[Note: Decoction should be prepared as per the procedure described for ''sandanga-paniya'' in C.S.Ci.3-145.] [20-22]

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==== Diet and drinks for ''atisara'' patient ====

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=== Diet and drinks for ''atisara'' patient ===

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*Depending upon the wholesomeness (''satmya'') of the patient, light food along with buttermilk or ''kanji'' (a sour drink), ''yavagu'' (thick gruel), ''tarpana'' (roasted flour of serials mixed with water), or alcoholic drink or honey should be given. Then gradually ''yavagu'' (thick gruel), ''vilepi'' (a sticky gruel), ''khanda'' (a sour appetiser), ''yusha'' (vegetable soup) and boiled rice mixed with meat soup which are prepared by adding digestive, stimulants and astringent (constipative) drugs should be given.

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Ingredients which are ''dipana'' (digestive stimulant) and ''grahi'' (constipating) are described in [~~[Charak Samhita]]~~ [[Sutra Sthana]] 4: 9 should be administered [23-25]

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Ingredients which are ''dipana'' (digestive stimulant) and ''grahi'' (constipating) are described in [Cha. Sa. [[Sutra Sthana]] 4/9 ] should be administered [23-25]

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==== Treatment of ''vataja atisara'' ====

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=== Treatment of ''vataja atisara'' ===

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*Drugs belonging to the ''vata'' and ''kapha'' alleviative group and those drugs which are ''dipana'' (digestive stimulant), ''pachana'' (carminative), ''grahi'' (constipating), ''balya'' (promoter of strength) and ''rochana'' (appetizer) should be prescribed. [26-29]

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==== Management of diarrhea associated with pain ====

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=== Management of diarrhea associated with pain ===

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After the maturity of ''ama'' (product of indigestion), if the patient experiences loose motions along with scybalous feces associated with colic pain and mucus very frequently in small quantities, and if there is griping pain, then he should be given food along with the soup of ''mulaka, badara, upodikā, kshirini, yavāni, vāstuka, suvarchala, chanchu'' (''nadika''), leaves of ''avalguja, shati, karkaruka, jivanti, chirbhata'' (karkati), ''lonika, patha'' or ''shushka-shaka'' (''kasamarda'' according to Chakrapani). These soups should be cooked along with curd (yogurt) and ''dadima'', and added with ghee in copious quantities [30-33]

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==== Treatment of ''pravahika'' (dysentery) ====

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=== Treatment of ''pravahika'' (dysentery) ===

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*It is prepared by adding the paste of tender fruits of ''bilva'', equal quantities of the paste of sesame, cream of sour curd and copious quantities of ghee [34].

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==== Treatment of ''varcha-kshaya'' (scanty formation of stool) ====

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=== Treatment of ''varcha-kshaya'' (scanty formation of stool) ===

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*The meat soup of the trunk of sheep should be added with its blood and sizzled by adding the extract of ''dadima, dhanya'', ghee and ''nagara''. This soup should be used for boiling red variety of ''shali'' rice. Intake of this cooked rice and drinking this soup make the patient free from the ailments caused by ''varcha-kshaya'' (scanty stool) [35-41]

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==== Treatment of prolapse of rectum ====

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=== Treatment of prolapse of rectum ===

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If there is prolapse of rectum and colic pain, and if the diarrhea is free from ''ama'', then the patient should be given medicated ghee prepared with sour drugs or ''anuvasana'' (unctuous enema). [42]

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==== ''Changeri ghritam'' ====

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=== ''Changeri ghritam'' ===

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Ghee should be cooked with the juice of ''changeri'', decoction of ''kola'' and sour curd, and the paste of ''nagara'' and ''kshara'' (alkali preparation). Intake of this medicated ghee cures ailments caused by prolapse of rectum. Thus, ends the description of ''changeri-ghrita'' [43].

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==== ''Chavyadi ghritam'' ====

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=== ''Chavyadi ghritam'' ===

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Thus, ends the description of ''chavyadi -ghrita'' for prolapsed rectum [44].

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==== ''Anuvasana basti'' in prolapse of rectum ====

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=== ''Anuvasana basti'' in prolapse of rectum ===

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*Chitraka cooked with fat [45].

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==== Management of strangulated prolapsed rectum ====

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=== Management of strangulated prolapsed rectum ===

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If the prolapsed rectum becomes stiff or strangulated, and does not go inside of its own, then oil should be applied over it and fomentation should be given. Thereafter, when the prolapsed rectum is well fomented and has become soft, then with the help of a cotton pad (or pad made of thick cloth) it should be pushed inside and restored to its original place [46].

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==== Use of medicated milk ====

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=== Use of medicated milk ===

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Milk boiled with the root of castor or tender fruit of ''bilva'' may also be given in the above mentioned condition. By the intake of the recipes of medicated ghee mentioned above, bleeding and mucus discharge from the anus stops. These recipes also cure colic pain, dysentery and constipation [47-49]

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==== Treatment of ''pittaja atisara'' ====

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=== Treatment of ''pittaja atisara'' ===

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*If ''pittaja atisara'' (diarrhea) patient is also afflicted with ''ama'' which can be determined by causative factors, ''upachaya'' (habituation), and signs and symptoms, then the patient should be given ''langhana'' (fasting therapy) and ''pachana'' (carminative therapy) appropriate to the strength of the patient.

*If the patient is thirsty, then the decoction of ''musta, parpataka, ushira, sariva, chandana, kiratatiktaka'' and ''udichya'' should be given to drink.

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*After the proper fasting therapy, during meal time, the patient should be gradually given ''yavagu'' (thick gruel), ''manda'' (a type of thin gruel) and ''tarpana'' (roasted flour of cereals added with water) or decoction prepared (according to the procedure suggested for ''shadanga-paniya''~~(C.S~~. ~~Chi~~. 3/ 145-146)) of ''bala, atibala, surpa-parni'' (''mudga-parni'' and ''mansa-parni''), ''shala-parni, prashni-parni, brahati, kantakari, shatavari'' and ''shvadanshtra''.

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*After the proper fasting therapy, during meal time, the patient should be gradually given ''yavagu'' (thick gruel), ''manda'' (a type of thin gruel) and ''tarpana'' (roasted flour of cereals added with water) or decoction prepared (according to the procedure suggested for ''shadanga-paniya''[Cha.Sa. [[Chikitsa Sthana]] 3/ 145-146] of ''bala, atibala, surpa-parni'' (''mudga-parni'' and ''mansa-parni''), ''shala-parni, prashni-parni, brahati, kantakari, shatavari'' and ''shvadanshtra''.

+

*''Agni'' (power of digestion) should be stimulated gradually with the vegetable soup of ''mudga, masura, harenu, makustha'' and ''adhaki'' or with the soup of the meat of ''lava, kapinjala, shasha, harina, ena'' and ''kalapuchcha''. These vegetable soups and meat soups may or may not be sour.

+

*If the ''pittaja atisara'' persists even after the administration of the above mentioned measures, then the patient should be treated with recipes which are ''dipaniya'' (digestive stimulant), ''pachaniya'' (carminative), ''upashamaniya'' (dosha-alleviator) and ''sangrahaniya'' (constipating). [50]

−

==== Recipes for ''pittaja atisara'' ====

+

=== Recipes for ''pittaja atisara'' ===

Line 921: Line 934:

*''Katphala, nagara, patha,'' seed-pulp of ''jambu'' and ''amra'', and ''duralabha''. Once the above mentioned recipes are digested, the patient should be given to eat red variety of rice harvested in earlier seasons, along with appropriately cooked meat-soup added with constipating drugs [51-56]

−

==== Administration of milk ====

+

=== Administration of milk ===

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''Satapushpadi'' ghee is advised for ''anuvasana basti'' [57-62].

−

==== ''Piccha basti'' (slimy medicated enema) ====

+

=== ''Piccha basti'' (slimy medicated enema) ===

Line 1,053: Line 1,066:

Green stalks of ''shalmali'' should be covered with green ''kusha'' and tied. This bundle is then smeared with the mud of black soil and placed over cow-dung fire. After the mud is dried up, the stalks of ''shalmali'' is removed. These stalks are then triturated in a pestle and mortar. One ''mushti'' (''pala'' or handful) of this paste should be mixed with one ''prastha'' of boiled milk and filtered. In this milk, oil, ghee and paste of ''madhuka'' is added in adequate quantity. This recipe is used for medicated enema to be given to the patient after massaging the body with oil. When the nasty material comes out, the patient should take bath and thereafter take food along with either milk or the meat soup of the wild animals. This ''piccha-basti'' (mucilaginous enema) cures ''paittika'' type of diarrhea, fever, edema, ''gulma'' (abdominal lumps), chronic diarrhea, ''grahani'' (digestive disorders) and the acute complications of purgation as well as of ''asthapana basti'' [63-68]

−

==== ''Raktatisara'' (bloody diarrhoea) ====

+

=== ''Raktatisara'' (bloody diarrhoea) ===

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If a ''pittaja atisara'' patient does not follow the therapeutic measures and resorts to such foods and drinks which cause aggravation of ''pitta'', then the excessively provoked ''pitta'' causes ''raktatisara'' and instantaneous vitiation of ''rakta'' (blood). This leads to serious complications like morbid thirst, colic pain, burning sensation and suppuration of the anus. It can also manifest itself directly on account of excessive aggravation of ''pitta'' and vitiation of blood [69-70]

−

==== Treatment of ''raktatisara'' ====

+

=== Treatment of ''raktatisara'' ===

Line 1,146: Line 1,159:

*Butter along with honey and sugar may be given before meals [71-76].

−

==== Measures to alleviate bleeding in ''raktatisara'' ====

+

=== Measures to alleviate bleeding in ''raktatisara'' ===

Line 1,182: Line 1,195:

*Consumption of ghee cooked by adding the paste of fruits of ''kutaja'', along with the scum (upper part) of ''yavagu'', and followed by intake of ''peya'' (thin gruel) is advised [77-79].

−

==== Treatment of ''sannipataja atisara'' ====

+

=== Treatment of ''sannipataja atisara'' ===

Line 1,207: Line 1,220:

Ghee should be cooked by adding the six drugs, viz., the bark of ''daru-haridra'', fruits of ''kutaja, pippali, shringavera, draksa'' and ''katukarohini''. Intake of ''peya'' (thin gruel) and ''manda'' (very thin gruel) along with this medicated ghee cures a serious type of diarrhea even if caused by ''sannipata'' (simultaneous aggravation of all the three ''doshas'').[80-81]

−

==== Hemostatic recipes ====

+

=== Hemostatic recipes ===

Line 1,263: Line 1,276:

*Intake of ''chandana'' along with rice-water, mixed with sugar and honey cures burning sensation, morbid thirst, ''prameha'' and bleeding [82-86].

−

==== Treatment of anal suppuration ====

+

=== Treatment of anal suppuration ===

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*The powder of ''dhataki'' and ''lodhra'', taken in equal quantities, may be used for dusting over the suppurated anus.

*If there is excessive bleeding (from the anus), the cold decoction of the above mentioned drugs should be impregnated with ghee, and sprinkled over the anal region, pelvic region, lumbar region and thighs.

−

*Excessive bleeding should be controlled with a cotton pad soaked with ''chandanadya-taila'' (C.~~S Ci~~ 3-258) or ''satadhauta-ghrita'' (ghee washed with cold water for one hundred times), and the oil or ghee; squeeze this pad over the anal and pelvic regions [87-92 ½]

+

*Excessive bleeding should be controlled with a cotton pad soaked with ''chandanadya-taila''[Cha.Sa. [[Chikitsa Sthana]] 3-258] or ''satadhauta-ghrita'' (ghee washed with cold water for one hundred times), and the oil or ghee; squeeze this pad over the anal and pelvic regions [87-92 ½]

−

==== ''Pichcha-basti'' (mucilaginous enema) for dysentery ====

+

=== ''Pichcha-basti'' (mucilaginous enema) for dysentery ===

Line 1,372: Line 1,385:

When the movement of the aggravated ''vata'' (flatus) gets obstructed or moves with difficulty or seizing of ''vata'' inside the abdomen, then the patient voids blood frequently in small quantities which is associated with pain. ''Piccha-basti'' should be administered to such patients. This type of patient may also be managed by ''anuvasana basti'' given with medicated ghee prepared with ''prapaundarika''. Because of chronic diarrhea, the anus of the patient generally becomes weak. Therefore cotton soaked in medicated ghee should be inserted into the anus frequently or ''anuvasana basti'' with medicated ghee is given [93-95½ ].

−

==== Medicated enema and recipes of linctus ====

+

=== Medicated enema and recipes of linctus ===

Line 1,426: Line 1,439:

*The aggravated vata becomes stronger in its own site in ''atisara'' patients. For the pacification of aggravated ''vata'' associated with ''pitta'' (which takes place in bloody diarrhea), ''basti'' (both the ''anuvasana'' and ''niruha'' types) is the best therapy.

−

*If bleeding takes place before evacuating the stool or after evacuation of stool (i.e., a case of ''raktatisara''), then ''shatavari-ghrita'' (C.~~S Ci~~ 30: 64-69) in the form of linctus should be given.

+

*If bleeding takes place before evacuating the stool or after evacuation of stool (i.e., a case of ''raktatisara''), then ''shatavari-ghrita'' [Cha.Sa. [[Chikitsa Sthana]] 30/64-69] in the form of linctus should be given.

*Intake of freshly collected butter along with half the quantity of sugar and one fourth quantity of honey cures the above mentioned ailments. While taking this potion, the patient should take wholesome food. Adventitious roots of ''nyagrodha, udumbara'' and ''ashvattha'' should be crushed and kept soaked in hot water for twenty four hours. Ghee should be cooked along with this water. This medicated ghee should be added with half the quantity of sugar and one fourth in quantity of honey, and taken in the form of linctus. It cures ''raktatisara'', associated with bleeding either before or after the passing of stool [96-100½]

−

==== Suppuration of anal sphincters ====

+

=== Suppuration of anal sphincters ===

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A patient who has become weak because of ''raktatisara'', if indulges in ''pitta''-aggravating ingredients out of ignorance, then the anal sphincters gets suppurated. This is a serious condition leading to instantaneous death [101½].

−

==== Treatment of ''kaphaja atisara'' ====

+

=== Treatment of ''kaphaja atisara'' ===

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*Intake of ''pippali'' along with honey, or butter-milk added with the powder of ''chitraka'' or the powder of the tender fruits of ''bilva'' cures diseases of digestive system [102-112½].

−

==== Management of complications of ''atisara'' ====

+

=== Management of complications of ''atisara'' ===

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*If the movement of ''vata'' (flatus) is obstructed resulting in colic pain and dysentery, then the patient should be given tender fruits of ''bilva'', jaggery, oil, ''pippali'' and ''shunthi''.

*Diet prepared with ''vata'' alleviating ingredients along with the vegetable soup, meat soup and ''khada'' (a type of sour drink) described under ''vataja atisara'' should be given.

−

*Sour medicated ghee like ''changeri ghrita'' or ''shatpala ghrita'' (C.~~S. Chi~~. 5: 147-148 or (ten years) old ghee mixed with ''yavagu'' (thick gruel) and ''manda'' (thin gruel) should be given [113-116].

+

*Sour medicated ghee like ''changeri ghrita'' or ''shatpala ghrita'' [Cha.Sa. [[Chikitsa Sthana]] 5/ 147-148 ] or (ten years) old ghee mixed with ''yavagu'' (thick gruel) and ''manda'' (thin gruel) should be given [113-116].

−

==== ''Piccha-basti'' and ''anuvasana-basti'' ====

+

=== ''Piccha-basti'' and ''anuvasana-basti'' ===

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*If ''vata'' and ''kapha'' are obstructed in the ''mahasrotas'', if there is excessive evacuation of ''kapha'' (mucus) and if there is colic pain as well as dysentery, then ''piccha-basti'' (mucilaginous enema) should be administered.

*''Piccha-basti'' should be prepared of the paste of ''pippali, bilva, kustha, shatahva'' and ''vacha'' by adding salt.

−

*Patient feels comfortable after the ingredients of ''pichcha-basti'' come out of the rectum and then patient should be advised to take bath followed by intake of food. ''Anuvasana basti'' with lukewarm oil of ''bilva'' (C.S.Si 4: 4-7) should be given in the afternoon.The ''anuvasana basti'' can also be given frequently with the oil cooked with the paste of ''pippali, bilva, kushtha, shatahva'' and ''vacha'' [117-120].

+

*Patient feels comfortable after the ingredients of ''pichcha-basti'' come out of the rectum and then patient should be advised to take bath followed by intake of food. ''Anuvasana basti'' with lukewarm oil of ''bilva'' [Cha.Sa.[[Siddhi Sthana]] 4/ 4-7] should be given in the afternoon.The ''anuvasana basti'' can also be given frequently with the oil cooked with the paste of ''pippali, bilva, kushtha, shatahva'' and ''vacha'' [117-120].

−

==== Need for immediate control of ''vata'' ====

+

=== Need for immediate control of ''vata'' ===

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When ''kapha'' gets reduced because of the above mentioned therapeutic measures, the ''vata'' undoubtedly gets aggravated in its own location (colon). This aggravated ''vata'' may cause instantaneous death and hence should be controlled without delay [121]

−

==== Principle of treatment of ''sannipataja atisara'' ====

+

=== Principle of treatment of ''sannipataja atisara'' ===

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*Alternatively, the most aggravated one should be controlled first followed by the treatment of the remaining two ''dosha'' [122].

−

==== Summary ====

+

=== Summary ===

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Thus, ends the nineteenth chapter of [[Chikitsa Sthana]] (section on the treatment of diseases) dealing with the treatment of ''atisara'' (diarrhea) in the work of Agnivesha as redacted by Charak [19]

−

=== Tattva Vimarsha (Fundamental Principles) ===

+

== Tattva Vimarsha (Fundamental Principles) ==

*''Atisara'' is caused by intake of heavy to digest, excessively hot and food that is incompatible to the body, impairment of ''agni'' and mind. The body reacts to expel out the incompatible material out of gut in the form of ''atisara''.

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*In case of ''sannipataja atisara'', at first the aggravated ''vata'' shall be pacified followed by ''pitta'' and ''kapha''. Alternatively, the most aggravated one should be controlled first followed by the treatment of the remaining two ''dosha''.

−

==~~= ''~~Vidhi Vimarsha~~'' /~~ Applied Inferences===

+

== Vidhi Vimarsha (Applied Inferences ) ==

The disease ''atisara'' resembles the clinical condition of diarrhea and is defined as the passage of frequent, liquid stools (usually of more than 200 g of stool) daily. In the most severe instances of ''atisara'', incontinence is a commonly observed symptom. Diarrhea, among adults, could broadly be categorized as sudden onset(acute), or chronic diarrhea that could last for 14 days or more.

−

==== Acute (sudden onset) diarrhea ====

+

=== Acute (sudden onset) diarrhea ===

This is most common variant and in over 90% of cases is infectious, caused due to ingestion of contaminated food or water. Other causes may include drug induced especially antibiotics, diverticulitis, ischemia, radiation enterocholitis, food allergies or initial presentation of various gastrointestinal diseases.

−

==== Chronic (or relapsing) diarrhea <ref>Patient Education: Chronic Diarrhea among adults, UptoDate

+

=== Chronic (or relapsing) diarrhea <ref>Patient Education: Chronic Diarrhea among adults, UptoDate

(https://www.uptodate.com/contents/chronic-diarrhea-in-adults-beyond-the-basics?topicRef=4021&source=see_link)

−

</ref> ====

+

</ref> ===

Defined as loose stools (occurring three or more times a day) that last for weeks. A most common variant is the Irritable Bowel Syndrome (IBS). Chronic diarrhea could be a symptom of an inflammatory bowel disease like Crohn's Disease, ulcerative colitis, malabsorption syndrome, metabolic or endocrine disorders, food allergies, laxative abuse, neoplasm, or reaction to certain medications.

Careful assessment of the patient's medical history, physical examination, CBC, electrolytes, stool and urine examination are initial tests advised to help assess the underlying causes. Further specialised investigations may be needed depending upon the condition of patient.

−

==== Pathophysiological factors of endogenous diarrhea ====

+

=== Pathophysiological factors of endogenous diarrhea ===

*Dosha: Vata dominant three dosha

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*Type of samprapti: atipravritti (excess discharge)

−

==== Management protocol of endogenous diarrhea ====

+

=== Management protocol of endogenous diarrhea ===

−

===== Assessment of strength of patient =====

+

==== Assessment of strength of patient ====

Excess dehydration in case of diarrhea can lead to serious complications. Hence the strength of the patient should be assessed first for severity of dehydration. This helps to design treatment protocol. Vital parameters including pulse rate, its volume, blood pressure, heart rate shall be examined.

−

===== Subjective and objective parameters =====

+

==== Subjective and objective parameters ====

Frequency of bowel more than three times a day with stool weight less than 200 grams with more watery content are considered as diarrhea. The quantity is less in ''vata'' dominance, medium in ''pitta'' dominance and more in ''kapha'' dominant. Frequency is more in ''vata'' dominance, medium in ''pitta'' dominance and less in ''kapha'' dominance. The consistency of stool also differs according to ''dosha'' dominance as described in the text. ''Purisha pariksha'' (stool examination) is researched further in view of frequency, consistency, smell, its specific gravity in water to determine the ''ama'' and ''nirama'' status of ''purisha''.

[[File:Atisara.png]]

−

==== Prevention of ''atisara'' ====

+

=== Prevention of ''atisara'' ===

−

===== ''Atisara'' can be prevented by following measures =====

+

==== ''Atisara'' can be prevented by following measures ====

#Avoiding causative factors

#Strengthening ''agni'' (digestive processes) by following dietary rules

#Observing body purification treatments as per ''prakriti'' and season

−

===== Current clinical management in [[Ayurveda]] practice =====

+

==== Current clinical management in [[Ayurveda]] practice ====

*'''Principles of treatment''': ''deepana, grahi, pachana,'' buttermilk

*'''Main drugs''': ''kutaja, ahiphena, bhanga, bhallataka, bilva''

Line 1,868: Line 1,881:

|}

−

===== Researches on ''atisara'' and medicines =====

+

==== Researches on ''atisara'' and medicines ====

A combination of ''musta'' (cyperus rotundus), ''ativisha'' (aconitum heterophyllum), ''kutaja'' (holarrhena antidysenterica), ''chitraka'' (plumbago zeylanica) and ''bilva'' (Aegle marmelos) was found effective in management of ''atisara''.<ref>Sridhar B.N., Gopakumar K., Jaya N. Mustadi yoga-A new preparation for treatment of atisara. Aryavaidyan,10(4).May-July 1997;222-225. </ref>

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In a study, ''vatasakadi'' syrup was observed 70 % effective in treatment of ''atisara'' in children as compared to ''bala-chaturbhadra'' syrup.<ref>Shah Kiran. A Comparative Study of Vatsakadi Syrup & Balachaturbhadra Syrup in Management Balatisara with reference to Diarrhea, Int. J. Ayu. Alt. Med., 2014; 2(1):28-33.</ref>

−

==== Management of exogenous diarrhea/''atisara'' ====

+

=== Management of exogenous diarrhea/''atisara'' ===

#Diarrhea due to mental factors: These patients need counseling along with therapeutic management of diarrhea as discussed above.

Line 1,899: Line 1,912:

Loperamide should not be used by patients with fever or dysentery because its use may prolong diarrhea in patients with infection due to Shigella or other invasive organisms.

−

==== Important guidelines and precautions for diarrhea management ====

+

=== Important guidelines and precautions for diarrhea management ===

The World Health Organization , beginning 2002, recommended a “reduced osmolarity/reduced-salt” Oral Rehydration Solution (ORS) to adequately rehydrate the patient, which is key to treating any case of diarrhea.<ref>WHO Press Release, 8 May 2002, http://www.who.int/mediacentre/news/releases/release35/en/</ref> The Centers for Disease Control and Prevention (CDC) considers rehydration as “the cornerstone of treatment of cholera”.<ref>https://www.cdc.gov/cholera/treatment/rehydration-therapy.html</ref> CDC also recommends other treatment alternatives, based on recent studies in Bangladesh and other areas affected by cholera, such as zinc treatment.<ref>https://www.cdc.gov/cholera/treatment/zinc-treatment.html</ref> Severe cases need to take a recourse of antibiotics, though there are instances of resistance to tetracycline and other antimicrobial agents .<ref> https://www.cdc.gov/cholera/treatment/antibiotic-treatment.html</ref>

−

==== List of research on review of ''atisara'' ====

+

=== List of research on review of ''atisara'' ===

#Uikey R, Kar AC. A review on Purisha Pariksha in [[Ayurveda]]. AYU [serial online] 2015 [cited 2018 Jun 12];36:125-9. Available from: http://www.ayujournal.org/text.asp?2015/36/2/125/175536

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#S Durgalakshmi, Pious Uthara Anu, Ajantha. An Overview on Nidana Panchaka of Atisara (Diarrhea). IAMJ: Volume 3(8); August. 2015 available from http://www.iamj.in/current_issue/images/upload/2419_2425.pdf downloaded on 12/06/2018

−

==== Research Areas ====

+

=== Research Areas ===

*Though there are many anti-diarrheal and ant-dysentery medicines are available in conventional systems of medicine, the immediate stoppage of diarrhoea may lead to complications as mentioned in the text. Therefore a survey study is needed to examine the prevalence of such complications caused by stoppage of diarrhea.

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*More researches are needed to study effect of [[Ayurveda]] medicines in chronic diarrhea and psycho somatic disease like irritable bowel syndrome.

−

~~=== Glossary ===~~

−

~~#Ādikālē (आदिकाले): At the commencement of ancient time (Satya-yuga)~~

−

~~#Anuvāsana Basti (अनुवासनबस्तिः): oily medicated enema~~

−

~~#Asthāpana Basti (स्थापनबस्तिः): medicated enema with decoction~~

−

~~#Atīsāracikitsitaṁ (अतीसारचिकित्सितं): treatment of diarrhoea~~

−

~~#Candrakōpagatam (चन्द्रकोपगतम): coloured patches circular in shape like moon~~

−

#Dadhighr̥tamajjatailavasākṣīravēsavārābham (दधिघृतमज्जतैलवसाक्षीरवेसवाराभम): looks like curd, ghee, bone-marrow, oil, muscle fat, milk and minced meat

−

~~#Gauravādauṣṇyādasātmyatvāda (गौरवादौष्ण्यादसात्म्यत्वाद): due to heavy, hot & unwholesome~~

−

~~#Grahnipradosa (ग्रहणीप्रदोषान्): grahani, sprue syndrome~~

−

~~#Gudapākaṁ (गुदपाकं): suppuration of the anus~~

−

~~#Gulma (गुल्म): localized growth in abdomen~~

−

~~#Hāridra (हारिद्र): yellow colour like turmeric~~

−

~~#Harita (हरित): green~~

−

~~#Hutāgnihōtram (हुताग्निहोत्रम): oblations to the fire~~

−

~~#Jāṅgalānāṁ (जाङ्गलानां): wild animals~~

−

~~#Karburam (कर्बुरम): stool of variegated in colour~~

−

~~#Kr̥tāhnikaṁ (कृताह्निकं): completion of daily worship~~

−

~~#Kuṇapgandhyama (कुणपगन्ध्यम): smell like that of a dead body~~

−

~~#Lakṣaṇa (लक्षण): signs and symptoms~~

−

~~#Laṅghita (लङ्घित): undergone lighening therapy~~

−

~~#Makṣikākāntaṁ (मक्षिकाकान्तं): stool attracts flies in excess~~

−

~~#Māṁsadhāvanasannikāśaṁ (मांसधावनसन्निकाशं): appears like washing of meat~~

−

~~#Maṇḍā (मण्डा): liquid portion of cooked rice~~

−

~~#Māñjiṣṭha (माञ्जिष्ठ): reddish colour like of mnjistha~~

−

~~#Matsyagandhi (मत्स्यगन्धि): smell like that raw fish~~

−

~~#Mēcakābha (र्मेचकाभ): like tar coloured~~

−

~~#Mēdōmāṁsōdakasannikāśaṁ (मेदोमांसोदकसन्निकाशं): like washing of fat or flesh~~

−

~~#Muktanāla (मुक्तनाल): paralysed anus sphictor~~

−

~~#Musti (मुष्टि): handful, fist~~

−

~~#Nīla (नील): blue~~

−

~~#Nimitta (निमित्त): cause~~

−

~~#Niryūha (निर्यूह): decoction~~

−

~~#Pañcavalkama (पञ्चवल्कम): bark of five plants viz. Nyagrodha, Udumbara, Ashvattha, Pārasa and plaksha~~

−

~~#Patitagudavaliṁ (पतितगुदवलिं): prolapsed anal sphincters~~

−

~~#Picchā-basti (पिच्छाबस्ति) medicated enema with mucilaginous drugs~~

−

~~#Prāgutpatti (प्रागुत्पत्ति): origin~~

−

~~#Prajānugrahārtham (प्रजानुग्रहार्थम): for wellbeing of humanity.~~

−

~~#Pratyavarakālaṁ (प्रत्यवरकालं): age following performance of sacrifice by Daksa Prajapati~~

−

~~#Pravāhikaḥ-(प्रवाहिकः): passing stool with spasmatic pain~~

−

~~#Pūtipūyagandhyam (पूतिपूयगन्ध्यम): putrid smell or smell like undigested food~~

−

~~#Samsarjanakrama (संसर्जन): gradual bringing from lighter to normal food after purification therapy~~

−

~~#Srastapakvagudaṁ (स्रस्तपक्वगुदं): prolapsed and inflamed of the anus~~

−

~~#Tarpaṇā (तर्पणा): roasted flour of cereals added with water~~

−

~~#Upahatāgnī (उपहताग्नी): loss of the power of digestion~~

−

~~#Upahatamanasāṁ (उपहतमनसां): afflicted mental equilibrium~~

−

~~#Upaśamana (उपशमन): treatment~~

−

~~#Varāhabhēdaḥsadr̥śa (वराहभेदःसदृश): white yellowish colour like of pig-fat~~

−

~~#Vibaddha (विबद्ध): blocked~~

−

~~#Yakr̥tkhaṇḍōpamaṁ (यकृत्खण्डोपमं): like piece of liver~~

−

~~#Yamaka (यमक): mixture of two unctuous substances e.g. mixture of ghee and oil~~

−

~~#Yavāgū (यवागू): thick gruel~~

=== Further reading ===

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#Harrison’s principles of internal medicine 17th Ed. (2008) Ed. by Fauci Kasper D.L., A.S., Longo D.L., Braunwal Eugene, Hauser S.J., Jameson J.L.. Joseph Loscalzo., Pub. MacGraw-Hill USA, Chapter 128. Acute Infectious Diarrheal Diseases and Bacterial Food Poisoning

#Harrison’s principles of internal medicine 17th Ed. (2008) Ed. by Fauci Kasper D.L., A.S., Longo D.L., Braunwal Eugene, Hauser S.J., Jameson J.L.. Joseph Loscalzo., Pub. MacGraw-Hill USA, Vol.-2, Chapter 338.

+

</div>

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==~~= Reference =~~==

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== References ==

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