🔘 Atisara (Diarrhoea)

ATISARA (DIARRHOEA):-

💫 ACCORDING TO AYURVEDA (ATISARA):-

👉🏻 Introduction:-

- Atisara is disease of intestinal disturbances; involves

water & electrolyte imbalances, malnutrition and undernutrition.

- Atisara is not only affects health of children 

but also considered responsible for infant mortality especially in tropical and sub-tropical countries.

- The traditional text of Ayurveda described various treatment options for the management of Atisara including medicine and it is believed that drugs possess Madhura, Mridu, Laghu, Surabhi sampurna, Sheetala & Sanshamaka

 properties may offer relief in Atisara.

- Ayurveda described that Deepan and Pachan drugs may break the samprapti of Atisara.

👉🏻 Derivation:-

 • अतिशयेन सारयति (रेचयति) मलम् इति अतिसारः।

- Atisara word is derived from root word 'Ati' and 'Sru'.

• Ati means in excessive quantity

• Sru means Sarana or passing

- So Atisara means drava mala is passed frequently so many times. 

👉🏻 Definition:-

• अतिसरणम् अतिसारः। (डल्हण)

• संशम्यापां धातु शकृन्मिश्रो सरत्यतीवातिसार। (Su.U.40/6)

- The disease in which frequent loose watery stool is passed is called as Atisara.

👉🏻 Marga vyadhi:- Abhyantara marga

👉🏻 Srotasa:-

- Annavaha srotasa

- Udakavaha srotasa

👉🏻 Synonyms:-

- Udaramaya

- Annagandhi

- Trikanda shotha etc.

👉🏻 Samanya Nidana:-

• गुर्वतिस्निग्धरुक्षोष्णद्रवस्थूलातिशीतलैः । विरुद्धाध्यशनाजीर्णैरसात्म्यै श्चापि भोजनैः॥

स्नेहायेरतियुक्तैश्च मिथ्यायुक्तैर्विषाद्भयात् । 

शोकाद दुष्टाम्बुमद्यातिपानात् सात्म्यर्तुपर्ययात् ॥

जलातिरमणैर्वेगविघातैः कृमिदोषतः । 

नृणां भवत्यतीसारो लक्षणं तस्य वक्ष्यत ॥

(Su.U. 40/3-5)

- Intake of food items which are excessively oily, unctous, very dry, hot, spicy, watery, bulky or Chilled and hard to digest.

- Intake of incompatible food items.

- Overeating

- Imbalance diet

- Due to abnormal seasonal changes

- Intake of food which is prepared by adding excessive fat or oil in it.

- Intake of food which is rotten or poisoned.

- Overwhelming emotions like extreme fear or sorrow.

- Intake of contaminated water or liquid.

- Enjoying water by swimming etc. for longer period of time.

- Intake of water in large quantity.

👉🏻 Purvaroopa:-

• हन्नाभिपायूदरकुक्षि तोदगात्रावसादानिलसन्निरोधाः ।

विट्सङ्ग आध्यानमथाविपाको भविष्यतस्तस्य पुरःसराणि॥

(Su.U. 40/8-9)

- Pricking type of pain around heart, umbilicus, flanks, abdomen and at the anus.

- General weakness

- Abdominal distension

- Constipation

- Indigestion

👉🏻 Samanya Lakshana:-

- Frequent passing of watery loose faecal matter

- Uncontrolled defecation with pain around the umbilicus

- Exhaution and fatigue

- Roughness of skin

- Pain in the chest

- Loss of tolerance to sound

- Dyspnoea

👉🏻 Samanya Samprapti:-

• संशम्यापां धातुरन्तः कृशानुं, व!मिश्रो मारुतेन प्रणुन्नः ।

वृद्धोऽतीवाध: सरत्येष यस्माद, व्याधिं घोरं तं त्वतीसारमाहुः ॥ (Su.U. 40/6)

- Due to repeated acceptance of relevant predisposing factors, vata dosha aggravates and forces Ap dhatu - body fluid which is already in imbalance form to koshtha.

- This Ap dhatu mixes with faecal material vto make it unformed or loose.

- This loose faecal material is expelled frequently via anus.

- This condition is called as Atisara.

👉🏻 Samprapti ghataka:-

- Dosha:- Vata, Pitta, Kapha

- Dushya:- Rasa, Rakta, Mansa, Meda

- Srotasa:- Annavaha, Udakavaha

- Adhisthana:- Amashaya, Pakwashaya

- Srotodushti:- Atipravrutti

- Swabhava:- Ashukari and Chirakari

- Agni dushti:- Jathadagni, Rasa dhatwagni

👉🏻 Types of Atisara:-

✓ According to Charaka:- 6 types

1. Vataja Atisara

2. Pittaja Atisara

3. Kaphaja Atisara

4. Sannipatika Atisara

5. Shokaja Atisara

6. Bhayaja Atisara

✓ According to Sushruta:- 6 types

1. Vataja Atisara

2. Pittaja Atisara

3. Kaphaja Atisara

4. Sannipatika Atisara

5. Shokaja Atisara

6. Aamaja Atisara

1) Vataja Atisara:-

✓ Nidana:- 

• अथावरकालंवातलस्य वातातपव्यायामात्रनिषेविणो रूक्षाल्पप्रमिताशिनस्तीक्ष्णमद्यव्यवायनित्यस्योदावर्तयतश्चवेगान्वायुः प्रकोपमापद्यते ।  

(Cha.Chi. 19/5)

• 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

- Suppression of natural urges.

✓ Samprapti:-

• यक्ता चोपहन्यते, स वायुः, कुपितोऽनावुपहते मूत्रस्वेदौपुरीषाशयमुपहत्य ।

ताभ्यां पुरीषं द्रवीकृत्य, अतीसाराय प्रकल्पते ॥

(Cha.Chi. 19/5)

- Due to above said nidana sevana, aggravate vata, afflicting the power of digestion (or reducing the agni). 

- With the depletion of agni, the aggravated vata forces urine and sweat to the colon (purishashaya) and liquefying the stool.

- It produces Vataja Atisara.

✓ Roopa:-

• अरुणं फेनिलं रुक्षमल्पमल्पं मुहुर्मुहुः । 

शकृदामं सरुक्शब्दं मारुतेनातिसार्यते॥

(Ma.Ni. 3/6)

- Faecal matter is reddish, frothy and dry.

- It is passed repeatedly in smaller quantity with pain and sound.

2) Pittaja Atisara:-

✓ Nidana:-

• पित्तलस्य पुनरम्ललवणकटुक क्षारोष्णतीक्ष्णातिमात्रनिषेविणः प्रतताग्निसूर्यसन्तापोष्णमारुतोपहत गात्रस्यक्रोधेर्ष्याबहुलस्य पित्तंप्रकोपमापद्यते ।

(Cha.Chi. 19/6)

• 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

• Affliction of the body by excessive exposure to the heat of strong fire, hot rays of the sun and hot wind

• Excessive disposition to negative emotions such as anger, jealousy, etc.

✓ Samprapti:-

• तत् प्रकुपितं द्रवत्वादूष्माणमुपहत्य पुरीषाशयविसृतमौष्ण्याद् ।

द्रवत्वात् सरत्वाच्च भित्वा पुरीषमतिसाराय प्रकल्पते॥

(Cha.Chi. 19/6)

- Due to nidana sevana, aggravated pitta supprasses the power of agni.

- Then aggravated pitta having arrived at the colon and disintegrates the stool because of heat liquidity and mobility.

- It produces Pittaja Atisara.

✓ Roopa:-

• पित्तात् पीतं नीलमालोहितं वा । तृष्णामूर्छादाहपाकज्वरातः॥ 

(Su.U. 40/11)

- Gudapaka (due to excessive in pitta and rakta, paka is developed)

- The faeces is yellow and bluish

- Tha patient has burning sensation and perianal suppuration in such cases

- Severe thirst

- Excessive sweating

- Pain in abdomen

- Fever

- Stupor

- Atyanta gandhayukta mala

- The motions are massive, forceful and uncontrolled.

3) Kaphaja Atisara:-

✓ Nidana:-

• श्लेष्मलस्य तु  गुरुमधुरशीतस्निग्धोपसेविनः सम्पूरकस्याचिन्तयतो दिवास्वप्नपरस्यालसस्य श्लेष्माप्रकोपमापद्यते ।

(Cha.Chi. 19/7)

• 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

- Inactivity of the mind and indolence

- Habitually sleeping during the day time

✓ Samprapti:-

• स स्वाभावाद् गुरुशीतमधुरस्निग्धः स्रस्तोऽग्निमुपहत्य ।

सौम्यस्वाभावात् पुरीपाशयमुपहत्योपक्लेश पुरीषमतिसाराय कल्पते॥

(Cha.Chi. 19/7)

- Due to nidana sevana, kapha gets aggravated.

- Kapha moves downward and afflicts the Agni because of cooling property.

- Then having arrived at the colon, liquifies the stool and produces Kaphaja Atisara.

✓ Roopa:-

• स्निग्धंश्वेतंपिच्छिलं तन्तुमदामंगुरुदुर्गन्धं श्लेष्मोपहितमनुबद्ध शूलमल्पाल्पमभीक्ष्णमतिसार्यतेसप्रवाहिकं ।गुरूदरगुदबस्तिवङ्क्षणदेशःकृतेऽप्यकृतसञ्ज्ञःसलोमहर्षःसोत्क्लशोनिद्रालस्यपरीतःसदनोऽन्नद्वेषीचेतिश्लेष्मातिसारः ।।

(Cha.Chi. 19/7)

- The stool is unctuous, white, slimy, fibrous, mixed with mucus as well as undigested food particles, heavy, foul-smelling and mixed with phlegm

- The patient suffers from continuous, griping, colic pain

- The patient evacuates stool frequently in small quantities

- The patient suffers from heaviness in the abdomen, in the region of urinary bladder and in the pelvic region

- The patient feels the urge for passing stool even after having evacuated

- Suffers from horripilation, nausea, excessive sleep, indolence, prostration and dislike for food

4) Sannipataja Atisara:-

✓ Nidana:-

• अतिशीतस्निग्धरूक्षोष्ण गुरुखरकठिन विषमविरुद्धासात्म्यभोजनादभोजनात्कालातीतभोजनाद्यत्किञ्चिदभ्यवहरणात्प्रदुष्टमद्यपानीयपानादतिमद्यपानादसंशोधनात्प्रतिकर्मणांविषमगमनादनुपचाराज्ज्वलनादित्यपवनसलिलातिसेवनादस्वप्नादतिस्वप्नाद्वेगविधारणादृतुविपर्ययादयथाबलमारम्भाद्भयशोकचित्तोद्वेगातियोगात्कृमिशोषज्वरार्शोविकारातिकर्षणाद्वाव्यापन्नाग्नेस्त्रयोदोषाः प्रकुपिताभूयएवाग्निमुपहत्यपक्वाशयमनुप्रविश्यातीसारं सर्वदोषलिङ्गंजनयन्ति ||

(Cha.Chi. 19/8)

• 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, hot, heavy, coarse and hard ingredients

- Intake of irregular meals, ingredients of food having mutually contradictory properties and unwholesome food

- Intake of food long after the scheduled time

- Intake of food without caring for its wholesomeness

- Drinking of alcohol and other drinks which are polluted, toxic or harmful

- Drinking of alcohol in excess

- Not resorting to elimination therapies (in appropriate seasons)

- Inappropriate administration or non administration of therapeutics

- Excessive exposure to fire, hot rays of the sun, strong wind and bath etc., in strong current of water

- Not sleeping or sleeping in excess

- Suppression of natural urges

- Not resorting to appropriate regimens during different seasons

- Over courageous attitude

- Excessive exposure to fear, grief and anxiety

- Excessive emaciation due to worm-infection, consumption, fever and piles (bleeding).

✓ Samprapti:-

• त्रयो दोषाः प्रकुपिता भूय एवाग्निमुपहत्य पक्वाशय ।

मनुप्रविश्यातीक्षारं सर्वदोषलिङ्गं जनयन्ति॥

(Cha.Chi. 19/8)

- Due to nidana sevana, all three doshas are aggravated.

- Because of that agni gets vitiated by dosha prakopa.

- These aggravated doshas further afflict the agni and entered into Pakwashaya and produces Sannipataja Atisara.

✓ Roopa:-

- Sannipataja Atisara having rakta as the prevalent aggravated element. It produces dark yellowish, green, blue coloured loose motions which are extensively painful or totally painless.

- Insipid mouth

- Loss of digestive power

- Delirium

- Lassitude

5) Shokaja Atisara:-

✓ Nidana:- Due to excessive shoka.

✓ Roopa:-

- Depressed, sad mental status

- Loss of sleep

- Restlessness

- Giddiness

- Dryness of the mouth

- Loathing of food

- Foamy, soft, smooth, watery loose motions

6) Bhayaja Atisara:-

✓ Nidana:- Due to excessive fear (Bhaya)

✓ Roopa:-

- Paleness of body

- Delusion and tremors

- Fever

- Foamy loose motions

✓ Samprapti of Shokaja and Bhayaja Atisara:-

- Due to continuous fear or shoka vata etc. vitiated Tridoshas are spread in all over the body.

- It vitiates the ushna and rakta of the body and in end produces kshobha. Which results in Bhayaja or shokaja Atisara.

7) Aamaja Atisara:-

✓ Roopa:-

- Indigested food passes in partially digested form in the form of faeces.

- Faecal material is sticky, mucoid and foul smelling.

8) Raktaja atisara:-

✓ Nidana:-

- In Pittatisara, if ushna, tikshna, vidahi etc. Pitta prakopaka ahara-vihara should be adopted then Raktatisara will be produced.

✓ Roopa:- 

- Blood stained loose motions

- Severe thirst

- Severe burning sensation

- Pain in abdomen

- Fever

- Suppuration of anus

👉🏻 Upashaya:-

- Opposite to all Nidana (Causitive factors)

👉🏻 Pathyaapathya:-

✓ Pathya:-

Ahara:-

- Intake of light, easy to digest type of food

- Intake of buttermilk

- Drinking water boiled in earthen pot

- Purana Shashtika shali

- Vilepi, laja manda, masura, mudga, jambu, dadima, bilva, tinduka, jeeraka, dhanyaka, kadali etc.

- Takra, Ajadugdha

Vihara:-

- Langhana

- Nidra

- Vishrama

✓ Apathya:-

Ahara:-

- Intake of hard to digest, hot, acidic food

- Masha, ati jalapana, guru snigdha ahara

- Badara, tambula, madhya, draksha

- Dadhi, Khira, Puri, Samosa, kachori

Vihara:-

- Snana

- Avagahana

- Abhyanga

- Nasya karma

- Vyayama

- Aatapa sevana

- Diwasvapna, Ratrijagarana

- Maithuna karma

- Swedana, dhumapana, vegadharana

- Krodha erc.

- Physical exertion

👉🏻 Upadrava:-

- Edema

- Pain in abdomen

- Fever

- Thirst

- Dyspnoea

- Cough

- Inspid mouth

- Vomiting

- Stupor

- Hiccough

- Delirium

- Severe restlessness

- Incoherent speech

- Abdominal distension

👉🏻 Udarka:-

- Arsha

- Grahani

👉🏻 Sadhyasadhyatva:-

√ Vataja, Pittaja and Kaphaja Atisara:- Sukha sadhya

√ Sannipataja, Shokaja, Bhayaja Atisara:- Kruchrasadhya

√ Ashadha Atisara Lakshana:-

- Colour of faecal material resembles to fruit of Jambu, yakruta khanda, ghrita, taila, vasa, majja, veshvara, dudha, dadhi, in which mamsa is washed.

- Colour of faecal material resembles to copper blue, green, orange, grey, black, red, resembling like black kajal or feather of peacock.

- Faecal material appears as clear like water or turbid and fibrous.

- Faecal material smells like dead body, fish, fermented decaying food.

- Presence of flies on faecal material 

- Faecal material is mostly watery in nature or with very small amount of faeces.

- Incurable when patient suffers from severe dyspnoea, abdominal pain, thirst, burning sensation,hiccough, pain in bones, restlessness etc. 

👉🏻 Chikitsa:-

✓ Samanya Chikitsa sutra:-

• तमसाध्यतामसम्प्राप्तं चिकित्सेद् यथाप्रधानोपक्रमेण हेतूपशयदोषविशेषपरीक्षयाचेति ।।

(Cha.Chi. 19/10)

- 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.

• आमपक्वक्रमं हित्वा नातिसारे किया यतः।

अतः सर्वातिसारेषु ज्ञेयं पञ्चामलक्षणम् ॥

(Chakradatta 3/1)

- In Atisara without knowing the condition of Amavastha and Pamwavastha, chikitsa is not possible.

- So in all types of Atisara, it is necessary to knowing the lakshanas of ama and pakwa mala.

- In Amavastha, for balavana rogi Langhana is the best treatment. Because Langhana alleviates the aggravated dishas and ama pachana both actions.

✓ Vishesha Chikitsa:-

1) Vataja Atisara:-

- Vataja Atisara is of 2 types:-

a. Aamatisara (undigested food passed in stool)

b. Pakwatisara (digested stool)

√ Sama and nirama mala pariksha:-

- In sama mala, it is durgandhita, picchila and apakwa anna yukta and sinking in the water.

- In nirama mala, it will not sink in water and devoid of above features.

a. Aamatisara:-

√ Sangrahi Aushadha nishedha in aamatisara:-

- Do not try to stop diarrhoea when undigested food is being expelled. i.e. Sangrahi or stambhaka aushadha or Kashaya rasa dravya are to ne avoided initially.

- Haritaki can be administered to expelled the doshas.

√ Aamatisara with madhya dosha:-

- Pramathya for deepana-pachana

√ Aamatisara with alpa dosha:-

- Langhana is the best treatment in aamatisara

√ Pramathya used are:-

1. Pippalyadi pramathya

2. Hriveradi pramathya

3. Musta parpataka

4. Vacha, ativisha

b. Pakwatisara:-

- Sangrahi and Stambhana aushadha prayoga

- Khada yusha

- Dhanya yusha

- Dadhisara

- Mamsarasa prayoga (Titira, draksha, vartaka etc.)

√ Purisha kshaya Chikitsa:- 

- Mamsa rasa prayoga i.e. Masha, dadima, Dhanyaka, ghrita, Sunthi

√ Vibandha nashaka yoga:-

- Eranda moola kalka siddha kshira

- Baala bilva kalka siddha kshira

√ In Gudabhramsha:-

- Changeri ghrita

- Chavyadi ghrita

- Sneha basti

- Amla rasa yukta ghrita

- Pichu prayoga after manual replacement of rectum.

√ Formulations for Vatatisara:-

- Panchamula siddha takra

- Putikadi kwatha

- Pathyadi kwatha

- Vachadi kwatha

- Agastisutaraja rasa

- Kanak sundara rasa

2) Pittaja Atisara:-

- Langhana

- Pachana

- Trishna nigrahana with musta, parpataka, ushira, sariva, chandana, kiratatikta, udichya siddha jala prepared by Shadangapaniya vidhi.

- In strong patient, virechana is administered to expel dosha.

- Ativisha, vatsaka, kutaja kalka mixed with madhu and tandulodaka cures Pittaja Atisara.

- Ajadugdha prayoga

- Anuvasana basti in case of shula i.e. Shata pushpadi anuvasana basti

√ Pichha Basti:-

- Green stalks of shalmali is covered with green kusha and coated with black mud.

- This pinda is placed over the cow dung fire

- Aftee the mud is dried up, the stalk of shalmali is removed

- This is triturated in khalwa tantra and then 9 mushti (1 pala) of shalmali is mixed with 1 prastha of shruta Dugdha and filtered.

- Now ghrita, taila and yashtimadhu churna are added to this milk in adequate quantity and this mixture is used for basti after proper snehana.

- After coming out the basti, patient should take bath and eat rice with milk or mamsa rasa.

Indications:-

- Pittaja Atisara

- Kaphaja Atisara

- Grahani

- Jwara

- Atiyoga of niruha basti

√ Formulations for Pittaja Atisara:-

- Shadangapaniya

- Dhanya chatushka kwatha

- Kiratatiktadi kwatha

- Madhukadi churna

- Bilwadi kwatha

- Piyushavalli rasa

- Kamadudha rasa

- Pravala pamchamrita rasa

- Sutashekhara rasa

3) Kaphaja Atisara:-

- Langhana

- Pachana

- Aamatisaraghna deepaniya dravyas

- Eating apakwa bilva phala

- Ajajyadi churna with dhataki and matuunga swarasa

- Rasanjanadi with madhu and nagara

- Kapitthadi churna with trikatu, madhu and sharkara

- Piccha Basti

- Baalabilwadi churna

√ Formulations for Kaphaja Atisara:-

- Chavyadi Kwatha

- Hingwadi churna

- Ajachyadi churna

- Rasanjanadi churna

- Kapitthadi churna

- Lokanath rasa

- Lakshmivilasa rasa

4) Sannipataja Atisara:-

- First of all vata should be controlled then pitta and after pitta the kapha should be controlled.

- However amongst all these whichever dosha is maximum aggravated or strongest should be treated first.

√ Formulations for Sannipataja Atisara:-

- Kutaja Putapaka

- Samangadi Kwatha

- Kutajavaleha

- Ankotavataka

- Chaursama modaka

5) Agantuja (Bhayaja - Shokaja) Atisara:-

• मारुतोभयशोकाभ्यांशीघ्रंहिपरिकुप्यति |

तयोःक्रियावातहरीहर्षणाश्वासनानिच ||

(Cha.Chi. 19/12)

- Vatahara chikitsa

- Harshana

- Aashvasana chikitsa

- Deepana,grahi dravya prayoga

- Abhraka bhasma or Varatika bhasma should be mixed with Sunthi churna and madhu.

6) Raktaja atisara:-

- Ajadugdha mixed with madhu and sharkara in case of Trishna

- Neelakamala, mocharasa, samanga, kamala keshara churna mixed with Ajadugdha and should be given. Along with it before food 20gm butter adding with 6gm madhu and 3gm sharkara should be given.

- Shatavari kalka + Milk

- Krishna tila kalka mixed with 4 times sharkara

- Pichha Basti

- Vatsakadi kwatha

- Guda bilwa

- Mamsa rasa prayoga

- Kutaja kwatha

- Darvyadi ghrita

- Pittaja Atisara chikitsa

√ Formulations for Raktatisara:-

- Raktapitta kulakandana rasa

- Kutaja rasakriya

- Kutajavaleha

👉🏻 Important formulations useful in Atisara:-

1) Rasa / Bhasma / Parpati:-

• Matra:- 125-250 mg

• Anupana:- Takra, madhu

- Jatiphala rasa

- Purna chandrodaya rasa

- Chintamani rasa

- Rasa parpati

- Pamchamrita Parpati

- Ramabana rasa

2) Vati:-

• Matra:- 250-500 mg

• Anupana:- Takra

- Jatiphaladi vati

- Sanjivani vati

- Kutajashtaka vati

- Atisarahara vati

- Chincha bhallataka vati

- Visha tindukadi vati

3) Churna:-

• Matra:- 2-6 gm

• Anupana:- Madhu, guda

- Narayana churna

- Jatiphaladi churna

- Dadimashtaka churna

- Laghugangadhara churna

- Kapitthashtaka churna

4) Asava / Arishta:- 

• Matra:- 20-40 ml

• Anupana:- Samabhaga jala

- Kutajadya arishta

- Ahiphenasava

- Karpurasava

- Jirakadhyarishta

5) Avaleha:-

• Matra:- 10-20 gm

• Anupana:- Madhu, ksheera

- Dadimavaleha

- Kutajadhyavaleha

- Vijayavaleha

- Ativishavaleha

6) Ekala aushadha:-

- Kutaja, Mocharasa, bilwa, ahiphena, karpura, jatiphala, nagarmotha, bhanga, dadima etc.

💫 ACCORDING TO MODERN (DIARRHOEA):-

👉🏻 Introduction:-

Diarrhoea is a condition in which there is:- 

- Unusual frequency of bowel movements (more than 3 times a day)

- Changes in the amount (more than 200g a day)

- Change in consistency (liquid stool)

- It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide.

👉🏻 Definition:-

- Diarrhoea is the condition of having at least three loose or liquid bowel movements each day or as having more stools than is normal for that person.

- It often lasts for a few days and can result in dehydration due to fluid loss.

👉🏻 Types of Diarrhoea:-

1) Acute Diarrhoea:-

- Acute Diarrhoea is defined as an

abnormally frequent discharge

of semisolid or fluid fecal matter from the bowel, lasting

less than 14 days.

- It is caused by an infection of the large intestine, but may be 

associated with infection of gastric mucosa and 

small intestine. 

- The term “acute gastroenteritis” is most frequently used to describe acute diarrhoea.

2) Chronic Diarrhoea:-

- Chronic diarrhoea is termed when the loose motion is occurring for 3 weeks or more.

- It is usually related to underlying organic diseases with or without malabsorption.

- If Diarrhea with watery stools and visible blood in the stools it is called dysentery.

- Persistent diarrhea refers to the episodes of acute 

diarrhea that last for 2 weeks or more and may be due to infective origin.

✓ Other types:-

1. Short duration watery diarrhoea

2. Short duration bloody

diarrhoea

3. Persistent diarrhoea (lasting

more than 2 week – watery/

bloody)

👉🏻 Causes of Diarrhoea:-

• Usually infection:-

- Viral

- Bacterial-

shigella

- Parasitic - Giardia

• Non infectious:-

- lactose intolerance

- IBS

- Coeliac disease

- Ulcerative colitis

• Due to Medications:-

- Ampicilline

- Amoxicilline

- Clindamycin

- Cephalexin

- The main causes of this disease are lack of 

 knowledge of hygiene and sanitation, home 

environment, feeding practices of the parents and under five years of children.

- It can be caused by chronic ethanol ingestion.

- Chronic mild diarrhoea in infants and toddlers may occur with no obvious cause and with no other ill

effects ,this condition is called toddler’s diarrhea.

👉🏻 Epidemiology:-

- About 1/3 of total hospitalized children are due to diarrheal diseases and 17%of all deaths in indoor pediatric patients are related to this condition.

- The

morbidity rate in terms of diarrhea episodes per year per child under the age of 5 years is about 1.7.

👉🏻 Reservoir of infection:-

- Man is the main reservoir of enteric pathogens ,so most transmission originates from human factors. 

- For some enteric pathogens and viral agents 

animals are important reservoir.

👉🏻 Mode of transmission:-

- It is mainly feco-oral route.

- It is water- borne,food-

borne disease or may transmit via fingers,fomites,flies or dirt.

👉🏻 Clinical features:-

- Stools are usually loose watery in consistency.

- It may be greenish or yellowish-green in color with offensive smell.

- It may contain mucus, pus or blood and may expelled with force,preceded by abdominal pain.

- Frequency of stools varies from 2 to 20 per day or more.

- The child may have low grade fever ,thirst, anorexia.

- Behavioral changes like irritability, restlessness, weakness, lethargy, sleepyness, delirium, stupor and flaccidity are usually presengors.

- Physical changes like loss of weight, poor skin turgor, dry mucus membranes,drylips, pallor, sunken eyes,depressed fontanelles are also found.

- Vital signs are changed as low blood 

pressure, tachycardia, rapid respiration, cold limbs and collapse.

- Decreased or absent urinary output.

- Convulsions and loss of consiousness may also present in some children with diarrheal diseases.

👉🏻 Diagnosis:-

- History taking and physical assessment.

- Stool examination can be done for routine and microscopic study and identification of causative organisms. 

- Blood examination can be performed to detect electrolyte imbalance, acid- base 

disturbances, hematocrit value, TC,DC,ESR etc.

- The suspected associated cause should be ruled out for adequate management.

- Fever, severe abdomen, tenderness – Colitis

- Vomiting+ Diarrhoea – Toxin

- Fever + headache – Infection

- Diarrhoea with blood – E. histolytica

👉🏻 Prognosis:-

- Mortality is higher in neonate and infants than the older children.

- Malnourished children are having poor prognosis and greater mortality.

- Antibiotic resistant type E.Coli and shigella cause very severe illness and poor prognosis.

- Presence of severe dehydration ,electrolyte 

imbalance and pneumonia have poor prognosis

👉🏻 Complications:-

- Dehydration

- Hypovolemic shock

- Renal failure

- Paralytic ileus

- Thromboembolism

- CCF

- Convulsions

- Overdehydration

- Hypoglycemia

- Consumptive coagulapathy

- Toxic megacolon

- Malnutrition 

- Growth retardation

- Mental subnormalities

👉🏻 Dietery management:-

- Diet to be planned to prevent malnutrition and allow normal nutritional requirement.

- Food items may include energy rich food with rice,potatoes,wheat,pulses,vegetables, oil, curd, fish, high fiber content foods and soft drinks should be avoided.

- Breast feeding to be continued during diarrheal episodes even along with ORS.

- Cereal mixture like rice- milk, dalia- sagu, or khichri can be given to the infants more than 6 months of age.

- If the infant is non breast fed,cow’s or buffalo’s milk should not be diluted with water.

- Feeding to be given in small quantity frequently every 2 to 3 hours.

👉🏻 Prevention:-

1) Improvement of food hygiene and environmental hygiene:-

- Safe water,adequate sewage disposal, hand washing practices,clean utensils, avoidance of exposures of food to dust and dirt, fly control, washing of fruits and vegetables etc.

2) Avoidance of bottle feeding is most significant practice needed for prevention of diarrhoea.

3) Boiling or filtering to be practiced for safe drinking water.

4) Prevention of LBW and prematurity,exclusive breast feeding, appropriate weaning practices, balanced

diet, immunization are significant aspects of child care.

👉🏻 Treatment:-

- IV – severe dehydration

- Antibiotic – Bloody diarrhoea, high

fever

- Loperamide -Loperamide usually

starts to work within 1 hour

- Lowing intestinal motility and by

affecting water and electrolyte movement through the bowel.

- Bismuth subsalicylate -

slowing down the movement

of the gut.

- Most of cases self limiting and

requires fluid therapy only.

✓ Fluid:-

- Standard home solutions such

as salted rice water, salted

yogurt

- Oral rehydration solution (ORS)

(a slightly sweetened and salty

water) can be used to prevent

dehydration.

- The appropriate amount of ORS solution to be given in the first 4 hours are as follows:-

1. Age less than 4 months or weight less than 5 kg-

200 to 400ml.

2.Age 4 to 11months or weight 5 to 7.9 kg – 400 to 600ml.

3. Age 12 to 23 months or weight 8 to 10.9 kg – 600 to 800ml.

4. Age 2 to 4 years or weight 11 to 15.9 kg – 800 to 1200ml.

5. Age 5 to 14 years or weight 16 to 29.9 kg – 1200 to 

2200 ml.

6. Age 15years or older or weight 30kg or more to 2200 to 4000ml

✓ Rice water:-

- Rice water has a

binding effect in the digestive

tract, resulting in firmer, bulkier

stools.

- Yogurt Probiotics are made up of

good bacteria

- This good bacteria helps in

many ways, including fighting off

bad bacteria

✓ Antimotility drug – Opiates (morphine , codeine)

✓ Bismuth subsalicylate –

Stimulation of absorption of

fluids and electrolytes by the

intestinal wall

✓ Antispasmodic – dicyclomine

and hyoscine – Anticholinergic drug

with high affinity for muscarinic

receptors located on the smooth

muscle cells of the GI tract.

✓ Anticholinergic action smooth

muscle relaxing

✓ In case of Bloody diarrhoea, high fever:-

Antibiotic:-

- Norfloxacin – 400 mg/BD

- Ciprofloxacin – 500mg/BD

- Levofloxacin – 500mg/OD

🔘 Janu Basti

 

JANU BASTI:-

👉🏻 Introduction:-

 

- The word Janu basti has 2 terms:-

• Janu:- means knee joint

• Basti:- means to retain or hold (compartment which holds). 

- So Janu basti means hold or retain something like lukewarm oil on knee region.

- Janu Basti reduces shoola (pain), stabdhata (stiffness) and discomfort of the knee. 

- Knee joint is one of the most important joints in the human body. Degeneration, inflammation, and injury of knee results for knee pain and other conditions and Janu Basti can useful in these conditions.

- In simple words, Janu Basti is a pain relieving oil-pooling treatment conducted for knee joint pain caused due to many causes.

👉🏻 Reference:-

- Keraliya Panchkarma chikitsa vijnana by T. L. Devraj.

👉🏻 Defination:-

- The procedure in which, retaining of warm medicated oil is retained within a specially formed frame over the knee region is known as 'Janu basti'.

👉🏻 Indications:-

• Osteosrthriris:-

- It is the most common form of arthritis in the knee joint. It is a degenerative wear and tear type of arthritis.

• Rheumatoid arthritis

• Patello-femoral pain syndrome (Chondromalacia patellae):-

- Pain is present between the patella and the underlying thighbone (femur).

• Knee injuries:-

- ACL (Anterior cruciate ligament injury)

- Torn meniscus

- Patellar tendonitis

• Osgood-Schlatter Disease

• Iliotibial band syndrome

👉🏻 Contraindications:-

- Acute inflammatory conditions of knee

👉🏻 Materials:-

- Black gram flour:- 400gm

- Medicated oil:- 300ml

- Vessel:- 1

- Bowl:- 1

- Spoon:- 1

👉🏻 Commonly used medicated oil:-

- Ksheerabala taila

- Mahanarayana taila

- Mahamasha taila

- Pinda taila

- Ashwagandhabalakshadi taila

- Sahacharadi taila

- Tila taila

- Dhanwantara taila

- Vishagarbha taila 

- Kottamchukkadi taila

- Murivenna taila

- Guggulutiktaka ghrita

- Nirgundi taila etc.

👉🏻 Preparation of Basti:-

- Add sufficient quantity of water and prepare a dough from black gram flour.

- Prepare a round pit of about 10-15 cm, thickness of 3 cm and height of 5 cm.

👉🏻 Preparation of Patient:-

- Janu basti can be carried out in four different locations of knee joint.

- Supine position of client with knee extended is ideal for treating anterior part of knee joint.

- Popliteal area in prone, medial and lateral part of knee in lateral positions.

- For comfort a pillow can be supported below knee and Prepared dough is fixed to the area in circular shape, steel or plastic rings can be used. - Ensure proper sealing and to avoid leakage of oil.

👉🏻 Procedure:-

- The prescribed medicated oil should be made warm by keeping the vessel on a hot water bath.

- After ensuring the tolerable temperature, oil should be poured inside along the sides of dough. 

- The temperature of the oil should be maintained at 40°C- 48°C by replacing a small quantity after reheating on hot water bath.

👉🏻 Precautions:-

- Uniform temperature is maintained throughout the procedure.

- Be cautious about temperature of oil to avoid accidental burns.

- Ensure proper sealing to avoid leaking of oil.

👉🏻 Duration:- 

- 30 min, usually done for a period of 7 days.

- As per medical condition of patients along with other important therapies like Yoga basti, Patra pottali sweda and Tiktaksheera Basti.

👉🏻 Post Operative Procedure:-

- After removing the dough, the part is massaged with circular and linear strokes.

- The part is given fomentation with a towel dipped in hot water.

👉🏻 Benefits of Janu basti:- 

- Janu Basti is an effective therapy for people experiencing different conditions in the knee. 

• The medicated oil used in the therapy effectively alleviates the pain, stiffness, and inflammation in the joints.

- Additionally, toxins are eliminated and joints are strengthened. 

• When Janu Vasti is combined with effective treatments like Abhyanga (massage with herbal oils), Patra Pinda Sweda (leaf bolus fomentation) and Basti (medicated enemas), with disease modifying drugs and compounds, it provides a very good relief in many painful knee conditions like Osteoarthritis etc.

• Reduce pain:-

- The warm oil poured over the Janu sandhi helps to feel person relax and effectively alleviates joint pain.

• Dissipate stiffness:-

- Janu Basti increases the flow of oxygen and nutrient-rich blood, so it also helps in stiffness.

• Increases circulation

- It Increases blood circulation around the knee; thus strengthening and nourishing the joints by increased circulation.

• Improves mobility and flexibility:-

- Janu Basti is known to improve mobility of the knee joints (knee flexion and knee extension).

• Reduces inflammation:-

- The medicated oils possess anti-inflammatory properties that can help with inflammation and pain.

• Strengthens knee joints:-

- Janu Basti boosts blood flow strengthening the muscles, bones and joints of the knee.

• Pacifies aggravated vata dosha in the knee region.

• It Lessen pain in Knee joint restoring the lubricating fluid in the joint and maintain integrity of the structures involved in the joint

👉🏻 Mode of action:-

- Almost all pains are caused due to aggravation of Vayu (mainly degenerative types of pain). This further leads to depletion and degeneration of tissues.

- Avarana of Vayu by one or the other element of the body including Pitta, Kapha, Dhatus etc.

- Ama, which hamper the smooth functioning of Doshas and Dhatus and block the excretion of body wastes by blocking them.

- Excessive Pitta can cause inflammatory type of pain in the knee joints.

- Excessive Kapha can cause stiffness and loss of movements in the knee joints

- Udavartana and or Churna Pinda Sweda done before Janu Vasti would dry up ama and kapha, liquidity of sama pitta and relieve stiffness and loss of movements. 

- Janu Basti nourishes the knee joints, pacifies the dosha causing pain or discomfort, soothes the nerves, relieves degeneration, stiffness and inflammation and cures pain. 

- Patra Pinda Sweda further rejuvenates the knee by controlling Vayu. 

- Shashtika shali pinda sweda strengthens and nourishes the knee and lower limbs.

- Virechana detoxifies the system and relieves inflammation and Vasti drives the morbid Vayu out of the system and fortifies the cure.

- Basti and Virechana also help in removing the avarana of Vayu and also in preventing the recurrence of knee pain. 

- Basti and Virechana together helps in preventing degeneration and inflammation, nourishes and rejuvenates the bones and soft tissues around the knee, enhances immunity and prevents its recurrence.

👉🏻 Complications and management:-

• Accidental burns:-

- Stop the procedure and perform agnidagdha chikitsa.

👉🏻 Conclusion:-

- Janu Basti is the best treatment which Ayurveda provides to heal your acute and chronic knee pains. 

- All you need to do is to meet an experienced Ayurvedic doctor and put forth your problems

- The doctor will help you to get your sore knee into its rhythm.

- The beauty of Janu Vasti is that it can even be administered on healthy individuals and health freaks. 

- Thus Janu Basti forms an important part of prophylactic knee care, a part of ‘prevention is better than cure’ mantra.

🔘 Shastika Shali Pinda Sweda

SHASHTIKA SHALI PINDA SWEDA:-

👉🏻 Introduction:-

- The term Shashtika Shali Pinda Sweda is made up of 4 words:-

• Shashtika means sixty

• Shali means rice

• Pinda means bolus

• Sweda is sweat

- Shashtika Shali pinda sveda is performed as Ekanga or Sarvanga with the bolus of boiled Shashtika shali with Balamoola kwatha and

Ksheera. 

- The main properties of Shashtika are Snigdha, Guru, Sthira, Sheeta and Tridoshaghna.

- Though a svedakarma, it has a Brimhana guna

- It is a treatment in which a special type of rice called Shashtika Shali (which is harvested in 60 days and is exclusively used for treatment purposes in Ayurveda) prepared in milk processed with herbal decoction is tied in boluses and used for rubbing on the body parts, which are intended to receive nutrition and strength. 

- The treatment is also used in painful and degenerative conditions like Osteoarthritis, Myalgia, GB Syndrome, Fibromyalgia, various types of Neuro-muscular and Musculoskeletal diseases.

👉🏻 Definition:-

- Shastika Shali Pinda Sweda  is a unique Ayurveda therapy using a special variety of Indian rice in a bolus, dipped in a nourishing herbal milk decoction and massaged onto the body.

👉🏻 Reference:- Keraliya Panchkarma

👉🏻 Synonyms:-

- Navara Kizhi

- Shashtika Sweda

- Shahstika Pinda Sweda

- Njavara Kizhi

👉🏻 Indications:-

- Emaciation

- Weakness of nerves and muscles

- Bone and joint disorders

- Sandhigata vata (Osteoporosis)

- Amavata (Rheumatic arthritis)

- Gridhrasi (Sciatica)

- Muscular dystrophy

- Guillain Barre Syndrome

- Muscle weakness, stiffness, wasting disorders, recurrent muscles spasm, myalgia

- Parkinson’s Disease,

- Paralysis, paresis, numbness, paresthesia, hemi/paraplegia, tremors

- Spondylosis, spondylolisthesis, prolapse of intervertebral disc

- Delayed walking milestones in children

- General debility, old age

- Chronic back ache, chronic neck or knee pain, frozen joints

- Post fracture or post trauma tissue healing

👉🏻 Contraindications:-

- Diabetes mellitus 

- High blood pressure (Hypertension)

- Severe varicosity of veins

- Deep vein thrombosis

- Fractures

- Fever

- Severe inflammation

👉🏻 Materials required:-

1. Shashtika shali:- 250gm

2. Balamoola:- 250gm

3. Water:- 4 L

4. Cow's milk:- 1 L

5. Kora cloth (45cm × 45cm):- 4 pieces

6. Threads (75cm):- 4

7. Vessels:-

- (a) For preparing Kwatha

- (b) For cooking rice

- (c) To heat the boluses in mixture of Kwatha and milk during the procedure (5 litres capacity with wide mouth made of bronze)

8. Oil for talam:- 10ml

9. Rasnadi choorna:- 5gm

10. Suitable oil for abhyanga:- 100ml

11. Masseurs:- 2

• For Abhyanga:- Taila or Ghee

• For shirobhyanga:- 

- Ksheerabala Taila

- Chandanabala Lakshadi Tailam

- Shatavari Tailam

-  Lakshadi Tailam etc.

• For Sarvanga Abhyanga:-

- Sahacharadi Taila

- Ksheerabala Taila

- Chandanabala Lakshadi Tailam

- Dhanwantara Tailam

- Mahanarayana Tailam

- Balashwagandhadi Tailam

- Karpasastyadi Tailam

- Panchaguna Tailam

👉🏻 Preparation of the Medicine:-

• Balamoola Kwatha:-

- 250gm of Balamoola is cleaned, crushed and

boiled in 4 litres of water and reduced to 1 litre.(1:16 parts and reduced to 1/4th)

• Shashtika Rice Cooking:-

- In 0.5 litres of Balamoola kashaya and 0.5 litres of milk, 250 g of Shashtika rice should be added and boiled till it becomes thick and semisolid.

- Sufficient quantity of hot water can be used for proper cooking of the rice.

- Another method is that the Shashtika rice can be semi cooked in cooker also.

👉🏻 Preparation of the Boluses:-

- The cooked rice should be divided into 4 equal parts and put into 4 pieces of Kora cloths.

- Three corners should be folded together so that

they come under the fourth corner and the fourth fold is used to cover the other three corner folds underneath. 

- One end of the thread is held tight with left hand and the other end is wound around the folds.

- In short, the boluses should be tied in such a way that the mouth of the sac leaves a tuft at the top of the bundle, for holding it with ease.

👉🏻 Pre-operative procedure:-

- The patient should be seated with leg extended over the droni and talam should be applied with suitable oil. 

- Abhyanga should be then performed with prescribed oil for about 20 minutes.

- Out of 4 Pottalies, 2 are kept in the mixture of Balamoola kwatha and milk (0.5 litres of each was already kept for this purpose), which should be put on a stove with moderate heat.

👉🏻 Different postures of Shastika Shali Pinda Sweda:-

1. Sitting posture

2. Sleeping by facing the roof (supine position)

3. Sleeping in left lateral position (towards left)

4. Sleeping on tummy (prone position or face downwards)

5. Sleeping in right lateral position (towards right)

6. Sleeping back by facing the roof

7. Sitting posture

👉🏻 Procedure:-

- Two warm Pottalies should be gently applied in a synchronised manner by the two therapists on two sides of droni. 

- It is followed by a gentle massage with other hand. 

- They should ensure that the heat of the boluses is bearable to the patient by touching them over the dorsum of their hand. 

- The temperature of the boluses should be maintained throughout the procedure by continuous relay of the four boluses after

reheating by dipping in ksheera-paka.

- The process should be continued till the patient gets samyak swinna lakshana or until the contents of the boluses exhausted.

👉🏻 Duration:-

- 45 minutes or the procedure can be stopped if the medicine in the boluses or the ksheera-paka is exhausted.

👉🏻 Post-operative procedure:-

-At the end of the procedure, the medicine remained over the body should be scraped off and the body is wiped dry with tissue paper or soft towels. 

- After that medicated oil should be applied.  - Talam should be removed and Rasnadi choorna applied over the head.

- Gandharvahastadi kashaya can be given for drinking.

- The patient should take complete rest for at least half an hour, and then the patient is allowed to take warm water bath.

👉🏻 Signs of good Navarkizhi process (Samyaka sweda lakshana):- 

• शीत शूल व्यूपरमे स्तंभ गौरव निग्रहे।

संजाते मार्दवे च एव स्वेदनात् विरतिर्मता॥

(सु.चि.१४/१३)

- Sheetoparama – The feeling of coldness pacifies

- Shuloparama – Pacification of pain

- Stambha nigraha – reduction of stiffness

- Gaurava nigraha – reduction of the feeling of heaviness

- Maardava – smoothness of the body or body parts

- Sweda praadurbhaava – sweating of body or body parts subjected to fomentation

- Roga lakshana prashamanam – Pacification or reduction of the symptoms of the disease

- Sheetaartitvam – Liking towards taking cold foods and comforts

👉🏻 Precautions:-

1. During the preparation of the rice, care should be taken to avoid over/under cooking and should be stirred frequently for the better extraction and cooking.

2. Tie bolus firmly to avoid leaking of contents during rubbing.

3. The therapists in both the sides of the patient should massage with the bolus in a synchronised manner.

4. Ensure uniformity of pressure and temperature on all the body parts.

5. Boluses should be applied with sufficient warmth (40°C-45°C).

6. Therapy should be stopped at any time if the patient gets good perspiration or shivering.

👉🏻 Combination therapies:-

- It may be combined with Abhyanga, Pizhichil, Upanaha or Basti depending upon the disease condition.

👉🏻 Benefits of Shashtika shali pinda sweda:-

• सर्वांगगाः बलयुताश्च समीररोग।

रक्तप्रकोप जनिताश्च तथा अति कृच्छ्राः।

ये सति देहबलनाशकरा नराणां।

नश्यत्यनेन विधिना सहसाखिलास्ते।। 

(Keraliya Panchakarma)

- Shastika shali pinda sweda is very useful in Sarvanga aashrita balayuta vatarogas.

- It is also beneficial in diseases due to Rakta prakopa and in diseases which decreases the bala of the shareera.

- As a Swedana (sweat inducing) heat therapy, it creates a sense of lightness and improved energy.

- This therapy tones up and nourishes the body tissues and helps in detoxification and rejuvenation.

- It enhances flexibility and movement of joints.

It prevents degeneration of body tissues by improving the tone, compactness, stability, strength and function of muscles, ligaments, nerves, bones and joints.

- It stimulates blood circulation and releases toxin build-up in the pores of the skin, thus improving complexion.

- Regular therapy can greatly benefit in debilitating and emaciating conditions especially of the loco-motor and nervous systems.

- It is useful for older people to improve and maintain their health.

👉🏻 Complications and Management:-

1. Shivering:-

- It usually occurs due to the uneven distribution of temperature or prolonged time gap in between the taking up of new boluses; if body is exposed to cold breeze immediately after the procedure. 

- Allow the patient to take rest, cover with a blanket and give warm liquid diet.

2. Fainting:-

- Due to increased body temperature or low heat

threshold of the patient or atiyoga of kriyakrama. - Sprinkle cold water over the face and body, and put talam with appropriate medicated oil and choorna. 

- Drakshadi kashaya can be given internally.

3. Rashes:-

- Due to heat intolerance of the patient of pitta prakriti.

- Apply madhu & ghrita, preferably Shatadhouta Ghrita or Murivenna.

👉🏻 Advised:-

- As with all Ayurvedic treatments, the Navara Kizhi must be performed by a trained Ayurvedic therapist under the supervision of an Ayurvedic doctor.

👉🏻 Conclusion:-

- Shashtika Shali Pinda Sweda is the best treatment which Ayurveda provides for enhancing strength, immunity and nutrition to the tissues, to prevent degeneration and inflammation, to tackle pain, swelling and catches related to Arthritis, Neuromuscular and Musculoskeletal disorders.

🔘 Forceps Delivery

Forceps delivery:

👉🏻 Definition:

• Obstetric forceps is a pair of instruments specially designed to assist extraction of the foetal head and thereby accomplishing delivery of the foetus.

👉🏻 Introduction of Forceps:

• Only three varieties are commonly used in present day obstetric practice.

• These are:-

1. Long-curved forceps with or without axis traction device

2. Short-curved forceps

3. Kielland’s forceps

• The basic construction of these forceps is the same in that each consists of two halves (blades) articulated by a lock.

• In India, Das’s variety is commonly used with advantages.

👉🏻 Parts: 

i) Blades - There are two blades and are named right or left in to relation to maternal pelvis in which they lie when applied.

ii) Shank

iii) Lock

iv) Handle with or without screw

👉🏻 Types of forceps:

1. Long curved Obstetric Forceps:

• Measurements - Length is 37 cm, distance in between the tips is 2.5 cm and widest diameter between the blades is 9cm.

i) Blade:

• The blade is fenestrated to facilitate a good grip of the foetal head. - There is usually a slot in the lower part of the fenestrum of the blades to allow the upper end of the axis traction rod to be fitted.

• The toe of the blade refers to the tip and the heel to the end of the blade that is attached to the shank.

• The blade has got two curves:

a. Pelvic curve:

• The curve on the edge is to fit more or less the curve on the axis of the birth canal (curve of Carus).

• The front of the forceps is the concave side of the pelvic curve. Pelvic curve permits ease of application along the maternal pelvic axis.

b. Cephalic curve:

• It is the curve on the flat surface which when articulated grasps the foetal head without compression.

ii) Shank:

• It is the part between the blade and the lock and usually measures 6.25 cm.

• It increases the length of the instrument and thereby, facilitates locking of the blades outside the vulva.

iii) Lock:

• The common method of articulation consists of a socket system located on the shank at its junction with the handle (English lock). 

• Such type of lock requires introduction of the left blade first.

iv) Handle:

• The handles are apposed when the blades are articulated. It measures 12.5 cm.

• There is a finger guard on which a finger can be placed during traction. A screw may be attached usually at the end (or at the base) of one blade (commonly left). 

• It helps to keep the blades in position

2. Short curved obstetric forceps:

• The instrument is lighter, about a third of the weight of a long curved forceps.

• It is short which is due to reduction in length of the shank and handles.

• It has a marked cephalic curve with a slight pelvic curve.

3. Kielland’s Forceps:

• It is a long almost straight (very slight pelvic curve) obstetric forceps without any axis traction device.

• It has got a sliding lock which facilitates correction of the head. 

• One small knob on each blade is directed towards the occiput.

👉🏻 Classification of forceps operation:

1. Outlet Forceps:

• Scalp is visible at the introitus without separating the labia

• Foetal skull has reached the level of the pelvic floor

• Sagittal suture is in direct anteroposterior diameter or in the right or left occiput anterior or posterior position.

• Foetal head is at or on the perineum. (Wrigley forceps)

2. Low forceps:

• Leading point of the foetal skull (station) is at +2 cm or more but has not yet reached the pelvic floor.

3. Mid forceps:

• Foetal head is engaged

• Leading point of the foetal skull (station) is above +2 cm (Kielland's forceps)

👉🏻 Classification of forceps operation:

1. Outlet Forceps:

• Scalp is visible at the introitus without separating the labia

• Foetal skull has reached the level of the pelvic floor

• Sagittal suture is in direct anteroposterior diameter or in the right or left occiput anterior or posterior position.

• Foetal head is at or on the perineum. (Wrigley forceps)

2. Low forceps:

• Leading point of the foetal skull (station) is at +2 cm or more but has not yet reached the pelvic floor.

3. Mid forceps:

• Foetal head is engaged

• Leading point of the foetal skull (station) is above +2 cm (Kielland's forceps).

👉🏻 Indications:

• Delay in the 2nd stage.

a. Maternal:

• Maternal distress

• Pre-eclampsia

• eclampsia

• Heart disease 

• Post caesarean pregnancy

• Failure to bear down

b. Foetal:

• After coming head of breech.

• Prolonged second stage of labour

👉🏻 Prerequisites for vaginal operative delivery:

• The cervix must be fully dilated and effaced.

• Membranes must be ruptured.

• The head must be engaged with no parts of head palpable abdominally.

• Head position is exactly known

• No appreciable CPD

• The bladder must be empty

• Presence of good uterine contractions as a safeguard to postpartum haemorrhage

• Adequate maternal analgesia

• Informed consent with prior clear explanation

1) Low forceps operation:

• The women’s vulval area is thoroughly cleaned and draped with sterile towels using aseptic technique. 

• The bladder is emptied using a straight catheter.

• A vaginal examination is performed by the obstetrician to confirm the station and exact position of the foetal head

• A pudendal block, supplemented by perineal and labial infiltration with 1 % lignocaine hydrochloride, is given to produce effective local anaesthesia.

• An episiotomy may be done prior to introduction of the blades or during traction when the perineum becomes bulged and thinned out by the advanced head.

• The forceps are identified as left or right by assembling them briefly before proceeding.

Step 1- Identification and application of the blade:

• The left blade is passed gently between the perineum and foetal head with the four fingers of right hand of the operator’s hand lying alongside the foetal head protecting the maternal tissue. 

• The handle of the left blade is taken lightly by three fingers of left hand.

• The blade is introduced between the guiding internal fingers and foetal head, manipulated by the thumb.

• When correctly applied, the blade should be over the parietal eminence, the shank should be in contact with perineum and superior surface of the handle should be directed upwards.

• The procedure is repeated with the right blade until it sits on the right of the pelvis.

Step 2 - Locking of the blade:

• It should then be easy to lock the two blades and there should be little or no gap between the handles.

• A significant gap suggests that the forceps are wrongly positioned and they should be reapplied after carefully checking the position of head.

• Correct application is evidenced by:

a. Easy locking

b. The blades are equidistant from the lamboid suture

c. Firm gripping of the head on the biparital diameter.

Step 3-4 - Traction and removal of blades:

• Principle: Steady but intermitted traction should be given if possible during contraction.

• In outlet forceps the pull may be continuous.

• Gripping the articulated forceps during traction: the traction is given by gripping the handle, placing the middle finger in between the shanks with ring and right fingers on either side on the fingers guard.

• During the final stage of traction, the four fingers are placed in between shank and thumb which is placed on the under surface of the handles and exerts the necessary force.

• Direction of the pull: corresponds to the axis of the birth canal.

• Downward n backward - until the head comes to the perineum. 

• Horizontally straight toward the operator till the head almost crowned - Upward and forward, toward the mother’s abdomen to deliver the head by extension.

• Blades are removed one after another, right one first.

• Following the birth of the head, usual procedure are to be taken as normal delivery.

• IV methergin 0.2 mg is administered with the delivery of the anterior shoulder.

• Episiotomy is repaired.

2) Outlet forceps operation:

• Wringley’s (short curved) forceps are used exclusively in outlet forceps operation.

• Local anaesthesia with1% lignocaine.

• The blades are introduced as in the low forceps operation with long curved forceps except that two fingers are to be introduced into the vagina for application of the left blade.

• Traction is given indirection of the pull is straight horizontal and then upward and forwards.

3) Mid forceps operation:

• The commonest indication of mid forceps operation is following manual rotation of the head in mal rotated occipito-posterior position.

• Commonly used – long curved forceps

• Kielland’s forceps is useful.

Procedure:

• General anaesthesia is preferable.

• Prior correction of the malrotation then introduction of the blades.

A) Without axis – traction device:

• Blades introduce as low forceps. An assistant is required to hold the left handle after its introduction.

• Traction- Downward n backward- Horizontally straight - Upward and forward.

B) With axis – traction device:

• During introduction of the right blade, the traction rod must be held forward otherwise it will prevent locking of the blades. 

• Traction during raction, the traction rods should remain parallel with the shanks. When the base of the occiput comes under the symphysis pubis, the traction rods are to be removed.

👉🏻 Complication of forceps operation:

1. In the mother:

a. Immediate:

• Injury

• Extension of the episiotomy towards rectum or upwards up to the vault of vagina

• Vaginal lacerations

• Cervical tear especially when applied through an incompletely dilated cervix.

• Bruising and trauma to the urethra

• Postpartum haemorrhage due to trauma, or atonic uterus related to prolonged labour or effects of anaesthesia.

• Shock due to blood loss, prolonged labour and dehydration.

• Sepsis due to devitalisation of local tissues and improper asepsis.

b. Late:

• Chronic low backache due to tension imposed on softened ligaments of lumbosacral or sacroiliac joints during lithotomy position.

• Genital prolapse or stress incontinence.

2. In the infant:

a. Immediate:

• Asphyxia due to intracranial stress out of prolonged compression.

• Intracranial haemorrhage due to misapplication of the blades.

• Cephalhaematoma

• Facial palsy due to damage to facial nerve.

• Abrasions on the soft tissues of the face and forehead by the forceps blade

• Skull fractures, cervical spine injury.

b. Remote:

• Cerebral or spastic palsy

🔘 Plague (Granthika Jwara)

PLAGUE (GRANTHIKA JWARA):

💫 ACCORDING TO MODERN (PLAGUE):-

👉🏻 Introduction:-

- Plague is an infectious disease known as 'black death' caused by 'Yersinia pestis', a gram negative non motile bacillus.

- Enzootic inflammation- rats and other rodents.

- Salvatic rat - through other rat species- Human.

👉🏻 Spread:-

1. Direct contact:-

- Tissue and fluid

- Physical

- Sexual

- Bite

- Droplets

- Laboratory Plague

2. Indirect contact:-

- Soil contaminated surface

- Faecal-oral contaminated food and water

👉🏻 Incubation period:-

- Bubonic Plague:- 2-7 days (can be longer)

- Pneumonic Plague:- less than 1 day upto 4 days following inhalation exposure to yersinia pestis.

👉🏻 Types and Clinical features:-

1) Bubonic Plague:- 

It usually occurs from bite.

Swollen gland is called 'bubo' hence named as bubonic plague.

- High fever with chills

- Vomiting

- Swollen and painful lymph nodes

- Confusion

- Anxiety

- Oligouria

- Most common type of plague

2) Septicaemic Plague:-

- It occurs when bacteria enters in blood stream.

- Septicaemic Plague is complication of untreated bubonic and Pneumonic Plague with

• High fever

• Chills

• Malaise

• Gangrene of acral (extremities of peripheral body parts) regions; top of nose, toes, finger due to small artery thrombosis.

• Abdominal pain

• Shock

3) Pneumonic Plague:-

- Only Plague which can transmitted from person to person.

- Occurs by primary respiratory infection.

- Complication of Septicaemic and bubonic Plague.

- It shows:

• Sneezing

• Headache

• High fever

• Vomiting

• Abdominal pain

• Diarrhoea

• Cough

• Chest pain

• Haemoptysis (blood with cough)

• Respiratory failure quickly with septic shock and mortality is high.

• Difficulty in breathing

• Without antibiotics disease is fatal in 2 to 3 days.

👉🏻 Risk factors:-

- Risk factors for plague include being bitten by fleas as well as exposure to rodents.

- Scratches or bites from infected domestic cats are also a risk factor.

- Contact with individuals with pneumonic plague is also a risk factor for acquiring the infection.

👉🏻 Diagnosis:-

1. Bubonic Plague:-

- Bubo fluid must be taken by using needle from swollen lymph nodes.

2. Pneumonic Plague:-

- Throat swab and sputum is taken from Airways by tube inserting down in nose also called as 'bronchoscopy'.

3. Septicaemic Plague:-

- Blood test (CBC, ESR)

- Thrombocytopenia in 50% cases

- Blood smear

- Leucocyte count > 20,000 mm³

👉🏻 Prognosis:-

- Plague is a very serious disease, often life-threatening disease. 

- About 50% of people with bubonic plague die if their illness is not treated. 

- Pneumonic plague is typically always fatal if untreated. 

- With treatment, about half of people with pneumonic plague will survive.

- The earlier that antibiotic treatment is given, the better the chance for recovery.

👉🏻 Management :-

1) Antibiotics:-

- Fatalitity rate decreases

- 5% in bubonic Plague

- 10% in Septicaemic and Pneumonic Plague.

• Streptomycin is drug of choice

• Gentamicin

• Ciprofloxacin

• Levofloxacin

• Doxycycline for 10 days

2) Isolation:-

- Pneumonic Plague must be isolated from others.

3) Prevention:-

- To prevent human to human transmission (in Pneumonic Plague):- 4 days isolation

- Active surveillance

- Environmental sanitation.

💫 ACCORDING TO AYURVEDA (GRANTHIKA JWARA):

👉🏻 Introduction:-

- The Jwara which produces shotha (swelling) in lasika granthi (lymph nodes) of Greeva (neck), Kaksha and vankshana; and produced due to teevra peeda yukta damsha (bite with excessive pain) is known as 'Granthika Jwara'.

- In modern it is correlated with Plague.

- This disease spreads very quickly and fatal.

- It is entered in human body by bite of rats or other rodents, in which Yersinia pestis bacteria enters and produces this fever.

👉🏻 Nidana:-

• भूम्नारोगातखुभी रोगयुक्तस्थाने श्वासोच्छ्वासतः स्पर्शतोऽपि।

दण्डाकारास्तस्य कीटाणवो वै मूलं प्रोक्तं मूषकोत्था भिषग्भिः॥

- The main reason of Granthika jwara is Yersinia pestis bacteriaz which is present in rats.

👉🏻 Samprapti:-

• यदा मूषकस्थायिकीटः कथंच्चिन्नरं संदशत्यत्र दशात्तदानीम्।

विनिःसृत्य कीटाणवस्तल्लसीकावहासु प्रकुर्वन्ति संचारमेव॥

यदा ते ततो यान्ति तद्ग्रंथिमध्ये तदा क्षोभमायान्ति तद्ग्रंथयोऽपि।

(मा.नि.परि.)

- After bite of rats or other rodents the rogotpadaka jeevanu (bacteria) enters in Lasika and spreads in lasika.

- It reaches to the lasika of greeva, kaksha and vanskhana and produces swelling in lasika.

- It results in enlargement of lasika.

- Teevra jwara is produced due to effect of jivanu janya visha (bacterial toxins).

👉🏻 Samprapti ghataka:-

- Dosha:- Tridosha

- Dushya:- Rasa, Rakta, Lasika

- Srotasa:- Rasavaha, Raktavaha

- Srotodushti:- Sanga

- Adhisthana:- Lasika granthi

- Swabhava:- Ashukari

- Sadhyasadhyatva:- Yapya/Asadhya

👉🏻 Types:-

• तभेदास्तु ग्रंथिक: कीटरक्त: संदृश्यन्ते फुफ्फुसस्य प्रदाही।(मा.नि.परि.)

- According to madhava nidana it is of 3 types:-

1. Granthika (Bubonic)

2. Keeta raktaja (Septicaemic)

3. Phuphphusa pradahi (Pneumonic)

👉🏻 Purvaroopa:-

- Along with samanya lakshana of Jwara, the following purvaroopa will produced in Granthika jwara:-

• व्यथाशीष्णि शैथिल्यमङ्गेषु सादोमनोदैन्यमुत्क्लेशभक्तारुची च।

ज्वरोक्तं च सामान्यं पूर्वरूपं भवेद् ग्रंथिकाख्ये ज्वरोग्दोग्ररुपम्॥ (मा.नि.परि.)

1. Shirashoola (Headache)

2. Shaithilya (Looseness of body)

3. Avasada (Depression)

4. Manasika deenata (Mental fatigue)

5. Jwara (fever)

6. Utklesha (nausea)

7. Aruchi (anorexia)

👉🏻 Lakshana:-

1) Granthika Jwara:-

• तीव्र ज्वरो भवति पूर्वमिहक्वचिद्वामन्दः शिरोरुगरतीवमनं भ्रमश्च।

उत्क्लेशगात्रशिथिलत्वतृषाप्रलापा

उन्मादमोहधमनीद्रुतगामिताश्च॥

इदं ग्रंथिकाख्यज्वरस्याद्यभेद स्वरूपं यथावद् भिषग्भिः प्रदिष्टम्॥

(मा.नि.परि.)

- Teevra jwara (hyperpyrexia)

- Shirashoola (headache)

- Arati (restlessness)

- Bhrama (vertigo)

- Utklesha (nausea)

- Sharira shaithilya (looseness of body)

- Trishna (Polydypsia)

- Pralapa (Delirium)

- Unmada (Psychosis)

- Rapid pulse rate

- Murchha (fainting)

- Nidranasha (sleeplessness)

- Daurbalya (weakness)

- Inflammed lasika granthi

- Tenderness over lymph glands

- Suppuration of lymph glands

- Numbness in ear

2) Keeta Raktaja Granthika jwara:-

• बहुग्रंन्थय: कीटरक्ताख्य भेदे ज्वरे ग्रंन्थिके नापि वर्द्धन्त एव।

भवेत्तत्र रक्तस्य दुष्टिस्तथा च ज्वरस्यानिशं तीव्रता वै विशेषात्॥ 

(मा.नि.परि.)

- Teevra jwara (Hyperpyrexia)

- Pulse weak and fast

- Sangya nasha (loss of sensation)

- Sannipataja jwara Lakshana

3) Phuphphusa pradahi Granthika jwara:-

• शीतपूर्वक दारुण ज्वर आशु संजायतेहि, शिरसि शूलमथाङ्गमर्दो भ्रमश्चोत्क्लेशोऽधिमाहि........ लक्ष्य जातं लक्ष्यते ॥

(मा.नि.परि.)

- No enlargement of lasika granthi

- Sheeta purvaka jwara (fever with chills)

- Shirashoola (headache)

- Angamarda (bodyache)

- Bhrama (vertigo)

- Utklesha (nausea)

- Urashoola (chest pain)

- Kasa (cough)

- Kantha kunjana (wheezing)

- Rakta sthivana (Haemoptysis)

- Consolidation of lungs

👉🏻 Upadrava:-

• कासोऽतिसारोऽप्यथ रक्तपित्तं मूत्रावरोधो वमनं तथैव।

उपद्रवा ग्रंथिक नामकेऽस्मिन् ज्वरे त्वमी बैद्यजनैः प्रदिष्टाः ॥(मा.नि.परि.)

1. Kasa (cough)

2. Atisara (Diarrhoea)

3. Raktapitta (Epistaxis)

4. Mutavarodha (Retension of urine)

5. Vamana (Vomiting)

👉🏻 Sadhyasadhyatva:-

• सर्वोन्द्रियाणां मनसोऽप्यशेषव्यापारनाशो यदि वाऽतिसारः।

अत्युल्बणा स्यात्तुतदा सुवैद्याऽरिष्ट वद्द ग्रंथिकपीडितस्य॥

ष्ठीवेत् सुसिन्दूर समोज्वलं चेद् रक्तं कफेनानुगतं तु रोगी॥(मा.नि.परि.)

It is considered as sukha sadhya if :

- Granthis are at many places

- Shighra paki

- Patient is of Children or old age

It is considered as Asadhya if :

- Atisara at peak

- Kapha sthivana of Sindura varna

- Teevra shwasa

- Loss of sensory functions

👉🏻 Chikitsa Siddhanta:-

- Nidana parivarjana

- Uttama paricharya and drava ahara

- Ushna seka on granthis, and if Suppuration present then Incision is made on it.

- Lakshanika chikitsa (symptomatic treatment) of patient should be done.

- Prevention from rats and rodents should be done

👉🏻 Chikitsa:-

- All jwarokta Samshamana yoga

1) Rasa / Bhasma / Pishti:-

Matra:- 125-250 mg

Anupama:- Ushnodaka / Madhu

- Tribhuvanakirti rasa

- Hunguleshwara rasa

- Swarna vasanta malati rasa

- Kasturi bhairava rasa

- Jwara keasari rasa

- Jwara Samhara rasa

- Godanti and shringa bhasma

- Jaharamohara pishti

- kaphaketu rasa

2) Vati:-

Matra:- 250-500mg (1-2 tab)

Anupana:- Ushnodaka

- Sanjivani vati

- Saubhagya vati

- Samshamani vati

- Vishatindukadi vati

- Jaya vati

- Amruta sattwa

3) Churna:-

Matra:- 3-6 gm

Anupana:- Ushnodaka

- Sudarshana churna

- Panchakola churna

- Sitopaladi churna

- Talisadi churna

- Lavangadi churna

4) Kwatha / Asava / Arishta:- 

Matra:- 10-20 ml

Anupana:- Jala

- Nagaramotha + Parpata

- Sunthi + Parpata

- Patha + Khasa + sugandhabala

- Patola panchaka kwatha

- Darvyadi kwatha

- Guduchyadi kwatha

- Amritarishta

5) Ghrita / Taila:-

Matra:- 10-20 ml

Anupana:- Ushnodaka

- Panchatikta ghrita

- Amrutadi ghrita

- Shatapalaka ghrita

- Chandanadi ghrita 

6) Avaleha:-

Matra:- 20-30 gm

Anupana:- Dugdha

- Drakshavaleha

- Chyavanprasha

- Specific yogas are:-

1. Bruhat vatachintamani rasa

2. Yogendra rasa

3. Bruhat Kasturibhairav rasa

4. Chandeshwara rasa

5. Tamrea bhasma

6. Rasa sindoor

7. Ashwagandha churna

8. Shatavari choorna

9. Rohitaka lauha

👉🏻 Pathyapathya:-

1) Pathya:-

Ahara:-

- Purana shali, mudga, masura, karavellaka, sahijana, chaulai, guduchi, jeevanti, munakka, kapittha, dadima.

- Laghu ahara

- Yavagu, peya, vilepi, yava, laja manda etc.

Vihara:-

- Langhana

- Vamana

- Virechana

- Basti

- Nasya

- Abhyanga

- Vishrama

2) Apathya:-

Ahara:-

- Guru, vidahi, vishtambhi padartha

- Dushita jala sevana

- Ankurita anna, tilakuta, samosa, kachori, pizza, burger, Halwa, mithai, lassi etc.

Vihara:-

- Vegadharana

- Vyayama

- Diwaswapna

- Snana

- Maithuna

- Adhyashana

🔘 Nimba

Nimba

👉 Basonym of Drug:

• निम्बति सिञ्चति स्वास्थ्यमिति, स्वस्थवृत्तिकरमिति यावत् ।

- Nimba (Azadirachta indica) is very useful drug, which maintains health.

👉 Synonyms:

1. हिमुनिर्यासः-

The exudate from Nimba resemble Hingu Niryāsa

(Gum of Ferula narthex).

2. अरिष्टः- 

Nimba cures many diseases, does good always if used.

3. कृमिघ्न :- 

Very efficacious in helminthiasis.

4.नियमन-

Nimba alleviates many diseases.

5.पारिभद्र-

If used, Nimba always does good.

6. पिचुमर्दः-

Nimba is very efficacious drug when it comes to skin diseases. 

7. सुतिक्तकः- 

Nimba is one of the best among drugs having bitter taste.

8. वरत्वच:- 

Bark of Nimba is very useful.

👉 Regional Name:

English  - Neem tree or Margosa tree

Hindi - Nim

Kannada Bevina Mara

Malayalam - Veppu

Marathi - Kadunimba

👉 Botanical Name- Azadirachta indica Juss.

• Azadirachta- Persian name meaning best tree

• indica- Native of India.

👉 Family- Meliaceae

👉 Kula- Nimba kula.

👉 Gana vargikarana (Classical categorization): 

• Charaka - Kandughna varga

• Susruta-

- Aragvadhadi gana

- Guduchyadi gana

- Lakshadi gana

• Bhavaprakasa Nighantu - Guducyadi varga.

👉 Taxonomy Classification:

Kingdom - Plant

Class - Dicotyledons

Sub class -  Polypetalae

Series - Disciflorae

Order - Geraniales

Family - Meliaceae

Genus - Azadirachta

Species - indica

👉 Habitat:

Nimba (Neem) tree grows all over India. It is commonly planted as avenue trees.

👉 Types:

1. Nimba - Azadirachta indica

2. Mahanimba - Melia azadirachta

3. Parvata Nimba (Aralu) Ailanthes excelsa

4. Akasha Nimba - Malingtonia horensis.

👉  Rasapanchaka:

निम्बः शीतो लघु ग्राहीकटुपाकोऽग्निवातनुत् ।

अहृद्य श्रमतृट्कासज्वरारुचिकृमिप्रणुत् ।।

व्रणपित्तकफच्छर्दिकुष्ठहृल्लासमेहनुत्

        - भा.प्र. गुडूच्यादि वर्ग ९४

Rasa - Tikta Kasaya

Guņa - Laghu Ruksa

Vipāka - Katu

Virya - Sita

Action on Dosa - Pitta kapha samaka.

👉 Action :-

Krimighna - vermicidal

Kusthaghna - useful in skin diseases.

Vranaghna - wound healing

Raktashodhak - blood purifier

Sothahara - relieves inflammation.

- Neem leaf is used for leprosy, eye disorders, bloody nose, intestinal worms, stomach upset, loss of appetite, skin ulcers, diseases of the heart and blood vessels (cardiovascular disease), fever, diabetes, gum disease (gingivitis), and liver problems.

- The bark is used for malaria, stomach and intestinal ulcers, skin diseases, pain, and fever.

- Neem twigs are used for cough, asthma, hemorrhoids, intestinal worms, low sperm levels, urinary disorders, and diabetes. 

- The flower is used for reducing bile, controlling phlegm, and treating intestinal worms.

👉 Contraindications of Nimba:-

- Nimba can lower blood glucose levels; so if person is on fasting it is better to avoid oral intake of it.

- People with diabetes should use nimba only under medical supervision, with constant blood sugar level monitoring.

- Because nimba reduces blood sugar, If a diabetic person is already taking medications for zamd, consuming nimba along with it may cause very low blood sugar.

- Nimba should not be taken during childhood, pregnancy or lactating without advice of doctor.

- It is Contraindicated in Autoimmune diseases such as; Multiple sclerosis, Systemic lupus erythematosus, rheumatoid arthritis etc. conditions.

- Nimba cause the immune system to become more active, this could increase the symptoms of auto immune diseases.

- Aragwadhadi kashaya (in which nimba is one of the content) is causes gastritis if taken in very high dose

- Lakshadi guggulu also contraindicated in pregnancy and person with heart disease

👉 Matra (Dosage):

Swarasa (Juice) - 10 to 20 ml

Kalka (Paste) – 10 to 20 g

Kasaya (Decoction) - 50 to 100 ml

Curna (Powder) - 2 to 4 g

Taila (Oil) - 5 to 10 drops.

👉 Chemical Composition:

- Bark of Nimba contain Azadirachtin, Salanin, Nimbidin, Nimbin, Nimbinin, Volatile oil, Nibosterol, Tanin and bitter substance margostine

- Seed oil contain sulphar, resin, glucosides, fatty acids

- Leaves contain nimbin , azadirone, the flavanoid quercetin, nimbosterol, limonoids

- Flowers contain nimbosterol , kaempferol.

- Fruits contain azadiradione , azadirone

👉 Pharmacological action :

Antipyretic

Anti-diabetic

Antioxidant

Antibacterial

 Antiviral

Antiplasmodial

Fungicidal

👉 Yoga (Important formulation):

1. Nimbadi curņa - Kustha, Vatarakta

2. Nimbadi kwatha - Kapha jwara, Pitta soth

3. Nimbamritadi kasaya  - Visphota

4. Panchanimba curna  - Sarvakustha, Visarpa

5. Tiktaka ghrta - Kustha, Visarpa

6. Pancatikta ghrata guggulu  - Kustha, Prameha.

👉 Effect of Chemical constituents of Nimba:

- Neem plays role as free radical scavenging properties due to rich source of antioxidant. 

- Azadirachtin and nimbolide showed concentration-dependent antiradical scavenging activity and reductive potential in the following order: 

Nimbolide > Azadirachtin > Ascorbate

- Neem ingredient shows effective role in the management of cancer through the regulation of cell signaling pathways. 

- Neem modulates the activity of various tumour suppressor genes, angiogenesis (VEGF), transcription factors (e.g., NF-κB), and apoptosis (e.g., bcl2, bax).

- Neem also plays role as anti-inflammatory via regulation of proinflammatory enzyme activities including cyclooxygenase (COX), and lipoxygenase (LOX) enzyme.

🔘 Typhoid Fever (Antarika Jwara)

TYPHOID FEVER (ANTRIKA JWARA):-

💫 ACCORDING TO MODERN:- TYPHOID

👉🏻 Introduction:-

- Typhoid fever is due to systemic infection mainly by Salmonella typhii.

- The disease is clinically characterised by a typical continuous fever for 2-3 weeks.

- In Ayurveda it is correlated with  'Enteric fever, आन्त्रिक ज्वर or मन्थर ज्वर.

👉🏻 Causitive organism:-

- Salmonella typhii (Gram -ve, anaerobic bacilli)

👉🏻 Incubation period:-

- 10-14 days

👉🏻 Source of infection:-

√ The primary source of infection are:-

- Contaminated food, milk and water

- Pollution of drinking water supplies

- Open air defecation and urination

- Low standards of food

- Low personal hygiene and health ignorance

√ Transmission :- Feco-oral route

√ Carrier :- House flies

👉🏻 Risk factors:- 

- Typhoid fever is a serious worldwide threat and affects about 27 million or more people each year.

- The disease is established in India, Southeast Asia, Africa, South America and many other areas.

- Worldwide, children are at greatest risk of getting the disease, although they generally have milder symptoms than adults do.

√ If you live in a country where typhoid fever is rare, you're at increased risk if you:-

- Work in or travel to areas where typhoid fever is established

- Work as a clinical microbiologist handling Salmonella typhi bacteria

- Have close contact with someone who is infected or has recently been infected with typhoid fever

- Drink water polluted by sewage that contains Salmonella typhi.

👉🏻 Pathogenesis:-

- Due to contaminated food, milk and water, salmonella typhi bacilli enters and reaches to the intestine.

- In intestine, it penetrate the mucosa of intestine and reaches to the intestinal lymphatic through peyer's patches.

- From peyer's patches it enters in blood stream.

- In blood stream, the bacteria is disseminated throughout body via blood and intracellular multiplication occurs.

- The organism enters intro the blood stream and producing bacteremia when all organs are repeatedly exposed.

- It affect different body organs.

• Brain:- Encephalitis

• Heart:- Cardiac failure

• Lungs:- Pneumonia, Bronchitis

• Liver:- Hepatomegaly

- 3rd week is most critical phase.

👉🏻 Clinical features:-

✓ 1st week (Prodromal stage):-

- Mild fever (99-100° F)

- Malaise

- Headache

- Generalised bodyache

- Cough

- Sore throat

- Often with abdominal pain

- Constipation

- Stepladder fashion (pattern) fever

- Relative lynohocytosis with leucopenia.

✓ 2nd week:-

- High grade fever (Temperature gradually rise upto 107° F)

- Fever reaches at peak and patient looks toxic appearing exhausted.

- Marked abdominal tenderness

- Mild hepatospleenomegaly

- Relative bradycardia

- Diarrhoea:- Pea soup like stool

- Red rose spots or red spots may seen on chest and abdomen, disappeared within 2-3 days

- Constipation:- Caused by swelling on lymphoid tissue around ileocaecal junction.

✓ 3rd week (Stage of complication):-

- Intestinal perforation and haemorrhage

- Meningitis

- Pneumonia, bronchitis

- Cardiac failure

- Encephalitis

👉🏻 Diagnosis:-

- CBC:- Leucopenia - 1st week

- Antigen:- WIDAL test - 2nd week

- WIDAL test detects O and H Antigen of Salmonella typhii.

- Culture:- Stool, Urine - 3rd and 4th week

- Typhi DOT:- More accurate than WIDAL, shows early result on 2nd or 3rd day

👉🏻 Diffrential diagnosis:-

- Pneumonia

- Dengue fever

- Malaria

- Cerebrospinal fever

- Tuberculosis

- Relapsing fever

👉🏻 Management:-

1) For prevention:-

- Providing clean water to public

- Proper excreta disposal

- Protection of water from contamination

2) For treatment:-

- Bed rest

- Fluid management:- Oral / IV

- Antibiotics

- Steroid therapy

- Surgical intervention:- 3-5%

✓ Antibiotics:-

1. Chloramphenicol:- 3-4 gm/day 

(Continues with 2gm/day for 18 days)

2. Amoxicillin:- 4-6 gm/day (In 4 divided doses)

3. Ciprofloxacin:-:500-750mg BD

4. Ampicillin

5. Ceftriaxone:- 75 mg/kg/day

6. Cefexine:- 400mg BD

7. Azythromycin:- 1gm, once in a day for 5-7 days

✓ Steroid:-

1. Dexamethasone:- 1mg/kg every 6hrs

💫 ACCORDING TO AYURVEDA:- ANTRIKA JWARA Or MANTHARA JWARA

👉🏻 Introduction:-

- There are presence of Pidakas or manthari in this type of jwara, hence named as Manthara jwara.

- It is also known as Antrika Jwara, because this fever widely affect intestine.

- In this type of Jwara, all tridosha lakshana are present. 

- In modern it is correlated with Typhoid fever.

👉🏻 Samanya Nidana:-

• "बह्वध्व क्लान्ततनवस्तथाऽनश्नकर्षिताः। 

दुर्गन्धिपूर्णभूमौ वा नित्यमेव निवासिनः॥

आंत्रिककेत्यभिधानं चापरमस्यैव कथ्यते। 

सामस्य कारणं प्रोक्तं विशिष्टं तु निगद्यते॥"

(मा.नि. परि. मंथर ज्वर 1-4)

- Ati margagamana

- Ati upavasa

- Durgandha purna, dushita sthana nivasa

- Intake of food and drinks contaminated with dushita mala etc.

👉🏻 Vishista Nidana:-

- Agantuja karana:- Bacterial infection

👉🏻 Samprapti:-

• कीटाणवो बेसिलस टाइफोसस नामकाः । 

दण्डाकाराः कृतावासा रक्ते मूत्राशये मले।

स्वेदे पित्ताशये प्लीह्नि पिडिकास्वान्त्रिकव्रणे। 

जनयन्ति नृणां देहे ज्वरं प्रोक्तं विशेषतः॥"

(मा.नि.परि.)

• मलमूत्रस्वेदजात दोष संसर्ग दूषिते। 

भक्ष्यपेयादिभिद्रव्यैर्नाना संक्रमणकारणैः ॥

लक्ष्येत यदि रक्तस्थस्रावो भिन्नान्त्रता तदा॥" 

(मा.नि.परि.मन्थर ज्वर 7/11)

- Due to nidana sevana and Bacterial infection (Jivanu sankramana) jivanu (bacteria) enters into antra (intestine).

- After entering, it produces swelling in sntra granthis.

- Due to swelling doshas, rasa and rakta dhatu exists in intestine are aggravated and producing kshata (injury) to the intestine.

- After some time kshata (injury) increases and produces chhidra in antra (perforation of intestine) and causes continuous blood flow in intestine.

- It creates Manthara (antrika) jwara, and this condition is Asadhya when antra is perforated.

👉🏻 Samprapti ghataka:-

- Dosha:- Tridosha

- Dushya:- Rasa, Rakta

- Srotasa:- Annavaha, Rasavaha

- Srotodushti:- Sanga

- Adhisthana:- Antra

- Swabhava:- Chirakari

- Sadhyasadhyatva:- Kruchrasadhya

👉🏻 Purvaroopa:-

• शिरोव्यथा स्यादरुचिस्ततोऽरतितमोऽवसादौऽपि च बिड्बद्धता।

सप्ताहपर्यन्तमिति स्फुटास्फुटं ज्वरेऽग्ररुपं नियंत सदाऽऽत्रिके॥

 (मा.नि.परि.)

- Shirovyatha (headache)

- Aruchi (anorexia)

- Restlessness

- Darkness in front of eyes

- Depression

- Malabaddhata (constipation)

👉🏻 Lakshana (Clinical features):-

• तदग्ररुपं च ततोऽष्मेऽहनि भवेदभिव्यक्तिमवाप्यलक्षणम्।

ज्वरोऽथ नित्यं क्रमश: प्रवर्द्धते सहापरैमर्थरेकऽत्र लक्षणैः ।।

भवेत्तदा तु ज्वरजाप सीमा चतुर्भुतं पञ्चमुतं शतं वा॥

उपद्रवसमाधिक्यं सप्ताहितं सेविन:।

(मा.नि. परिशिष्ट)

- It is similar to Pittolbana Sannipataja jwara.

- It is explained by Acharya Gananath sena in Siddhanta nidana, which are similar to Typhoid fever in modern.

✓ 1st week:-

- Jwaradhikya (Hyperpyrexia)

- Pleehavriddhi (Spleenomegaly)

- Jihva malina evum rakta varna (Tongue coated and reddish)

- Adhmana (Flatulence)

- Vibandha (Constipation)

- Red spots on neck, abdomen and chest area

✓ 2nd week:-

- Jwaradhikya (Hyperpyrexia)

- Pralapa (Delirium)

- Tandra (Drowsiness)

- Kasa (Cough)

- Furrowed tongue, dry with reddish coloration

- Durbalata (weakness)

- Mukhashosha (Dryness of mouth)

- Arati (Restlessness)

- Adhmana (Flatulence)

- Dicrotic pulse

- Blood mixed stool

👉🏻 Asadhya Lakshana:-

- Ati raktasrava (Excessive bleeding)

- Increased pulse rate

- Acute pain in abdomen

- Tendency of raised body temperature during morning hours and night

- Generalized peritonitis

- Excessive weakness

- Tremora in hands and feet

- Intestinal bleeding

👉🏻 Upadrava:-

- Antra kshaya (Intestinal tuberculosis)

- Vishaktata (Toxaemia)

- Raktasrava (Haemorrhage)

- Peritonitis

- Antra vidarana (Intestinal perforation)

- Vrukka Shopha (Nephritis)

👉🏻 Chikitsa sutra:-

- Firstly Langhana should be done for dosha pachana.

- In Sannipataja jwara, when there is ugra vega of jwara; first treat pitta then treat kapha and vata dosha respectively.

• कफस्थानानुपूा तु सन्निपात ज्वरं जयेत्।" (च.चि. 3)

- In lakshana Manthara jwara is similar to Sannipataja jwara so its treatment should be done according to Kapha sthana

- Firstly done Kapha and Amadosha pachanaz then treat aggravated vata and pitta.

- In case of constipation sramsana aushadha should be used for koshtha shodhana according to Bala of rogi.

- In antra pradhaha sheeta, tikta and madhura rasatmaka dravya should be used.

- If Trishna present, then use Shadangapaniya.

- Pathya Palana

- Pushtikaraka, balaprada and supachya drava ahara should be taken.

👉🏻 Chikitsa:-

1. Samshodhana Chikitsa:-

√ Same as Sannipataja jwara treatment:- 

 a) Langhana

 b) Swedana :- Baluka, Sandhava sweda, Snigdha sweda

 c) Shirovirechana:-

- Trikatu churna pradhamana nasya

- Kataphala twak churna pradhamana nasya

- Shwara kuthara rasa nasya

 d) Anjana prayoga

2. Samshamana Chikitsa:-

a) Rasa / Bhasma / Pishti:-

• Matra:- 125-250 mg

• Anupana:- Ushnodaka / Madhu

- Sutashekhara rasa

- Pravala pamchamrita

- Karpura rasa

- Ramabana rasa

- Yogendra rasa

- Bola parpati

- Navayasa lauha

 b) Vati:-

• Matra:- 250-500 mg

• Anupana:- Ushna jala

- Madhurantaka vati

- Saubhagya vati

- Samshamani vati

c) Churna:-

• Matra:- 3-6 gm

• Anupana:- Koshna jala

- Sitopaladi churna

- Yavani shadava churna

d) Kwatha / Asava / Arishta:-

• Matra:- 10-20 ml

• Anupana:- Jala

- Chandanadi kwatha

- Mustadi kwatha

- Kiratadi kwatha

- Chandana kiratadi kwatha

- Lohasava

- Draksharishta

e) Anya yogas:-

- Lavanga:- 7 

- Jatiphala:- 2gm

- Sunthi:- 2gm

- Ela:- 2

- Tulasi:- 5 patra

• These all should be added with 400 ml water and boiled until 50 ml is remained and given with madhu.

👉🏻 Pathya-Apathya :-

1) Pathya:-

- Ahara:- 

Kurchika, dadima, draksha, munnaka, godugdha, mudga, yava manda, laja manda, Purana shali, peya, vilepi, patola, lavangodaka, Shadangapaniya etc.

- Vihara :- 

Langhana, Vishrama, avoid vega dharana

2) Apathya:- 

- Ahara :- 

Guru, Abhishyandi, tikshna bhojana, pizza, burger, samosa, kachori, halva, malpuva etc.

- Vihara :- 

Adhyashana, Vyayama, Vyavaya, Shrama, Chinta, Jagarana etc.