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DDeeccllaarraattiioonn bbyy tthhee CCaannddiiddaattee

I hereby declare that this dissertation entitled “EFFECT OF PATHADI

CHOORNA IN BALATISARA w.s.r. INFANTILE DIARRHEA”” is a

bonafide and genuine research work carried out by me under the guidance

of DDrr.. MM..SS..KKAAMMAATTHH professor,Dept. of P.G. Studies in

Kaumarabhritya, Alva’s Ayurveda Medical College, Moodbidri- 574227.

Date: DR. TRIMBAK R.KALE Place: Moodbidri PG Scholar

Dept. of PG Studies in Kaumarabhritya Alva’s Ayurveda Medical College

Moodbidri- 574227

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CCeerrttiiffiiccaattee

This is to certify that the Dissertation entitled ““ EFFECT OF

PATHADI CHOORNA IN BALATISARA w.s.r. INFANTILE

DIARRHEA”” is the bonafide record of research work conducted by

““TTRRIIMMBBAAKK RR KKAALLEE”” under my direct supervision and guidance as a

part fulfillment for the award of the degree of M.D. in Ayurveda –

Kaumarabhritya.

The candidate has fulfilled all the requirements of ordinances laid

down in the prospectus of Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka for the award of Degree of Doctor of Medicine

(Ay.) Kaumarabhritya. This title has not formed a title for any degree,

associate ship, fellowship or for any similar studies in this university. I

am fully satisfied with his work and recommend this thesis to be

forwarded for adjudication.

Date: DDrr.. MM..SS..KKAAMMAATTHH Place: Moodbidri Professor , Department of K.B Alva’s Ayurveda Medical College Moodbidri – 574227 AALLVVAA’’SS AAYYUURRVVEEDDAA MMEEDDIICCAALL CCOOLLLLEEGGEE && HHOOSSPPIITTAALL,, MMOOOODDBBIIDDRRII

((AAFFFFIILLIIAATTEEDD TTOO RR..GG..UU..HH..SS,, KKAARRNNAATTAAKKAA,, BBAANNGGAALLOORREE))


EEnnddoorrsseemmeenntt

This is to certify that the Dissertation entitled ““ EFFECT OF

PATHADI CHOORNA IN BALATISARA w.s.r. INFANTILE

DIARRHEA”” ”” is the bonafied record of research work conducted by

““TTRRIIMMBBAAKK RR KKAALLEE”” under the guidance of Dr. MM..SS..KKAAMMAATTHH

Professor, Dept. of P.G. Studies in Kaumarabhritya, Alva’s Ayurveda

Medical College, Moodbidri-574227

PPRRIINNCCIIPPAALL,,

AAllvvaa’’ss AAyyuurrvveeddaa MMeeddiiccaall ccoolllleeggee,,

MMooooddbbiiddrrii..

HHeeaadd ooff tthhee DDeeppaarrttmmeenntt,,

DDeeppaarrttmmeenntt ooff kkaauummaarraabbhhrruuttyyaa,,

AAllvvaa’’ss AAyyuurrvveeddaa MMeeddiiccaall ccoolllleeggee,,

MMooooddbbiiddrrii..

DDaattee::

PPllaaccee:: MMooooddbbiiddrrii CCOOPPYYRRIIGGHHTT

DDEECCLLAARRAATTIIOONN BBYY TTHHEE CCAANNDDIIDDAATTEE

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and

disseminate this dissertation / thesis in print or electronic format

for academic / research purpose.

DR. TRIMBAK R.KALE PG Scholar

Dept. of P.G Studies in Kaumarabhritya Alva’s Ayurveda Medical College

Moodbidri- 574227 Date: Place: Moodbidri

©© RRaajjiivv GGaannddhhii UUnniivveerrssiittyy ooff HHeeaalltthh SScciieenncceess,, KKaarrnnaattaakkaa

AAcckknnoowwlleeddggeemmeenntt

Words are not enough to express my gratitude and indebt to the sacrifices of

my beloved and respected parents Shri R. N. Kale &Smt. Lavanyawati R. Kale for

supporting, blessing, praying and standing by me in all situations of my life.

It is an inexplicable pleasure to offer my salutations to

Dr. M. Mohan Alva, Chairman of this institution for his blessings, which made me

to complete my thesis without any hurdles.

It is a matter of great privilege for me to work under the able and highly

exceptional guidance of Dr. M.S.KAMATH, Prof., P.G. Studies in

Kaumarabhritya and Dr.VINAYCHANDRA SHETTY Principal, Alva’s Ayurveda

Medical College, Moodbidri, the person who have nurtured my capabilities and always

gave me ample freedom. I am deeply indebted for his guidance, broadmindedness and

affection towards me.

I am thankful to Dr. Chandrakanth Joshi, Professor, Department Of

Kaumarabhritya for rendering help in getting permission from anganwadi authorities

and his valuable suggestions during the study.

Earnest favour has been obtained from all the staff members of Alva’s

Ayurveda Medical College. I hereby express my gratitude for them.

My thanks to all the staffs’ members, Alva’s Pharmacy, Mijar, Moodbidri, for

their immense cooperation for preparing the study formulation.

I shell out my gratitude towards my colleagues, Dr. Santosh, Dr. Vikas,

Dr. Shreeraj and my juniors Dr. Sachin, Dr. Amit for helping me throughout

this work.

I indebted to my friends, Atul,Kavitha, Sunita and other friends for helping

me throughout this work.

Last but not the least I thank all the innocent children and their parents who

have cooperated with me in all aspects during the research work.

Date- 21/04/2012 Dr. Trimbak R.Kale.

Place-Moodbidri

CCoonntteennttss

List of Tables………………………………………………………….II-III.

List of Figures ………………………………………………………..III

List of charts & graphs………………………………………………IV

Abbreviations………………………………………………………….V-VII

Abstract………………………………………………………………..VIII-IX.

1. Introduction…………………………………………….1-3

2. Objectives……………………………………………….4

3. Conceptual Study……………………………………...5-77

a. Review of

literature……………………………. 5-29

b. Ayurvedic

Review……………………………..30-64

c. Modern

Review………………………………..65-91

d. Drug

Review…………………………………...92-98

4. Methodology……………………………………………99-107

5. Observations & Results……………………………….108-129

6. Discussion………………………………………………130-136

7. Conclusion……………………………………………...137-138

8. Summary………………………………………………..139-140

9. Previous work done………………………………….141

10. References & Bibliography…………………….…….142-147

11.Annexure……………………………………..…………I-XII

a. Model Research Proforma……………………I-VII

b. Master Chart…………………….……………..VII-XII

Contents

Effect of pathadi choorna in Balatisara w.s.r.Infantile diarrhea. Page II

List of Tables

Sl. No. Titile Page No.

1 Samanya nidana of Atisara 35,36

2 Lakshana of Pittatisara 51,52

3 Kaphaja atisara lakshana 52,53

4 Sannipataja atisara lakshana 55

5 Criteria for assessment of cure 57

6 Asadhya lakshana 57,58,59

7 Upadrava/complication 59,60

8 Defferential diagnosis 63

9 Defferentiation of osmotic & secretory diarrhea 68

10 Defference between viral & bacterial diarrhea 73

11 Assessment of dehydration 84

12 Composition of WHO ORS 86

13 Use of ORS in plan A 87

14 Fluid therapy in severe dehydration 88

15 Sex incidence of the sample 108

16 Age group incidence of the sample 108

17 Incidence of Geographical distribution of the sample 110

18 Incidence of Socio-economic status 110

19 Incidence of Religion 112

20 Incidence of Dietic regimen 112

21 Incidence of Hygienic environment

(Home / School Surroundings)

114

22 Prakriti wise distribution 115

23 Koshta wise distribution 116

24 Distribution based on Agnibala 116

25 Distribution of children according to Nutritional status 118

26 Incidence of onset of symptoms 119

27 Sign and Symptoms wise distribution 119

Contents

Effect of pathadi choorna in Balatisara w.s.r.Infantile diarrhea. Page III

28 Response rate with respect to Jwara 122

29 Response rate with respect to Vivarnata 123

30 Response rate with respect to Udarashoola 124

31 Response rate with respect to Trishna 125

32 Response rate with respect to pus cells/Mucus 126

33 Response rate with respect to Atisara 121

34 Overall improvement of children in the study group 127

List of Figures

Sl. No. Title Page No.

1 Diadram of Mahasrotas 14

2 Drug Patha used for the study 97

3 Raw drug Patha used for the study 97

4 Raw drug Mango seed used for the study 98

5 Drug Mango seed used for the study 98

List of Charts


1 Classification of Atisara 31

List of Graphs


1 Sex wise incidence of the sample 109

2 Age group incidence of the sample 109

3 Incidence of Geographical distribution of the

sample 111

4 Incidence of Socio-economic status 111

5 Incidence of Religion. 113

Contents

Effect of pathadi choorna in Balatisara w.s.r.Infantile diarrhea. Page IV

6 Incidence of Dietic regimen 113

7 Incidence of Hygienic environment 114

(Home / School Surroundings)

8 Prakriti wise distribution 115

9 Koshta wise distribution 117

10 Distribution based on Agnibala 117

11 Distribution of children according to Nutritional

status 118

12 Incidence of onset of symptoms 120

13 Sign and symptoms wise distribution 120

14 Overall improvement of children in the study group 128

Abbreviation

Effect of pathadi choorna in Balatisara w.s.r.Infantile Diarrhea Page V

ABBREVIATIONS

A. H. – Astanga Hridaya

A. S. – Astanga Samgraha

B. P. – Bhava Prakasha

B. P. Ni. – Bhava Prakasha Nighantu

B. S. – Bhela Samhita

B. R. – Bhaishajya Ratnavali

C. S. – Charaka Samhita

Dh. Ni. – Dhanvantari Nighantu

G. N. – Gadanigraha

H. S. – Haritha Samhita

K .S. – Kashyapa Samhita

Ka. Ni. – Kaiyyadeva nighantu

M. N. – Madhava Nidana

N. R. – Nighantu Ratnakara

R. Ni. – Raja Nighantu

Sha. Sa. – Sharngadhara Samhita

S. S. – Sushruta Samhita

Y. R. – Yoga Ratnakara

V. S. – Vangasena Samhita

R. V. – Rigveda

Y. V. – Yajurveda

A. V. – Atharva veda

A. K. – Amara Kosha

Abbreviation

Effect of pathadi choorna in Balatisara w.s.r.Infantile Diarrhea Page VI

Ch. – Charaka

Su. – Sushruta

Pu. Kh. – Purva Khanda

Chi. – Chikitsa sthana

Ma. Kh. – Madhyam Khanda

Ni. – Nidana sthana

Su. – Sutra sthana

St. – Sthana

Ut. – Uttara sthana

Vi. – Vimana sthana

No. – Number

Mal. N. – Malnutrition

Sl. No. – Serial Number

Ltd. – Limited

Pb. – Publication.

Dr. – Doctor

Prof. – Professor

Dept. – Department

P. G. – Post Graduation

K.B. – Kaumarabhritya

i.e. – that is

viz. – namely

etc. – etceteras

Abbreviation

Effect of pathadi choorna in Balatisara w.s.r.Infantile Diarrhea Page VII

Symbols used in Master Chart

A. T. – After treatment

B. T. – Before treatment

P – Probability

z – Test of significance

> – More than

< – Less than

% – Percentage

0, 1, 2, 3 – Grades of severity

Abstract

Effect of Pathadi choorna in balatisara w.s.r. Infantile diarrhea. Page VIII

ABSTRACT

Background:

Diarrhea is the most common disease seen especially in children. This disease

when untreated gradually leads to mild to severe dehydration, which in turn adversely

affects children & is the major concern of mortality in children.

In classical Ayurvedic texts, scatered references about this disease are found.

Management of Diarhea is considered to be a major problem especially in the urban

and rural areas. Hence to evaluate a potent, safe, economical & easily available

Antidiarrheal drugs/Yoga from Natural sources, i.e.the Pathadi Choorna is being

selected.

The compound Pathadi choorna is the best antidiarrheal, viewed classical

scripts made the attempt of evaluation under clinical studies on selected cases.

Objective

• To study the effect of Pathadi choorna in Bala Atisara.

• To highlight the formulation Pathadi choorna said in Bhavaprakasha to relive

Atisara in children.

Methods:

30 diagnosed children of Atisara (i.e. infantile diarrhea), between the age

group of 06 months to 1 year were selected from the O.P.D. of Alva’s Ayurveda

Medical College hospital and schools in and around Moodbidri. 750mg to 1500mg of

Pathadi choorna with curd was given to the selected children for a period of 7 days.

Detailed research proforma was prepared to record the observations which were

graded as per their severity.

Abstract

Effect of Pathadi choorna in balatisara w.s.r. Infantile diarrhea. Page IX

Results:

Clinical evaluation has showed its significance at a better range in the

symptoms of Diarrhea like Drava mala Vega, Trishna, Jwara etc. by the trial group.

Discussion:

Clinically almost all the children have completely relieved under Pathadi

choorna. Hence the trial group showed highly significant relief in the management of

subjective and objective symptoms of diarrhea. Drug has not shown any side effect

even after full course of the treatment.

Conclusion:

1. It is not only anti-diarrheal drug but also a very good Appetizer drug.

2. The drug is very effective and useful in the management of children with diarrhea.

Keywords:

Pathadi choorna; Balatisara etc.

Introduction

Effect of pathadi choorna in balatisara w.s.r. Infantile diarrhea Page 1

INTRODUCTION

Atisara is one of the commonest disease found these days in the children. When

it occurs in children, it is a cause of concern for the parents as the child will have

sunken eyes, flabby skin and looks severely ill and weak even if diarrhea occurs for a

day or two. The parents would want the doctor immediately to stop it within a short

duration, as this may lead to severe complications in the children if not treated at the

earliest.

The detailed description of atisara in children is not explained in Ayurveda and

an effort is made in this thesis to understand the nidan panchaka of Balatisara with the

help of scattered references.

Many research works have been carried out in relation to Stambana and Grahi

treatment in Bala atisara as directed in Ayurveda and proved their therapeutic effect.

Many more herbal combinations are described in various texts of Ayurveda and their

therapeutic effect in Balatisara is yet to be explored. The Yoga selected to the present

study – Pathadi churna, is one among such herbal combinations mentioned by

Bhavaprakasha42.

Purpose of Ayurveda is to maintain health of healthy person and cure the

disease. In the age of 06months to 1 yrs i.e. Ksheerannad avastha,due to improper

Annaprashana vidhi, child is having indigestion and produces so many disease i.e. one

which is Bal-Atisara.

Ayurveda the indigenous system of medicine is an integral part of Indian

culture. Herbal drugs have been in use for centuries by our ancient acharya for

Introduction


preventing and curing various ailments. In the present era, people are still attached

towards these treatment modalities because of its preventative and cost effective

advantage the war between health and disease starts with the onset of life hence every

child needs to be protected from mortality and morbidity to grow up as a healthy

citizen. In urban places due to fast life and work load and in villages due to

povetry,uneducated mother can’t attention to child levels solving condition play vital

role in the disease manifestation, due to lack of clean water, overcrowding,

insufficient understanding deficiency and ingestion of contaminated food and water

overall sanitation are major contributing factors for developing the Balatisar vyadhi.

India is counted of the faster developing country the industrial development

leads to unhygienic environment, causing water pollution, air pollution and sound

pollution etc. This unhygienic environment along the poverty is some of reason

causing any health problem of which is ‘Balatisar vyadhi’

Alteration in consistency or Frequency of stool result in a net loss of fluid and

Electrolytes from the body. It is termed as Atisara. In some tribal places of India

parents are unaware of this Atisara disease and its treatment and their negligence

results in severe dehydration which finally result in death of baby. In India so many

death due to Atisara Vyadhi are noted today also.

In Stanyapanayanum the child should be taken off from the Breast gradually to fed

with other solid and nutrients food and during the period of dental eruption the baby

has a tendency to take every object in to the mouth. This may cause trauma or lead to

further infection. Therefore the pain during eruption may force the child to swallow

the food without proper chewing. This is another possible cause for several digestive

disturbances such as Diarrhea.

Introduction


The present study is Effect of pathadi choorna in Balatisara. Now a days, as soon

as atisara occurs, the first treatment given are the stambana aushadi, especially in

children as the fear of further complications of atisara setting in are more. But this line

of treatment is not advised in the classics, as stambana itself may lead to many

complications. So, instead of such drugs,patha,Aambra bija Madhya twak are selected

here as both are grahi in nature43.

The clinical study deals with observation and discussion regarding the effect of

Pathadi churna combination on 30 patients of Balatisara, After complete examination

of patients and diagnosis of the disease. Pathadi Choorna in the dosage of 750mg to

1500mg43 (according to the age) per day in the divided doses will be administered

before feeding in the morning and evening hours along with equal quantity of Dadhi

for 1 week.in the age group of 6-12 months.

Discussions are made on the observations and results elaborately based on the

observations made during the study, conclusion is drawn and the list of the whole

work is summarized in the summary.

Objective

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page 4

OBJECTIVE

Pathadi choorna indicated in Balatisara by Bhavprakasha although is a simple

formulation containing only 2 easily available drugs, is not in a wide practice

especially in pediatric age group. By considering the properties of the ingredients and

the formulation as a whole and as there was no research wok conducted on the effect

of pathadi choorna in pediatric age group the present study was undertaken.

Objective of the Study;

• To study the effect of Pathadi choorna in Bala Atisara.

• To highlight the formulation Pathadi choorna said in Bhavaprakasha to relive

Atisara in children.

Hypothesis:

Ho: There is no significant effect of Pathadi churna on Balatisara.

Ha: There is significant effect of Pathadi churna on Balatisara

.

Review of litrature

Effect of pathadi choorna in balatisara w.s.r.Infantile diarrhea Page 5

Review of literature:

The life of all living beings is food & the whole world seeks food. The body is the

outcome of food so some times even diseases are the out come of food. Food is the

factor which sustains and supports the Deha, Dhatu’s, Ojas, Bala. The difference

between Ease & disease arises on account of wholesome nutrition or lack of it

respectively. Complication, cleaness of mind, good voice, longevity, pleasure,

satisfaction, growth, strength & intelligence are all dependants upon good utilisation

of food for the above depends upon Agni to contribute the nourishment of the body. It

is obvious that the body elements or sharira dhatus cannot be nourished & developed

when the food is not properly digested by Agni.Atisara is one such disease caused by

mandagni.

1. Review of literatures related to diarrhoea from modern text books like Nelson's

textbook of pediatric IAP, O.P.Ghai’s Essentional paediatric.

1. Review of literatures in detail related to Bala Atisara as per Bhruhatrayi,

Laghutrayi and other text books of Ayurveda.

2. Review of the ingredients of Pathadi choorna including the properties and action

of yoga as per Bhavaprakasha.

4 .Other realiable sources like books of recent authors, research work, journals,

internet related information about diarrhoea and its formulation will be thoroughly

screened.

Review of litrature


Nirukthi:

The disease which is characterised by mala atisarana through guda is called as

Atisara.

Too much flow & in this context, too much flow from anus.

According to Dalhana:-

Too much flow or several bouts of stool passed is Atisara.

According to Manimadhukosha vyakhya:-

Excessive flow of water or fluids through guda1.

This indicates the disturbed udakavaha srotas i.e. atipravriti & vimarga

gamana of APA Dhatu from Udakavaha srotas is brought to kostha & from there

excreted through guda1.

The source of (jala+udaka) water is present in the form of Kledak Kapha in

koshta which is adequate to render normal semisolid consistency to the stools

(Paripindikatwa of purisha).

This is a disease characterised by atidrava mala pravritti due to vimarga

gamana of udaka from udakavahasrotas to the annavaha & purishavaha srotas. The

atisara is caused by the influence of pureeshavaha sroato dusti. Essential factor in this

condition is the abnormal rapid passage of food materials mixed with fluid drawn

from the whole body through the mahasrotas due to vitiation of ahara parinamakara

bhavas.

Review of litrature


PARIBHASHA: (Defination)

Atisara may be defined as a disease characterized by Bhahu drava mala

pravriti related to Annavaha srotas & Purishvaha srotas produced by the disturbance

in Udakvaha srotas.

It is a condition, where watery stool are passed in excess, several times a day

through rectum.

The essential factor in this condition is abnormal rapid passage of food

particles & stools through the gut (Mahsrotus) due to increased peristalsis.

Paryaya:

1) Vireka

2) Atisara

3) Udaramaya

BALA VICHAR:-

BALA AVASTHA:

Aahar For experessing a particular matter the most accepted scientific

approach is the simple process of classification, in Ayurvedic classics, total age of a

human being is classified of all is physical dynamics (i.e.Dhatu pusti.) of these

kaumarbhritya deals with the 1st phase of life i.e. stage of Dhatu pushti, the basic of

which is the maturing Anavaha srotus so the most no of classification are based nature

of food taken by baby.

Review of litrature


According to Vagbhata:A.H.U2/1

Three Avastha of balak are narrated by Vagbhata2:

1) KSheera Vrutti

2) Anna Vrutti

3) Ubhaya Vrutti

Acc to Kashyap Samhita3:

Intrauterine life is also one of the avastha of Balak i.e. Garbhavastha and after

the birth Garbha is called as balak Immediate after birth balak is called as Sadhyojat

balak up to cutting of umbilical cord. After that balak is called as Navajata balak up to

1 months of age3 (28days).

1) Garbhavastha: - This means right from Garbhadhan up to delivery of garba.

2) Balya avastha: - In this Avastha baby on milk feed i.e. since birth to one years of

age is a balya avastha.

3) Kumara avastha: - This Avastha starts from one years of age up to 16 years of

age.

According to Sushruta also described 3avastha of balak4.

1) Kshirap avastha: Is from birth to one years of age. During this period balak is

depends on milk, it also suffers from vyadhi like during this period.

2) Kshiraanad Avastha: - In this Avastha balak is on milk feed as well as some soft

solid diet.

Both are main component of Aahar. This is 1 years to 2 years of age.

3) Anaad Avastha: - It starts from 2 to 16 years of age in this Avastha balak is on full

diet4.

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AHAR /VIHAR:

In Ksirapa Avastha :-

Acco. to Kashayapa is the explained that, give phalarasa at the 9 months of

age after prior to the introduction of the solid3.

Sushrutacharya comments that:

S.S. Sa. 10/49

After the 6th month child should be given Laghu gunatmak aahar.5

Acc. to Vagbhata: - When milk and food is pure then balak remain healthy and if milk

and food is impure then it leads to various diseases6. A.S.U1/40

After teeth eruption, the child should be gradually taken away from breast

feed. At the same time, the child should be given Ksheera along with laghu & bruhna

Aahar.When we detach the child from Breast feed, such child should be fed with

modakas of preenana and jeevana in nature, and the quantity of top feed is increased

top feed following manner7. (A.H. U1/33-38).

1) Manda 2) Peya 3) Vilepi

4) Yavagu 5) Yusha 6) Odana

(Sha.sam.Mad.2/164-166)

1) Manda: - It is prepared in 14 part of water & 1 part of dravya.It is only liquid form

with any food particles e.g. Lajamanda It is a Laghu, Bruhan & Santarpan.

2) Peya: - It is Alpa Sikthayukta i.e. less food particles peya is shulaghni, deepankar,

Pachan, mala sandankar.

3) Vilepi: - It is prepared in 4 part of water & 1 part of dravya. It is Tarpan, Bruhan,

and Pittashamak.

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4) Yavagu: - It is prepared in 6 part of water & 1 part of dravya.It is Balya, Grahi, and

Tarpan & Vatashamak

5)Yusha:- It is prepared by 1 part of food particles i.e. green grain etc. and 14 part of

water & boiled and make it ½ part of total mixture. e.g. Mudga yusha,Kulatya yusha.

It is Ruchikar, deepan & swara, Varna, bala is increased and Agnivardhak.

6) Odana: - It means well cooked rice e.g.shastik shali is used for odana8.

Above gradual process help the Balaka to accept new food with upsetting the

G.I.T.

In Ksiranaad Avastha:-

In this Avastha Balak is on milk feed as well as some soft solid diet. Both are

main component of aahar & total quantity of milk intake to slightly reduced this is 1

yrs to 2 yrs of age. The regular intake of food is advised after 12 months i.e.

Kshiranaad Avastha the factor influencing the frequency of feeding are

According to Ka.khi12/25

1) Desha- Regional practice

2) Agni - Digestive capacity

3)Bala - Activity

4)kala – Seasonal9 .

In spite of all these, the ultimate criteria to determine the frequency of feeding

should be the hunger of the child above (demand schedule)

After the 12 month i.e. Ksiraanad Avastha the child should be given different

types of food according to his desire.

According to ka.Sam.12/19-20

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In this context, food is advised to be mixed with lavan. Lavan rasa is known to

enhance appetite & remove srotaavrodha ensuring maximum bioavailability of

nutrients lehya has been indicated so that the food is given in the semi solid form for

better deglutition10.

For a baby with predominance of pitta is constitution mridweeka with honey

& grutha should always be given, similarly in predominance of vata an appreciable

amount of Matulungha rasa salt should be used also, in Ksiraanad balak vihar is play

important role, due to more exposure of vayu sevena, Atapa sevan, dushita jalapan,

jalakrida, unhygenic surrounding area etc. these produces so many diseass10.

GROWTH AND DEVELOPEMENT:

The net increase in the size or Mass of tissue refers to the term Growth, where

as functional maturation is designated as developement.Hence growth is confinen to

somatic increase deha vridhi & development is concerned with mental or psychic

increase satva vridhi.Though both of these dynamics go hand in hand but are not

interchangeable.

The Ayurvedic concepts which include these processes are arranged

methodically here under the process of growth starts from the time of conception of

the fertilized ovum & continue until the child grows in to a fully matured adult.

At the age of 9 months standing with support and without support at 1 year of age.

At the end of one year child should walk with support & independentely by 15

months.In second year child progress to speak articulated words.

Dentition:

Central incisior: Lower incisior 7 month & Upper incisior 9 month.

Lateral incisior: Lower 11 month & Upper 10 month.

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First molar: 15 month

Canines 18 month

Second molar: 26 month

during the period of dental eruption the baby has a tendency to take every object to

the mouth.This may cause trauma or lead to further infection.Therefore the pain

during eruption may force the child to swallow the food without proper chewing.This

is one of the cause for several digestive disturbance such as Diarrhea.

PARICHARYA:

The general principels and precaution of diet and behaviours with reference to

growing children are laid down as follows:

Maintenance of environment:

The bed,bed sheets,blankets,cloths and other clothes of the child together with the

furniture used by the child should be light,hygienic and of good fragrance.

The said materials must be subjected for fumigation by Rakshoghna drugs like

sarshapa, hingu, vacha etc.

The child should be protected from excessive wind, hot sun light, over shades,

trees, bushes, destructed houses and evil forces.

Maintenance of Personal hygiene:

Child should be thoroughly cleaned from his own excreta like faeces, urine & sweat

etc.The utensile meant for the the usage of child & other garments should also be

fumigated well; deeply spoiled cloths should also discarded.

Childs should be put on the following ornaments, Manidharan, herbs jivaka &

vrashabhaka.etc

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Psychic Support: It is necessary to maintain the pleasant mood of child

kumaragaram is mentioned.

This auditorium is expected to be designed by a skilled person of vastu & the

construction should be very strong with proper lighting & ventilation.such as

arrangement to prevent the entry of animals (dogs, pigs, rats etc.)should be

ensured.The hall should have the facilities like latrine,bathroom,bedroom etc. with in

the auditorium should be maintained sacred traditions like bali,homa,prayaschitta &

raksha karma etc.

Kridanak(Toys)to be given to the child are specially described to be clean

,light,attracting with beautifull shapes,devoid of sharp edges,should not be too small

least child may swallow.

Child should not be put to fear as usually done when he is non cooperative, not

taking feed, especially should not be frightened on the name of devils or demons.

Gentile & delicate handling is required while putting the baby in lap or on shoulder.

Each & every point of the above description speaks of the intense care pertaining

to environmental & personal hygiene coupled with psychic support & nutrients diets

of several choices, ultimately facilitating for proper growth and development of the

baby besides healthy personality. In this way, in the before Ksiraanad Avastha and

Annad Avastha, we should follow the proper Aahar ,Vihar & Paricharya, then

balak will be free from the disease, but we don’t follows the above mentioned criteria,

the baby will suffer from so many disease and the one which is Atisara.

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MAHASTROTASA SHARIR:

Atisara may be defined as a disease characterized by Bhahu Drava mala

pravriti related to Annavaha srotas & Purishvaha srotas produced by the disturbance

in Udakvaha srotas.

Considering function of Purishavaha, it is essential to denote the Sharir of

Mahasrotas, including Annavaha and Purishavaha together and Udakvaha Srotus.

Mahasrotas termed as Sharirmadhya, Mahanirmana described as internal rogmarga,

it is termed as Kostha.

Purishavaha srotas described differently regarding its functions. Anatomically

Purishavaha is distal, end portion of Mahasrotas, proximal portion termed as

Annavaha srotas.

Studying the Purishavaha one should consider the Annavaha also

FIG-1

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MAHASTROTAS:

It consists of following organs:

1. Mukha (mouth)

2. Grasanika (pharynx)

3. Annapranali (Esophagus)

4. Amashaya (stomach)

5. Lagwantra (small intenstine)

6. Bruhadantra (large intenstine)

7. Malashaya (rectum)

8. Gudnalika ( Anal canal)

9. Guddwar (Anus).

From mouth to small intenstine, it is Annavah srotas and other all remains are in

‘Purishvaha srotas’

Sharir Rachana and Kriya of Mahasrotasa:

Sharir Rachana:

Knowledge of Rachana & kriya is very important to understand physiology and

pathology of any disease.

Srotasa means the channel through which each and every matter in the

living body carried away from one place to another.

The Mahasrotus start with Mukha (mouth) and end in terminal portion

Guda (anus).It is the continous tube of irregular shape and size. Hence the name

Mahasrotas (Big Channel.)

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Annavaha Srotasa is concerned with Anna Adana (ingestion of food) Anna

Pachana (Digestion), Sarakitta Vivechana (separation of nutrient and waste portion)

and Rasa dosha (absorption of neutrients).

It is made up of Kala pesi, 20 hands in length having Annapaka or digestive

function.

Mukha:

Mukha is the first part of the Maha Srotasa.

Two Ostha (lips), Danta (teeth), Danta Vestana (gums), Talu (palate), Jihva

(tongue) & Gala (pharyngeal part) together form Mukha.

Annanalika (Oesophagus):

It is also called as Annanadi.

It is made up of Kala pesi.

In Garbha sharira, it is formed in the third month of pregnancy.

Function: Annanadi receives food from the pharynx and passes it to the

stomach by series of peristaltic contractions.

Amashaya (Stomach):

Amashya is the Mulasthana of Annavaha Srotasa.

It is one of the 15 Kosthangas explained by Charaka.

According to Susruta, it is one of the seven asayas.

It is akasa Mahabhuta Pradhana Avayava.

Amashaya is composed of two words.

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Ama and Shaya Ama means undigested food and shaya means cavity or hollow

bag.

Function of stomach

Receives food material, helps in proper mixing of food with digestive

juices by movements and propel food into duodenum.

Secretes gastric juices, which acts as a digestive fluid HCl of gastric juice

acts as an antiseptic against swallowed bacteria.

With the help of gastric juice, converts protein to peptone, coagulates milk,

causes hydrolysis of food stuffs, and digests fats to some extent.

Small quantities of water, saline, alcohol, glucose & certain drugs are absorbed

from the stomach.Manufactures gastrin & castle’s intrinsic factor which act as

stimulants.

Reflexes like gastrosalivary, gastro iliac etc are initiated from the stomach.

Grahani:

Grahani is the first part of Laghwantra receieves food from Amashaya for

further digestion i.e., to receive and retain food for the duration of digestion.

Dosha

Pachaka pitta

Saman vayu

Srotasa: Part of Annavaha Srotasa.

Marma: Nabhi – Which is Sira and Sadyapranahara Marma.

Kala: Grahani is the seat for Pittadhar kala.

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Agni: Seat of Jatharagni.

Function: Grahani holds the food for some time for the further digestion to take

place; and Digests food.

After Sara kitta Vibhajana, part of digested food gets absorbed and remaining

is forwarded to Ksudrantra

SROTAS SHARIR:-

ANNAVAHA SROTAS:

Synonyms- Annavahini, Dhamani, Annanadi, Annavipak Nadi, Galanadi,

Annavahi.

Moolsthana of Annavaha srotas-

Acco.to Su. Sha. 9/13

Sushruta denoted as Aamashaya and Annavaha Dhamani as Mahasrotas,

whether charak described Aamashaya and vamaparshwa. Aamashaya is a common

site for Moolsthana of Annavaha srotas11.

Cause of Annavaha srotas Dusti-

Cause of dysfunction of Annavaha are, ingestion of food which is not tolerated by

the individual (Ahita), Akaal (diet at any time before or after the urge of hunger),

Atimatra (excess quantity of ingestion of food), Agni dushti (digestive juices available

are inadequate), improper dietary habits which vitiates the Annavaha srotas.

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Symptoms of Annavaha srotas dushti:

Acco.to sushruta-Adhaman(flatulence), Shool(colic), Annadwesh(rejection of

food), Chardi(vomiting), Pipasa(thirst) ,Andhaya, Marana(death), are the symptoms

described by Susharut Samhita.

Acco.to cha.vim. 5/7

Anannabhilasha (not willing for food), Arochak (Diminished taste), Avipak

(improper digestion), chardi (vomiting).

Total length of Annavaha srotas is given twenty hasta12.

Digestion of food is done in these two srotas. This digestion is nothing but

conversion of outer panchabhautik matter into suitable bodily panchabhautik matter.

According to Ayurveda this Pachan (digestion) is done through sthulpachan and

sukshmapachan.

That means from outer food material their sthulpachan (i.e. from ahar to ahar

ras) is done, while from liquid material & O2 (i.e. Ambarpiyush) sukshmapachan is

done. This Pachan is done in Pachyamanashay (i.e. Annavahasrotas) and

sthulantra (i.e. Pakvashaya or Purishvaha srotas).

Dosha, Dhatu and mala are derived from ingestion of food .Creamy portion

and waste portion is separated from food. Four type of diet i. e.

Asheet (chewed), Khadita (ingested), Peet (drinked), Leedh converted into

body element by processing through Agni. Agni resides in the alimentary tract.

Agni –

Agni is the digestive capacity of individual. Normal status of Agni represents

strength, life- span, and happiness of individual.

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Classification of Agni-

There are 13 type of Agni- jatharagni, 7 Dhatvagni, 5 Panchabhutagni.

Jatharagni is the main type of Agni which nourishes the other type of Agni.

Grahani is the site of Agni, and function of Annavaha srotas takes place through Agni.

Agni converts the external elements into body constituents.

Utsaha (promptness-alertness), Upachay, Aayu (life span), Swasthya (health),

Oja (active principal-vital capacity), Prabha (lusterness), all depends upon normalcy

of Agni.

Digestion of food is the main function of Agni. Another function related to

digestion is separation of Purisha mala and Mootra mala as solid and watery end

products of the food. All those functions are carried out uninterruptedly by Agni.

Due to vitiation of Agni, it can produce a disease. It is one of vyadhi ghatak.

Abnormal Agni classified into 3 types.

Acco.to Sarangadhara:-

1- Mandagni (diminished digestive capacity)

2- Vishamagni(uneven status of Agni, sometimes normal functioning,

sometimes abnormal)

3- Tikshnagni (Aggravated function of Agni, especially of digestion)

Samagni - indicates normal functioning of Agni. Samagni is responsible for

maintaining health and continuity of life in easy way13.

Mandagni – mandagni is the etiological factor of all disorder. Inactive or diminished

activity of Agni can results in production of Aam (undigested food material) which

cause srotorodha and various types of diseases. Effects of mandagni results in

improper digestion and Vivechan of Aahar – rasa also increase quantity of faeces, foul

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odor and converts it Guru, due to presence of Aam. Mandagni may give rise to

Ajeerna, Adhman, Atisara, Pravahika, Grahani, and group of disorders13.

Vishamagni - vishamagni creates many disorders as Ajeerna, Badhakostha, and

Grahani. Vishamagni affects the purishamal as shushka, ruksha, and causes painful

excretion of faeces.

Teekshagni – sharpened strength of digestion, due to pitta. Relation between Agni

and pitta is that Agni situated into the pitta. Teekshagni digests food material very

rapidly, if food not present in annawaha, reversely it digest the Dhatu13.

Etiological factors responsible for Agni Vikruti-:

There are peculiar factors for vitiating jatharagni is as follows:-

Abhojan(fasting for longer periods),Ajeerna(indigestion), Atibhojan(excess ingestion

of food),vishamasan(food intake irrelevant to Agni and time) ,Asatamya(in tolerated

food)and also ingestion of extreme dry ,oily, guru etc. food excess water intake

diminishes the capacity of digestion.

Anger, fear, passion, anxiety, excitement can causes vitiation of Agni.

AGNIMANDYA in turn affects Avasthapk, improper Avasthapak may lead to Aam,

which is noxious substance having major role in production of disease.

Awasthapaka in Mahasrotas:

The Digestive process in Ayurvedic text is described as Avasthapaka. External

dietary stuffs may not be absorbed there natural form, the ingested food should have

gone through various process. Awasthapaka is essential for conversion of qualities of

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food in the body substances because all the substances ingested are not assimilated in

their original form of body.

For continuity of life, digestion (Awasthapaka) is only the way. There are eight

‘Aahara Vidhi Visheshayatana’ i. e. eight types of rules should be obeyed during

ingestion of food, they are as follows14.

Acco.to:-Ch. Vi. 1/21

1)-Prakruti 2)-Karan 3)-Samyog 4)-Rashi

5)-Desh 6)-Kaal 7)-Upyogawstha 8)-Upayokta14

These guidelines for ingestion of diet are of much importance for proper digestion of

food.

1-Pratham Awashthapaka:

Acco.to- cha.ci9/9

Intake of food is initiated from mouth; Pranvayu helps for the swallowing and

deglutition of food. Material of bolus from mouth passes into the stomach through the

esophagus. During the act of chewing in the oral cavity the bodhak kapha get mixed

with the bolus of food. Jivha as Rasendriya and site of bodhak kapha, tastes are

decides the acceptance of food. Predominance of kapha in pratham Awashthapaka

turns food material in to acceptable manner15.

Entry of the bolus in Amashaya initiates the udiran of poshak kapha in frothy

manner. Pohsak kapha converts ingested matter in more absorbable form, it taste more

sweet and in more liquid form. The food material converted in semi digested form

indicates predominance of kapha in pratham awasthapaka which is limited for

Amashaya, the first processing step of digestion is also responsible for nourishment of

poshya kapha. Deranged function of Amashaya or kapha during pratham

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Awashthapaka affects the consistency of end product i. e. purisha. Improper mixing of

kapha i. e .excess quantity of kapha, makes the Agni diminishes the power of

digestion and purisha appears as saam and Durgandhi. Improper chewing of food

causes the food material to be expelled as it is, in the excreta15.

It is termed as Madhur Awashthapaka.

2- Dwitiya Awashthapaka:

Acco.to- ch.ci. 9/10

Dwitiya Awasthapaka takes place in Grahani, the site of Agni. Pachak pitta

containing Agni performs its functions with the help of Pittadharakala which covers

the Grahani. Function of Grahani are described as Grahan (intake), pachan

(digestion), Vivechen (selective absorption), and Munchan (excretion). All those

function are responsible for centralized digestive process. As the food materials enter

in the Grahani (Duodenum, jejunum, and ileum) from Amashaya, pitta udirana takes

place. Pitta for digestive purpose is good in nature. Samaan Vayu helps all the

functions in Grahani and increase capacity –strength of the Agni, samaan vayu and

Agni are always in correlation with each other. In Dwitiya Awasthapaka, all material

get digested here and separated into two portion i. e. Ahar-ras and Mala portion.

Ahar-ras get absorbed and remained Mala portion is pushed forward for third

Awasthapaka15.

It is termed as Amla Awashthapaka.

Tritiya Awasthapaka:

ch.ci. 9/11

Site of third Awashthapaka is Pakwashya. Apan vayu initiates absorption and

excretion of remaining portion of Ahar. It is termed as Katu Awashthapaka. Poshak

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vayu being created for strengthening of the poshya vayu in body. Vayu being a

ruksha,laghu,chal sukshma etc. performs total absorption and forms fasces which is

soft and bulky , it also helps for the excretion of fecal matter , having completed the

absorption, abnormality in functions of poshak vayu creates various disorders like

Grahani, Atisara, Pravahika.etc15.

Purishadharakala resides along with Pakwashaya performs all these functions of

separation of solid and liquid portion in third Awashthapaka. The liquid portion gets

absorbed and transported to the Basti as Mootra mala. Remaining solid portion from

diet is termed as purisha15.

PURISHAVAHA SROTAS:

Terminal portion of Mahasrotas where formation of Purisha takes place.

Moolsthan:

Cha sha.7/10

Pakvashaya and guda are moolsthan of Purishvaha strotas16.

Dusti Hetu:

Cha.vi. 5/2

It means vidharanat (to withhold the motion of stool), atyashanat (to eat more),

ajirnata (improper digestion), adyashanat (to eat when the first food taken is not

digested), and agnimandya, krushata causes dusti of Purishvahstrotas17.

Dusti Laxan:

Cha.vi.5

It means defecation with stress (sakashta malpravrutti), less and with pain

defecation, hard stool with more quantity and to sit more time for defecation17.

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Su.sha.9/12

-Susrutachcrya, described viddha lakshanani of Purishavaha srotas as Anah

(flatulence), Grathitantrata (hard-bead like stool formation), and Durgandhi18.

Purishadharakala:

Su.sha. 4/17

Sushruta emphasized the concept of kala in sharirsthana. Total numbers of kala given

in the text are seven i.e.

1-Mansadharakala. , 2- Raktadharakala , 3- Medodhara ,4- Shleshmdharakala

5-Prishadharakala, 6- Pittadharakala, 7- Shukradharakala.

Chronologically 6th is the Pittadharakala, situated in the Grahani, which is the site of

Agni responsible for digestion, absorption and sepration of Ahara.

Pittadharakala represents exactly the anatomical site of Agni. Active and inner most

lining of Grahani is pittadharakala. Two basic function of pittadharakala are Pachan

(digestion), vivechan (selective absorption), where the total digestion of food take

place19.

Function of Purishadharakala:

The fifth purishdhara kala is situated in Bruhadantra (Pakwashaya) and work

as ‘Malavibhajana Kala’ (i.e. stool formation). It is also termed as Maldharakala. Diet

which is digested and received from the Grahani should be absorbed by the

purishadharakala. Purishadharakala divides digested food into two portion, solid and

liquid portion i.e.stool and urine. The description of kala point out the portion of large

intestine i. e. mucus membrane and various glands spread throughout the tract.

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Pakwashaya (Purishaadhisthana)

Formation of purisha as a solid and excretable material takes place in the distal

end of the alimentary system. Function of the distal part is totally different as

compared with the proximal portion of gut.

Kostha or Kosthanga given in the text are 15 in number, they are classified according

to their function as follows,

1- Organs pertaining to the process of digestion – Nabhi (Grahani), Amashaya,

Kshudrantra, Yakruta (liver), kloma.

2- Organs pertaining Ras and Rakta - Hrudaya and Pleeha.

3- Organs pertaining to Purishavaha and Pakwashaya- Uttarguda, Adharguda,

Sthulantra, Mutravaha, Vruka and Basti.

4- Covering to all the intra abdominal organs – Vapavahanam.

Pakwashaya is the moolsthan of purishavaha srotas. Role of Pakwashaya in processing

of Purisha (Stool) is extraordinary. Apanvayu in coordination with the maladharakala

situated along with the Pakwashaya separates the Mala portion.Pittadharakala is

responsible for the vivechana of food, so as Purishadhrakala is essential for the

vivechana (selective absorption) of Purisha.

Pakwashaya:

Synonyms- Sthulantra, Bruhadantra, Pakwadhara, Pakwadhan, Malashaya,

Purishadhara, Maladhara, Purishashaya,

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1) There is no controversy in mentioning the Pakwashaya as moolsthana of

Purishavaha srotas. In charak samhita and sushruta samhita also mentioned the

moolasthana of purishavaha srotas. Another moolasthana of purishavaha is mentioned

by texts is different, Sushrut mentioned it as a Guda, Charaka mentioned as a

sthulguda, and Vagbhata mentioned it as a Stulantra.

2) Purishadharakala remains with the support of Pakwashaya. Obviously the function

of the Purishadharakala is observed in the pakwashaya only. Purishadharakala covers

all GI system but a function of it is active in the Pakwashaya that indicate the

functionally active part of Pakwashaya is Purishadharakala.

3) The site of Apan vayu is Pakwashaya; it helps Purisdharakala for selective

absorption and formation of Purisha.

4) Formation of Poshya (Asthayi) vata dosh takes place in Pakwashaya, during the

formation of Purisha. Poshak vata dosh nourishes the other site of vata all over body

to determine the organ Pakwashaya one should consider the function and location of

Pakwashaya. It is one of organs of Kosthanga. Pakwashaya is situated in the pelvis

cavity, amongst Nabhi (umbilicus) and upper portion of abdomen.

Haranchandra clearly stated that, Ashaya (hollow organ) containing Pakwa (ripped

portion of diet) is Pakwashya. Unduka/Purishadharakala is situated at the beginning of

Pakwashaya, and here initiates the function of separation of mala until the defecation.

Pakwashaya begins from Unduka up to the anus. Derangement in the Pakwashaya

anatomically and physiologically alters the constitution of Purisha (Varna, Gandha,

Swaroopa etc.). Disorder of Pakwashaya affecting and changing the stool, one can

determine the nature of the disease of Pakwashaya by examining the stool.

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Guda (Anus):

Second moolsthana of Purishavahasrotas along with Pakwashaya is gud. End organ

as well as part of alimentary canal is termed as Gud. Gud anatomically devided in three portions:

1-Uttargud 2-Adhargud 3-Sthulgud.

1- Uttargud- site for accumulation of purisha mal. Purisha remains in uttargud for a

certain periods, urge of defecation does not occur.

2- Adharguda- expels fecal matter from Pakwashaya; urge for defecation starts when

Purisha enters in the Adhargud.

3- Sthoolagud- contains three structures (Trivalee).

A- Pravahanee B- Visarjanee C- Samvarnee

UDAKAVAHA SROTUS:

C.chi.9

Talu(Palate)& kloman are the site of origin(controlling organ) of the channeles

carrying watery element.The characteristic manifestation of the vitiation of these

channeles are the dryness of the tongue,palate,lips,throat & kloman & excessive

thrist20.

Srotodushti Karan:

cha.chi.9

Excessive Heat, Ama Fear, Excessive intake of liquid, Excessive intake of ruksha

aahar is the causes of Udaka vaha sroto dushti along with Trishna Vega dharan which

is the main cause of its dushti20.

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Udakvahasrotus Chikitsa.

Cha.vi.5/26

Accharya Charak has advised to follow the treatment of Trishana Vyadhi for the

treatment of Udakavaha Srotus as follows: Sheeta jalpan, shitaveeryatmak Dravya

like chandanasav, Phalarasa, Manda, Madhu, Jala along with sugar21.

Disease Review


DISEASE REVIEW

AYURVEDIC VIEW Nirukthi :

The disease which is characterized by mala atisarana through guda is called as

Atisara.

Too much flow & in this context, too much flow from anus.

According to Dalhana:-

Too much flow or several bouts of stool passed is Atisara.

According to Manimadhukosha vyakhya:-

Excessive flow of water or fluids through guda1.

This indicates the disturbed udakavaha srotas i.e. atipravriti & vimarga gamana of

Apa Dhatu from Udakavaha srotas is brought to kostha & from there excreted through

guda1.

The source of (jala+udaka) water is present in the form of Kledak Kapha in

koshta which is adequate to render normal semisolid consistency to the stools

(Paripindikatwa of purisha).

This is a disease characterised by atidrava mala pravritti due to vimarga

gamana of udaka from udakavahasrotas to the annavaha & purishavaha srotas. The

atisara is caused by the influence of pureeshavaha sroato dusti. Essential factor in this

condition is the abnormal rapid passage of food materials mixed with fluid drawn

from the whole body through the mahasrotas due to vitiation of ahara parinamakara

bhavas.

Disease Review


NIDAN PANCHAK:

THE NIDANA OF ATISAR:

The concept of nidana panchaka plays important role in knowing the vyadhi, so

among the panchanidana, nidana is the first and it's description is given below

NIDANA:

Nidana is the one which reflects the characters of vyadhi. Nidana is the prime

cause of vyadhi. That is why the acharyas gave the chikitsa sutra as nidana

parivarjana i.e., by avoiding the nidana we can get rid of diseases.

The Nidana can be classified into two categories.

1. Samanya Nidana

2. Vishisha Nidana

1. Samanya Nidana: It is the common set of nidana, which leads to the

vitiation of doshas and that in turn produces the samanya samprapti.

2. Vishisha Nidana: When the nidana causes the vitiation of particular doshas

and produces the disease accordingly, which will be predominant of that particular

dosha is called as "Vishishta Nidana".

For Ex: Ati snigdha Guru Ahara leads to kapha prakopa, which in turn produces

kaphatisara. In the same way Ushna tikshna ahara leads to the pitta prakopa and

hence produces pittatisara, the vatika nidana causes vataprakopa and produces shoola

and vatatisara.

The Nidanas described in Ayurveda can be broadly divided into

Disease Review


1. Ahara (Dietic or Nutritional)

2. Mitya upacharaja - Mainly panchakarma

3. In Grahabhadhajanya for Ex.Putana, Revati.

4. Associated with other disease like Krimidosha etc.

5. Rutu viparyaya etc.,

6. Psychological-Bhayam,Shoka

The etiological factors are broadly divided into four

1. Infections

2. Dietic or Nutritional

3. Drugs

4. Non Specific

Looking at the broad classification of Nidana in the both the sciences we can include

non-specific type of nidana in rutu viparyaya etc., (type of non specific) type of

nidana explained in Ayurveda.

The etiological classification i.e. Drugs or Antibiotics can be included under

Mitya upacharaja, but one can not attribute antibiotics directly but the nidanas that are

discussed under mityaupacharaja in Ayurveda are snehapanadi panchakarma kriya

vibrhama where in we can include the mityaupacharaja of Shamana dravyas also. So

that antibiotics or Drugs as etiological factor for atisara can be understood as similar.

The nutritional catagory can be included under aharaja i.e., guru snigdha

atimatra, virudda, adyashana etc., type of bojana which have direct similarity to the

cause attributed in modem science such as overfeeding, starvation, food allergy, food

Disease Review


poisoning etc., The infections which includes parasites, virus, fungal, bacteria etc.,

whether it can be included under dustambupana, krimidoshataha etc., is debitable.

Specific Guru Gunatmaka Food Substances

1. Ati Guru - Heavy (difficult to digest) food

2. AbhiSyandi - like Dadhi, Matsya (which creates secretion).

3. Atiushna - Very hot foods – like Citraka, chilly etc.

4. Ati snigdha - Too oily.

5. Ati Ruksha - Too dry like Yava, Kulattha.

6. Ati Drava - Liquid diet

8. Dushita Jal pan - Contaminated food

9. Paryujeeta - Disintigrated food, rotten or adulterated food, Overnight food.

Non – adherence to or transgression of Aaharvidhivisheshayatanas i.e.

1. Prakuti: (Quality or nature of the food article)

2. Karana (Method of preparation)

3. Sayoga (Combinations)

4. Rasi (Quantity)

5. Dosa (Habitat)

6. Kala (Season, time)

7. Upayoga sanstha (Method of usage)

Disease Review


8. Upayokta (Person using the food, his body constitution, his likes dislikes etc).

Eating style:

1. Adyashana - Consuming food just after previous food is digested.

2. Ajeerna Bhojana - Eating when there is already indigestion.

3 Viruddahar -mamsa ahar +milk +banana

4Vega vedharana -Mala, mutra Vega dharan

Table no-1

SL.NO SAMANYA NIDANA Su. A'H B’P M’N

1. Atiguru matraguru, Swabava guru,

Samskara guru Ahara + - + +

2. Atisnigdha Ahara + - + +

3. Atiruksha Ahara + + - +

4. Atiushna Ahara - - - +

5. Atidrava Ahara + - - +

6. Dooshita Jalapana + - + +

7. Dooshita Madyapana + - - +

8. Atyambu Pana + - - +

9. Atimadyapana + + - -

10. Atisheethala (Jala kreeda etc.,) - - - -

11. Virudhashana + - - +

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12. Adyashana + - + -

13. Apari pakvashana + - - -

14. Vishama bhojana + - - +

15. Ayoga + + - +

Vamana Ayoga

Sneha sweda, Virechana

Asthapana and Anuvasana ayoga

16. Atiyoga - + - +

Vamana Atiyoga

Sheha sweda, Virechana

Asthapana and Anuvasana atiyoga

17. Viparyaya + - + +

Satmya Viparyaya and ruthu Viparyaya

18. Bhaya + - + -

19. Shoka + - + +

20. Mutradi vega vidharana + - - +

21. Kmsha pashu mamsa bakshana - + - -

22. Tila sevana - + - -

23. Upadrava roopa + + + -

24 Ajeema + + - +

VISHESHA NIDANA

Disease Review


VATATISARA:

Excessive exposure to vata (wind), Vyayama (Excerise), Atapa (Sunlight),

Rooksha (Dry), Alpa (Little Quantity), Madya (Alcohol), Excessive Sexual

intercourse, Vegavarodha.

PITTATISARA:

Excessive consumption of Salty, Sour, Spicy, alkali, hot teekshana food and

exposure to Surya santhapa, Usha marutha, Krodha and Santhapa.

KAPHAJATISARA:

Heavy, Sweet, Cold, Excessive eating, tension free, sleeping during day time

and laziness.

SANNIPATAJATISARA:

Cold, Oily, Dry, Hot, Heavy, Rough, Hard, Incompatible, non accustomed,

Untimely food, Contaminated alcohol, Procedure of oleation etc, excessive exposure

to vayu (wind), agni (heat), surya (sun light), jala (water), improper sleep, day sleep

& suppression of urges.

RAKTATISARA:

Intake of Pittakara ahara during Pittatisara.

SHOKATISARA:

Due to loss of property, due to bandhunasha and alpa bhojana.

JWARATISARA:

Disease Review


Nidana of both jwara and atisara.

It is upadrava of jwara

It is caused due to revathi dosha22

- Kasyapa Samhita Ni. 4/20-29

One who drinks first in hunger and eats first in thirst develops athisara23.

- Kasyapa Samhita Ni. 7/27

POORVA ROOPA OF ATISARA:

Pricking type of pain in Hrudaya, Nabhi, Payu, Kukshi and Udara.

Bodyache

Obstruction in Vata movement

Constipation

Distention of abdomen

Indigestion

Yogaratnakara Balrog

Sushruta

Sam.Uttaratantra 40

MadhavaNidana Atisar nidan

Bhavaprakash Mdhym khad2

Toda in Hrudaya, Guda and Koshta

Disease Review


Body ache (especially Pindikodwestan)

Constipation

Distention of abdomen

Indigestion

Astanga sangraha chi

Kukshi, Udara, Vaksha, Nabhi and Payu satata Vedana

Obstruction of movement of Vata24 Harit sam.3/3

SAMPRAPTI:

SAMANYA SAMPRAPTI:-

Due to Nidan sevana Vata gets vitiated because of the abnormal

function of Aharaparinamakara bhavas leading to mandata of Jatharangi

Causing the increase dravatwa in pureesha in Pakwashaya resulting in

Atisara25.

(Ma.Ni.Atisar ni,

A.S.Ni.8/3-4)

Disease Review


Nidana Sevana

Vitiation of Vata +Apa dhatu vikriti

[By the impairment in aharaparinamakara bhavas in Amashaya]

Mandagni

[Leads to]

Dravatwa of Pureesha in Pakwashya

Bahu Drava Mala Pravritti.i.eAtisara

SAMPRAPTI GHATAK:

Dosha: Vata pradhan Tridosha.

Dushya: Udakya Dhatu.

Rogmarga: Abhaynatar.

Disease Review


Sancharstan: Pittadhar kala, Purishadhara kala.

Udabhavastan: Amapakvashaya.

Adishtan: Pakvashay.

Srotas: Annavaha, Udakavaha, Purishavaha srotas.

Srotodusti Laxana: Vimargaman & Atipraviriti.

Agni: Jatharagni Mandya.

Ama: Jatharagni Mandya janya ama.

SAMPRAPTI VIGHATAN:

In Pathadi Churna there are following ingridients:

1) Patha 2) Ambrabija madhya

Pathadi churna works at various levels of samprapti of Atisar and correct

Dosha Dushti and improves functioning of Agni.

By virtue of its Tikta, Katu- Rasa, Katu -Vipak, Ushna-Virya, Laghu –Guna and

Kapha shamak karma, Pathadi churna causes shoshna of Apa Dhatus which is Drava,

Sara, Adra, Kledak, Sheeta and Guru and there by reduces the Atipravrti lakshana in

Atisar

Disease Review


Pathadi churna reduces Agnimandya by its Tikta, Katu Rasa, Ushna veerya and

Deepan guna.it acts as Ama pachan by Katu rasa ,Katu vipak and Pachan karma.

It causes Vata anuloman and there by correct Vimarga gaman and Ati Drava pravriti

lakshanas in Atisar.

In this way Pathadi churna corrects Dosha dushti, improves Agni, functioning of

Pakwashaya and treat the Atisar.

VISHESHA SAMPRAPTI:

VATATISAR:

Due to the Nidana sevana, Vata gets increased, diminishes the gastric fire, the

water content of Mutra and swedha which is present in Pakwashaya will not been

absorbed which leads to liquification of mala and results in Vataja Atisara

Nidana Sevana

Increase of Vata

Which in turn brings water content of Mutra and Sweda into Malashaya

Mandagni

Disease Review


Atisara26 (cha.chi.19/5)

PITAJATISAR:

Due to the Nidana sevana, the Drava and Ushna guna of Pitta increases and

causes the Pakvashaya Dushti where Purisha bhedana takes place resulting in

Pittatisara26.

(Ch.chi.19/5)

Nidana Sevana

Vitiation of Pitta & Increase of Drava guna of Pitta

Agnimandya

Pakwashaya dusti

[Pureesha bedana]because Ushana,Drava Sar guna

Disease Review


Atisara26

SLESHMATISAR:

Due to the Nidana sevana, guru, madhura, sheeta, snigdha, guna of Kapaha

increases and gets collected in the Amashaya where it decreases the Jatharagni comes

to the Pakvashaya forms drava mala resulting in Sleshmaja Atisara26.

(Cha.Chi.19/5)

Nidana Sevana

Vitiation of Kapha &Increase in Guru, Madhura, Sheeta, Snigda guna of

Kapha in Amashaya

Mandagni

[By the abnormality of Aharaparinamakar bhava]

in Pakwashaya does the dravatwa of mala

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Atisara26

SANIPATAJATISAR:

-Due to Nidana sevena, Tridosha increases lead to Athi Krishata, Mandagni and

Pakavashaya dushti resulting in Sannipataj Atisara27.

SHOKATISAR:

When hetu sevan (shoka etc.)is more, ashru vegadharan takes place,due to

which vimarga gaman of ashru its reach in koshta and agni become manda and rakta

shobha takes place and it goes downwords & mixes with purisha.Its kakanatika

sadrasha colour is taken by purisha and shokatisar takes place28.

Nidan sevan Shoka etc.

Aasru (Tears)

Vegadharan

Disease Review


Kostagaman

Agnimandya

Raktakshobha

Purish misran

Atisar28

But according to Charaka the lakshana of Shokathisara is mentioned. He says

that both bhayaja and Shokathisara are caused due to Manasika dosha and will have

the same clinical feature of Vataja Atisara.

RAKTATISAR:

Disease Review


If a Person with Pittatisara,does not take treatment and follows Pitta vitiating

Ahara Vihara there will be the further aggravation of Pitta and will vitiate the Rakta

and causes Raktatisara29.

If the Person suffering from Pittatisara consumes the Pitta aggravating diet in

large quantity, then he will develop the dreadful Raktathisara30

The person with Pittatisara when consumes the Pittavardhaka Ahara, the vitiated Pitta

causes Raktatisara and alongwith it there will be serious symptoms like fever, pain,

burning sensation and guda paka31.

DISCUSSION ON THE SAMPRAPTI OF ATISARA:

Atisara can be discussed under two heading

1. Amatisara

2. Pakwatisara

In this context, the applicability of the pathology of these two to the present

age and time is discussed.

In Amatisara, the Pathology is more dominant in the Pittadhara kala rather

than the Pureeshadhara kala. Here the vitiation of Pittadhara kala occurs due to the

Nidanasevana like guru snigda ahara, dushita ambupana etc.. This Pathology is

similar to that of the Osmotic Diarrhoea where even the causes are similar like the

excessive intake of carbonated fluids (Dushta ambupana), non absorbable solutes etc.,

Disease Review


and the treatment is also similar to that of Amatisara where langhana is indicated i.e.,

here the Diarrhoea comes down by the non intake of food.

In Pakwatisara, the Pathology is more dominant in Pureesha dahara kala i.e.,

Pakwashaya is more dominant in Pureeshadhara kala i.e., Pakwashaya than Pittadhara

kala. Here the vata vriddhi occurs due to nidana sevana and this vriddha vata hampers

the dosha samshoshna (Kleda somshoshna) and it drags the udakamsha from the

udakavaha srotas (rasa, kapha, meda etc) in leading to the increased watery stool. The

pathology is similar to that of the secretory Diarrhoea, where there is the activation of

intracellular mediation and water is dragged into the colon.

SAMANYA LAKSHANA:

Alteration in consistency or frequency of stool result in a net loss of fluid and

electrolytes from the body. It is termed as atisara.

The excessive saran of purishayukta apa dhatu through Adhomarga is termed as

Atisar32.

A.H.Ni8/17

Bahumala Pravriti i. e excessive watery stool from anus is the Pratyatmik lakshana of

ATISAR

Dryness of skin,mucous membrane,

Increased Thrist,

Dreased urine out put

Disease Review


The Symptomalogy of Vatatisar is presented in two heading

1) Amatisara

2) Pakvatisara

1)Amatisara Lakshnas

Amayukta shweta Varna mala pravriti, with bad odour.

Mala along wih pain,

Mala along with sound

Admana

Atopa

Due to Ajeerna Amma the vitiated dosha will further vitiate the Kosta and will

bring out the feces along with the food and the mala will have different colours

coming out with difficulty very frequently33

2)Pakvatisara Lakshana:

Little by little in small quantity of mala

Mala Along with sound,

Mala Along with Pain

Mala Along with froth

Mala Along with tearing pain

Mala with nodule

Disease Review


Horripilation

Difficulty in breathing

Dryness in mouth,

Pain in Kati, Uru, Trika, Janu, Parswa,

Stricture in anus

In Astanaga Hrdaya ch. it has been told that when the ama has been well digested, the

Agni gets strong and the Patient will eliminate feces which is frothy, slimy associated

with the Pain in little quantity and very frequent.

According to Ma.Ni Atisr ni, Su.Sam.Ut 40 & Yogaratna Balrogadikr

He explains the features of Amatisara as follows i.e

- When put in water it sinks, along bad odor.

- Broken an little by little. When these features are absent then it considered as

Pakvathisara, here there is feeling of lightness in body . If the feces is immature it

sinks in water whereas, the mature one floats on water except in condition excess

liquidity, compactness, coldness and presence of mucus.

- The immature stool has foul smell with painful flatulence, distressing constipation,

and abnormal salivation. It is free from ama.

Disease Review


Pittatisara Lakshana:

According to various accharyas the Symptomalogy of Pittatisar as follows

Table no.2

LAKSHANA Ch. A.S. Bh.r. Su. Y.R. M.N. Bh.p. G.N.

Ha.

Pureesha With

Yellow, green, + + + + + + + + +

Black colours

Pureesha with blood

And pitta + + + - - - - - -

With thirst + + + + + + + + +

With Burning sensation

All over the body + + + + + + + + +

With Sweat + + + + + + + + +

With Unconsciousness + + + + + + + + +

With Pain + + + - - - - - -

With Inflamation of the

Rectum + + + - - - - - -

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WithPaka + + + + + + + + +

WithJwara, shosha, pandu

Brama & arati - - - + - - - - -

Kaphatisara Lakshana:

According to various accharyas the Symptomalogy of Kaphatisar

as follows

Table no.3


Ha.

Oily Feces + + + - - - - - -

White Feces + + + + + + + + +

Slimy Feces + + + - - - - - -

Thread like Feces + + + - - - - - -

Feces with Ama + + + - - - - - -

Feces Heavy in nature + + + + + + + + +

Feces With bad odor + + + - - - - - -

Feces With kapha + + + + + + + + -

Disease Review


Feces With pain + + + - - - - - -

Passing feces

Very frequently + + + - - - - - -

With Pravahika + + + - - - - - -

Heaviness in guda, udara,

Basti & vankshna + + + - - - - - -

Un-satisfaction even

After the elimination of

Feces + + + + + - - - -

Horripilation + + + + + - - - -

Feeling Sleepy + + + + + - - - -

Feeling Lazyness + + + + + - - - -

Dislike for food + + + + + - - - -

Feces Spreads - - - - - - - + +

Cold - - - - - - - + -

Tiredness - - - + + - - - -

Heaviness in the body - - - + + - - - +

Disease Review


Vomiting - - - + + - - - -

Anorexia - - - + + - - - +

Sannipathaja Atisara Lakshana:

According to various accharyas the Symptomalogy of Sannipathaja ATISAR as

follows

Table 4


Ha.

According to Dosha and

Datu involvement different

Colours of Pureesha will be there like

Green, yellow, blue,

Manjista red, black, white + - - - - - - - -

Colour of meat cleaned + - - + + + + + -

Water

Like pork + - - + + + + + -

Pureesha With flatulence + - - - - - - - -

Pureesha With

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/without pain + - - - - - - - -

Pureesha With nodules

and ama + - - - - - - - -

Tiredness - + + - - - - - -

With fainting - + + - - - - - -

Looseness of joints - + + - - - - - -

Dryness in mouth - + + - - - - - -

Pureesha With

many colours - + + - - - - - -

With thrist - + + - - - - - -

Pureesha Like

colour of tila - - - - - - - + -

Pureesha Like

the colour ripen

jambufruit - + + - - - - + -

Disease Review


Raktathisara Lakshana:

Thirst

Pain

Burning sensation

Inflamation of rectum34,35

Cha.Sa.19

Ha.Sam.3/3

Jwara, pain, bruning sensation, inflamation of rectum33

-

Su.SaUt.40

In Atisara manifestaion of laxanas depends on the involvement of Doshas, just like

the clinical presentation in Diarrhoea depends upon the underlying

pathophysiological changes taking place in the gastro intestinal tract.Though many

types of Atisaras have been identified, the pathophysilogy is mainly due to Vata, Pitta

and Kapha Dosha. In a similar way in Diarrhoea three clinical types have been

identified. Each reflecting a different mechanism which can be corelated to these

doshic type, Vatajatisara resembles with that of secretary Diarrhoea because both of

them are characterised by acute watery Diarrhoea, Pittaja variety of Atisara matches

with that of invasive Diarrhoea because of the resemblens of symptoms like that of

blood and mucous mixed stools etc., where in Kaphaja variety of Atisara will be

corelated with Osmotic Diarrhoea. The reason behind it is similarity between the

etiological factors i.e., intake of high osmolar solutions like fluides with high sugar

Disease Review


contents etc., more over the clinical features of Kaphaja Atisara resembles with that

of Osmotic Diarrhoea90

CRITERIA FOR ASSESSMENT OF CURE:

Table no.5

LAKSHANA Su. M.N. Y.R.

One who passes feces without - + -

Obstruction of vata and mutra

With good gastric fire + + -

Lightness in abdomen + + -

The vyapatu is controlled - - +

Control of flatulence - - +

SADHYASADHYATHA

Asadhya Laxana

Table 6

Lakshana Related to Pureesha

Ch. M.N. Su.

Like the colour of the ripen jambu fruit + + -

Disease Review


Like the pieces of liver + + -

Like ghee, oil, vasa, majja, veshavara, milk and

Curd + + +

Colour of meat washed water + + -

Black, blue and aruna + + -

With different colours + + -

Dirty + + -

Slimy + + -

Thread like + + -

Colour of peacock feather + + +

Smell of dead body + + -

Datu srava with or without mala + + -

Colour of milk, honey, medha, manjista - - +

Like matsulunga - - +

With pus - - +

Sthanika Laxan

Disease Review


Inflamed rectum + + +

.Prolapsed rectum + + -

Pain in all joints + + -

Loss of sphincter control - - +

Sarva Daihika laxana

Person who has losted bala, mamsa

And rakta + + -

Tastelessness + + -

Tiredness + + -

Excessive talking + + -

Giddiness + + -

One who has lost confidence + + -

UPADRAVA / COMPLICATION:

Table 7

- Thirst (Trishna)

- Burning sensation (Daha)

Disease Review


- Breathlessness (Shwsa)

- Giddiness (Brhama)

- Hiccup (Hikka)

- Fever (Jwara)

- Shofa - Pain (Ruja)

- Fever (Jwara) - Thirst (Trishna)

- Breathlessness (Shwasa) - Cough (Kasa)

- Tastelessness (Amchi) Cha.Sam19

- Su.Sa.Ut40

Shofa- Pain - Fever (Jawara)

- Thirst (Trishna) - Breathlessness (Shwasa)

- Cough (Kasa) - Tastelessness (Aruchi)

- Vomiting (Chardi) - Fainting (Moorcha)

- Hiccup (Hikka)

Yogaratnakara balrogadhay

Now I would like to discuss the consequences or the complications of atisara. The

most important complication of diarrhoea is dehydration and malnutrition. As we

Disease Review


look at some of the upadravas of atisara like thrishna, shwasa, moorcha, arati,

sammoha, tandra etc., they are well indicative of severe stage of dehydration. At this

stage acharyas have suggested to treat the patients carefully or not to treat at all. Also

aruchi, ksheena bala, mamsa, shonita are very much indicative of malnutrition.

Even though many other complications are mentioned in the context of atisara, in case

of balatisara dehydration and malnutrition are to be highlighted

PATHYAPATYA:

Pathya:

Fruits, cereals, hot water are beneficial.

Apathya:

Patients with Athisara should not take lasuna.

Unctious substance, sudation, meat soup36

Pathya:

Looking at the predominance of the doshas, the physicians should

prescribe the laghu,ruchikar for good result during treatment. The curd with

cream is mixed with honey is consumed alongwith food, the milk which is

boiled and cooled in a golden vessel, the food given with vidari gandhadi

shirpak, sangrahi and ruchikar drugs, masya, the mamsa rasa mixed with the

vata hara drugs processed oil and ghee, ajamamsa, deer, avi the aja rakta

processed with oil and ghee consumed with curds or the thick meat soup of

peacock and tittira bird mixed with yusha of green gram and added to curds,

Disease Review


the well cooked black gram mixed in ghruta manda alongwith pepper powder

and consumed with curds.

The dharoshna milk is beneficial, the yavagu which quenches thrist

which is light appetizing is always beneficial in fever and athisara37,38.

- Su.Sam.40-145/149

‐Yogratnak. Balarogadhyaya

Disease Review


TABLE 8

Disease Review


MODERN REVIEW:

Diarrhea is one of the scourges of mankind. It is an important cause of

mortality and morbidity in children; especially in developing countries. There are 5

billion episodes of diarrhea every year, out of which 3 to 5 million children die. Thus

1 child is dying of diarrhea every minute in the world. This is very unfortunate as

most of these deaths are preventable39.

Derivation of the word 'Diarrhea' -

The term diarrhea is derived from Greek and it means to flow through.

Definition -

It is a condition characterized by an increase in frequency, fluidity and weight

of the stool, compared to normal bowel habit of the child. A neonate may pass 8 to 10

liquid stools per day which is normal for him, but it is abnormal in an older child40.

Fluid absorption by gut -

Total fluid reaching GIT in adult - 9 litres

• 2 liters - from food

• 7 liters - from various body secretions like saliva, bile, gastric juice, pancreatic

juice and intestinal juice

GIT is having enormous absorptive capacity.

Out of 9 litres, 8.8 litres will be absorbed. (99%)

Absorption by small bowel - 7.5 litres

In diarrhea - upto 12 litres

Disease Review


Absorption by colon - 1.3 to 1.4 litres

In diarrhea - upto 5 litres

Thus fluid content of stool - 100 to 200 ml. / day

There are reserve mechanisms in GIT and diarrhea can occur only if these

mechanisms are overcomed39.

The absorption of nutrients and fluids in acute diarrhea is normal and hence

the child with acute diarrhea should not be starved. He should be given his normal

diet and fluids.

Classification of diarrhea -

• Depending on duration

• Depending on the site of pathology

• Depending on pathophysiology

Depending on duration39 -

1. Acute diarrhea - Usually subsides within 1 week but may go upto 2 weeks.

2. Chronic diarrhea - Lasts for more than 2 weeks.

Depending on the site of pathology –

1. Small bowel diarrhea

2. Large bowel diarrhea

Depending on pathophysiology39 –

1. Osmotic diarrhea

2. Secretory diarrhea

3. Invasive diarrhea

Disease Review


4. Congenital secretory diarrhea

5. Hypermotility diarrhea

Osmotic diarrhea –

It is caused by,

1. Ingestion of solutes that can not be digested or absorbed.

2. Diseases that prevent the patient from absorbing solutes that are normally

absorbed.

It is characterized by malabsorption of nutrients, electrolytes and water.

Causes –

1. Unabsorbable solutes e.g. lactose, magnesium, lactulose

3. Small molecules e.g. amino acids, monosaccharides

4. Juices containing large quantities of carbohydrates e.g. apple juice

5. Mucosal diseases e.g. celiac disease, Crohn's disease, short gut syndrome39

Pathophysiology of Osmotic Diarrhea

Non - absorbable solutes

↓

Accumulation in the gut

↓

Increase in intraluminal osmotic pressure

↓

Disease Review


Retards water and electrolyte absorption

↓

Osmotic diarrhea

Osmotic diarrhea decreases if ingestion of solute is discontinued.

Secretory diarrhea80 -

It is due to abnormal secretion of water and electrolytes.

Causes –

Exogenous factors

1. Laxatives

2. Bacterial toxins

3. Prostaglandins

4. Endogenous factors

1. Gut peptides e.g. Vipoma, gastinoma

2. Bile acids

3. Fatty acids

4. Defective transport of sodium or chloride Secretory diarrhea persists in spite of

fasting.

Disease Review


Difference between Osmotic and Secretary Diarrhea39

Table no-9

Osmotic diarrhea Secretory diarrhea

Stool volume < 1000 ml/day > l000 ml/day

Response to 24 hours of fast Decreases Persists

Reducing substance Present Absent

Causative agents of acute diarrhea39

• Viruses

1. Rota virus

2. Norwalk agents

3. Adenovirus

4. Calici virus

5. Astra virus

6. Arbo virus

7. Corona virus

8. Enteroviruses

• Bacteria

1. E.coli

2. Vibrio cholerae

3. Shigella

4. Salmonella

Disease Review


5. Campylobacter jejuni

6. Staphylococcal aureus

7. Clostridium perfringens

8. Yersinia enterocolitica

9. Vibrio parahemolyticus

10. Bacillus cereus

• Protozoa

1. Entamoeba histolytica

2. Giardia lamblia

3. Balatidium coli

• Helminthes

1. Strongyloides stercoralis

2. Trichuris trichuria

• Fungal

1. Candidia albicans

2. Croptosporidium

• Associated with respiratory and urinary tract infections

• Non-infectious causes (rare)

1. Dietic

2. Food poisoning

3. Food allergy

4. Drug induced e.g. Ampiciilin

5. Psychogenic (emotional)

6. Overfeeding

7. Metabolic causes e.g. hyperthyroidism

Disease Review


8. Inflammatory bowel disease

Viral diarrhea -

Rota virus is the most common cause in children between 6 months to 2 years of

age.

It can cause diarrhea in adults also and it is called as adult diarrhea rotavirus.

Incubation period - 2 to 3 days.

Rota virus -

Rota means wheel.

It is a double walled virus.

Size - 65 to 70 nm

It resembles like a little wheel with short spokes radiating from a wide hub to an

outer rim.

Pathophysiology :

Lactase is the receptor for rotavirus. In older children, the lactase levels are low and

therefore there is lower incidence of rotaviral diarrhea in them.

Disease Review


Pathophysiology of Rotaviral Diarrhea41

More receptor sites are used

↓

More brush border destroyed

↓

Destroyed cells are replaced by cuboidal cells

which have no brush border

↓

Level of lactase becomes low

↓

Osmotic diarrhea

Rota virus may also cause secretory diarrhea through increased secretion of chloride

by hyperplastic crypts.

Pathophysiology of Rotaviral Diarrhea41

Rotaviral infection

↓

Transient increase in gut permeability

↓

Disease Review


Formation of antigen antibody complexes

↓

Damages gut mucosa

↓

Diarrhea aggravates

Clinical features of viral diarrhea39 -

1. Profuse watery stools

2. Stools do not contain blood or mucus

3. Stools are not foul smelling

4. Vomiting

5. Dehydration

6. Perianal excoriation.

Facts about viral diarrhea -

Self limiting disease

Temperature becomes normal quickly

Vomiting subsides within 1 to 2 days

Diarrhea subsides within 2 to 7 days

Treatment – ORS

Disease Review


Differential diagnosis of Viral and Bacterial diarrhea41

Table no-10

Viral diarrhea Bacterial diarrhea

Profuse watery stools Small quantities of stools

No blood or mucus in stools Stools contain blood or mucus

No foul smelling to stools Stools are foul smelling

Vomiting & dehydration common Vomiting & dehydration are rare

Low grade fever High grade fever

Pathogenesis of acute diarrhea -

1. Organisms produce enterotoxins e.g. Enterotoxigenic E.coli

2. Or, organisms damage the brush border and its enzymes e.g. Rota virus,

Enteropathogenic E.coli

3. Or, organisms invade the mucosa and proliferate in intestinal epithelium e.g.

Enteroinvasive E.coli

4. Or, organisms proliferate in lamina propria and invade the mesenteric lymphnodes

e.g. non typhoid salmonella

5. Or, disordered small intestinal epithelial renewal e.g. Rotavirus.

Disease Review


Modern Anatomy and Physiology of G.I. T (Gastro intestinal Tract)

Digestion is the chemical process by which complex and large food molecules

are broken down in to smaller molecules by the action of digestive enzymes, so that

they become suitable for absorption.

This digestion of food occurs in the cavity of the alimentary tract, that extends

from the mouth to the anus. Various digestive glands are associated with the

alimentary canal to form a definite digestive system. The food is ingested through the

mouth and through the gut coming under the action of digestive juices at specific

regions. Enzymes contained in the juices act on the food and digest it in this way food

is digested outside the cells, but within a cavity lined by cells. This is extra-cellular

digestion49.

The mouth cavity is provided with a tongue, cheeks, jaws carrying teeth. In

human being there are 4 types of teeth incisors, canines, premolars and molars. The

teeth appear in two sets, milk or temporary teeth and permanent teeth. The permanent

set consists 3 to 2 teeth, 16 in each jaw. The pharynx or throat serves for the passage

of food. It receives the openings from the nasal cavities, mouth, middle ear,

oesophagus and the glottis of the trachea. The oesophagus is a muscular tube of about

25cm. length. It connects pharynx and stomach. In most of its length it is with in

chest cavity. It penetrates the diaphragm before reaching the stomach Normally the

lower end of oesophagus remains closed and dilates only during passage of food50.

Stomach is a muscular bag forming the widest and most distendable part of

the digestive tube which connects the lower end of oesophagus to duodenum. It acts

as a reservoir of food and helps in digestion of proteins, milk.

Disease Review


Small intestine extends from the pylorus to the ileocaecal junction. It is the

main digestive and absorptive area of the tract. It is divided into (a) an upper part

fixed part called duodenum which measures about 25cm in length (b) lower mobile

part forming a very long convoluted tube. The upper 2/5th part of the mobile intestine

is known as jejunum and the lower 3/5th part as the ileum. The inner surface of the

intestine is a dense carpet like structure produced by the microscopic finger like

projections called villi49,50.

The large intestine extends from the ileocaecal junction to the anus is often

referred to as colon. It is much shorter than the small intestine but has a large

diameter. It is devisable in to ascending, transverse and descending portions. At the

junction of the small and large intestine there is a pouch like caecum. A tube

measuring 10-15 cm called the appendix from the projects from the caecum. The

descending colon is S shaped portion. The sigmoid colon joins a small tube the

rectum. The terminal opening on it is the anus. its structure is adopted for storage of

the faecal matter and for absorption of the fluids and solutes from it. Thus the

epithelium is absorptive in nature. But they are characteristically absent. For onward

passage of the partially dehydrated faecal matter, adequate lubrication is provided by

plenty of goblet cells scattered in the crypts as well as on the surface of the mucous

membrane. For protection against the faecal bacteria, the solitary lymphatic follicles

in the mucous are more numerous than in the small intestine50.

Rectum is the distal part of large gut, placed between the sigmoid colon above

and anal canal below. Distension of rectum causes the desire to defecate. It ends by

becoming continuous as the anal canal at the anorectal junction50.

Disease Review


Anal canal is the terminal portion of large intestine situated below the level of

the diaphragm. It provides voluntary and involuntary sphincters at the out let of the

rectum.

The Glands of the gastrointestinal tract

They are salivary glands, liver, pancreas. There are 3 pairs of salivary glands.

They are parotid, sub mandibular and sub lingual. The ducts of these exocrine glands

open into the oral cavity. There combined secretions is called saliva51.

The liver is the largest gland in body situated in the right upper quadrant of

the abdominal cavity. It is made up of lobes. Its digestive secretion called the bile is

stored in the gall bladder and released with response of food material.

The pancreas is a double gland being partly exocrine and partly endocrine.

The exocrine part secretes the digestive pancreatic juice.

The small intestine is provided with 2 types of glands duodenal glands or B

runner's glands and the crypts of luberkuhn. Though their secretions are different,

they are sometimes together referred to as succus entericus or intestinal juice55.

The food is first chewed or masticated by the teeth aided by the cheeks. The

tongue then rolls up into a soft spherical mass called the bolus. The bolus of the food

in the mouth receives saliva.

The salivary amylase acts on polysaccharides like starch and glycogen and

hydrolyses them into disaccaharides called maltose.

The bolus of the food passes down the oesophagus by the peristaltic

movements and enters the stomach. The inner lining of the stomach has numerous

Disease Review


gastric glands. There are 2 types of cells, chief cells that secrete enzymes and partial

cells or oxyntic cells those secrets Hcl. There are also numerous mucous secreting

cells. Combined secretion forms the gastric juice. The acid kills the bacteria and

loosens the fibrous components of food. Gastric juice contains three enzymes, pepsin,

renin and gastric lipase52.

Pepsin is first secreted in an inactive form called pepsinogen. It is converted

into active pepsin when it comes in contact with Hcl. Once Hcl has converted some

pepsinogen into pepsin, pepsin acts on other molecules of pepsinogen to convert them

into more pepsin. Pepsin is an endopetidase as it hydro lyses peptide bonds situated

internally with in the proteins. So larger protein chains are converted into shorter

protein chains, proteoses, peptones, polypeptides.

The enzyme renin is also secreted in an inactive state called prorenin. It acts

on soluble milk protein casein, in the presence of calcium salts and converts them into

paracasen. In this process milk is converted into curds. As a result of curdling milk

proteins remains in the stomach enough to be acted upon by pepsin53.

Gastric lipase is a fat hydrolyzing enzyme. The amount of fat digested in

stomach is very small. As digestion proceeds in the stomach, the food becomes more

or less liquefied. Such a liquid acidic content of the stomach is called chyme. The

muscular contractions of the stomach wall force the chyme slowly into the intestine.

A major portion of the digestion and absorption is completed in the small

intestine. Three secretions enter at the regions of duodenum. They are bile, pancreatic

juice & intestinal juice.

Disease Review


Bile is secreted continuously from the liver and stored in the gall bladder. In

the gall bladder it is concentrated by absorption of water. When the food enters the

duodenum bile is released into it through the bile duct. Bile does not contain any

digestive enzyme. Bile salts are important in digestion and absorption of fats. First

they emulsify fats, converting them into a soapy mixture or emulsion in which fat

droplets are suspended in the liquid chyme. This provides a greater surface area for

the action of the fat hydrolyzing enzymes. Bile salts combine with fatty acids and

monoglycerides to form water soluble complexes. In this form these lipids can be

easily absorbed52.

Pancreatic juice contains a wide variety of enzymes important in digestion of

all classes of foods. Pancreatic juice, bile and intestinal juice together are important in

neutralizing the acidity of the chyme that comes from the stomach.

There are two proteases (Trypsin, chemotrypsin) one peptidase (Carboxy

peptidase) one carbohydrase (Pancriatic amylase) one lipase and two nucleases

(deoxyribonuclease) and (ribo nuclease) in the pancreatic juice.

Trypsin and endopeptidase is first secreted in an inactive condition as

trypsinogen. The conversion of trypsinogen into trypsin is done by an enzyme called

enteropeptidase secreted by the inner deuodenal surface. It converts protein into di, tri

or polypeptidase53

Chymotrypsin is also secreted in an inactive condition called

chymotrypsinogen. It is converted into its active state chymotrypsin by trypsin.

Disease Review


It is also an endopeptidase and hydrolyzes proteins into polypeptidase.

Carboxy peptidase acts on the terminal peptide bonds lying immediately next to the

free carboxy group of poly peptides. The products are amino acids.

The Pancreatic amylase acts on polysaccharides like starch and glycogen. As a

result of this all polysaccharides are converted into maltose, a dissaccharide.

Pancreatic lipase acts on fats. Its action is made easier by the fact that fats have

already been emulsified by the bile salts; lipase hydrolyzes fats into fatty acid and

glycerol54.

The Nucleases split nucleic acids. Deoxyribonuclease splits DNA and

ribonuclease splits RNA into respective nucleotides.

The intestinal juice also called succus entericus is a collective secretion of the

Burner's gland (duodenal gland) and crypts of Leiber Kuhn (intestinal glands) there

are three peptidases and three carbohydrates. The peptidases are amino peptidase

dipeptidase and Tripeptidase. Amino peptidase breaks the peptide bond next to the

ammo groups, Tripeptidase hydrolyzes dipeptides. The products are free amino acids.

Since they are the end products of protein digestion they are ready to be absorbed52.

Ten enzymes of the intestinal juices concerned with carbohydrate digestion

are called disaccharides. Maltase acts on maltose and hydrolyses it into glucose.

Lactase acts on lactose and converts it into glucose and galactose. Sucrase acts on

sucrose and converts it into glucose and fructose.

The end products of the digestion of carbohydrates are the monosacchardies

glucose, fructose and glactose. They are all simple molecules that cannot be broken

down further. They are ready for absorption.

Disease Review


Absorption:

Absorption is the passage or movement of end products of digestion into

blood or lymph. There is very little absorption in the stomach. The inner layer of the

intestine is produced into cylindrical finger shaped projection called villi. These villi

are the actual organs of absorption of digested food. In the human intestine they are

estimated 5 million ville. Each villus has with in it a lymph vessel and blood

capillaries. Monosaccararides and amino acids are absorbed by the capillaries.

Glycerol and fatty acids move into lymph vessels instead of blood capillaries.

Absorption can occur by diffusion, osmosis or any other means of transport.

The main function of the large intestine is absorption of water, minerals and

some vitamins and Na+. The vitamins absorbed are those synthesized by the large

number of bacteria inhabiting the colon. The colon converts the liquid content that it

receives from the ileum into semi solid faeces. It is mixture of undigested material,

water and bacteria. The faeces are thrown out through the anus54.

Normal colonic function

Each day approximately 9 litres of fluid enters the digestive tract 2 litres

represents ingested fluid and the remainder comes from salivary, gastric, biliary

pancreatic and intestinal secretions that are needed to provide an appropriate media

for food digestion. Most of this fluid is absorbed in the upper bowel. Approximately 1

liter containing undigested dietary residue and cellular debris passes across the

ileocaecal valve to the colon. Little of nutritional value remains following the

excessive digestive processing and absorption that occurs in the small intestine. The

colon's principal function is to convert this liquid ileal effluent to solid faeces before

Disease Review


it is advanced to the rectum and evacuated. Several important physiologic process

underline normal colonic function, among these are absorption of fluid and

electrolytes, peristaltic contractions that include mixing, dessication, and passage of

faeces to the rectum, and finally defaecation52.

Absorption of Fluid and Electrolytes:

In western countries where dietary fiber contents are relatively low, the

average daily stool weight is less than 200g of which 60 % to 80 % is water. Thus the

colon normally absorbs approximately 80-90 % of the fluid it receives, and this

occurs well within its absorptive capacity of 6 litres water and 800 meq sodium per

day. Fluid and electrolyte absorption occurs primarily in the ascending and transverse

colon. Water absorption occurs passively: Osmotically following the active transport

of sodium and chloride ions.

In addition, bicarbonate is secreted in exchange for chloride. The secreted

bicarbonate gets converted into carbon dioxide by reacting with acids produced by

colonic bacteria

The term diarrhoea generally denotes frequent or loose stools, based on

physiologic events. Diarrhoea may be defined quantitatively as fecal output

exceeding 200gms per day when dietary fiber content is low. Diarrhoea can be further

classified on the basis of underlying mechanisms. In secretary diarrhoea, faecal fluid

rich in sodium and potassium is lost as a sequence of impaired absorption and or

excessive secretion of electrolytes by the bowel.

In the osmotic diarrhoea, absorption of water is decreased by ostmotic effect

or non absorbable, intraluminal molecules.

Disease Review


Exudative diarrhoea is caused by an outpouring of necrotic mucosa, colloid

fluid, and electrolytes from inflamed colon which in addition is less able to carry out

its normal absorption function. Increased amounts of arachidonic acid. Metabolites

present in inflamed mucosa may also promote increased ion secretion.

Anatomic dearrangements of the bowel and motility disorders causes

diarrhoea by reducing the surface area or the contact time necessary for adequate

absorption to occur53.

Defaecation

The defaecatory reflex is initiated by acute distention of the rectum. When it is

allowed to progress by supraspinal centers, sigmoidal and rectal contractions heighten

the pressure within the rectum and also obliterate the rectosigmoidal angle.

Concomitant relaxation of the internal and external sphincters then permits the

evacuation of faeces56.

Pathophysiology:

Water and electrolytes are absorbed as well as secreted in the intestine.

Jejunum is freely permeable to salt and water which are passively absorbed secondary

to nutrient (glucose, ammo acids etc) absorption. In the ileum and colon active Na+,

K+, ATPase mediated salt absorption occurs, primarily in the mature cells lining the

villous tips, water flows so osmotically. In addition glucose facilitated Na+

absorption takes place in the ileum, one Na+ ion is transported along with each

molecule of glucose absorbed. This mechaism remains intact even in severe

diarrhoea72, 73.

Disease Review


Absorption of Cl and HC03 is passive (paracellular as well as by exchange of

HC03 of Cl (transcellular). Bicorbonate is absorbed also by the secretion of H+

(similar to that in proximal tubule of kindeny) and Na+ accompanies it. K+ is

excreted in faecal water by exchange with Na+ as well as by secretion into mucous

and in desquamated cells. The osmotic load of luminal contents plays an important

role in determining final stool water volume. When non-absorbable solutes are

present and in desquamated cells. The osmotic load of luminal contents plays an

important role in determining final stool water is increased. Inhibition of Na+., K+,

ATPase and structural damage to mucosal cell (by Rota virus) causes diarrhoea by

reducing absorption. Decreased segmenting activity in the intestine may promote

diarrhoea by allowing less time for the absorptive process.

Intracellular cyclic nucleotides are important regulators of absorptive and

secretory processes. Still enhancing a AMP or cGMP causes net loss of salt and

water, both by inhibiting NaCI absorption in villous cells and by promoting anion

secretion (Na+ accompanies) in the crypt cells which are primarily secretory. Many

bacterial toxins, eg - cholera toxin, exotoxins elaborated by enterotoxigenic E coli,

staph.Aureus, Salmonella etc. activate adenyl cyclase which enhances secretion that

reaches its peak after 3 -4 hrs and persists until the stimulated cells are shed in the

normal turn over i.e. 36 hrs after a single exposure. Concurrent to inhibition adds to

the rate of salt and water loss. Prostaglandins and intracellular Ca2+ also stimulate

secretory process. All acute enteric infections produce secretory diarrhoea74,75.

Disease Review


Assessment of dehydration:

Dehydration can be assessed on the basis of signs and symptoms presented

In table.

Assessment of Dehydration41

Table no-11

Characteristics Grade 1

Mild dehydration

Grade 2

Moderate dehydration

% of loss of fluid volume 0 to 5 % 5 to 10 %

Loss in ml/kg. 50 ml/kg 50 to lOOml/kg

General appearance Thirsty Irritable/ Lethargic

Pulse Normal Rapid/Normal

Blood pressure Normal Decreased

Respiration Normal Normal/Rapid

Eyeballs Normal Soft

Anterior fontanelle Normal Slighdy depressed

skin turgor Normal Normal to decreased

Mucus membranes, tongue &

other Moist Dry

Disease Review


Tears Present Reduced

Urine output Normal Decreased

Management:

1. Correction of dehydration

2. Use of drugs

Correction of dehydration:

Oral rehydration therapy 40(ORT) -

Today ORT is at the core of management of diarrhea.

The term ORT includes:

1. Complete oral rehydration salt solution (ORS) with composition within the WHO

recommended range

2. Solutions made from sugar and salt

3. Food based solutions

4. In presence of continued feeding, commonly available and culturally acceptable

fluids irrespective of presence of glucose or without salt when the former are

present.

Physiological Basis -

In diarrhea, electrolytes such as chloride and sodium besides water are actively

secreted from the gut mucosa and are thus lost in the stools. But at the same time,

nutrients such as glucose, amino acids and dipeptides continued to be absorbed

without difficulty. The carrier mechanisms for the transport of glucose and sodium

across the cell membrane are interlinked. As glucose is absorbed, some sodium is also

Disease Review


absorbed in the small gut, even though sodium is being actively lost at the same time

in the stools. Sodium absorption also promotes the absorption of water. This is the

physiological basis of oral rehydration therapy.

Composition of WHO Oral Rehydration Salt Solution39

Table no-12

Ingredients Concentration in mmol/L

Sodium 90

Potassium 20

Chloride 80

Citrate 10

Glucose 111

Treatment of Dehydration39 -

For,

• Mild/No dehydration - Plan A

• Moderate/Some dehydration - Plan B

• Severe dehydration – Plan C Plan A:

Disease Review


Use of ORS at home.

If the child does not get better in 3 days or develops danger signs such as

many watery stools, repeated stools, marked thirst, eating or drinking poorly,

fever or blood in stool, then ask the mother to take the child to the doctor.

Use of ORS in Plan A

Table no-13

Age Amount of ORS to be given after

each loose stool

Amount of ORS to be used

at home

< 24 months 50-100 ml 500 ml/day

2 to 10 years 100-200 ml 1000 ml/day

> 10 years As much as wanted 2000 ml/day

Plan B:

Child should be treated in hospital.

ORT must be initiated promptly and should be continued while transport.

Plan B has three components,

a) Deficit replacement - Give 75 ml/kg of ORS in the first 4 hours.

b) Maintenance fluid therapy - This begins when signs of dehydration

disappear, usually within 4 hours. ORS should be given in the volume

equal to diarrhea losses, approximately 10-20ml/kg for each liquid stool.

ORS is administered in this manner till diarrhea stops.

Disease Review


c) Provision of normal daily fluid requirements - Offer feeds, milk and

breastfeed frequently.

If the child continues to have some dehydration after 4 hours, repeat another 4 hours

of treatment with ORS solution.

Plan C:

Start i.v. fluids immediately.

While the drip is being set up, give ORS solution if the child can drink.

Best i.v. fluid is Ringer's lactate.

Give l00ml/kg of the chosen solution as give in the following table,

I.V. Fluid Therapy in Severe Dehydration

Table no.14

Age First give 30 ml/kg in Then give 70ml/kg in

< 12 months 1 hour 5 hours

12 months to 5 years 30 minutes Two and half hours

Reassess the child every 15-30 minutes.

Repeat the i.v. fluid if the radial pulse is still very weak or not detectable.

Give ORS also at the rate of 5ml/kg/hour.

Disease Review


If one is unable to give i.v. fluids, give ORS using nasogastric tube at

20ml/kg/hour. If no improvement in hydration after 3 hours, start i.v. fluids as

early as possible.

Drug Therapy41:

Most episodes of diarrhea are self limiting and no medication is necessary except in

few situations. Drugs have very limited use.Some of the formulations are:-

1. Antimicrobials and chemotherapeutic agents –

Since a large majority of cases of diarrhea are caused by viruses and there is

little evidence of inflammation of gut mucosa, it is neither necessary nor desirable to

use antibacterial drugs.

Antibiotics do not shorten the duration of illness except in cases of

cholera.Their indiscriminate use leads to emergence of resistant strains of harmful

bacteria and eliminates resident flora which protect the gut. Antimicrobials should be

used only for infectious agents such as Shigella, Vibrio cholerae, Entamoeba

histolytica and Giardia.

2. Binding agents –

Formulations based on pectin, kaolin or bismuth are popular. But so far there

is little evidence that they are useful. These agents do not reduce excessive losses of

fluids and electrolytes, even though the stools appear more solid and the parents are

psychologically reassured.

3. Anti-motility agents –

Synthetic analogues of opiates such as diphenoxylate hydrochloride (Lomotil)

and loperamide (Imodium) reduce peristalsis or gut motility. But reduction of gut

Disease Review


motility does not abort an attack. On the other hand, it may give more time to the

harmful bacteria to multiply in the gut. Therefore the course of illness is often

prolonged following their use.

4. Anti-secretory agents -

Several drugs are currently being evaluated for their anti-secretary properties

in the hope that they reduce the magnitude and duration of diarrhea and obviate the

need for hydration therapy. Drugs such as aspirin, chlorpromazine etc. has been

evaluated but is not recommended.

Drug Review


DRUG REVIEW

A well Prepared with paste of patha & Aambrabijamadhya (marrow inside the

mango seed) with curds of cow’s milk.This cures diarrhoea with burning sensation

without any doubt. (Bhavaprakasha) 42.

These are the folloing contents in Pathadi Churna.

1) Patha 2) Ambabijamadhyatwak.

1) Patha47:-

Botanical name: Cissampelos pareira Linn.

Family: Menispermaceae.

Clinical name: Patha.

Sanskrit names: Patha, Ambastha, Varatika, Abiddhakarni, piluphala.

Regional names:

Hindi : Parh, padh.

Marathi: Padvel.

Kanada: Padvali.

Malyal: Kattuvalli.

Tlugu : Pada.

Drug Review


Pharmacodynamics:-

Rasa : Tikta.

Guna : Laghu,tikshna.

Virya : Ushna.

Vipaka : Katu.

Doshakarma: Tridoshashamaka.

Kaphapittahara.

Defferent Varieties:

Rajpatha : Cyclea Peltata.

Laghupatha: Cissampelos pariera.

Properties & actions:-

Karma:- Stanyashodhahara,Raktashodhaka-

shothahara,Vranaropana,Dipana,pachanagrahi.Vishaghna,krimighna,kandughna,Mutr

ala,Jwaraghna,dahaprashamana,balya,chardinigrahana,vranaropana,hrudya,shulahara,

arshoghna.

Roga:-

Shitajwara,Jwaratisara,Stanyadusti,stanyavikara,Agnimandya,ajirna,wudarashula,Atis

ara,Pravahika,Plihodara,Kasa-

shwasa,kusta,kandu,Daha,dourbalya,arsha,rameha,Rajayashma etc.

Drug Review


Therapeutic uses:-

The drug patha is anthelmintic,antidote to poison,antilithic

astringent,cardiac,carminative,diuretic,expectorant,sedative,supportive & toxic in

action.Plant drug is medicinally used for asthma,cold &

cough,colic,diarrhea,dysentery,fever,indigestion,inflammatory affections of the

bladder & kidney(chronic cystitis),nephritic disorders,piles & ulcers.

The roots of plant drug patha are employed in Indian system of medicine in various

classical formulations.Drug is ingredient of Kutajavaleha, patoladi kwatha choorna,

pushyanuga choorna & other preprations.

Patha is useful as anthelmintic,anti-

histaminic,antipyretic,astringent,bitter,cardiotonic,diuretic,refrigerent & stomachic.It

is used in abdominal pain,anorexia,cystitis,dropsy,fever & heart diseases,internal

rupture,respiratory disorders & skin diseases.

The drug patha is therapeutically considered useful for combating toxicosis arising

out of systemic disorders, ingested poisons & stings, bites & other similar poisonous

or toxic conditions.

Parts used:-

Roots & stem.

2) Amra48:-

Botanical names- Mangifera indica Linn.

Drug Review


Family:-ANACARDACEAE.

Vernacular names:-

Hindi :-Aam.

English :-Mango.

Telugu :-Mamidi chettu.

Synonyms :-Rasala, cuta, pika-vallabha.

Introdution:-

It is a tree groing to about 20 m height bearing clusters of small yellow

flowers.It grows all over India.

In the therapeutics the Amrabija & twak are mainly used in all the major texts &

nighantus for astringent property.Sou fruits are consideredto be hrudya.The ripen fruit

is Braamhana in nature.Its leaves are mentioned under ‘Pancha pallavas’.

Major chemical constituents:-

Mangiferin, mangiferolic acid, homonangiferin, indicenol.

Properties:-

Rasa:-Kashaya (Bark, seed)

Guna:-Laghu

Karma:-Vata hara (ripen fruit), Kapha-pittahara (other parts), Hrudya,

grahi.

Virya:-Shita.

Drug Review


Vipaka:-Katu.

Indications:- Atisara,Rakta pradara,prameha,Hrudroga,chardi etc.

Therapeutic Usage:-

Atisara:-A well constructed with paste of patha & Ambrabijamadhya (marrow

inside the mango seed) Prepared with curds of cow’s milk.This cures diarrhoea

associated with buning sensation (Bhavaprakasha) 42.

Raktapitta:-Amrasthi rasa as nasya. (c.s.ci.4).

Ajirna:-The unripen fruit or seed are useful (B.P).

Parts used:-Stem bark, leaf, flower, and seed kernal.

3) Dadhi/Curd:-

A.H.SU.5/29-32.

Dadhi is sour both in taste & also at the end of digestion,water absorbant(causing

constipation),hard to digest,hot(in potency),mitigates vata,increases

fat,semen,rakta,agni(digestive activity),improves (taste or appetite) ,is ideal for use in

loss of taste,intermitant fever,cold,diarrhea,rhinitis,dysurea.It is ideal for diseases of

duodenum45. Dadhi is Abhishyandi in nature.

Acco.to Ch.su.27/225,226.

Dadhi is Rochana(produces taste),Deepan,vrushya,balawardhak,having

amlavipaka,ushna virya,vataghna & bruhana.It is usefull in diseases like

Drug Review


peenasa,Atisara,shitajwara,vishamajwara,Aruchi,Mutrakruchra & krishata.Manda is

vatakaphahara & does the srotovishodhan.

PICTURES OF PATHA/AMRA SEED.

PATHA

PATHA Stem in Row form.

Drug Review


Mango seed

MANGO WITH SEED

Methodology

Effect of pathadi choorna in Balatisara w.s.r. Infantile diarrhea Page 97

Materials & Methods:-

A research study should always be well planned so that a proper blueprint is

taken up well in advance to avoid any inaccuracy in the study. The present clinical

study entitled “Effect of pathadi choorna in balatisara w.s.r. infantile diarrhea”

was carried out with the following procedures.

Different phases of the study

The current study was carried out through different systematically designed

steps to get the unbiased results. The following steps were adopted to complete the

study.

1. Preparation of Pathadi choorna

2. Preparation of case proforma

3. Conceptual study

4. Study design

5. Collection and analysis of data

6. Discussion and interpretation of findings

7. Conclusion of the study

Ethical Clearance:

The topic of the study, together with the case proforma was submitted to the

Institutional Ethical Committee of Alva’s Ayurveda Medical College, Moodbidri. The

significance, aims and objectives, methodology and probable result of the study were

clarified to the committee and ethical clearance was obtained for the conduction of the

study.

Methodology


1) Prepration of pathadi choorna:-

A well prepared with paste of patha & Ambrabija Madhya (marrow inside the

mango seed) with curd of cow’s milk89.

DOSAGES:-

Pathadi Choorna in the dosage of 750mg to 1500mg (according to the age) per day

in the divided doses will be administered before feeding in the morning and evening

hours along with equal quantity of Dadhi(Anamla) for 1 week89.

Dose of drug in children told by Sharangadhara samhita poorva khanda 8/48-51.

For 1 month child give 1Ratti(gunja)=125mg, increase 1 Ratti every month means 12

month child having 12 Ratti.here age group 6-12 month(750mg-1500mg)88.

2. Preperation of the case proforma

The case proforma was finalized after studying the subject in detail and

discussions with departmental experts. The case proforma consists of 4 parts. The first

part consists of primary data. The second part consists of the presenting complaints

and history about the disease, past illness, family and socio-economic history,

personal history and immunization history. The third part consists of examination of

the patient which includes Dashavidha pariksha, general examination and systemic

examination. The fourth and final part consists of the diagnosis, observation and

assessment criteria.

The proforma was discussed in the Institutional Ethical committee of the

college and got approved. The case proforma is attached in the appendix.

Methodology


3. Conceptual Study

For the purpose of the present study, various text books were referred to get

the detailed description about Atisara which was mentioned by various authors in

different classics. Moreover several modern text books, journal and other researches

done on Atisara collected from the internet are also included. The literary review with

conceptual study done was already placed in the first part of dissertation.

4. Study Design:

30 children with the complaints of Diarrhea with any two or more

symptoms as explained in Kashyapa samhita, Charaka samhita, & other text were

selected from Kaumarabhritya O.P.D of Alva’s Ayurveda Medical College Hospital,

Moodbidri and from other referrals and camps during the period of September 2010

to July 2011.

The Pathadi churna as treatment of Bal-Atisara is mentioned in following Ayurvedic

text Bhavprakasha of Bhavamishra.

Inclusion criteria:

The selection of patient will be made with the following criteria.

a) Infants suffering from Atisara in between the age group of 6 month to 1

year irrespective of sex, religion, socioeconomic status and food habits.

b) Diarrhoea during dentition period, malnutritional and Infective origion.

c) Diarrhoea with mild dehydration.

Methodology


Exclusion criteria

a) Infants above the age of 1year below 6 months.

b) Infants suffering from Atisara with moderate and severe dehydration.

c) Infants suffering from Pravahika & Visuchika.

d) Infants suffering from Atisara as Upadrava in other diseases

Method of the study:

1. The children of either gender between the age group of 06months to 12

months were selected for the study.

2. The selected children were taken for study under a single group of 30

members.

3. Pathadi choorna per day in two divided doses morning and evening after food

along with curd for 7 days.

5. Collection and analysis of data

The vital datas like name, age, sex, religion, occupation, habitat, diet, socio

economic status, were recorded first. Education of the father and mother as well as

their occupation was also noted down.

Every child was enquired for various etiological factors described for Atisara

during the period of taking history of present illness. The general etiological factors of

Balatisara were tried to trace during this occasion.

All the children were enquired for the presence of sign and symptoms with

atisara like, dravamalavega, Jwara, Vivarnata, Udara Shoola, and Trishna. An effort

Methodology


was made to evaluate the status of Lakshanas of atisara with the help of prepared table

before and after the treatment.

Samhanana, Satwa, Satmya, Sara, Agni, Bala, Deha Bala, Ahara Shakti and

Koshta of the children were ascertained and recorded in the proforma.

Pramana of the children like height and weight were recorded by using

necessary instruments.

Under Vikruti Pareeksha, effort was made to evaluate the Doshas with the

help of Ashtavidha Pareeksha.

Using a thermomter, the temperature of the children was noted before and

after the treatment.

All the Srotases were examined using available Ayurvedic and modern

parameters before and after the treatment. Special emphasis was given to Purishavaha

Sroto Pareeksha.

The Investigations like Heamoglobin, and Microscopic stool examination

were done in all the children before and after treatment, to evaluate the improvement.

Detailed evaluation of Gastro intestinal system was made to diagnose the

disease and to know the severity of the disease, also to assess the improvement in the

condition of the children before and after treatment.

The diagnosis of Atisara is done when patient having 3 or more than 3 watery

loose stools in 24 hours with following 2 or more symptoms. They are Trishna, Jwara,

Vivarnata, Udarshoola etc.

Methodology


Assessment Criteria

1. Assessment was made by observing the improvements in the clinical

features based on the gradation before and after the treatment.

2. Assessment was made on the following schedule

a. Initial assessment before the commencement of treatment

b. II assessment on 8td day after treatment, finally III one on 15th day, to

assess whether there is a recurrence in sign and symptoms of Atisara.

Gradation of clinical features:-

Assesment criteria:

Atisara: Score

Absent - 0

3 to 4 loose stools with out any significant wt. loss - 1

4 to 5 loose stools with some wt. loss - 2

Diarrohea lasting for more than 2 weeks - 3

Jwara: Score

Absent T-980F - 0

Mild T-990F to 1000F - 1

Moderate T-1010F to 1030F - 2

Severe T >1030F - 3

Methodology


Vivarnata: Score

Normal - Absent - 0

Only on face - Mild - 1

Any half of the body - Moderate - 2

All over the body - Severe - 3

Tenesmus: Score

Normal - Absent - 0

Occasional straining - Mild - 1

With pain

Continuous straining - Moderate - 2

With pain

Cries due to pain - Severe - 3

Trishna: Score

Normal - Drinks normally, not thirsty - 0

Mild - Thirsty, drinks eagerly - 1

Moderate-Drinks poorly - 2

Severe -Not able to drink - 3\

Methodology


Gradation of lab investigation:

Pus cells or Mucus in Microscopic stool examination:

Score

Normal Pus cells in the stool 0-3/hpf - 0

Mild Pus cells in the stool 4-10/hpf - 1

Moderate Pus cells in the stool 10-15/hpf - 2

Severe Pus cells in the stool >15/hpf - 3

6. Discussion and interpretation of findings

The results and findings from the statistical analysis were subjected to

scientific discussion.

Overall Assessment:

The overall assessment of the patient was made based on the following

criteria.

Absence of signs & symptoms Cured

Reduction in the signs & symptoms Improved

No change in signs & symptoms No Improvement

The details of discussion are given in a separate chapter

Methodology


7. Conclusion of the study

After the discussion, the final conclusions were drawn from the study. The

conclusions with evidence are given in a separate chapter.

Observations & Result


OBSERVATIONS AND RESULTS

In the present study 38 children were registered. Among those, 8 children were

drop outs during various stages of the study. Remaining thirty children have completed the

clinical study. So the observations of 30 children only were shown.

Table.15

Sex incidence of the sample:

Sl. No. Sex No. of children Percentage

1 Male 18 60

2 Female 12 40

The study shows that maximum incidence of Diarrhea was reported in male 60%

while the incidence in female was 40%.

Table.16

Age group incidence of the sample:

Sl. No. Age group (in months) No. of children Percentage

1 06-09 11 36.67

2 09-12 19 63.33



It has observed that maximum number of children i.e. 63.33 % was belonged to the

age group of 6-9 months and 36.67% were belonged to 9-12 months.

Graph No.1.

Sex wise incidence of the sample.

Graph No.2.

Age group incidence of the sample.



Table.17

Incidence of Geographical distribution of the sample:

Sl. No. Geographical area No. of children Percentage

1 Rural 24 80

2 Urban 6 20

It has been observed that out of 30 children, 24 (80%) were from rural and 6

(20%) were from urban area.

Table.18

Incidence of Socio-economic status

Sl.

No. Socio – Economic status No. of children Percentage

1 Poor 9 30

2 Middle Class 21 70

3 Rich 0 0

The incidence of Socio-economic status in the sample shows that, 9(30%)

children belonged to poor class, 21(70%) belonged to middle class and none (0%) in

the group of rich class.



Graph No.3.

Incidence of Geographical distribution of the sample.

Graph No.4.

Incidence of Socio-economic status



Table.19

Incidence of Religion:

Sl. No. Religion No. of children Percentage

1 Hindu 18 60

2 Muslim 11 36.67

3 Christian 1 3.33

In the study it’s found that out of 30 children, maximum were i.e.60% Hindus,

36.67% Muslims, and 3.33% were Christians.

Table.20

Incidence of Dietic regimen:

Sl. No. Diet No. of children Percentage

1 Vegetarian 13 43.33

2 Non-vegetarian (mixed) 17 56.67

Among 30 children, 13 (43.33%) were on vegetarian diet and 17 (56.67%)

were non-vegetarian (Mixed) diet.



Graph No.5.

Incidence of Religion

.

Incidence of Religion

Graph No.6.

Incidence of Dietic regimen



Table.21

Incidence of Hygienic environment (Home Surroundings):

Sl. No. Hygienic environment No. of children Percentage

1 Good 5 16.67

2 Poor 25 83.33

The incidence of hygienic environment of surrounding of children showed that

maximum 25 (83.33%) have lived in bad hygienic environment and 5 (16.67%) have

lived in good hygienic condition.

Graph no-7



Incidence of Hygienic environment (Home

Surroundings)

Table.22

Prakriti wise distribution

Sl. No. Prakriti No. of children Percentage

1. Vata-Kapha 17 56.67

2. Vata-Pitta 11 36.66

3. Pitta-Kapha 2 6.67



Out of 30 children maximum 17 (56.67%) children belongs to Vata Pradhana

Kapha Prakriti where as 11 (36.66%) children belongs to the Vata Pradhana Pitta

Prakriti and only 2 (6.67%) children belong to the Pitta Pradhana Kapha Prakriti.

Graph No.08.

Prakriti wise distribution

Table.23

Koshta wise distribution:

Sl. No. Koshta No. of children Percentage

1. Mridu 4 13.33

2. Madhyama 12 40

3. Krura 14 46.67

Out of 30 children, only 4 (13.33%) were having Mridu Koshta and 12 (40%)

were having Madhyama Koshta and remaining 14 (46.67%) were belonging to Krura

Koshta.



Table.24

Distribution based on Agnibala:

Sl. No. Agnibala No. of children Percentage

1 Pravara 4 13.33

2 Madhyama 9 30

3 Avara 17 56.67

Maximum no. of children 17 (56.67%) were having Avara Agnibala while 9

(30%) were having Madhyama Agnibala and remaining 4 (13.33%) were having

Pravara Agnibala.

Grph no.9

Koshta wise distribution

.



Graph No.10.

Distribution based on Agnibala

Table.25

Distribution of children according to Nutritional status:

Sl. No. Nutritional status No. of children Percentage

1. Normal 18 60

2. Grade –I (Mal-N.) 11 36.67

3. Grade –ii (Mal-N.) 1 3.33

4. Grade –iii (Mal-N.) 0 0

5. Grade –iv (Mal-N.) 0 0



The above table shows that 60% children of the study group were having

normal nutritional status but 36.67% children were in grade I malnutrition and 3.33%

of children were in Grade II malnutrition and none (0% )children in Grade III and

Grade IV malnutrition.

Graph No.11.

Distribution of children according to Nutritional

status.

Table.26

Incidence of onset of symptoms:

Sl. No. Onset of sysmptoms No. of children Percentage

1 Sudden 7 23.33

2 Gradual 23 76.67



Maximum 23(76.67%) children had gradual onset of symptoms, where as

7(23.33%) had sudden onset of the symptoms

Table no.27

Sign and Symptoms wise distribution

Sl. No. Sign and Symptoms No. of children Percentage

1. Atisara 30 100

2. Vivarnata 15 50

3. Jwara 08 26

4. Tenesmus/Udarashula 30 100

5. Trishna 30 100

6. Pus cells/Mucus 09 30

It is observed thatOut of the 30 patients taken for the study Atisara was

reported in 100 % , 26 % patients suffered from Jwara, 50 % patients reported

complaint of Vivarnata, as well as Udarashula & Trishna is observed in 100%

patients.

Graph No.12.



Incidence of onset of symptoms

Graph No. 13.

Sign and symptoms wise distribution

OBSERVATIONS & RESULTS BASED ON ASSESSMENT CRITERIA



Table.28

Response rate with respect to Diarrhea

Table no.28(a)

Fallow

up

Sign and

Symptoms

Mean

Mean

AT

SD(Paired

Difference)

T value P value

1st(8th

day)

Diarrohea 1.63 1.06 0.55 3.6 <0.001

2nd(15th

day)

Diarrohea 1.63 1.03 0.53 3.1 <0.001

Before treatment mean score was 1.63 and after treatment mean score was

reduced to 1.03. it showed reduction in diarrohea. Statistical test showed that t –

value is 3.1, p < 0.001. Means there was highly significant improvement in diarrohea


Score BT AT 8th

Day

AT

15th Day

00 00 05 30

01 11 17 00

02 19 08 00

03 00 00 00



Table no.29

Response rate with respect to jwara

Table no.29(a)

Fallow

up

Sign and

Symptoms

Mean

BT

Mean

AT

SD(Paired

Difference)

T value P value

1st(8th

day)

Fever 0.27 0.03 0.43 2.97 P<0.01

2nd(15th

day)

Fever 0.27 0.00 0.45 3.25 P<0.01

Before treatment mean score was 0.27 and after treatment mean score was reduced to

0.00. it showed 100% reduction in jwara. Statistical test showed that t – value is

3.25, p = 0.003, p < 0.01. Means there was significant improvement in jwara after

treatment.

Score BT AT 8th

Day

Follow up 1

15th Day

00 22 29 30

01 08 01 00

02 00 00 00

03 00 00 00



Table no.30

Response rate with respect to vivarnta

Score

BT AT 8th

Day

Follow up 1

15th Day

00 15 27 30

01 15 03 00

02 00 00 00

03 00 00 00

Table no.30(a)

Fallow

up

Sign and

Symptoms

Mean

BT

Mean

AT

SD(Paired

Difference)

T value P value

1st(8th

day)

Vivarnata 0.50 0.10 0.50 4.40 P<0.00

1

2nd(15th

day)

Vivarnata 0.50 0.00 0.51 5.39 P<0.00

1


0.00. it showed 100% reduction in vivranta. Statistical test showed that t - value is

5.39, p = 0.000, p < 0.001. Means there was highly significant improvement in

vivranata after the treatment.

Table no.31



Response rate with respect to udar shool/Tenesmus

Table no.31(a)

Falloup Sign and

Symptoms

Mean

BT

Mean

AT

SD(Paired

Difference)

T value P value

1st(8th

day)

Pain in the

Abdomen

1.53 0.87 0.48 7.62 P<0.001

2nd(15th

day)

Pain in the

Abdomen

1.53 0.37 0.70 9.14 P<0.001


0.37. it showed 63.33% reduction in uadar shool. Statistical test showed that t -

value is 9.14, p = 0.000, p < 0.001. Means there was highly significant improvement

in udar shool after the treatment.

Table no.32

Score BT AT 8th

Day

Follow up 1

15th Day

00 00 04 19

01 14 26 11

02 16 0 0

03 0 0 0



Response rate with respect to Trishna

Score BT AT 8th

Day

AT

15th Day

00 00 05 30

01 11 17 00

02 19 08 00

03 00 00 00

Table no.32(a)

Fallow

up

Sign and

Symptoms

Mean

Mean

AT

SD(Paired

Difference)

T value P value

1st(8th

day)

Thirst 1.63 1.06 0.55 3.6 <0.001

2nd(15th

day)

Thirst 1.63 1.03 0.53 3.1 <0.001




1.03. It showed reduction in Thirst.Statistical test showed that t - value is 3.1, p <

0.001. Means there was highly significant Improvement in the symptom of Thirst

after the treatmentment

Table no.33

Response rate with respect to pus cells/ mucus

Score BT AT 8th

Day

Follow up 1

15th Day

00 21 24 26

01 04 06 04

02 05 0 0

03 0 0 0

Table no.33(a)

Fallow

up

Sign and

Symptoms

Mean

BT

Mean

AT

SD(Paired

Difference)

T value P value

1st(8th

day)

Pus

cells/Mucus

0.47 0.20 0.58 2.50 P<0.05

2nd(15th

day)

Pus

cells/Mucus

0.47 0.13 0.66 2.76 P<0.05



Before treatment mean score was 0.47 and after treatment of 7 days mean score was

reduced to 0.20 and after 15 days it was 0.13 after 55.55% it showed overall

reduction in pus cells. Statistical test showed that t - value is 2.76, p = 0.010, p <

0.05. Means there was mild significant improvement in pus cells after the treatment.

Overall improvement of children in the study group

Table 34

Sl.

No.

Criteria’s Improvement in %

1. Udarashoola/Tenesmus 63.63%

2 Atisara 100%

3 Vivarnata 100%

4 Jwara 100%

5 Trishna 100%

6 Pus cells/Mucus in the stool 55.55%



Graph No14

Overall improvement in the children of study group

Overall improvement on the clinical features in the study group showed

maximum benefit in the main features like Dravamalavega/Atisara (100%), Jwara &

Trishna (100%) and Udarashoola (63.33%) Followed by benefit in the stool report

i.e.improvement in the pus cell 55.55%.

Discussion

Effect of pathadi choorna in Balatisara w.s.r. Infantile diarrthea Page 127

DISCUSSION

Discussion on Dehydration:

It is observed that out of 30 Patients all Patients came with symptoms

of mild Dehydration but after treatment all patients having decreased

dravamalavega & increased the oral intake so weight & hydration get

improved & they get relief completely.

Discussion on Nidan Panchak:

It is Observed that Patients of Bala Atisar mainly took shita jala pana,

atiruksha, Atiguru, matra guru, samskar virudha ahara etc, also these Nidhan

parivarjan is done & in some patients poorvarupa is observed like udarshul,

daurbalya, trishna. According to bheda in Vataj- Atisar sashabda mala

pravuruti todvat vedna. In Pittaj atisar pureesha with yellow, green, blue

colour, with burning sensation & in kaphaj Atisar oily feces & white feces,

cold,heaviness in the body all these lakshanas are found but after treatment all

these lakshnas reduced & patient get relief completely.

Discussion on Pathyapathya:

It is observed that, during treatment of Bala Atisar when Patint was

examined & at the time of giving medicine we told to patient about diet to

take only coconut water, mand, peya, lajamand, takra ORS has been taken by

the patient. Diet is same for all patients.

Discussion on Udarshool/Tenesmus:

It is observed that, all patients came with symptom of Udarshool but

on 8thday 4 patients got relief from udarshool & 26 having occasional pain. on

15td day 19 patients got complete relief but 11 patients having occasional

pain. In pathadi Churna, acts as Dipan, Pachan, and Krimighna. So

Udarshool/Tenesmus symptoms get reduced and patient got complete relief.

Before treatment mean score was 1.53 and after treatment mean score was

Discussion


reduced to 037. It showed 63.33% reduction in uadar shool. Statistical test

showed that t - value is 9.14, p < 0.001. Means there was highly significant

improvement in udar shool after the treatment.

Discussion on DravaMalavega/Atisara:

It is Observed that,Out of 30 patients,11 patients having 3-4 loose stools

without any significant weight loss while 19 patients having 4-5 loose stools with

some weight loss.On 8th day 05 patients are completely cured while 17 patients having

3-4 loose stools without any significant weight loss,while 08 patients having 4-5 loose

stools with some weight loss.On 15th day all patients get cured. Before treatment mean

score was 1.63 and after treatment mean score was reduced to 1.03. it showed

reduction in diarrohea. Statistical test showed that t - value is 3.1, p < 0.001. Means

there was highly significant improvement in diarrohea after the treatment.

Discussion on Jwara:-

Out of 30 patients 08 patients having Mild Jwara.On 8th day 7 patients got

complete relief while 1 patient having mild Jwara.On 15th day all patients got

complete relief from Jwara. Before treatment mean score was 0.27 and after treatment

mean score was reduced to 0.00. it showed 100% reduction in jwara. Statistical test

showed that t - value is 3.25, p = 0.003, p <0.01. Means there was significant

improvement in jwara after the treatment.

Discussion on Thirst:-

Out of 30 patients all paients came with complaits of trishna.On 8th day 05

patients got complete relief while on 15th day all patient having normal trishna. Before

treatment mean score was 1.63 and after treatment mean score was reduced to 1.03. it

showed reduction in Thirst. Statistical test showed that t - value is 5.39,p < 0.001.

Means there was highly significant Improvement in the symptom of Thirst after the

treatment.

Discussion


Discussion on Vivarnata:-

Out of 30 patients, 15 patients having discoloution of body.On 8th day 12

patients having normal Varna while on 15th day all patints got nomal. Before

treatment mean score was 0.50 and after treatment mean score was reduced to 0.00. It

showed 100% reduction in vivranta. Statistical test showed that t - value is 5.39, p =

0.000, p < 0.001. Means there was highly significant improvement in vivranata after

the treatment.

Discussion on Lab Investigation:

1) Microscopic stool examination

2) Blood routine.

Other laboratory investigations will be carried out, if necessary.

Discussion on Malapariksha/Pus cells or Mucus in the stool:-

Out of 30 Patients,09 patients having pus cells/Mucus in the stool i.e.04 mild,05

moderate pus cells/mucus.On 8th day 03 patients got Normal report & 06 having mild

pus cells/mucus in the stool.On 15th day 05 patients got normal report while 04 having

Mild pus cells/mucus in the stool. Before treatment mean score was 0.47 and after

treatment of 7 days mean score was reduced to 0.20 and after 15 days it was 0.13 after

55.55% it showed overall reduction in pus cells. Statistical test showed that t -

value is 2.76, p < 0.05. Means there was mild significant improvement in pus cells


Discussion on Chikitsa Upashay:

It is observed that, Out of 30 patients 05 patients got complete Upashay on

seventh day, while 25patients got complete Upashay on fifteenth day.

Discussion


Discussion on Bhed:

It is observed that, Out of 30 patients, 08 patients have Vataj

Atisar,(26.66%) 10 patients have Pittaj Atisar(33.33%) and 12 patients have

Kaphaj Atisar.(40%)

Incidence of disease based on Sex:

Out of 30 children 60% were male and 40% were female. It showed that

maximum number of children was male. Study showed that male children have more

affected. This may be due to more exposure to the causative factors. The sex of the

children does not have any significant role to play in the disease process.

Incidence of disease based on age:

Out of 30 Patients maximum number of Infants i.e. 19(63.33%) patients

belongs to the age group of 09 to 12 months, and 11 (36.66%) belongs the age group of

06 to 09 months.Thus age group of 09 to 12 Months as these infants are in the dentition

period, put infected object into the mouth & some are poor socio-economic i.e.

malnutritional period.

Incidence of the disease based on geographical distribution:

Majority of children in the present study were from rural area i.e. 80%, where

as 20% of children were from urban area. This high incidence in rural area may be

influenced by other factors contributed by residential locality of children.

Incidence of the disease based on socioeconomic status:

Socio-economic status was always a matter of concern to cure or prevent any

ailment. High-class people can afford better for health care. Maximum number of

children i.e. 70% belongs to the middle class economic group. 30% of children of

Discussion


children belonged to poor economic groups and no rich economic group were found.

This showed that the poor and middle economic status will affect in the hygiene and

sanitation. In addition to this, study was carried only in Govt. school where usually

children from low and middle economy group are studying.

Incidence of the disease based on Religion:

In religion incidence 18 were Hindus, 11 were Muslims and 1 was Christians.

This may be because of locality of the residence.

Incidence of the disease based on Dietic regimen:

In the incidence of dietic regimen, more of the children i.e. 17 were mixed and

13 were vegetarian. It may be due to the improper cooking of meat (soup) products.

Incidence of the disease based on hygienic environment:

In the present study 05 of children have good hygienic environment and 25

children were exposed to one or other poor hygienic condition at home.

Incidence of the disease based on Prakriti:

Prakriti analysis is difficult in children because of ‘Sarva Dhatu

Asampoornata’. Still an attempt has been made to analyse the Prakriti on the basis of

Current behaviour, physical features and other physical characters.

Most of the children i.e. 17(56.67%) were of Vata Pradhana Kapha Prakriti,

11(36.66%) of children were of pitta Pradhana kaph Prakriti. Remaining 2(6.67%)

were of vata Pradhana pitta Prakriti. Childhood is considered as Kapha dominant and

if they indulged in Vata and Kapha aggravating factors, Vata and Kapha Doshas get

easily aggravated and may result in Vishama or Mandagni.

Discussion


Incidence of the disease based on Kostha:

Majority of the children that 12 (40%) were having Madhyama Koshta and

14(46.67%) were belonging to krura Koshta while 04 having mridu kostha. Mridu

and Madhyama Koshta may get easily vitiated with Pitta, Kapha and Vayu. Usually

Pachaka Pitta and Samana Vayu get easily vitiated.

.

Incidence of the disease based on Agni bala:

Out of 30patients 04(13.33%) was Pravara, 09(30%) Madhyama & 17(56.67%)

was belongs to Avara Agnibala before treatment, after treatment all patient observed

with madhyama agnibala.

Incidence of the disease based on nutritional status:

Out of 30 patients, 18(60%) Patients having good nutritional status, while

11(36.7%) patients have Grade 1st Malnutrition & one has Grade 2nd Malnutrition.

Incidence of the disease based on Onset of sign and symptoms:

Out of 30 patients 23(76.67%) had Gradual onset of symptoms while

7(23.33%) had sudden onset of symptoms.

Incidence of the disease based on sign and symptoms:

In the clinical observations, symptoms like diarrohea, pain abdomen were

observed in all of the children which were the main diagnostic features. These

symptoms leads to Vivarnata, fever were observed in few cases.

Discussion


Mode of action of drugs:-

In Treatment of Pathadi churna the drugs like Patha,Ambrabija Madhya which are

Deepan,Pachan,Vatanuloman & Grahi, Trishanahar in nature and it correct the

vimargagaman & Ati drava mala prvruti lakshnas in Atisar,Improves

Agni,Functioning of Pakvashaya and treat the Atisar and its compound used along

with dadhi grants Bala, Varna to the Patients.

Dadhi is Amla, ushna virya vitiates vata, water absorbant (causes constipation), &

is rochana, deepana, bruhana.So it is useful in Atisara, shitajwara, vishamajwara,

Aruchi etc.

Conclusion


CONCLUSION

The Dissertation entitled “.TO STUDY EFFECT OF PATHADI CHURNA

ON BAL-ATISARA AT AGE 06-12MONTHS” It consist of five parts Literary

review,Drug review,Clinical Study & Observation,Discussion,Conclusion.

First Part the literary aspect of disease,second part details of Drug review & its

prepration.Thrird part deals with clinical study & observation,in the beginning the

materials & method adopted for study have been described it follows the description

of observation on patients by single blind clinicaly study. The results obtained in the

clinical study have been discussed in the Fourth part the dissertation,the logical

conclusion drawn on the basis of discussion were as follows.

1)In Balatisar the causative factor like Dietary factor,Associated in other disease like

krimi,amoebiasis ,etc.here these Nidan pariverjan is done& in some patient porvarupa

is observed like Udarshola,ajeerna,dourbalya,&In Rupa the Drava mala vega 3-4

times are obtained with mild dehydration. And According to bhed In Vataj Atisar

(Amatisar) sashbda mala pravriti, todavat vedna.In Pitajatisar stool is yellow, green

colour with burning sensation, In Kaphajatisar oily, Whitish yellow coloured stool

these lakshana are found

2) We have to get result on Vataj (Amaatisar) Atisar 26.66%, Pittajatisar 33.33% &

Kaphajatisar 40%.

3)In Treatment of Pathadi churna the drugs like Patha,Ambrabija Madhya which are

Deepan,Pachan,Vatanuloman & Grahi, Trishanahar in nature and its correct the

vimargagaman & Ati drava mala prvruti lakshnas in Atisar,Improves

Conclusion


Agni,Functioning of Pakvashaya and treat the Atisar and its compound used along

with dadhi grants Bala, Varna to the Patients.

4) We observed best results of Pathadi churna in Kaphaj Bal-Atisar in mild stage of

Atisar.

5) We observed 100% results of Pathadi churna on Bal-Atisar at age 06-12 months of age.

Summary


SUMMARY

Diarrhoea is the most common pediatric complaint worldwide in tropical and

sub tropical geographical areas. The complaints of diarrhea in dentition period come

with greater incidence in pediatric practice. Povetry, ignorance, lack of hygiene

maintanance, bad sanitation and use of uncooked food or improper washing of food

materials etc. are the important factors for diarrhoea in developing countries like India

The dissertation entitled “Effect of pathadi choorna in balatisara w.s.r.

infantile diarrhea.” was undertaken with the objective of evaluating the efficacy of

Pathadi Choorna in Balatisara w.s.r infantile diarrhoea in children of 06months to

1 year, for the duration of 7 days. The drug was chosen for the clinical trial as it has

been directly indicated in Balatisara.

The entire dissertation is divided into two main parts. The first part, Conceptual

study deals with the literary review of the disease and the drug. Disease review

consists of details of infantile diarrhoea. Drug review includes the conceptual matters

related to the ingredients of the trial drug compound, Pathadi choorna.

Clinical study incorporates the methodology, the observations of the clinical

trial, and discussion of the results, conclusion and summery.The clinical study was

conducted in 30 children, who were diagnosed as suffering from Diarrhoea. They

were randomly selected from the OPD of Alva’s Ayurveda Medical College Hospital,

Moodbidri and from schools in and around Moodbidri. It was a single blind, fixed

dose, observational study with pre test and post test design wherein children were

assigned to a single group. 750mg to 1500mg (according to the age) of Pathadi

choorna was administered along with Godaghi in the age group of 06 months to 1year

Summary


for a period of 7 days. Initial assessment was done before starting the study followed

by review on 8th & 15th day. CBC and Microscopic stool examinations were carried

out only before and after the treatment. Both subjective and objective criteria were

obtained for assessment. The obtained data was analyzed statistically and overall

assessment was also done.

The study illustrated a remarkable effect of pathadi choorna in balatisara w.s.r.

infantile diarrhoea with a highly significant cure rate in most of the assessment

criteria in the duration of 7 days. The medication was well tolerated by the children

and showed no untoward effects. To summarize, the present study was conducted to

evaluate the Effect of pathadi choorna in Balatisara w.s.r. infantile diarrhoea of

children renders scope for future studies in this area.

Previous work done


PPRREEVVIIOOUUSS WWOORRKK DDOONNEE

1. Clinical study of Kutaja twak w.s.r to Balatisara by Dr.Rajkumar, National institute of

Ayurveda, Jaipur, 2004.

2. Clinical study of Ankotha vataka w.s.r to Balatisara by Dr.Verma Ramsinh, National

institute of Ayurveda, Jaipur, 2003.

3. Treatment of Balatisara with certain Indigenous drug by Dr.Poddar S,Gopbandhu

Ayurveda Mahavidyalaya,Puri(Orissa), 2002.

4. A comparitive study on the Effect of Balachaturbhadra and Shadanga yoosha in

Balatisara by Dr. Praveen SDM College of Ayurveda Hassan,2000-2001.

5.To study effect of Rajnyadi choorna in balatisara in age group 1-2 years.by Dr.Atul

patil,Bharati vidyapeeth pune,2010-2011

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References


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35)H.S. 3/3.

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References


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51.K. Sembulingam, Textbook of Physiology Page No. 169-170

52.Anne wagh, Textbook of Anatomy & Physiology pg No. 291-292.

53.Anne wash, Textbook of Anatomy & Psysiology pg No. 294

54.K. Sembulingam, Textbook of Physiology Pg No. 177-178 BD Chaurasia, Textbook of Anatomy Vol 2 -Page No. 245

55.BD Chaurasia, Textbook of Anatomy Vol 2 -Page No. 246

56.LAST’S Anatomy – Pg No. 335

57.BD chaurasia, Textbook of Anatomy Vol 2 -Page No. 251

58.Cunningham’s, Practical Anatomy - Page No - 139

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60.K. Sembulingam, Textbook of Physiology - Pg No. – 203

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65.Anne wagh, Textbook of Anatomy & Physiology - Pg No. 292- 293

66.Guyton, Textbook of Physiology Pg No. 783.

67.Guyton, Textbook of Physiology Pg No. 784-785




71.Guyton, Textbook of Physiology Pg No. 817

References


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73.K. Sembulingam, Textbook of Physiology Pg No- 226.

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75.K. Sembulingam, Textbook of Physiology Pg No. – 226

76.Dr. CC. Chatterjee, Human Physiology Pg.No. 511


78.Dr. CC. Chatterjee, Human Physiology- Pg.No. 512

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Annexure

Effect of pathadi choorna in Balatisara ws.r. Infantile diarrhea. Page I

CASE PROFORMA

P.G. DEPARTMENT OF KAUMARABHRITYA

ALVA’S AYURVEDA MEDICAL COLLEGE, MOODBIDRI

Title: Effect of pathadi choorna in Balatisara w.s.r.Infantile diarrhea.

............................................................................................................................................................

Scholar: Dr.Trimbak R. Kale.

Guide : Dr. M.S.Kamath

Name : SL. NO :

Age : Date :

Sex : M /F O.P.D No :

Religion: H / M /C / J / O

Address:

School :

Informant:

Presenting complaints:

Chief Complaints with Duration-

Diarrhoea

Jwara

Vivrnata

Udara Shool/Tenesmus

Trishna

Associated complaints:

History of Present illness:

Annexure

Effect of pathadi choorna in Balatisara ws.r. Infantile diarrhea. Page II

Family history:

Personal History – Ahara Sambandhi:

Nature-veg / mixed

Appetite

Dominant rasa

Vihara:

Nidra:

Diva swapna:

Koshta: Krura/ madhyama/ mrudu

Mala:

Mutra:

Other dedtails:

Latrine used

Hygenic environment

Nutritional status: grade 1 /2 /3 /4

Family history: Fathers occupation-

Mothers occupation-

Education of parents-

Birth order-

Socio-economic status-

Immunization status Regular / Irregular / Not followed Clinical assessment 1. General Examination

B.T A.T

General appearance: healthy / dull / sick

Temperature :

Pulse :

Annexure

Effect of pathadi choorna in Balatisara ws.r. Infantile diarrhea. Page III

Resp: Rate :

Cyanosis : present / absent

Icterus : present / absent

Clubbing : present / absent

Lymph nodes : palpable / not palpable. Site:

Eyes: Nose: Mouth: Throat:

Ears: Neck: Chest: . Abdomen:

Tongue: clear/coated

Oedema:

Any other findings:

2. Dasavidha Pariksha :-

Prakruti : V / P / K / VP / VK / PK / S

Sara : Tw / R / Ma / Me / As / Mj / Su / St

Samhanan : P / M / A

Pramana : P / M / A

Sathmya : P / M / A

Satva : P / M / A

Aharashakti : Abhyavaharana Shakti - P / M / A

Jaranashakti - P / M / A

Vyayamashakti : P / M / A

Vaya :Balya / Madhyama / Vridha

Vikruthi : Nidana:

: Dosa: Vata /Pitta /Kapha /Tridosha

: Dushya:

: Srothas:

: Srothodushti Prakara: atipravruthi / sanga / siragranthi /

Vimargagamana

: Agni:

: Ama: jataragnimandya janya / dhatvagnimandya janya

: Adhishtana:

: Desha: Janma: Nivasa: Vyadhita:

:Rogi bala: Pravara/Madhyama/Avara

Annexure

Effect of pathadi choorna in Balatisara ws.r. Infantile diarrhea. Page IV

:Roga bala: Pravara/Madhyama/Avara

:Kala:

3. Systemic Examination – G.I.T.– Respiratory – C.V.S – C.N.S- LABORATORY INVESTIGATION: Microscopic stool examination: Blood routine B.T A.T

Hb

TC

DC

ESR

AEC

Drug intervention: Pathadi choorna was given for a period of 7 days

06months to 1year-750mg to 1500mg in two divided doses.

Observation:

Annexure

Effect of pathadi choorna in Balatisara ws.r. Infantile diarrhea. Page V

Assesment criteria:

Atisara: Score

Absent - 0

3 to 4 loose stools without any significant wt. loss - 1

4 to 5 loose stools with some wt. loss - 2

Diarrhoea lasting for more than 2 weeks - 3

Jwara: Score

Absent T-980F - 0

Mild T-990F to 1000F - 1

Moderate T-1010F to 1030F - 2

Severe T >1030F - 3

Vivarnata: Score

Normal - Absent - 0

Only on face - Mild - 1

Any half of the body - Moderate - 2

All over the body - Severe - 3

Tenesmus/Udarshla: Score

Annexure

Effect of pathadi choorna in Balatisara ws.r. Infantile diarrhea. Page VI

Normal - Absent - 0

Occasional straining - Mild - 1

With pain

Continuous straining - Moderate - 2

With pain

Cries due to pain - Severe - 3

Trishna: Score

Normal - Drinks normally, not thirsty - 0

Mild - Thirsty, drinks eagerly - 1

Moderate-Drinks poorly - 2

Severe -Not able to drink - 3

Gradation of lab investigation:

Pus cells or Mucus in Microscopic stool examination:

Score

Normal Pus cells in the stool 0-3/hpf - 0

Mild Pus cells in the stool 4-10/hpf - 1

Moderate Pus cells in the stool 10-15/hpf - 2

Severe Pus cells in the stool 15/hpf - 3

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page VIII

INCIDENCE CHART

Sl. No. Name

Age in Months Sex Place Religion

Economical Status

Food Habits

Sanitary Type

1 Rajesh 6 Male Rural Hindu Middle Class Vegetarian Open

2 Anitha 7.5 Female Rural Hindu Poor Mixed Open

3 Subha 8 Female Rural Hindu Middle Class Vegetarian Separate

4 Asif 12 Male Rural Muslim Poor Mixed Open

5 Sathish 6.5 Male Rural Hindu Middle Class Vegetarian Open

6 Joyson 8.5 Male urban Christian Middle Class Mixed Separate

7 Deepthi 7 Female Rural Hindu Middle Class Vegetarian Open

8 Ramesh 7.5 Male Rural Hindu Poor Vegetarian Separate

9 Parvez 9.5 Male Rural Muslim Middle Class Mixed Open

10 Prashanth 11 Male Rural Hindu Middle Class Vegetarian Open

11 Smitha 10.5 Female Rural Hindu Poor Mixed Open

12 Shruthi 6 Female urban Hindu Middle Class Vegetarian Separate

13 Lathif 11.5 Male Rural Muslim Middle Class Mixed Common

14 Girija 7 Female Rural Hindu Middle Class Mixed Separate

15 Sumithra 7.5 Female Rural Hindu Poor Vegetarian Separate

16 Nazeer 6 Male urban Muslim Middle Class Mixed Common

17 Manjunath 7.5 Male Rural Hindu Middle Class Vegetarian Common

18 Kumar 6 Male Rural Hindu Poor Mixed Common

19 Firoz 7 Male Rural Muslim Middle Class Mixed Open

20 Saritha 6.5 Female urban Hindu Middle Class Vegetarian Separate

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page IX

21 Ranjitha 9 Female Rural Hindu Poor Vegetarian Separate

22 Akbar 11.5 Male Rural Muslim Middle Class Mixed Open

23 Bhumica 10 Female Rural Hindu Middle Class Mixed Common

24 Prakash 6.5 Male urban Hindu Middle Class Vegetarian Separate

25 Zarina 7.5 Female Rural Muslim Poor Mixed Open

26 Mansoor 7 Male Rural Muslim Middle Class Mixed Common

27 Ganesh 6 Male urban Hindu Middle Class Vegetarian Separate

28 Riyas 7.5 Male Rural Muslim Poor Mixed Open

29 Zohara 6.5 Female Rural Muslim Middle Class Mixed Common

30 Irfan 12 Male Rural Muslim Middle Class Mixed Separate

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page X

Master Chart

Sl. No. Atisara Trishna

BT AT-8 DAY F1-15 DAY BT

AT-8 DAY

F1-15 DAY

1 1 0 0 1 0 0

2 1 0 0 1 0 0

3 1 0 0 1 0 0

4 1 0 0 0 0 0

5 2 1 0 1 0 0

6 1 0 0 0 0 0

7 1 0 0 0 0 0

8 1 0 0 1 0 0

9 1 0 0 1 0 0

10 1 1 0 1 0 0

11 1 0 0 1 0 0

12 1 0 0 0 0 0

13 1 0 0 1 0 0

14 1 0 0 1 0 0

15 1 0 0 1 0 0

16 2 1 0 1 0 0

17 1 0 0 0 0 0

18 1 0 0 1 0 0

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page XI

19 1 0 0 1 0 0

20 1 0 0 1 0 0

21 1 0 0 1 0 0

22 1 0 0 1 0 0

23 1 0 0 1 0 0

24 1 0 0 1 0 0

25 2 1 0 1 0 0

26 1 0 0 0 0 0

27 1 0 0 1 0 0

28 1 0 0 1 0 0

29 1 0 0 1 0 0

30 1 0 0 1 0 0

Master Chart

Sl. No. Vivarnatha Jwara

BT AT-8 DAY

F1-15 DAY BT

AT-8 DAY

F1-15 DAY

1 1 0 0 1 0 0

2 0 0 0 0 0 0

3 1 1 0 0 0 0

4 0 0 0 1 1 0

5 0 0 0 1 0 0

6 0 0 0 0 0 0

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page XII

7 0 0 0 0 0 0

8 0 0 0 0 0 0

9 1 0 0 1 0 0

10 0 0 0 0 0 0

11 0 0 0 0 0 0

12 0 0 0 0 0 0

13 2 1 0 1 0 0

14 0 0 0 0 0 0

15 0 0 0 0 0 0

16 0 0 0 0 0 0

17 0 0 0 1 0 0

18 1 0 0 0 0 0

19 0 0 0 0 0 0

20 1 0 0 1 0 0

21 0 0 0 0 0 0

22 0 0 0 0 0 0

23 0 0 0 1 0 0

24 0 0 0 0 0 0

25 0 0 0 0 0 0

26 0 0 0 0 0 0

27 2 1 0 0 0 0

28 0 0 0 0 1 0

29 0 0 0 1 0 0

30 1 0 0 1 0 0

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page XIII

Master Chart

Sl. No. Udara Shool/Tenesmus Pus cells/Mucus

BT AT-8 DAY

F1-15 DAY BT

AT-8 DAY

F1-15 DAY

1 2 1 1 0 0 0

2 1 1 1 1 0 0

3 2 0 1 0 0 0

4 2 1 0 0 0 0

5 1 1 0 0 0 0

6 2 1 1 1 0 0

7 1 0 0 1 0 0

8 2 1 1 0 0 0

9 2 1 0 0 0 0

10 2 1 0 1 1 0

11 1 1 1 1 0 0

12 1 1 0 1 0 0

13 2 1 1 0 0 0

14 2 1 1 1 0 0

15 1 0 0 0 0 0

16 1 1 0 1 1 0

17 2 1 0 1 0 0

18 2 1 1 0 0 0

Annexure

Effect of Pathadi choorna in Balatisara w.s.r. Infantile diarrhea. Page XIV

19 2 1 0 1 0 0

20 1 1 0 0 0 0

21 1 1 0 1 1 0

22 2 1 0 1 0 0

23 1 0 0 1 1 0

24 1 1 1 0 0 0

25 2 1 0 1 0 0

26 1 1 0 1 0 0

27 2 1 0 1 0 0

28 2 1 1 1 1 0

29 1 1 0 0 0 0

30 1 1 0 1 0 0

Documents

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