Lekhana garbhavyapad-psr

AKNOWLEDGEMENT

Completion of dissertation work is the hallmark in postgraduate studies. At this important junction of

my life my head bows down with great humility in the feet of Almighty, without whose inspiration I would

not have been able to attain these stages in my life and whose affectionate touch was and always will be with

me to triumph all the obstacles.

I would like to thank my parents, Sri Pampanagouda. S. Patil and Smt Lalitha. P. Patil for their

constant love and support, parent-in-laws, Vaidya. Sri Panchaxari. S. Hosmath and Vaidya. Smt Mahadevi.

P. Hosmath for their kindness and encouragement. Thanks to my sisters for valuable help.

Words are not enough to gratitude to my husband Dr. Sanjay. P. Hosmath for helping and

encouraging me throughout the study. Many thanks to my children Siddarth and Ananya who were allowed

me to concentrate on the work without troubling me.

It is indeed my fortune to have carried out this dissertation work at S.D.M. college of Ayurveda,

Udupi. In this regard, I would like to express my heartfelt gratitude to honourable Dr. D. Veerendra Hegde,

Dharmadhikari, Shri kshetra Dharmasthala, and president of S.D.M. Society.

I genuinely feel that any words of gratitude are inadequate to express my humble thanks to Dr.

V.N.K.Usha, Professor & HOD Dept of Prasooti tantra & Streeroga S.D.M.College of Ayurveda & Hospital.

It is my fortune to have her as my guide whose excellent guidance, moral support & kind words for each &

every step during my course of study gave me a way to success for the dissertation & in future career also.

I take this opportunity to thank my Co-guide Dr. Suchetha for all the expert advice & specific

suggestions during the course of my work. Without her, it would not have been what it ought to be.

I express my heartfelt thanks to Dr. Mamatha K.V, Asst. Professor, for feeding me with precious

training & constructive ideas, throughout my study period.

My sincere gratitude & thanks to Dr. Ramadevi, Asst. Professor, Dept of Prasooti tantra &

Streeroga, S.D.M.College of Ayurveda, Kuthpady, for her worthy suggestions.

I also thanks to Dr. Vidya for her suggestions and help.

I render my thanks to Dr. V.N.Prasad, Principal SDMCA, Kuthpady for his invaluable support and

guidance for the completion of the thesis.

My deep sense of gratitude to Dr. Shrikant. U. Dean of P.G. Studies and Dr. Govind raju Co-Dean of

P.G. Stidies for their valuable guidance.

I am thankful to Dr. Y.N.Shetty, Medical Superintendent and Mr. C.S.Hegde, Manager, S.D.M

Ayurvedic Hospital, Udupi, for providing all the facilities in the hospital for my study.

I express my regards to Dr. Krishna bai and Dr. Veena Mayya for their help.

I greatly indebted to Dr. Murulidhar Sharma, Dept of Shalya tantra, for his ablest guidance and

dragging me to the path of success.

I extend my regard to Mr. Harish Bhat, Liabrarian, S.D.M College of Ayurveda, Udupi for his

generous help during the course of my life.

My genuine thanks to all my friends Dr. Shilpa, Dr. Sukanya, Dr. Sujatha, Dr. Shubha, Dr. Kavya

for always being there to my difficulties and render moral support.

I also thanks to Miss. Rashmi and miss.Shruti for their support and encouragement to make myself

feel at home even in hostel.

My deepest gratitude to the staff of Sampark Xerox for perfection of final product of my dissertation.

I thank all those who have directly or indirectly contributed to the successful completion of this work

still, I apologize for errata and shortcomings.

Dr. Vijayalakshmi.S.Hosmath

LIST OF ABBREVIATIONS

Serial No Abbreviation

1 Su. Sa. Sushruta Samhita

2 A.Sa Astanga Sangraha

3 A.Hri. Astanga Hridaya

4 Gr Group

5 P/V Per vaginal

6 USG Ultra sonography

7 & And

8 % Percentage

Dedicated

To

My Family

ABSTRACT

Title: “Clinical evaluation of lekhana procedure in certain conditions of streeroga &

garbha vyapad”.

Background: Lekhana karma is one of the Astavidha shastra karmas described in

classics and it is only one of its kind. It causes pattalikarana. It is better than chedana,

bhedana etc procedures, because of little intervention to the tissues. The main instrument

which is used for Lekhana karma is Mandalagra shastra. The indications such as

mamsonnati, mamsankura, arsha and granthi which are explained by Sushruta can be

interpreted in Streeroga, as in conditions like hyperplasia of endometrium. It is very

efficient therapeutic modality in shesha amagarbha chikitsa because of shodhana effect.

Hence it has both diagnostic and therapeutic efficacy. The endeavor of the study is to

standardize the procedure as per changing era.

Objective:

• Conceptual study of Lekhana vidhi & it’s indications in certain conditions

of Stree roga & Garbha vyapad.

• Analysis of Lekhana vidhi in different conditions of Stree roga & Garbha

srava.

Design and setting: It is a descriptive observational study. Randomly selected 50

patients from OPD and IPD of S.D.M Ayurveda hospital, Kuthpady, Udupi, according

to inclusive criteria were registered for the study.

Methods: According to following groups, patients were diagnosed as

A) Atyartava , i.e. Excessive bleeding during menstruation.

B) Anartava, i.e. Secondary amenorrhoea.

C) Garbha srava, i.e. Inevitable abortion

D) Vandhyatva & other conditions of Stree roga.

After diagnosing the particular condition, the incidence of Lekhana karma in different

indications was assessed on different parameters like time taken for the procedure,

amount of collected endometrial material, complications and Samyak laxanas of the

procedure.

Results :

• The patients who underwent Lekhana karma, were maximum in the Group of

Garbha srava (48%), followed by patients of Atyartava (44%), Vandhyatva (6%)

and Anartava (2%).

• The efficacy of Lekhana karma was studied. The 52% of patients were cured,

followed by 40% of patients were relieved and in 8% of patients no effect was

seen.

Conclusion:

Lekhana karma is mainly recommended in cases of mamsonnati, mamsankura, granthi,

arsha which usually clinically presented with Atyartava and also in cases of shesha

amagarbha. It is difficult to draw any conclusion regarding Anartava and Vandhyatva

groups, because of small sample size.

Key words : Lekhana karma, Atyartava, Anartava, shesha amagarbha, Vandhyatva,

Garbhavyapad, Mandalagra shastra.

CONTENTS

CHAPTER NO. TITLE

PAGE NO

1 Introduction 1-2

2 Objectives 3

REVIEW OF LITERATURE

3.1 Historical review 4-5

3.2 Introduction of Lekhana karma 6-8

3.3 General description of Lekhana karma 9-14

3.4 Description of Lekhana karma in Streeroga & Garbha vyapad 15-20

3

3.5 Modern Review 21-31

CLINICAL STUDY

4.1 Materials and methods 32-34 4 4.2 observations

35-65

5 Discussion

66-74

6 Summary and conclusion 75-77

7 Bibliography

78-90

8 Annexure

91-102

LIST OF TABLES

Sl No Table heading Page No

1 Distribution of patients according to Age 35

2 Distribution of patients according to Religion 36

3 Distribution according to Education 37

4 Distribution of patients according to Socio economic status 38

5 Distribution of patients according to occupation 39

6 Distribution of patients according to Region 40

7 Distribution of patients according to Diet 41

8 Distribution of patients according to sleeping pattern 42

9 Distribution of patients according to previous menstrual history 43

10 Distribution of patients according to Obstetric history 44

11 Distribution of patients according to previous surgical history 45

12 Distribution of patients according to Prakriti 46

13 Distribution of patients according to Samhanana 47

14 Distribution of patients according to Sara 48

15 Distribution of patients according to Satva 49

16 Distribution of patients according to Satmya 50

17 Distribution of patients according to Aharashakti 51

18 Distribution of patients according to Vyayama shakti 52

19 Incidence of Lekhana karma in 50 selected patients 53

20 Incidence of diagnosis of conditions on the basis of clinical features

in selected 50 patients.

54

21 Incidence of total time taken for procedure in 50 patients 55

22 Incidence of requirement of Vardhana karma before the procedure 56

23 Incidence of P/V bleeding immediately after the procedure 57

24 Incidence of pain in abdomen immediately after the procedure 58

25 Incidence of amount of collected endometrial material obtained after

the procedure

59

26 Incidence of injury after the procedure 60

27 Incidence of infection after the procedure 61

28 Incidence of P/V bleeding after 1 hour, after the procedure 62

29 Incidence of pain in abdomen after 1 hour, after the procedure 63

30 Incidence of surgical interventions after Lekhana procedure 64

31 Incidence of final assessment of the procedure 65

LIST OF GRAPHS

Sl No List of Graphs Page No

1 Distribution of patients according to Age 35

2 Distribution of patients according to Religion 36

3 Distribution according to Education 37

4 Distribution of patients according to Socio economic status 38

5 Distribution of patients according to occupation 39

6 Distribution of patients according to Region 40

7 Distribution of patients according to Diet 41

8 Distribution of patients according to sleeping pattern 42

9 Distribution of patients according to previous menstrual history 43

10 Distribution of patients according to Obstetric history 44

11 Distribution of patients according to previous surgical history 45

12 Distribution of patients according to Prakriti 46

13 Distribution of patients according to Samhanana 47

14 Distribution of patients according to Sara 48

15 Distribution of patients according to Satva 49

16 Distribution of patients according to Satmya 50

17 Distribution of patients according to Aharashakti 51

18 Distribution of patients according to Vyayama shakti 52

19 Incidence of Lekhana karma in 50 selected patients 53

20

Incidence of diagnosis of conditions on the basis of clinical features

in selected 50 patients

54

21 Incidence of total time taken for procedure in 50 patients 55

22 Incidence of requirement of Vardhana karma before the procedure 56

23 Incidence of P/V bleeding immediately after the procedure 57

24 Incidence of pain in abdomen immediately after the procedure 58

25 Incidence of amount of collected endometrial material obtained after

the procedure

59

26 Incidence of injury after the procedure 60

27 Incidence of infection after the procedure 61

28 Incidence of P/V bleeding after 1 hour, after the procedure 62

29 Incidence of pain in abdomen after 1 hour, after the procedure 63

30 Incidence of surgical interventions after Lekhana procedure 64

31 Incidence of final assessment of the procedure 65

LIST OF FIGURES

Serial No Figure Page no

1 Vrittamukha mandalagra shastra 10

2 Kshurakara mandalagra shastra 10

3 Karapatra 10

4 Prayatagra Vruddipatra 11

5 Anchitagra Vriddipatra 11

6 Dantalekhana shastra 11

7 Krpasavihitoshnisha shalaka yantra 99

8 Yonivranekshana yantra 99

9 Sarpaphanamukha yantra 100

10 Svastika yantra 100

11 Garbhashaya eshani 101

12 Shalaka yantra 101

13 Dvitala yantra 101

14 Vrittamukha mandalagra shastra 102

15 Kshurakara mandalagra shastra 102

Chapter 1 Introduction

INTRODUCTION

Ayurveda is the system of medicine which serves ailing humanity. It is eternal

because it has no beginning, it deals with such thing as are inherent in nature and such

manifestations are eternal.

“soayamaayurvedah shaashvato nirdishyate, anaaditvaat,

svabhaavasamsiddalakshanatvaat, bhaavasvabhaavanityatvaachcha.” 1

Though the principles of Ayurveda are everlasting, their applications may differ

from time to time. Ayurveda is not only rich in medicine but is enriched in surgical field

also.

Acharya Sushruta is a pioneer of surgery starting from the basic principles of

surgery to the plastic surgery hence known as a Father of surgery. He explained all the

necessary details about instruments that are used till date, but are used in modified form

in present era. Asthavidha shastra karmas which are explained by Acharya Sushruta,

covers basic features of all surgical procedures.

In the course of period due to so many social & political factors, Ayurveda has

fallen from its height of practice & remained as conceptual. Due to these factors the

surgical procedures of Sushruta disappeared from the mainstream of Ayurveda . Surgical

operations such as the Nasa sandhana, couching for cataract, management of

Moodhagarbha, Asthibhagna chikitsa and many other procedures were not done by

traditional Vaidyas, but by illiterate practitioners who passed on their manual skill from

one generation to the next.2 What so ever we are implementing in contemporary surgical

practice already exists in our samhitas.

Lekhana karma is a distinctive technique which is one among the Ashtavidha

shastra karmas & it has its own efficacy. It is one type of shodana therapy which is used

in failure of shamana chikitsa. It does the shodana of Garbhashaya in conditions of

Artavadusti & Yonivyapad. As it is teekshna chikitsa, it can be also implemented in

Garbhasrava chikitsa. It is mainly indicated in vrana, vartmagata rogas etc.

1

Chapter 1 Introduction

Present study explores the incidence of the various gynecological and obstetric

pathologies which are indications of Lekhana karma. These pathological manifestations

have ill effect on the health and hamper reproductive capacity of the woman. If timely

treated with Lekhana karma, early diagnosis of the pathological conditions and avoidance

of surgical intervention like hysterectomy is possible. Hence Lekhana karma helps in

restorative effect of endometrium. Even in case of shesha amagarbha, teekhna upachara is

significant treatment for expulsion of remaining concepts. Hence Lekhana karma can be

considered.

The practical aspects of surgery were little focused in Ayurveda. Hence this study

helps to prove facts and information present in classics.

2

Chapter 2 Objectives

3

OBJECTIVE OF THE STUDY

1. Conceptual study of Lekhana vidhi & it’s indications in certain conditions of

Stree roga & Garbha vyapad.

2. Analysis of Lekhana vidhi in different conditions of Stree roga & Garbha

srava.

Chapter 3.1 Historical Review

4

HISTORICAL REVIEW

Ayurveda has historically made foundational contributions to the development of

the branch of surgery. Surgery in ancient India was quite specialized and highly

developed. There were number of eminent surgeons who performed surgical procedures

with great skill and success and composed of great compendia on surgery recording their

valuable experiences. Sushruta is called as the father of surgery and the first known

surgeon in the world and even wrote a book and his practices reached the middle east and

later to the west.3 Sushrutha was also the first surgeon to advocate the practice of

operations on inanimate objects such as watermelons, clay plots and reeds; thus predating

the modern practice of the surgical workshop by half a millennium.

There is wrong assumption that surgery waned and gradually came to a fall down

due to emphasis on non-violence by Jains and Buddists. On the contrary, Jain monks

carried with them a medicine chest which contained surgical instruments. Jivaka the

contemporary & devotee of Lord Buddha, was eminent surgeon who performed

miraculous cures by his surgical skill. The actual reason hindering the progress of surgery

in those times were want of anesthesia and lack of antiseptics, surgical operation on a

manmade unconscious with wine along with physical pressure could not be expected to

gain popularity and continue for long.4

Change in thinking strategies regarding surgery and lack of facilities probably

made the surgical aspects infamous in India, later on the same concepts have came up in

different countries and surgical practice has got flourished. One of them being curettage.

Vedic period In Vedic period, references about miraculous performance in surgeries by

Ashvini kumaras are available. But there is no direct reference about Lekhana karma.

Samhita kala –

Chapter 3.1 Historical Review

5

References regarding Lekhana karma are available in Bhruhatrayis.

• Acharya Charaka has explained Lekhana karma while explaining vrana chikitsa

in dvivraneeya chikitsa adhyaya.5

• Acharya Sushruta has explained Lekhana karma as it is one the of Astavidha

shastrakarma6 and it is one of the pradhanakarmas of the shasthi upakramas which

are explained in the vrana chikitsa7. He explained indications8 and procedure9 in

detail. He has described the instruments which are used in Lekhana karma with

the dimension of their sharp edges10, correct technique of holding11, method of

using, merits12 and demerits13 etc. In Lekhyaroga pratishedhadhyaya, he

enumerated the lekhana karma in vartma rogas with procedure14, indications15,

samyak laxana16 and asamyak laxanas17.

• Acharya Vagbhata explained the Lekhana karma mainly in netrarogas with

procedure18, samyak laxanas and asamyak laxanas19. He has described detail

description of shastras20 which are used in Lekhana karma.

• In Bhavaprakasha, reference for Lekhana karma is directly not available, but

indirect reference is available in Bhavamishra commentary while explaining

vrana chikitsa.21

• In Bhela Samhita, reference about Lekhana karma is available in vrana chikitsa22.

Modern -

• The procedure, indications and complications of curettage is explained in all text

books of Obstetrics and Gynecology.

Chapter 3.2 Conceptual study

6

INTRODUCTION OF LEKHANA KARMA

Nirukti23 –

• Lekhya – sÉãZrÉÇ, Ì§É, (ÍsÉZÉ+LrÉiÉ|) sÉãÎZÉiÉurÉqÉç sÉãZÉlÉÏrÉqÉç |

CÌiÉ ÍsÉZÉkÉÉiÉÉã: MüqqÉïÍhÉ rÉmÉëirÉrÉãlÉ ÌlÉwmÉ³ÉqÉç ||

(vÉoSMüsmÉSìÓqÉ)

The word lekhya is derived from ‘likha’ dhatu & ‘ya’ pratyaya.

• Lekhana –

ÍsÉZÉç + srÉÑOè

The word Lekhana derived from ‘likh’ dhatu and ‘kta’ pratyaya.

Paribhasha24 –

“Lekhanakarmakaree, pattaleekaranah”.

The process of thinning is called as Lekhana karma.

“Shastradigharshanena vranasya tanukaranam”.

Lekhana karma means thinning of vrana by rubbing with instruments.

“Upakramam shaslyatantre shastrena vilekhanam”.

Lekhana is upakrama of shalyatantra.

Related terms of the word Lekhana25 –

ÍsÉZÉç – ÍsÉZÉÌiÉ, sÉãÎZÉiÉç, sÉãÎZÉiÉqÉç, ÍsÉÎZÉiÉqÉç, ÍsÉZrÉ

To scratch, scrape, furrow, tear up(the ground)

ÍsÉÎZÉiÉ – scraped, scratched, scarified, written


7

sÉãZÉ – a line, stroke, a writing, manuscript

sÉãZrÉ – to be scratched or scraped or scarified, to be written

Introduction –

Lekhana karma is one type shadvidha shastra karmas.26

Lekhana karma is one among the Ashtavidha shastra karmas.27

Lekhana karma is one of the procedure in surgical management of vrana.28

Lekhana karma is one important procedure in sixty upakramas of vrana.29

According to Dalhana, vartma can be considered as vrana vartma or netra

vartma. So all the procedures which are carried on netra vartma, can be

implied on vrana vartma also.30

• Lekhana karma as main procedure –

It is one of the pradhana karma in shasthi upakramas of vrana

chikitsa.31

It is the one type of asthavidha shastrakarmas.

It is unique technique in some conditions like mamsonnati,

mamsakandi etc.32

In vartmavabandi, klistha vartma, bahala vartma, pothaki, shyava

vartma, kardama vartma, kumbhika vartma, vartma sharkara and

utsanga vartma, it is the main procedure.33

.

• Lekhana karma as adjuvant therapy-

In amarmaja apakva granthi Lekhana karma and kshara karma are

as alternate procedures in paachana chikitsa.34

In kumbhika vartma, vartma sharkara and utsanga vartma, lekhana

should be done after bhedana karma.35

In peedaka, bhedana followed by lekhana36


8

In pilla chikitsa, after lekhana procedure, if not satisfied, the

procedure should be repeated followed by application of jalouka.37

In nasa sandhana, Lekhana procedure following with other

procedures.38

In alaji, bhedana, lekhana followed by dahana.39

In arbuda, chedana followed by lekhana. 40

In case of upanaha, bhedana followed by lekhana.41

In case of surgical treatment of linganasha, Lekhana karma is

indicated with other procedures.42


9

GENERAL DESCRIPTION OF LEKHANA KARMA

Indications of Lekhana karma –

• General indications – Kilasa43

Kustha44

Mandala45

• Indications related with shalakya tantra –

4 types of rohini46

Upajihvika47

Dantavaidarbhya48

Vartma rogas49

Adhijihvika 50

Nasika sandhana51

Upanaha52

Linganasha 53

Dantasharkara54

• Indications related with shalya tantra and streeroga –

Granthi55

Arsha 56

Mamsa kandi (alpa mamsankuras)57

Mansonnati 58

Vrana vartma59

Instruments used in lekhana karma –

Mandalagra60

Karapatra61

Vruddipatra62

Dantalekhana shastra63


10

Description of shastras –

Mandalagra shastra –

According to Acharya Sushruta, it is a round tipped instrument & six angula in length.

According to Acharya Vagbhat, it has its edge in the shape of nail of index finger.

Types - Acharya Dalhana explained 2 types of Mandalagra shastra as follows -

1. Vrittamukha – having circular tip.

Fig No. 1

2. Kshurakaara – it resembles with shape of sickle.

Fig No. 2

Karapatra –

According to Acharya Dalhana, it looks like leaves of Kara which has rough edge. It is

shape of fingers in hand. There are some differences among Acharyas regarding the

length of this shastra. Acharya Sushruta has given its length as six angula while

according to Dalhana its length as twelve angula.

Fig No.3


11

Vruddipatra –

It resembles the barber’s knife in shape tapering to a sharp point at its tip for use in

unnata and gambheera. Other one is opposite to this, it is having backward bend and a sharp

edge outside.

Prayatagra -

Fig No. 4

Anchitagra -

Fig No. 5

Dantalekhana shastra –

It has four faces, each connected firmly with a band and one sharp edge, and is meant for

scrapping the tarter on the teeth.

Fig No. 6


12

Shastra dhara in lekhana procedure64 –

• sÉãZÉlÉÉlÉÉqÉkÉïqÉÉxÉÔUÏ

The dhara of shastras which are used for Lekhana karma should be size of half lentil.

Method of holding shastra in lekhana procedure –

• Vruddipatra & Mandalagra should be held by the hand slightly raised up for the purpose

of Lekhana karma & the procedure should be repeatedly.65

• For Lekhana karma, the shastra should be held carefully in between vrintaphala & the

edge with index & middle fingers and the thumb.66

Procedure-

• According to Acharya Sushruta, in management of vrana shopha67 –

Poorva karma-

“Langhanadi virekaantam purvakarma vranasya cha”

From langhana to virechana are considered to be poorvakarma of vrana chikitsa.

Pradhana karma –

‘Paatanam ropanam chaiva pradhaanam karma tat smritam.’

From paatana to ropana are called as pradhaana karma.

Pashchat karma-

“Balavarnaagnikaaryam tu paschatkarma samaadishet”

Impovement of bala, varna, agni to be considered in paschaat karma.

• According to Acharya Sushruta as in Lekhya rogadhyaya68 –

Poorva karma- snehana, vamana, virechana


13

Pradhana karma – Patient should lie down in supine position devoid of wind & sunrays.

He should be held firmly. The vartma lifted with the left thumb & index finger. It should

be everted & fomented carefully with a cloth dipped in warm water. The vartma should

be cleaned with a swab & lekhana should be done with shastra or patra. Later on

fomentation should be done after cessation of bleeding.

Paschat karma – Apply the kalka of fine powder of manashila, kasisa, trikatu, rasanjana,

saidhava mixed with madhu. Then sprinkle ghee after washing with the lepa with warm

water & further managed like vrana. After 3days swedana, pidana should be done.

• According to Astanga hridaya, in vartma roga chikitsa69 –

Poorva karma – shodhana therapy

Pradhana karma – The patient is made to lie in supine position in a place which is

devoid of air. Svedana should be given to the vartma with warm water. The vartma held

by the thumb & fingers of the left hand in such a way that it neither slips away nor makes

any movement. Then with the Mandalagra shastra, an incision should be made

horizontally, lekhana done by its own edge or leaves. The bleeding should be cleaned

with phena or pichu.

Paschat karma – after bleeding stops powder of saindava mixed with honey should be

applied. After some time it should be washed with warm water, then applied ghee, a

bolus of flour of yava mixed with honey & ghee should be applied. The vartma should be

bandaged, above &below the ears. On the second day the bandage should be removed &

parisheka should be given as described earlier. On the fourth day nasya should be done.

On the fifth day the bandage should be removed.


14

Samyak lekhya vartma laxanas70-

Asrugaasraavarahita (stoppage of bleeding), kandushopha vivarjitam (not associated with

itching and inflammation), samam (the lesion should be even), nakhanibham (like colour

of nail)

Durlikhita vartma laxanas 71–

Raktasraava , raga, shopha, parisraava, timira, the vartma becomes shyaava in colour,

guru, sthabhdha , and associated with kandu, paaka


15

DESCRIPTION OF LEKHANA KARMA IN STREEROGA &

GARBHA VYAPAD Chikitsa –

“yaakriyaa vyadhiharanee saa chikitsa nigadhate” 72

The measures or efforts, which destroys the disease is called as chikitsa.

Shastra karma as a variety of shodana karma –

“Samyak shodhayateeti samshodhanam; tadvidham –

bahiraashrayamabhyantaraashrayam cha.

Tatra bahiraashrayam shastrakshaaraagnipralepaadayah: abhyantaraashrayam

chatushprakaaram – vamana, virechanam, asthaapanam, shonitamokshanam cha:

anye tu shonitamokshanamityatra shirovirechanam manyate.”73

The procedure which does the shodhana is called as samshodhana. Samshodhana chikitsa

is divided in to two types – bahiraashraya and abhyantaraashraya.

Bahiraashraya is the application of shastra, kshaara, agni, pralepa etc.

Abhyantaraashraya is again divided into 4 types – vamana, virechana, asthapana,

raktamokshana. According to some other opinion that, instead of raktamokshana,

shirovirechana can be considered.

Any clinical condition if not treated by shamana (medical treatment) chikitsa,

shodhana (surgery) chikitsa indicated after analysis of dosha, dhatu, rogibala and

rogabala. So in such conditions minor surgical procedures like Lekhana karma can be

indicated in female genital tract.

Indications – Indications in Streeroga -

Atyartava – In this condition Lekhana karma can be implemented as Shodhana

therapy.

• Raktayoni –

“……raktayonyaakhyaa srugati sruteh”74

Excessive bleeding per vagina is a main character of Raktayoni.


16

• Kunapa gandhi artava dusthi – “Kunapagandhyanalpam cha raktena”75

Kunapa gandhi artava dusthi is caused by vitiation of rakta. There is excessive

amount of menstrual blood.

“chakaaraachchonitavarnam pittavedanam cha, kunapam shavastasyeva

gandho asyoti kunapaganghihi”

According to Dalhana Acharya In this condition the bleeding resembles with fresh

blood. It is associated with features of pitta and smell of dead body.

• Asrigdara-

“Tadevaatiprasangena pravruttamanrutaavapi

Asrugdhsram vijaaneeyaadatoanyadraktalakshanaat

Asrugdharo bhavet sarvah saangamardah savedanah.”76

According to Sushrutacharya, artava which is excessive in amount and is

for prolonged period, occurs during intermenstrual period and is different from

shudda artava lakshanas, is called as Asrigdara. Generalized body ache is a

symptom of Asrigdara.

“Rajah pradeeryate yasmaat pradarastena sa smrutah”77

According to Charakacharya, excessive excretion of menstrual blood is called as

pradara.

Types of Asrigdhara –

Vataja asrigdhara78 – The artava which is vitiated by vata dosha is

phenila, aruna, Krishna or shyava varnayukta, parusha, tanu, flows

quickly, does not clot is called as vataja asrigdhara.

Pittaja asrigdhara79 – In this condition the artava is neela, pita, harita or

shyava in colour, visra, katu in taste is not liked by pipilika and makshika.

Kaphaja asrigdhara80 – In this condition the artava is like gairikodaka,

snigdha, bahala, pichchila, chirasravi and gets clotted like muscle.

Sannipataja asrigdhara81 – In this condition the features of all doshas

present and the artava resembles kanji in colour and is foul in smell.


17

Dwidoshaja asrigdhara82 – In this condition the features of both involved

doshas are present.

Anartava – In this condition Lekhana karma can be indicated as Shodhana

chikitsa.

• Arajaska83 –

“Yonigarbhaashayastham chet pittam sandushayedasruk

Saaarajaskaa mataa kaarshyavaivarnya jananeebhrusham”

The pitta which is situated in yoni and garbhashaya, vitiates rakta, then the woman

becomes more emaciated and discolored, is called as Arajaska.

“Arajasketi anaartavaa”

According to Chakrapani, anartava is a symptom of Arajaska.

• Lohita kshaya – “........vaatapittaabhyaam ksheeyate rajah

Sa daahakaarshyavaivarnya yasyaa saa lohitakshayaa”84

According to Astanga sangraha, when raja vitiated by vaata and pitta, the amount

of raja becomes decreased. This condition is associated with daha(burning

sensation), karshya(emaciation) and vaivarnya(discolouration).

“ksheeyate raktamiti atipravrutyaa raktasya kshayah”85

In Madhukosha commentary excessive bleeding is the cause for raja kshaya.

• Shushkaa –

“Vegarodhaadrutou vaayurdushto vinmutrasangraham

Karoti yoneh shosham cha shushkaakhyaa saativedanaa”86

According to Vagbhatacharya, when vaayu gets vitiated due to suppression of

vegas during rutukala, produces retention of urine and feces, dryness in vagina.

“Shushkaa nashtaartavaa kathitaa”87

According to Adhamalla, amenorrhoea is only symptom of Shushka yonivyapad.


18

Vandhyatva & other conditions – In all these conditions Lekhana karma

explores the Garbhakostha for detection of Kshetra dusti and favors collection of

artava to detect artava dusti.

• Saprajaa –

“saprajaa apeeti avandhyaa api satee katham chirena garbha vindati”88

Failure to get conception even after having previous uneventful pregnancy is

termed as Saprajaa.

• Aprajaa –

“Yasyam labdheapi garbhe asrugatipravartate, saa taadrusharaktasrutyaa

aprajaa bhavati, iyam cha raktayoniruchyate iti raktaatisrutyaiva

labhyate….”89

Unable to conceive due to excessive bleeding (menstrual irregularities) is called

as Aprajaa. It is also called as Raktayoni.

Indications in Garbhavyaapad -

Garbhasrava -

If pregnancy fails in the 1st trimester due to embryonic or fetal death or in

incomplete spontaneous abortion or inevitable abortion or characterized by the

absence of an embryo in the gestational sac, then these conditions have been

managed with Lekhana karma.

In all these conditions Lekhana karma explores and cleanses the Garbhashaya

kostha.

• Shesha amagarbha –

“Aamagarbhasheshena hi punah punah shulamashajyet

Tasmaateekshnairanavasheshayannupaacharet”90

The amagarbha which is expelled incompletely, it troubles the woman repeatedly.

Hence this condition should be managed by teekshna upachara, till its complete

expulsion.


19

• Asrujaa –

“Raktapittakarairnaaryaa raktam pittena dushitam

Atipravartate yonyaam labdhe garbhe api saasrujaa”91

Due to excessive consumption of ahara and vihara which aggravates the rakta and

pitta, the rakta which is situated in reproductive organs, vitiated by dushita pitta,

causes excessive bleeding per vagina. This bleeding may be present even after

conception also.

• Vaamini yonivyapad –

“savaatamudigaredbeejam vaaminee rajasaa yutam”92

In this condition yoni excretes beeja with raja and vaata.

“Beejam shukram

Udgiret vamet

Rajasaa yutam artavamishram”

Beeja means shukra. The yoni which vomits shukra with artava.

Procedure – Poorvakarma –

• Preoperative assessment of the patient

According to Acharya Sushruta, if patient is not assessed properly, not

examined accurately and not elicited the clinical signs properly, all leads

to improper treatment.93

• Position –

Lekhana karma in Garbhashaya and Uttarabasti being the different

modalities, involving in same organ “the uterus ( Garbhashaya)”. The

procedure and principles described in Uttarabasti can be attributed to

Lekhana karma as

“Uttaanaayaah shayanaayaah samyak sankochya sakthinee”94

The woman should be in supine position with flexed thighs and elevated

knees.


20

• Cleaning the parts was described in Lekhana karma of Vartma rogas, same

can be employed

“Tatah pramrujya plotena vartma shastrapadankitam”95

• Exposing the yonimukha with the help of Yoni vikshana yantra.96

• Stabilization of the garbhashaya mukha97

• Vardhana of the garbhashaya mukha, if it is constricted.

“samvrutaam vardhayet punah”98

Pradhana karma –

• Lekhana karma should be samam likhet (uniformly), sulikhita (the lesions

should be scraped well), niravasheshavat (completely) and vartmanaam tu

pramaanena (with appropriate measure).

“Samam likhet sulikhitam likhenniravasheshatah

Vartmaanaam tu pramaanena samam shastrena nirlikhet”99

• The procedure should be according to the different conditions such as

Samalekhanam avagaadhalekhanam -‘ sama lekhana’ means deep

scraping

Sulekhanam mridulekhanam - ‘sulekhana’ means mild scraping

Niravasheshalekhanam nirlekhanam niravasheshalekhanamiti -

niravashesha lekhana’ means complete scraping 100

Paschat karma –

Improvement of bala, varna, agni101


21

MODERN REVIEW

Indications of curettage102 –

Diagnostic – Infertility

DUB

Pathologic amenorrhoea

Endometrial tuberculosis

Endometrial carcinoma

Postmenopausal bleeding

Therapeutic - DUB

Endometrial polyp

Removal of IUCD

Incomplete abortion

Combined - DUB

Endometrial polyp

Dysfunctional uterine bleeding103 –

It covers all forms of abnormal bleeding for which an organic cause cannot be

found. This type of bleeding usually occurs at the extremes of reproductive age. It

can be classified into two groups according to whether it is ovulatory or

anovulatory.

1. Ovulatory bleeding –

It is mainly due to defect of corpus luteum which present in the following way-

Irregular ripening of endometrium – It leads to inadequate bed for

implantation. So patients present with DUB or infertility.


22

Causes – Failure of corpus luteum to develop, rapid regression of corpus luteum

after development, failure of endometrium to respond due to decrease sensitivity

to progesterone and hyperestrinism with normal corpus luteum.

Histology – This condition is known as endometrium with irregular hormonal

response. On microscopic examination, mixture of proliferative secretory

endometrial glands or proliferative stroma & secretory glands are seen. Corpus

luteum is normal.

Irregular shedding of the endometrium –

• Menstrual bleeding is prolonged, delayed & excessive

• Stromal granulocytes of the endometrium fail to release their relaxin content &

consequently the reticulum fibers supporting the stroma are not destroyed.

• Shedding of endometrium is late & it occurs in large chunks causing membranous

dysmenorrhoea.

• Histology – Late secretory endometrium mixed with menstrual blood & early

proliferative endometrium. Glands are frequently shrunken, stellate shaped &

degenerated. They may show secretory activity or may regress. Stroma contains

many stromal granulocytes & occasional neutrophils.

Retarded luteal phase – Histology of endometrium lags behind dates by history.

The criteria for diagnosis are that the delay should be at least by 3 days or more.

In these cases corpus luteum is defective.


23

Pre & post- menstrual bleeding –This may be seen in ovulatory cycles due to

disorderly corpus luteum regression or irregular follicular response, respectively.

Here bleeding is self limiting & requires no therapy.

2. Anovulatory bleeding –

The endometrium remains fragile due to inadequate structural stromal support

due to absence of progesterone. Thus with the withdrawal of estrogen, due to

negative feedback action of FSH, the endometrial shedding continues for a longer

time because of lack of compactness.

Usually this condition is associated with endometrial hyperplasia.

Endometrial hyperplasia104 –

It is a hormone related, estradiol mediated condition and does not present in the

absence of female gonads or without estrogen therapy. The endometrial

hyperplasias are a heterogeneous group of proliferative disorders.

• Classification –

Endometrial hyperplasia – Simple

Complex (adenomatous)

Atypical endometrial hyperplasia – Simple

Complex (adenomatous)

• Etiology –

o Obesity, diabetes and other metabolic disorders may enhance the extra

gonadal estrogen production and the presence of high estrogen levels,

especially of estradiol, as a result of the binding of the hormone to

receptor sites in the nuclei of endometrial cells.


24

o Estrogen unopposed by progestin

o Tamoxifen therapy

• Macroscopic features –

- Uterus may be enlarged

- Opening it often shows an irregularly thickened pale tan

endometrium, that may be polypoid

- The increased thickness of the endometrium may be demonstrated

by ultrasound.

• Microscopic features –

Histological features of simple hyperplasia –

General – Diffuse changes throughout endometrium

Increased gland: stroma ratio (greater than 1:1)

Glands –

Architectural features – Variation in size and shape

Small to large and cystically dilated

Minimal & focal crowding

Minimal branching with infoldings & outpouchings

No complex angularity

Cellular features – Abundant & cellular epithelium

Ciliated cell change common

Pseudostratification

Nuclear features – Oval & elongated

No significant variation in size or shape

Evenly dispersed chromatin

Small, inconspicuous nucleoli

Variable mitotic activity

Stroma – Abundant & cellular

Small, oval cells with scanty cytoplasm


25

Mitotic activity in stroma

Prominent superficial venules

Inconspicuous spiral arterioles

Histological features of complex hyperplasia –

General – Focal to extensive

Greatly increased gland: stroma ratio (greater than 3:1)

Glands –

Architectural features – Marked variation in size & shape

Marked crowding

Branching with papillary infoldings & outpouchings

Complex angularity


Ciliated cell change (less than in simple hyperplasia)

Squamous change

Pseudostratification

Nuclear features – Oval & elongated

No significant variation in size or shape

Evenly dispersed chromatin

Small, inconspicuous nucleoli


Stroma – Scanty & inconspicuous

Dense & cellular

Atypical hyperplasia –

Histological features of simple atypical hyperplasia –

General – architectural changes diffuse throughout endometrium

Cellular changes focal to diffuse

Increased gland: stroma ratio (greater than 1:1)

Glands –

Architectural features – Variation in size & shape


26

Small to large & cystically dilated

Minimal & focal crowding

Minimal branching with infoldings & outpouchings

No complex angularity


Ciliated cell change common

Pseudo stratification

Dense eosinophilia

Nuclear features – Elliptical to round

Variation in size & shape

Hyperchromasia

Nucleoli prominent, enlarged & irregular

Coarse clumping of chromatin


Stroma – Abundant & cellular

Small, oval cells with scanty cytoplasm

Mitotic activity in stroma

Prominent superficial venules

Inconspicuous spiral arterioles

Histological features of complex atypical hyperplasia –

General – Focal to extensive

Greatly increased gland: stroma ratio ( greater than 3:1)

Glands –

Architectural features – Marked variation in size & shape

Marked crowding

Branching with papillary infoldings & outpouchings

Complex angularity


Ciliated cell change (less than simple hyperplasia)

Squamous change

Pseudostrtification


27

Dense eosinophilia

Nuclear features – Elliptical to round

Variation in size & shape

Hyperchromasia

Nucleoli prominent

Coarse clumping of chromatin

Vesicular nucleus – hypochromasia


Stroma – Scanty & inconspicuous

Dense & cellular

Endometrial carcinoma105 –

Endometrial adenocarcinoma is common type of neoplasma of endometrium.

Histologically, it arising from the endometrial glands, the glandular components of the

tumor are somehow reminiscent of the normal proliferative endometrium. In moderately

differentiated endometrial adenocarcinomas the glandular pattern is present in 50-90% of

the specimen with solid nest & sheets of tumor cells replacing the glands. These tumors

showing pleomorphic nuclei with intranuclear clearing, coarse clumps of chromatin &

multiple irregular nucleoli. Mitoses are numerous & atypical. Most cells have a high

nucleus-cytoplasm ratio with very scanty basophilic cytoplasm. Anaplastic carcinomas of

the endometrium show no glandular differentiation & a very marked degree of cellular

anaplasia with the resemblance to endometrial tissue being difficult to ascertain.

Endometrial polyps106 –

Endometrial polyps are overgrowths of endometrial glands and stroma with blood

vessels, sometimes also containing smooth muscle, which protrude into the

uterine cavity.

• Pathogenesis – A part of the thick endometrium projects into the cavity and

attains a pedicle. It arises from the basal endometrium surrounded by the


28

functional zone. Multiple polyps are usually present in endometrial hyperplasia

and are excluded from such a discrete polyp.

• Naked eye appearance – A small polyp size of about 1-2 cm, looks reddish and

feels soft.

• Microscopically – the core contains stromal cells, glands and large thick walled

vascular channels. The surface is lined by endometrium. The pedicle contains thin

fibrous tissue with thin blood vessels.

Chronic endometritis107 –

Every case of acute endometritis might go on to chronic endometritis. It is a rare

condition between the menarche and the menopause, because the regrowth of new

surface endometrium during each menstrual cycle prevents the persistence of any

infection which is not deep seated.

Causes –

Foreign bodies within the uterus

Malignant disease of the uterus

Infected polyps

Retained products of conception

With inflammatory cells including altered macrophages known as ‘foam

cells’

After menopause

Microscopic examination – As a diagnosis of chronic endometritis depends upon

the presence of plasma cells with maximum accuracy.

Tubercular endometritis108 –

• Incidence – 60% endometrium involved


29

• Pathogenesis –

The causative organism is Mycobacterium tuberculosis of human type

It is almost always secondary to primary infection.

• Pathology –

The infection starts from the tubes either by lymphatic or by direct

spread through continuity.

Corneal ends are commonly affected due to their rich blood supply

and their anatomical proximity to the tubes.

The tubercle is situated in the basal layer of the endometrium only

to come to the surface premenstrually. After the endometrium shed

at each menstruation, reinfection occurs from the lesions in the

basal layer or from the tubes.

Endometrial ulceration may lead to adhesion or synechiae

formation (Asherman’s syndrome )

Rarely infection spreads to the myometrium (2.5%)

Microscopic examination – The principal histological feature of tubercular

endometritis is the epitheloid cell granuloma. The epitheloid cell granuloma of

tubercular endometritis contains a central collection of epitheloid cells with both

Langhans & foreign body type gaint cells. There is usually a peripheral collar of

lymphocytes. The gland may be functionally unaffected in tubercular

endometrium. But they may show a poor response to ovarian hormones, as with

non-specific endometritis. It is possible that this factor contributes to the

infertility.

Inevitable abortion109 –

It is a clinical condition of abortion where continuation of pregnancy is impossible.

Clinical features –


30

• Symptoms and signs of pregnancy coincide with its duration.

• Vaginal bleeding is excessive and may be accompanied with clots.

• Colicky pain felt in suprapubic region radiating to the back.

• The internal os of the cervix is dilated and products of conception may be felt

through it.

Incomplete abortion –

Retention of a part of the products of conception inside the uterus is called as incomplete

abortion.


• History of expulsion of a fleshy mass per vagina

• Continuation of pain in abdomen and vaginal bleeding

• On examination, the uterus is less than the period of amenorrhoea. The cervix is

opened and retained contents may be felt through it.

• USG shows the retained contents.

Missed abortion -

When the fetus is dead and retained inside the uterus for a variable period, is called as

missed abortion. Carneous mole is a special variety of missed abortion in which the dead

ovum in early pregnancy is surrounded by clotted blood.


• Symptoms of threatened abortion may or may not be developed.

• Regression of pregnancy symptoms

• A dark brown vaginal discharge may occur

• The uterus is smaller in size

• Cervix feels firm


31

Findings in curettage in failed pregnancy110 –

• There are 3 basic criteria which are reporting product of conception from

abortions.

1) Confirmation of the pregnancy

2) Location of the pregnancy

3) To identify or exclude a serious disease process especially gestational

trophoblastic disease.

• In the majority of cases of 1st trimester abortions chronic villi are the only tissues

of fetal origin identified.

• The finding of a placental site trophoblastic reaction is important as it excludes

that the pregnancy was ectopic in the fallopian tube & after aborting washed in to

the uterus.

• The gross appearance of the intrauterine contents from products as follows -

The highest incidence of karyotypic abnormalities occurs in 9.4 wks of mean

gestational age.

Macroscopic features - Gelationous sacs that may be empty or contain a

disorganized embryo or umbilical cord stump.

Microscopic features - The villi are edematous. Some may show fibrosis &

vascular obliteration.

• Frequently the placenta is the only tissue available when examining the early

concepts.


32

Procedure of curettage111 – The patient should empty the bladder prior to operation. The procedure is

done under general anesthesia or Diazepam sedation. The patient is placed in

lithotomy position. Local antiseptic cleaning & draping done. Bimanual

examination is performed. Posterior vaginal speculum is introduced inside the

vagina. The anterior lip of the exposed cervix is grasped by multiple toothed

vulsellum & pulled down near the vaginal introits. The uterine sound is

introduced to confirm the position & to note the length of the uterine cavity.

Cervical canal is then gradually dilated by the graduated metal cervical dilators.

After the desired dilatation, the uterine cavity is curetted by an uterine curette

either in clockwise or anticlockwise direction starting from the fundus down to

internal os. The completion of the procedure should be confirmed by grating

sound. Vulsellum & the speculum are removed. The curetted material is preserved

in 10 per cent formal-saline (normal saline in suspected tubercular endometritis)

labeled properly & sent for histological examination.

Complications112 – Immediate complications are injury to the cervix, uterine

perforation, injury to the gut, infection. Remote complications are cervical

incompetence and uterine synechiae.

Chapter 4.1 Materials And Methods

MATERIALS AND METHODS

Source of data:

About 50 patients under inclusive criteria of Lekhana karma were selected from

IPD & OPD of S. D. M Ayurveda Hospital Kuthpady, Udupi, were selected for the study.

Method of collection of data:

It is a descriptive study on different indications where the method of collecting

the data was by participant observation method.

A minimum of 50 patients, diagnosed under inclusive criteria were taken for the

study. The Lekhana vidhi was observed with results and the utility of Lekhana vidhi was

evaluated.

A detailed proforma was prepared with all history taking, physical examination

which is explained in our classics & allied science to confirm the diagnosis.

Inclusion criteria:

• Patients between the ages of 18-50 years.

• Patients who are married,

• Patients who are diagnosed having,

A) Atyartava , ie Excessive bleeding during menstruation.

B) Anartava, ie Secondary amenorrhoea.

C) Garbha srava, ie Inevitable abortion

D) Vandhyatva & other conditions of Stree roga.

Exclusion criteria:

• Atyartava due to pittala yoni vyapad or tridoshaja yoni vyapad, ie acute

infective state of reproductive system.

• Endometriosis.

• Fibroid uterus.

32


• Unmarried.

• Patients with systemic disorder like severe anemia, diabetes, hypertension,

thyroid dysfunction.

Intervention:

After the diagnosis of particular condition of Streeroga & Garbha vyapad, the

Lekhana karma was observed. Later the patients were categorized in to 4 groups by the

procedure, which they underwent.

Group “A” – The patients of Atyartava.

Group “B” – The patients of Anartava.

Group “C” – The patients of Garbha srava.

Group “D”- The patients of Vandhyatva & any other conditions of Stree roga.

Assessment criteria:

• Incidence of Lekhana vidhi in different conditions of Streeroga & Garbha vyapad

in 50 selected patients was assessed.

• Reasons for implementing Lekhana vidhi in specific conditions of Streeroga &

Garbha vyapad were assessed.

• Effectivety & side effects of procedure in certain conditions of Stree roga &

Garbha vyapad were assessed.

Final assessment:

The reason for Lekhana karma either therapeutic or investigated and the efficacy

of treatment in curing disorders outcome assessed. The patients suffered from any other

complications within 3 days & use of any alternative methods were assessed.

33


Investigations:

Blood examination: Hb%

TC

DC

E.S.R

RBS

Urine examination:

Sugar

Albumin

Microscopic

USG (If necessary )

Urine Pregnancy Test (If necessary)

34

Chapter 4.2 OBSERVATIONS

35

OBSERVATIONS

Distribution of patients according to Age: Table No 1 Age group Group A Group B Group C Group D Total %

19-26 yrs 0 0 12 0 12 24

27-34 yrs 2 0 10 2 14 28

35-42 yrs 5 0 2 1 8 16

43-50 yrs 15 1 0 0 16 32

Graph no 1

0

5

10

15

20

25

30

35

Gr A Gr B Gr C Gr D Total %

19-26 yrs 27-34 yrs35-42 yrs43-50 yrs

The study of age shows that maximum no. of patients 32% were found in the age group

of 43-50 years, followed by 28% patients in 27-34 years age group, 24% patients in 19-

26 years age group & 16% patients in 35-42 years age group.


36

Distribution of patients according to Religion: Table No 2 Religion Group A Group B Group C Group D Total %

Hindu 18 1 17 3 39 78

Muslim 3 0 5 0 8 16

Christian 2 0 1 0 3 6

Graph no 2

0

10

20

30

40

50

60

70

80


HinduMuslim Christian

The study of religion shows that maximum no. of patients 78% were Hindus, followed by

16% patients were Muslims & 6% patients belong to Christian.


37

Distribution according to Education – Table No 3

Education Group A Group B Group C Group D Total %

Uneducated (U.E) 8 0 0 0 8 16

Primary (P) 8 1 7 0 16 32

Secondary (S) 4 0 9 1 14 28

Higher

secondary(HS) 1 0

7

0 8 16

Graduate (G) 1 0 0 2 3 6

Post graduate (PG) 0 0 1 0 1 2

Graph no 3

0

5

10

15

20

25

30

35


U.EPSH.SGP.G

The study of education shows that maximum no. of patients 32% were primary educated,

followed by 28% patients were secondary educated, 16% uneducated, 16% higher

secondary educated, 6% patients were graduated and 2% patients were post graduated.


38

Distribution of patients according to Socio economic status: Table No 4

Socio

economic

status

Group A Group B Group C Group D Total %

Lower (L) 0 0 0 0 0 0

Lower middle

(L.M) 14 1

17 1 33 66

Upper middle

(U.M) 8 0

7 2 17 34

Upper (U) 0 0 0 0 0 0

Graph no 4

0

10

20

30

40

50

60

70


LL.MU.MU

The study of socio-economic status shows maximum no. of patients 66% were found in

lower middle class and 34% patients were in upper middle class.


39

Distribution of patients according to occupation: Table No 5

Occupation Group A Group B Group C Group D Total %

House wife 13 0 22 1 36 72

Working 9 1 2 2 14 28

Graph no 5

01020304050607080


house wifeworking

The study shows maximum no. of patients 72% were house wives, and 28% patients were

working.


40

Distribution of patients according to Region : Table No 6

Region Group A Group B Group C Group D Total %

Urban 9 0 2 1 12 24

Rural 13 1 22 2 38 76

Graph no 6

01020304050607080


UrbanRural

The study shows that majority of patients 76% were from rural area and 24% patients

from urban.


41

Distribution of patients according to Diet: Table No 7

Diet Group A Group B Group C Group D Total %

Vegetarian 5 0 9 2 16 32

Mixed 17 1 15 1 34 68

Graph no 7

0

10

20

30

40

50

60

70


VegetarianMixed

The study of diet shows that maximum no. of patients 68% were mixed diet and 32%

patients were vegetarians.


42

Distribution of patients according to sleeping pattern: Table No 8

Sleeping pattern Group A Group B Group C Group D Total %

Sound 13 0 21 3 37 74

Disturbed 9 1 1 0 11 22

Graph no 8

01020304050607080


SoundDisturbed

The study of sleeping pattern shows that maximum no. of patients 74% were having

sound sleep, followed by 22% patients were having disturbed sleep.


43

Distribution of patients according to previous menstrual history: Table No 9

Menstrual history Group A Group B Group C Group D Total %

regular 6 1 22 2 31 62

Irregular 16 0 2 1 19 38

Graph no 9

0

10

20

30

40

50

60

70


RegularIrregular

The study of previous menstrual history shows that maximum no. of patients 62% were

having regular menstrual periods and 38% patients were having irregular menstrual

periods.


44

Distribution of patients according to Obstetric history: Table No 10

Obstetric history Group A Group B Group C Group D Total %

Nullipara 0 0 0 3 3 6

Primi 0 0 15 0 15 30

Multi 22 1 9 0 32 64

Graph no 10

0

5

10

15

20

25

30

35


NulliparaPrimiMulti

The study of obstetric history shows that the maximum no. of patients 64% were multi

gravidae, 30% patients were primi gravidae and 6% patients were nullipara.


45

Distribution of patients according to previous surgical history: Table No 11

Previous surgical

history Group A Group B

Group C Group D Total %

Curettage 2 0 6 1 9 18

LSCS 0 0 2 0 2 4

Tubectomy 15 0 0 0 15 30

Any other 0 0 0 0 0 0

Nothing specific 5 1 16 2 24 48

Graph no 11

05

101520253035404550


CurettageLSCSTubectomyAny otherNothing specific

The present study shows maximum number of patients 48% had no previous surgical

history followed by 30% patients were tubectomized, 18% patients previously underwent

curettage and 4% patients had history of LSCS.


46

Distribution of patients according to Prakriti :

Table No 12

Prakriti Group A Group B Group C Group D Total %

Vata-kapha 4 0 7 0 11 22

Vata-pitta 8 1 13 3 25 50

Pitta-kapha 10 0 4 0 14 28

Graph no 12

05

101520253035404550


Vata-kaphaVata-pittaPitta-kapha

The present study shows that maximum patients 50% were of vata-pitta prakriti, followed

by 28% patients were of pitta-kapha and 22% patients were of vata-kapha prakruti.


47

Distribution of patients according to Samhanana : Table No 13

Samhanana Group A Group B Group C Group D Total %

Pravara 5 0 1 0 6 12

Madyama 14 0 19 3 36 72

Avara 3 1 4 0 8 16

Graph no 13

01020304050607080


PravaraMadyamaAvara

The present study shows maximum number of patients 72% were of madyama

samhanana, followed by 16% patients were of avara samhanana and 12% patients were of

pravara samhanana.


48

Distribution of patients according to Sara: Table No 14 Sara Group A Group B Group C Group D Total %

Twak 0 0 0 0 0 0

Rakta 0 0 0 0 0 0

Mamsa 6 0 7 1 14 28

meda 10 0 3 2 15 30

asthi 6 1 14 0 21 42

majja 0 0 0 0 0 0

shukra 0 0 0 0 0 0

Satva 0 0 0 0 0 0

Graph no 14

05

1015202530354045


TwakRaktaMamsaMedaAsthiMajjaShukraSatva

The incidence of sara shows that maximum number of patients 42% were asthisara,

followed by 30% patients were meda sara and 28% patients were mamsa sara.


49

Distribution of patients according to Satva : Table No 15 Satva Group A Group B Group C Group D Total %

Pravara 1 0 0 0 1 2

Madyama 19 0 20 3 42 84

Avara 2 1 4 0 7 14

Graph no 15

0102030405060708090


PravaraMadyamaAvara

The present study shows that maximum number of patients 84% were of madyama satva,

followed by 14% patients were avara satva and 2% patients were pravara satva.


50

Distribution of patients according to Satmya : Table No 16 Satmya Group A Group B Group C Group D Total %

Pravara 1 0 0 0 1 2

Madyama 19 0 20 3 42 84

Avara 2 1 4 0 7 14

Graph no 16

0102030405060708090


PravaraMadyamaAvara

The present study shows that maximum number of patients 84% were of madyama

satmya, followed by avara satmya 14% and pravara satmya 2%.


51

Distribution of patients according to Aharashakti : Table No 17 Ahara shakti Group A Group B Group C Group D Total %

Pravara 1 0 1 0 2 4

Madyama 19 0 18 3 40 80

Avara 2 1 5 0 8 16

Graph no 17

01020304050607080


PravaraMadyamaAvara

The present study shows that maximum number of patients were of madyama ahara

shakti 80%, followed by avara ahara shakti 16% and pravara ahara shakti 4%.


52

Distribution of patients according to Vyayama shakti : Table No 18 Vyayama shakti Group A Group B Group C Group D Total %

Pravara 0 0 0 0 0 0

Madyama 19 0 18 3 40 80

Avara 3 1 6 0 10 20

Graph no 18

0

10

20

30

40

50

60

70

80


PravaraMadyamaAvara

The present study shows maximum number of patients were of madyama vyayama shakti

80%, followed by avara vyayama shakti 20%.


53

Incidence of Lekhana karma in 50 selected patients : Table No 19

Indication Total %

Group A 22 44

Group B 1 2

Group C 24 48

Group D 3 6

Graph no 19

Group AAtyartavaa

44%

Group BAnartava

2%

Group CGarbhasrava

48%

Group DVandhyatva

6%

%

In selected 50 patients, in present study maximum number of patients 48% in Group C,

followed by 44% patients in Group A, 6% patients in Group D and 2% patients B.


54

Incidence of diagnosis of conditions on the basis of clinical features in selected 50 patients: Table No 20

Vyadhi Group A Group B Group C Group D Total %

Vataja asrigdhara 13 0 0 1 14 28

Kaphaja

Asrigdhara 1 0

0 0 1 2

Vata-kaphaja

asrigdhara 8 0

0 0 8 16

raktayoni 0 0 0 2 2 4

shushka 0 1 0 0 1 2

Shesha

amagarbha 0 0

24 0 24 48

Graph no 20

0

10

20

30

40

50


Vataja asriddharaKaphaja asrigdharaVata-kaphaja asrigdharaRaktayoniShuskaShesha amagarbha

The present study shows the majority of patients 48% were diagnosed as Shesha

amagarbha, followed by 28% patients were diagnosed as Vataja asrigdhara, 16% were

Vata-kaphaja asrigdhara, 4% were Raktayoni & 2% each in Kaphaja asrigdhara &

shushka yoni vyapad.


55

Incidence of total time taken for procedure in 50 patients: Table No 21

Time Group A Group B Group C Group D Total %

3-4 mins 6 1 0 0 7 14

5-6 mins 16 0 11 2 29 58

7-8 mins 0 0 9 1 10 20

9-10 mins 0 0 4 0 4 8

Graph no 21

0

10

20

30

40

50

60


3-4 mins5-6 mins7-8 mins9-10 mins

The present study shows maximum number of patients 58% completed the procedure

within 5-6 mins, followed by 20% patients within 7-8 mins, 14% patients within 3-4 mins

and 8% patients with in 9-10 mins.


56

Incidence of requirement of Vardhana karma before the procedure: Table No 22 Procedure Group A Group B Group C Group D Total %

With Vardana 22 1 18 3 44 88

Without Vardana 0 0 6 0 6 12

Graph no 22

0102030405060708090


With vardanaWith out vardana

The present study shows maximum number of patients 88% required Vardana karma

before Lekhana karma and 12% patients does not required Vardana karma the procedure.


57

Incidence of P/V bleeding immediately after the procedure: Table No 23 Bleeding Group A Group B Group C Group D Total %

Absent 22 1 24 3 50 100

Mild 0 0 0 0 0 0

Moderate 0 0 0 0 0 0

Severe 0 0 0 0 0 0

Graph no 23

0102030405060708090

100


AbsentMildModerateSevere

The present study shows all patients 100% did not having P/V bleeding immediately after

the procedure.


58

Incidence of pain in abdomen immediately after the procedure: Table No 24

Pain Group A Group B Group C Group D Total %

No pain 0 0 0 0 0 0

Mild 20 1 21 3 45 90

Moderate 2 0 3 0 5 10

Severe 0 0 0 0 0 0

Graph no 24

0

10203040

50607080

90


No painMildModerateSevere

The present study shows maximum number of patients 90% were having mild pain

immediately after the procedure, followed by 10% patients were having moderate pain.


59

Incidence of amount of collected endometrial material obtained after the procedure: Table No 25 Amount Group A Group B Group C Group D Total %

1-10 ml 18 1 2 3 24 48

11-20 ml 4 0 6 0 10 20

21-30 ml 0 0 10 0 10 20

31-40 ml 0 0 6 0 6 12

Graph no 25

05

101520253035404550


1-10 ml11-20 ml21-30 ml31-40 ml41-50 ml

1-10 ml of endometrial bits obtained was maximum in 48% patients, followed by 20%

each in 10-20 ml & 21-30 ml group, 10% patients in 31-40 ml & 2% patients in 41-50 ml.


60

Incidence of injury after the procedure:

Table No 26

Injury Group A Group B Group C Group D Total %

Present 0 0 0 0 0 0

Absent 22 1 24 3 50 100

Graph no 26

0102030405060708090

100


presentAbsent

The present study shows 100% patients had no injury after the procedure.


61

Incidence of infection after the procedure: Table No 27

Infection Group A Group B Group C Group D Total %

Present 0 0 0 0 0 0

Absent 22 1 24 3 50 100

Graph no 27

0102030405060708090

100


presentAbsent

The present study shows 100% of patients had no infection after the procedure.


62

Incidence of P/V bleeding after 1 hour, after the procedure: Table No 28

Bleeding Group

A

Group

B

Group

C

Group

D Total %

Absent 1 1 3 0 4 8

Spotting 19 0 17 2 38 76

½ pad 2 0 4 1 7 14

More than ½ pad 0 0 0 0 0 0

Graph no 28

0

10

20

30

40

50

60

70

80


Absent Spotting1/2 padMore than 1/2 pad

The present study shows maximum number of patients 76% were having P/V spotting

1hour after the procedure, followed by14% patients were having ½ pad soaked and 8%

patients were having no bleeding.


63

Incidence of pain in abdomen after 1 hour, after the procedure: Table No 29

Pain Group A Group B Group C Group D Total %

Absent 0 0 8 0 8 16

Mild 17 1 16 3 37 74

Moderate 5 0 0 0 5 10

Severe 0 0 0 0 0 0

Graph no 29

0

10

20

30

40

50

60

70

80


Absent Mild Moderate Severe

The present study shows maximum number of patients 74% were having mild abdominal

pain 1 hour after the procedure followed by 16% patients were having no pain and 10%

patients having moderate pain.


64

Incidence of surgical interventions after Lekhana procedure : Table No 30 Surgical

intervention Group A Group B

Group C Group D Total %

Recurettage 0 0 0 0 0 0

Hysterectomy 3 0 0 0 3 6

Others 0 0 0 0 0 0

None 19 1 24 3 47 94

Graph no 30

0102030405060708090

100


RecurettageHystotectomyothersnone

The present study shows that maximum number of patients 94% not underwent any

surgical intervention after Lekhna karma, followed by 6% patients had hysterectomy.


65

Incidence of final assessment of the procedure: Table No 31

Result Group A Group B Group C Group D Total %

Cured 2 0 24 0 26 52

Relieved 17 0 0 3 20 40

No effect 3 1 0 0 4 8

Graph no 31

0

10

20

30

40

50

60


curedRelievedNo effect

The study shows majority of patients 52% cured from their complaints after Lekhana

karma followed by 40% of patients relieved and in 8% of patients no effect.

Chapter 5 Discussion

DISCUSSION

Ayurveda is the pioneer in the art of surgery. Judicious application of Ayurvedic

principles of surgical interventions can prevent complications and facilitate speedy

recovery. Surgery is a medical technology consisting of physical intervention of tissues.

Asthavidha shastrakarmas are the fundamental procedures to the development of surgery

which includes Lekhana karma.

• Lekhana karma is one of the important techniques in the management vrana. In

classics while explaining the vrana chikitsa, the method of procedure is explained.

In vartmagata rogas also we will get detail description of Lekhana karma with its

indications, procedure, samyak lakshanas, asamyak lakshanas and management of

complications.

• In some procedures it is a main therapy and in some procedures it is an adjuvant

therapy. Here this procedure is a main therapy.

• Lekhana karma is shodhana therapy in bahya ashraya vyadhis like granthi,

mamsankura, mamsonnati, arsha etc. If these conditions are present in yoni,

produces yonivyapads & artava vyapads, asrigdhara etc.

• Though different Acharyas mentions the instruments used for Lekhana karma,

among them Mandalagra shastra is suitable for the purpose of Lekhana procedure

in Garbhashaya. Because of its size and shape, it can be easily inserted in uterine

cavity and avoids injury to the adjacent parts.

• Even though Lekhana karma is described by Acharya Sushruta, in present days

manipulation of endometrium is done by a procedure called uterine curettage

which is widely in practice. As Ayurvedic instruments are not available for

practical usage today, the instruments used in uterine curettage are inevitably

taken for the purpose since same instruments which explained in classics are

modified according to changing era.

66


Procedure –

• Related to present topic, there was no direct reference in the classics.

• The principle of position during Lekhana karma was taken from Uttara basti

procedure as this procedure is comfortable for Lekhana karma.

• The principles of Lekhana karma which was explained in management of general

procedure of vartma rogas like

Cleaning the parts – for purpose of antiseptic precaution

Stabilization of the organ – in order to avoid the injury to adjacent parts

• Vardhana of Garbhashaya mukha – It facilitates easy insertion of the instruments

in uterine cavity.

• The technique of procedure means samam likhet, sulikhitam, niravasheshavat and

vartmanaam tu pramaanena were taken from vrana chikitsa.

• Paschat karma of the procedure taken from management of vrana shopha.

Samyak lekhya lakshana –

‘Asrigsravarahita’ means stoppage of the bleeding and Kandushopha vivarjitam (not

associated with itching and inflammation), it indicates that after Lekhana karma, it should

not associated with any infections which are explained in vartma rogas can be considered.

Utility of Lekhana karma in Streeroga and Garbha vyapad-

• Lekhana karma is said to be superior to shamana chikitsa, if it is done in proper

manner. Because shamana chikitsa takes longer time to act on particular dhatu

(target tissue), where as lekhana karma is done on directly on target tissues.

Shamana chikitsa is not effective in disease which is in bhedavastha, where as

lekhana karma is very effective in that condition.

• Niravasheshavat lekhana – Lekhana is niravasheshavat means without any

remnant. Lekhana is done up to that point, there is no vitiated dhatu is seen. This

can be confirmed by stoppage of bleeding.

67


• Sama lekhana & Sulekhana – which are probably, indicated superficial handling

of pathology where chedana and bhedana cannot be performed.

Eg- endometrium, eyelid

• Lekhana karma is indicated in relation to present study as follows –

Mamsonnati –

It refers to hyperplastic condition of muscular tissue of uterus.

Mamsankura & Arsha –

These are also hyperplasic condition of muscular tissue & can taken as

Endometrial polyps -

Endometrial polyps are overgrowths of endometrial glands and stroma

with blood vessels, sometimes also containing smooth muscle, which

protrude into the uterine cavity.

Granthi –

The definition of Granthi as follows –

“Vigrathitam granthiriti pradishtah”

“Granthi grathanaat smrutah”

Granthi is a type of shotha vikara & is a nodular structure. This condition

can be taken as Cystic glandular hyperplasia (metropathia haemorrhagica).

Shesha amagarbha-

When Amagarbha which is incompletely expelled, for complete expulsion

teekasna upachara is indicated. As shastra karma is teeksna upachara, it

can be indicated in this condition. Lekhana karma is one type of shastra

karma & suitable therapy among the astavidha shastra karmas, it can be

implement in this condition. Because this technique can applied repeatedly

till its complete expulsion.

“Teekshnairanavasheshayannupaacharet”

Out of 8 shastra karmas, Lekhana karma is simple, involving only

scraping of endometrium and not like chedana, bhedana etc. it is suitable

treatment protocol in soft uterus which is engorged in

recent pregnancy.

68


• Ayurvedic physicians depended upon macroscopic structure and nature of Artava

to diagnose the yonovyapads & artavavyapads.

For e.g. –

In Artava dusti –

Kunapa gandhi – depending upon the gandha. Gandha signifiees

putrification which indicates infenction.

Granthi – depending upon the rupa. It indicates nodular appearance.

In Yoni vyapad –

Raktayoni –depending upon laxana i.e.” srugati sruteh” excessive

bleeding. Probably it indicates anovulaton. This pathology also diagnosed

by remnants obtained from Lekhana karma.

Arajaska – depending upon laxana (Anartava)

Apraja – the woman remains without child

But for proper understanding of Artava dusti & Yonivyapads, further lead

to microscopic examination. Lekhana karma facilitates collection of endometrial

material which facilitates to diagnose the exact pathology of diseases available on

contemporary science. Based on available contemporary facilities the pathological

conditions can be further classified under the heading of

1. Infections

2. Inflammation

3. Neoplasia – benign or malignancy

4. Study of hypothalamo-pituitary-ovarian-uterian axis

To get the fresh and uncontaminated tissue right from the origin of

pathological area, Lekhana karma can be implemented as diagnostic procedure.

• As mamsonnati, mamsankura and granthi are main indications of Lekhana karma,

but in these conditions Lekhana karma can be adopted for diagnostic &

therapeutic purpose. On basis of USG when endometrial thickness is more than

normal on the particular day of menstruation, after the procedure the

histopathological reports showed maximum reports were endometrial hyperplasia

and cystic glandular hyperplasia. But no endometrial polyp cases are observed in

50 randomly selected patients.

69


• In case of shesha amagarbha (incomplete abortion) Lekhana karma is effective as

therapeutic procedure.

Discussion on incidence observations –

Age –

Age wise distribution of GroupA, Group B, Group C & Group D showed majority

of patients belonged to age group of 43-50 years. In this age group most patients were

having symptom of atyartava & one patient was having symptom of anartava. Atyartava

is common in this age group because anovulatory cycles lead to endometrial hyperplasia.

In group C majority of patients comes under the age group of 19-26 years & 27-34 years.

It may be due to common reproductive age of women in this area.

Religion –

Incidence of patients belonging to Hindu religion was highest i.e. 78%. This

reflects the geographical distribution of population in this area.

Education –

The study of education shows that maximum no. of patients 32% were primary

educated, followed by 28% patients were secondary educated, 16% uneducated, 16%

higher secondary educated, 6% patients were graduated and 2% patients were post

graduated.

Socioeconomic status –

Maximum number of women came from lower middle class i.e. 66% & 34% from

upper middle class. The S.D.M hospital is a charity hospital & most of the patients

visiting to the hospital are of middle class and poor.

Occupation -

70


Majority number of women were housewives, i.e. 72%. As women coming to this

hospital are from middle class background, non-working class seemed to have more

incidences.

Region –

The majority of patients came from rural area i.e. 76%.

Diet –

The maximum numbers of women was taking mixed diet i.e. 68% and 32%

women were vegetarians. The area where study was conducted is coastal area. Most of

the people are having their main food as fish. This observation gives that most of patients

had mixed type of dietary habit.

Sleeping pattern –

Maximum numbers of patients were having sound sleep i.e. 74% and 22%

patients were having disturbed sleep.

Previous menstrual history –

The study of previous menstrual history shows that maximum no. of patients 62%

were having regular menstrual periods and 38% patients were having irregular menstrual

periods. But maximum number of Group A (Atyartava) patients were having previous

irregular menstrual periods. It may be due to premenstrual age. In Group C, majority of

patients were having regular menstrual periods which are essential for conception.

Obstetric history –

The study of obstetric history shows that the maximum no. of patients 64% were

multi gravidae, 30% patients were primi gravidae and 6% patients were nullipara. In

Group A, all patients were multi para. In Group D all patients were nullipara & they came

with complaint of primary infertility. In Group C, majority of patients were primigravida.

71


Previous surgical history –

In this study the majority of patients who were having the previous surgical

history of curettage come under Group C.

Pareekshya bhavas -

The present study on prakruti shows that maximum patients 50% were of vata-

pitta prakriti, followed by 28% patients were of pitta-kapha and 22% patients were of

vata-kapha prakruti.

Maximum numbers of patients 72% were of madyma samhanana, followed by

16% patients were of avara samhanana and 12% patients were of pravara samhanana.

The incidence of sara shows that maximum number of patients 42% were

asthisara, followed by 30% patients were meda sara and 28% patients were mamsa sara.

The present study shows that maximum number of patients 84% were of

madyama satva, followed by 14% patients were avara satva and 2% patients were pravara

satva.

The study on Satmya shows that maximum number of patients 84% were of

madyama satmya, followed by avara satmya 14% and pravara satmya 2%.

The present study shows that maximum number of patients were of madyama

ahara shakti 80%, followed by avara ahara shakti 16% and pravara ahara shakti 4%.

The present study shows maximum number of patients were of madyama

vyayama shakti 80%, followed by avara vyayama shakti 20%.

72


Observations made for Lekhana karma in different pathological

conditions of Streeroga & Garbhavyapad –

• Incidence of Lekhana karma in different indications –

Majority of patients 48% were in Group C i.e. Garbha srava. As the USG of this

group showed incomplete abortion, missed abortion & nonviable pregnancy.

Group A i.e. Atyartava and Group D i.e. Vandhyatva underwent Lekhana karma for

the purpose of Asrigdhara. Most of the histopathological reports of these groups

showed endometrial hyperplasia.

In Group B i.e. Anartava, there is only one patient.

Diagnosis of conditions on the basis of clinical features in selected 50 patients:

The majority of patients 48% were diagnosed as Shesha amagarbha, followed by

28% patients were diagnosed as Vataja asrigdhara, 16% were Vata-kaphaja asrigdhara,

4% were Raktayoni & 2% each in Kaphaja asrigdhara & shushka yoni vyapad.

Time taken for Lekhana karma –

In present study the majority of patients 58% completed the procedure within 5-6

mins. The duration of the time taken for the procedure varies from person to person. It

may depend on endometrial thickness/ concepts part, co-operation of the patient etc.

Requirement of Vardhana karma before Lekhana karma –

The majority of patients 88% required Vardhana karma before Lekhana karma

because it facilitates the easy insertion of Lekhana shastra in the uterine cavity.

73


Remaining 12% of patients comes under the Group C i.e. Garbhasrava which does not

required Vardhana karma.

P/V bleeding immediately after the procedure:

In present study, P/V bleeding was not seen in any of the patients immediately

after the procedure. It shows Samyak lekhya lakshana of the procedure.

Pain in abdomen immediately after the procedure:

The present study shows maximum number of patients, i.e. 90% were having mild

pain immediately after the procedure. Due to surgical intervention, there is local injury to

the tissues and it leads to pain. The intensity of pain will be differing, because of patient’s

tolerance capacity towards pain.

Amount of collected endometrial material obtained after the procedure:

1-10 ml of endometrial bits obtained was maximum in 48% patients, followed by

20% each in 10-20 ml & 21-30 ml group & 12% patients in 31-40 ml.

Injury after the procedure:

100% patients had no injury after the procedure.

Infection after the procedure:

100% of patients had no infection after the procedure.

P/V bleeding after 1 hour, after the procedure:

Maximum number of patients 76% were having spotting P/V, 1hour after the procedure. So it shows the samyak lekhya lakshana of the procedure.

Pain in abdomen after 1 hour, after the procedure:

Maximum number of patients 74% were having mild abdominal pain, 1 hour after the procedure followed by 16% patients was having no pain and 10% patients having moderate pain.

Surgical interventions after Lekhana procedure:

74


In present study maximum number of patients 94% had no any surgical

intervention after Lekhna karma. It indicates that Lekhana karma is an effective

procedure in all indications of 50 randomly selected patients. Remaining 6% patients had

hysterectomy. These 6% patients comes under the Group A i.e. Atyartava.

Final assessment of the procedure:

Majority of patients 52% cured from their complaints after Lekhana karma

followed by 40% of patients relieved and in 8% of patients no effect.

75

Chapter 6 Summary and Conclusion

SUMMARY AND CONCLUSION

The present dissertation study entitled “Clinical evaluation of lekhana procedure

in certain conditions of streeroga & garbha vyapad” is planned with following aim &

objectives.

1) Conceptual study of Lekhana vidhi & it’s indications in certain conditions

of Stree roga & Garbha vyapad.

2) Analysis of Lekhana vidhi in different conditions of Stree roga & Garbha

srava.

The whole study was elaborated in terms of

• Review of literature

• Methodology

• Discussion

• Conclusion

1. Introduction: This chapter describes the need for the study & aim of under

taking the study.

2. Review of Literature :

2.1. History Review: This chapter deals with the historical aspects of

Lekhana karma.

2.2. Introduction of Lekhana karma: The chapter contains Nirukti &

Paribhasha of the words Lekhya & Lekhana, related words of the word

Lekhana.

2.3. General description of Lekhana karma: The chapter contains

general indications of Lekhana karma, indications related with

Shalakya tantra, Shalya tantra & Stree roga, instruments used in

Lekhana karma, procedure, samyak lakshana & asamyak lakshana of

Lekhana karma according to classics are explained.

2.4. Description of Lekhana karma in Streeroga & Garbha vyapad

: The chapter contains Lekhana karma is a variety of shodhana

75


chikitsa, indications of Lekhana karma in Streeroga & Garbha vyapad

and the procedure explained on the basis of principle from Lekhana

vidhi of vrana and vartma rogas.

2.5. Modern Review: Indications, procedure and complications of

curettage is described in detail in this chapter.

3. Clinical study :

3.1. Material and Methods : This study consisting of methodology of

the study, including assessment criteria has been discussed

3.2. Observations: Here, the incidence of occurrence of various

criteria has been observed corresponding observations have been

drawn.

4. Discussion: It is based on the observations obtained after the completion of the

study is done here.

5. Conclusion: Here concluding remarks have been made & future scope of study

on this topic is mentioned.

• Based on the present study it is summarized that the Lekhana karma

described by Bruhatrayis, has been one of the effective treatment

modality in conditions of Atyartava and Garbhasrava (Garbha shesha

avastha).

• The incidence of Lekhana karma in 50 patients was 44% of patients in

Group A, 2% of patients in Group B, 48% of patients in Group C and 6%

of patients in Group D.

• The efficacy of Lekhana karma shows majority of patients 52% cured

from their complaints after Lekhana karma followed by 40% of patients

relieved and in 8% of patients no effect seen.

Benefits of Lekhana karma –

76


• Lekhana karma is an effective treatment modality in cases of mamsonnati,

granthi, arsha, mamsankura which are present in Garbhashya.

• Lekhana karma can be implemented as only a diagnostic procedure as well as

therapeutic procedure in conditions like mamsonnati, granthi, arsha, mamsankura.

• As Lekhana karma is a teekshna upachara, it is therapeutically effective in shesha

amagarbha chikitsa.

• If Lekhana karma is used in proper way, then it has least complications, minimum

hospital stay and cost effective therapy.

Limitations of Lekhana karma –

• The patients who are having less pain threshold capacity, they may require

anesthesia during Lekhana karma.

• Need of antibiotic therapy whenever anticipated.

77

Chapter 7 Bibliography

78

BIBLIOGRAPHY

1. Agnivesha, Charaka samhita with Chakrapani commentary, Edited by Vaidya

Jadavaji Trikamji Acharya, Reprinted edition 2007, Chaukhambha orientalia,

Varanasi.

2. http i//WWW.ias.ac.in / currsci / may 10 2009/1186.pdf.

3. WWW. Ayurvedapages. Com /ayurveda_history.html.

4. History of medicine in India, Edited by Priya vrat Sharma, Published by The Indian

National Science Acadamy, New Delhi, First print 1992, Pp527:333.



Varanasi. Pp738:594

6. Sushruta, Sushruta samhita with the Nibandhasangraha Commentary of Sri

Dalhanacharya, Edited by Vaidya Jadavji Trikamji Acharya, Ninth edition:2007,

Chaukhambha Orientalia, Varanasi, Pp824:19.



Chaukhambha Orientalia, Varanasi, Pp824:19



Chaukhambha Orientalia, Varanasi, Pp824:118








79






















18. Vagbhatacharya, Ashtangahridayam with Sarvangasundara commentary of

Arunadatta and Ayurvedarasayana of Hemadri collated by late Dr.Anna

Moreshwara Kunte and Ramachandra Shastri Navare, Edited by Bhishagacharya

Harishastri Paradakara Vaidya, Reprint 9th edition 2005, Chaukhambha Orientalia,

Varanasi, Pp 956:807.


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Moreshwara Kunte and Ramachandra Shastri Navare Edited by Bhishagacharya








21. Bhavamishra, Bhava prakasha with the Vidyotini Hindi commentary, Edited by

Bhisagratna Pandit Sri Brahma sankara Misra (part II), 11th edition 2007,

Choukhambha Sanskrit Bhavan, Varanasi, Pp 836:463, 464.

22. Bhela, Bhela samhita (mula matra), Edited by Girijadayalu Suklah, Chaukhambha

Bharati Academy, Varanasi, Reprint 1999, Pp 285:227.

23. Shabda kalpadruma, syara-raja-radhakantadeva-brahmadurenaa virachita

shrivaradaprasadavasuna tadanujena shreeharicharanaavasuna cha, Chaturtha

kanda, Vyanjana varga Ya-Va, Reprint 1987, Published by Nag. Sharan Singh for

Nag publishers, Delhi, Pp 564: 228.

24. Ayurvediya mahakosha arthat Ayurvediya shabdakosha, Sanskrita-Sanskrita

prathama khandah, Edited by Ayurvedacharya Venimadhavashastri Joshi, Pp 915:

708.

25. A Sanskrit English dictionary by Sir Monier Monier-Williams, Reprint 2005,

Published by Motilal Banarsidass, Varanasi, Pp 1333: 901.



Varanasi. Pp738:594


81





























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37. Vriddha Vagbhata, Astanga sangrah with the Sasilekha Sanskrit Commentary by

Indu, Edited by Dr. Shivaprasad Sharma, Chowkhamba Sanskrit Series Office,







Varanasi, Pp 965:691









Chaukhambha Orientalia, Varanasi, Pp 824:631.



Varanasi. Pp738:59

Sushruta, Sushruta samhita with the Nibandhasangraha Commentary of Sri

Dalhanacharya, Edited by Vaidya Jadavji Trikamji Acharya, Ninth edition: 2007,



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Varanasi. Pp738:594
















Vagbhatacharya, Ashtangahridayam with Sarvangasundara commentary of





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Varanasi, Pp 965:689-692.


84





























85






























86






























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Choukhambha Sanskrit Bhavan, Varanasi, Pp 959:160.
















88



Varanasi. Pp738:643


















Varanasi. Pp738:635.







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85. Madhavakara, Madava nidana,with the commentary Madhukosha,Edited by Vaidya

Jadavaji Trikamji Acharya Chaukhambha Orientalia, Varanasi, , Pp 412:382.






87. Sarangadharacharya, sharangadhara samhita, with the commentaries Adhamalla’s

Dipika & Kasirama’s Gudhartha-Dipika, Edited by Pt. Parashuram Shastri

Vidyasara, Chaukhamba Surbharati Prakashana, Varanasi, Edition 2006, Pp

398:127.

















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102. D.C.Datta, Textbook of Gynaecology including contraception, Edited by Hiralal

Konar, Fifth edition 2008, New Central Book Agency, Kolkata Pp 627:557.

103. Disfunctioning Uterine Bleeding : An Update, Edited by

Chittaranjan.N.Purandare, Jaypee Brothers Medical Publishers, Reprint 2006, Pp

219:19-20.

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2002, Pp929:334-335



2002, Pp 929:298-300.



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2002, Pp929:745-747.


Konar, Fifth edition 2008, New Central Book Agency, Kolkata Pp 627:557-558.


Konar, Fifth edition 2008, New Central Book Agency, Kolkata Pp 627:558.

Chapter 8 Annexure

91

CASE PROFORMA

S.D.M. college of Ayurveda –Udupi Department of Prasooti Tantra and Stree Roga

2007 – 2010

“CLINICAL EVALUATION OF LEKHANA PROCEDURE IN CERTAIN CONDITIONS OF STREEROGA & GARBHAVYAPAD”

1) ATURA VIVARA- Atura nama : Serial No: vaya : Antaha kramanka: Jati: H / M / C / others Bahiha kramanka : Education: Pravesha dinanka : Vyavasaya : Nirgamana dinanka : Samajika stithi : Indication : Address : Date : 2)VEDANA SAMUCHRAYAM – PRADHANA VEDANA – Causes indicating Lekhana karma - Group ‘A’ –

Atyartava- a) Duration of illness-

b) Last menstrual period- c) Onset – Gradual/ Sudden d) Duration of blood loss – e) Interval of blood loss – f) Amount of blood loss – No of pads/ clothes per day Staining Clots

Chapter 8 Annexure

92

g) Character – Colour Consistancy

Staining Odour

Group ‘B’ - Anartava-

Period of amenorrhoea- H/O previous periods- Time of menarche- Group ‘C’-

Garbha srava- Period of amenorrhoea- Last menstrual period-

Vedana – Raktasrava - H/O bija nirgamana - Group ‘D’ -

• Vandhyatwa- Sapraja / Apraja –

• Artava sambandi vyadhi – Anartava – Artava kshaya – Atyartava – Kastartava – Artava dusti –

• Kshetra sambandi – Uterus – Cervix – Vagina –

• Beeja sambandi – History of ovulation – Ovarian pathology – Semen report of husband if any –

• Ambu – Varna –

Samhanana – Doshavabhava sthiti –

Chapter 8 Annexure

93

SAMANYA ITI VRITTANTA - Anya yoni srava sambandi – Vaginal discharge - Pr /Ab Amount – Character – Colour – Consistancy – Odour – Others – Relation with menses – before / during / after ANUBANDHA VEDANA- Angamarda- Dourbalya – Katishula – Brama –

Daha - Atisweda – Vibanda – Osha / Chosha – Gurutva -

POORVA VYADHI VRITTANTA- H/O D.M / HTN / HIV / V.D.R.L / TB / any other Previous surgical history – D&C Encirclage operation – Any other - KULA VRITTANTA- H/O HTN / D.M / HIV / VDRL / TB / any other

H/O Carcinoma / Early menopause / infertility / fetal congenital abnormalities / any other.

VAYAKTIKA VRITTANTA-

Diet – Vegetarian / Nonvegeterian / Mixed Sleep- Sound / Disturbed Bowel – Consistancy- Frequency- Micturation – Frequency –day- night- Any habits –

Chapter 8 Annexure

94

POORVA RAJO VRITTANTA –

Raja kala - days/ days Pramana – No of pads/ clothes per day- 1st day – 2nd day – 3rd day onwards -

Last menstrual period – Associated complaints, if any – Character – Colour Consistency Odor Staining PRAJANANA VRITTANTA – Married life – Gravida /Parity/Live/Abortions/Dead/Last delivery CONTRACEPTIVE HISTORY – Safe period /Contraceptive pills /IUCD/Any other DASHAVIDHA PAREEKSHA –

a) Prakriti – V / P / K / VP / VK / PK / VPK b) Vikriti – c) Sara – d) Samhanana – e) Satmya – f) Satva – g) Pramana – h) Vaya – i) Abhyavarana shakti –

Jarana shakti – j)Vyayama shakti – GENERAL EXAMINATION – Built & nourishment – Wt – Ht – Pallor – Icterus – Edema – Lymphadenopathy – Cyanosis – VITAL SIGNS -

BP – PR – RR – Temp – HR –

Chapter 8 Annexure

95

SYSTEMIC EXAMINATION- Respiratory system- Cardiovascular system- Gastrointestinal system- Any other- STHANIKA PAREEKSHA-

a) Per abdomen- Darshana pareeksha- Sparshana pareeksha- b) Per vaginal- a) Vulva- b) vagina- Darshana pareeksha- Sparshana pareeksha- C) Cervix - Size-

Condition- OS- Colour- d) Uterus- Size- Position- Mobility- Consistancy- e) Fornices-

INVESTIGATIONS- a) Hematological- Hb%- TC- DC- ESR- RBS-

b) Urine- Routine- Albumin- Sugar-

Chapter 8 Annexure

96

Microscopic- Epithelial cells- /hpf Pus cells- /hpf R.B.C.s- /hpf Casts, Crystals, any other-

c)UPT (If necessary d)USG (If necessary)- SAMPRAPTI GHATAKA VICHEDANA - Doshic conditions before procedure – Vata – pain / srava varna Pitta - daha / paka / jwara / srava Kapha – kandu / gurutva /tandra Dushya- Srotas- Srotodusthi- Agni- Ama- Udbhava sthana- Sanchara sthana- Adhisthana- Vyaktasthana- Rogamarga- UPASHAYA ANUPASHAYA- VYADHI- OBSERVATION- Date – Time- Poorva karma- Preparation of the patient- Consent – Prepare the parts -

Chapter 8 Annexure

97

Garbhashaya mukha vistrutikarana – Condition of the cervix -

Duration of the dilatation- Number of the dilators used-

Pradhana karma- Length of the uterus – Position of the uterus – Colour / nature of the evacuation – Amount of obtained endometrial material - Time taken for completion of the procedure -

Paschat karma- Vital signs –

B.P- P.R- R.R- Temp- H.R- Bleeding per vagina-

Immidiately after the procedure – Ab/ Mild/ Moderate/Severe After 1 hr of the procedure – Ab/Spotting/ ½ pad/More than ½ pad

Pain in abdomen – Immediately after the procedure – Ab/mild/moderate/severe 1 hr after the procedure - Ab/mild/moderate/severe

Sending the material for histopathology report- Yes/not Doshic conditions – Vata – vedana / varna / srava / any other Pitta – daha / srava / paka / jwara / any other Kapha – kandu / gurutva / tandra / any other COMPLICATIONS- During procedure- After procedure- Follow up after 15 days -

Chapter 8 Annexure

98

CONCLUSION- Signature of the Guide: Signature of the Co-guide

Dr. V.N.K. Usha, Dr. Suchetha kumari, M. D.(Ayu ) M. S. (Ayu)

Signature of the scholar Dr. Vijayalakshmi. S. Hosmath B.A.M.S

xuÉoÉÑ®rÉÉ cÉÉÌmÉ ÌuÉpÉeÉãSè rÉl§ÉMüqÉÉïÍhÉ oÉÑÌ¬qÉÉlÉç AxÉÇZrÉãrÉÌuÉMüsmÉiuÉÉcNûsrÉÉlÉÉÍqÉÌiÉ ÌlÉ¶ÉrÉÈ | xÉÑ.xÉÔ.

Yantras & Shastras For D&C ----An Ayurvedic Purview

Chapter 8 Annexure

99

An Attempt By,

Dept of Prasuti Tantra & Stree Roga S.D.M.College of Ayurveda,Udupi

Instruments used in D&C –

• Sponge holding - MüÉmÉÉïxÉM×üiÉÉãwhÉÏ

• Sims Speculum - rÉÉãÌlÉ uÉëhÉã¤ÉhÉ rÉl§É

• Anterior vaginal wall retractor - LMü iÉÉsÉ rÉl§É

• Vulsellum - ÍxÉÇWûqÉÑZÉ xuÉÎxiÉMü rÉl§É

• Uterine sound – aÉpÉÉïvÉrÉ LwÉhÉÏ

• Dilators - aÉlQÒûmÉS qÉÑZÉ vÉsÉÉMüÉ rÉl§É

• Ovum forceps - Ì²iÉÉsÉ rÉl§É

• Curette - sÉãZÉlÉ vÉx§É

Sponge holding –

• Fig No.7

iÉ§É xuÉÎxiÉMürÉl§ÉÉÍhÉ:A¹ÉSvÉÉÇaÉÑsÉmÉëqÉÉhÉÉÌlÉ,ÍxÉÇWûurÉÉbÉëuÉ×MüiÉU¤uÉÑ¤É²ÏÌmÉqÉÉeÉÉïU. xÉÑ.xÉÔ. 7/10 .MüÉmÉÉïxÉÌuÉÌWûiÉÉãwhÉÏwÉÉ: vÉsÉÉMüÉ: wÉOè mÉëqÉÉeÉïlÉã| A WØû xÉÔ 25/34 OûÏMüÉ Éë ÉÉ ÉïlÉã ÉÉ ÉlÉã ÉÉUY ÉãSÉSã

• Speculum

lÉÉQûÏrÉl§ÉÉÍhÉ – AlÉåMümÉëMüÉUÉÍhÉ, AlÉåMümÉërÉÉåeÉlÉÉÌlÉ, LMüiÉÉåqÉÑZÉÉlrÉÑpÉrÉiÉÉåqÉÑZÉÉÌlÉ cÉ, iÉÉÌlÉ xÉëÉåiÉÉåaÉiÉvÉsrÉÉå®UhÉÉjÉïÇ ,UÉåaÉSvÉïlÉÉjÉïqÉç,----- xÉÑ.xÉÔ.7/13 rÉÉåÌlÉuÉëhÉå¤ÉhÉÇ qÉkrÉå xÉÑÌwÉUÇ wÉÉåQûvÉÉXûaÉÑsÉqÉç | qÉÑSìÉoÉ®Ç cÉiÉÑÍpÉï¨ÉqÉqpÉÉåeÉqÉÑMÑüsÉÉlÉlÉqÉç || cÉiÉÑÈvÉsÉÉMüqÉÉ¢üÉliÉÇ qÉÔsÉå iÉÌ²MüxÉålqÉÑZÉå || A.WØû.xÉÔ.25/22,23 ÉÉåÌlÉ ÉëhÉ ÉÏ ÉiÉåÅlÉålÉåÌiÉ iÉiÉ ÉÉåÌlÉ ÉëhÉå ÉhÉÇ

Chapter 8 Annexure

100

Fig No. 8

• Retractor

Fig No. 9

vÉsÉÉMüÉrÉl§ÉÉhrÉÌmÉ lÉÉlÉÉmÉëMüÉUÉÍhÉ, lÉÉlÉÉmÉërÉÉãeÉlÉÉÌlÉ, rÉjÉÉrÉÉãaÉmÉËUhÉÉWûSÏbÉÉïÍhÉ cÉ, iÉãwÉÉÇ aÉÇQÕûmÉS xÉmÉïTühÉ vÉUmÉÑÇZÉ oÉQûÏwÉqÉÑZÉ²ã²ã, LãwÉhÉ urÉÔWûlÉ cÉÉsÉlÉ............ xÉÑ xÉÔ 7/14 OûÏMüÉ: xÉmÉïTühÉqÉÑZÉã ²ã, CÌiÉ LMüÇ

wÉÉãQûvÉÉÇaÉÑsÉqÉmÉUÇ ²ÉSvÉÉÇaÉÑsÉÍqÉÌiÉ pÉãSãlÉ xÉmÉïTühÉqÉÑZÉxrÉ ²æÌuÉkrÉÇ ¥ÉãrÉÇ||

LãwÉhÉÇ aÉqpÉÏUmÉÉMüÉSÉæ mÉÔrÉÉ±luÉãwÉhÉÇ | urÉÔWûlÉÇ FkuÉÏïçMüUhÉÇ ÍNû¨uÉÉã¨ÉÑÎlQûiÉxrÉÉã®UhÉÉjÉïÇ, uÉÉUÇaÉãhÉÉlÉÑxÉUhÉÍqÉirÉãMãü CÌiÉ QûsWûhÉÈ |

urÉÔWûlÉÇ iÉÑ cÉÔÍhÉïiÉÉvqÉrÉÉïSÏlÉÉÇ xÉÇaÉëWûhÉÇ CÌiÉ WûÉUhÉcÉlSì:

AÉ U urÉÔWûlÉÇ mÉëxÉ×iÉqÉÉÇxÉÉSÏlÉÉÇ

Swastika Yantra

• Simhamuhka Yantra

iÉ§É xuÉÎxiÉMürÉl§ÉÉÍhÉ:A¹ÉSvÉÉÇaÉÑsÉmÉëqÉÉhÉÉÌlÉ,ÍxÉÇWûurÉÉbÉëuÉ×MüiÉU¤uÉ×¤É²ÏÌmÉqÉÉeÉÉïU ´ÉÑaÉÉsÉqÉ×aÉæuÉÉïÃMüMüÉMüMüÇMÑüUUcÉÉxÉpÉÉxÉvÉvÉbÉÉirÉÔsÉÔçMüÍcÉÎssÉ.......... AÎxjÉÌuÉS¹vÉsrÉÉã®UhÉÉjÉïqÉÑmÉÌSvrÉliÉã|| xÉÑ xÉÔ 7/10 A¹ÉSvÉÉÇaÉÑsÉÉrÉÉqÉÉlrÉÉrÉxÉÉÌlÉ cÉ

Chapter 8 Annexure

101

Fig No.10

Uterine sound Fig No.11

iÉãwÉÉqÉãwÉMüqÉïhÉÏ || EqÉã aÉhQÕûmÉSqÉÑZÉã ||{A.¾û.xÉÑ 25\29} iÉãwÉÉÇ aÉèhQÕûmÉSxÉmÉïTühÉvÉUmÉÑÇZÉoÉÌQûvÉqÉÑZÉã ²ã ²ã ||LwÉhÉurÉÔWlÉcÉÉsÉlÉÉWûUhÉÉjÉïqÉÑmÉÌSvrÉãiÉã || {xÉÑ.xÉÔ 7/14}

LwÉhÉÏ Dilators Fig No. 12

vÉsÉÉMüÉrÉl§ÉÉhrÉÌmÉlÉÉlÉÉmÉëMüÉUÉÍhÉ,lÉÉlÉÉmÉërÉÉãeÉlÉÉÌlÉ,rÉjÉÉrÉÉãaÉmÉËUhÉÉWû SÏbÉÉïÍhÉ cÉ; iÉãwÉÉÇ aÉÇQÕûmÉS xÉmÉïTühÉ vÉUmÉÑÇZÉ oÉQûÏwÉqÉÑZÉ²ã²ã, LãwÉhÉ,urÉÔWûlÉ, cÉÉsÉlÉ............xÉÑ xÉÔ 7/14 ÌOûMüÉ-vÉsÉMüÉrÉl§ÉÉhrÉmÉÏirÉÉÌS rÉjÉÉ rÉÉãaÉmÉËUhÉÉWûSÏbÉÉïÍhÉÌiÉ mÉËUhÉÉWûÉã uÉiÉÑïsÉiÉÉ | iÉãwÉÉÇ vÉsÉÉMüÉrÉl§ÉÉhÉÉÇ qÉkrÉã|

Ovum forceps

iÉÉsÉrÉl§É -iÉÉsÉrÉl§Éã - ²ÉSvÉÉXçaÉÑsÉã qÉixrÉiÉÉsÉuÉSãMüiÉÉsÉÌ²iÉÉsÉMãü, MühÉïlÉÉxÉÉlÉÉQûÏvÉsrÉÉlÉÉqÉÉWûUhÉÉjÉïqÉç || xÉÑ. xÉÔ. 7/12 ²ã ²ÉSvÉÉXçaÉÑsÉã qÉixrÉiÉÉsÉuÉiÉç ½ãMüiÉÉsÉMãü | iÉÉsÉrÉl§Éã xqÉ×iÉã MühÉïlÉÉQûÏû vÉsrÉÉmûÉWûÉûËUhÉÏ || A.¾û.xÉÑ. 25/10 xÉ0 - ²ã iÉÉsÉrÉl§Éã pÉuÉiÉ: |

Chapter 8 Annexure

102

Fig No. 13

• Curette sÉåZÉlÉ vÉx§É F Fig No. 14 Fig No.15

• Excerpted from SOUSHRUTHI-PRASUTI, 2008 July.

qÉlQûsÉÉaÉë vÉx§É - qÉlQûsÉÉaÉëÍqÉÌiÉ qÉlQûsÉÍqÉuÉÉaÉëÇ rÉxrÉ iÉlqÉhçQûsÉÉaÉëÇ, iÉccÉ Ì²ÌuÉkÉÇ | iÉjÉÉÌWû, “rÉSåaÉëå qÉlQûsÉÇ uÉë¨ÉÇ ¤ÉÑUxÉÇxjÉÉlÉqÉåuÉ cÉ | qÉhçQûsÉÉaÉëxrÉ eÉÉlÉÏrÉÉiÉç mÉëqÉÉhÉÇ iÉÑ wÉQûXÒûsÉqÉç CÌiÉ” ||Ì²kÉÉ qÉlQûsÉÉaÉëçÇ wÉQûXÒûsÉmÉëqÉhÉqÉåMüÇ uÉëÑ¨ÉqÉÑZÉÇ, Ì²iÉÏrÉÇ ¤ÉÑUÉMüÉUÇ | xÉÑ.xÉÔ.8/3 qÉlQûsÉÉaÉëÇ TüsÉå iÉåwÉÉÇ iÉeÉïlrÉliÉlÉïZÉÉM×üÌiÉ | sÉåZÉlÉå NåûSlÉå rÉÉåerÉÇ mÉÉåjÉMüÐvÉÑÎhQûMüÉÌSwÉÑ ||

• Concept – Dr. V.N.K.Usha • Work done by

Dr. Mahejabeen, Dr. Shilpa, Dr. Seemanthini , Dr. Gayan, Dr.Girija, Dr.Shivani M.D. batch 2004

• Scientific advisors – Dr. Muralidhara Sharma Dr. K.R.Rama Chandra

• Executive advisors – Dr. U.N.Prasad Dr. Prasanna N. Rao

Documents

Lekhana garbhavyapad-psr