Dr Thushar Babu - Dissertation.pdf

“A COMPARATIVE STUDY OF SIRAVYADHA AND SAHACHARADI

KASHAYA WITH TAILA IN THE MANAGEMENT OF

SIRAJAGRANTHI W.S.R TO VARICOSE VEIN”

By

Dr. THUSHAR BABU

DISSERTATION SUBMITTED TO THE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF

AYURVEDA DHANWANTHARI (M.S)

IN

SHALYA TANTRA

Under the Guidance of

Dr. MANJUNATHA BHAT M.S.(Ayu) Professor & H.O.D.

DEPARTMENT OF POST GRADUATE STUDIES

IN SHALYA TANTRA

ALVA’S AYURVEDA MEDICAL COLLEGE & HOSPITAL

MOODBIDRI-574227

2014

ALVA’S AYURVEDA MEDICAL COLLEGE MOODBIDRI, KARNATAKA

DEPARTMENT OF POST GRADUATE STUDIES IN

SHALYA TANTRA

..

DECLARATION

I hereby declare that this dissertation entitled “A COMPARATIVE

STUDY OF SIRAVYADHA AND SAHACHARADI KASHAYA WITH

TAILA IN THE MANAGEMENT OF SIRAJAGRANTHI W.S.R TO

VARICOSE VEIN” is a bonafide and genuine research work carried out by me

under the guidance of Dr.MANJUNATHA BHAT M.S (Ayu), Dept. of P.G

Studies in Shalya Tantra, Alva’s Ayurveda Medical College, Moodbidri,

Karnataka.

Dr.THUSHAR BABU

III Year P.G. Scholar

Dept. of P.G Studies in Shalya Tantra

Alva’s Ayurveda Medical College

Moodbidri – 574227.

Date:

Place: Moodbidri



SHALYA TANTRA

..

Certificate

This is to certify that the dissertation entitled “A COMPARATIVE



VARICOSE VEIN” submitted by Dr.THUSHAR BABU in partial fulfilment

for the degree of Ayurveda Dhanwantari (M.S) in Shalya Tantra, of Rajiv

Gandhi University of Health Sciences, Bangalore, is a record of research work

done by him during the period of his study in this institute, under my guidance

and supervision and the dissertation has not previously formed the basis to the

award of any degree, diploma, fellowship or other similar titles.

I recommend this dissertation for the above degree to the University for the

approval.

Guide

Dr.MANJUNATHA BHAT M.S (Ayu)

Professor & H.O.D



Date: Moodbidri – 574227.

Place: Moodbidri



SHALYA TANTRA

..

Certificate




VARICOSE VEIN” is a bona-fide research work done by Dr. THUSHAR

BABU under the guidance of Dr. MANJUNATHA BHAT M.S(Ayu), Professor

and H.O.D, Dept. of P.G Studies in Shalya Tantra, for partial fulfilment of the

requirement for the award of the degree in Ayurveda Dhanwantari (M.S) in

Shalya Tantra, of Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore.

Dr.MANJUNATHA BHAT M.S (Ayu)

Professor & Head of the Department



Date: Moodbidri, D.K (dist.)

Place: Moodbidri Karnataka - 574227



SHALYA TANTRA

..

Endorsement




VARICOSE VEIN” is a bonafide research work done by Dr. THUSHAR

BABU under the guidance of Dr.MANJUNATHA BHAT M.S(Ayu), Professor

and H.O.D, Dept. of P.G Studies in Shalya Tantra,for partial fulfilment of the

requirement for the award of the degree in Ayurveda Dhanwantari (M.S) in

Shalya Tantra, of Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore.

Dr. B. VINAYACHANDRA SHETTY M.D (Ayu), PhD Principal


Date: Moodbidri, D.K (dist.)

Place: Moodbidri Karnataka - 574227

COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this dissertation

in print or electronic format for academic/research purpose.

Dr. THUSHAR BABU

III Year P. G. Scholar



Moodbidri - 574227

Date:

Place: Moodbidri

Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENT

Completion of dissertation marks the milestone in the post graduate studies.

So here I take the opportunity to acknowledge the help received from different people.

First of all I would like to dedicate this work to my parents and my sister. My

mother, Smt. Radha Babu, who knows me better than myself, inspired to be a better

person. My father, Sri. P.K Babu, who is my role model, guided me well to stay

focused and achieve my goals. My sister Sheethal, whose love and care always

remained a source of energy for me.

I am grateful to my father in-law Sri. M.P Sajeev, my mother in-law Smt.

Ashadevi K.J and brother Hiran M.S, for their encouragement and affection.

It is my duty to thank Dr. Mohan Alva, Chairman, Alva’ s Educational

Foundation, for providing me an opportunity in his institution for Post Graduate

Studies.

I heartily extend my sincere gratitude to my beloved teacher & venerated

guide, Dr. Manjunatha Bhat M.S (Ayu), who was behind this thesis, whose heartening

inspiration and guidance helped me to contrive this task. Besides this, his masterly

suggestions & ablest guidance at every step which has molded, shaped, and

enlightened my work into accomplishment.

I express my heartfelt respect and gratitude to the Principal

Dr. Vinayachandra Shetty M.D (Ayu), Alva’s Ayurveda Medical College, Moodbidri for

his support and encouragement.

I express my deepest feeling of veneration towards Dr. Sukesh A M.S (Ayu) and

Dr. Ravisanker A.G M.S (Ayu) for their valuable guidance and support throughout my

study period.

I express my special thanks to Dr. Rajeshwari P N M.S (Ayu),(Ph.D.), Dr. Subhada

M.S (Ayu), Dr. Swapna M.S (Ayu) and Dr. Mahabalesh M.S (Ayu), Department of P.G. Studies

in Shalya Tantra, for their kind guidance and timely help during the study.

I express my gratitude to Dr. Zenica D’souza M.D (Ayu) and Dr. K.N

Rajashekhar M.D (Ayu) for providing facilities and timely help for doing my clinical

study.

I would like to thank my departmental colleagues Dr. Sreejith S, Dr. Pouse

Poulose, Dr. Caroline and Dr. Najeeb for being with me throughout this work.

I solely thank my seniors Dr. Rashmi Holla, Dr. Krishnanand C and Dr.

Binu Balachandran for their valuable suggestions and support.

I express my sincere thanks to my friends Dr. Rajish R and Dr. Shimi Ben

who helped me during the preparation of the medicines for my clinical trial.

I wish to express my deep sense of gratitude to my wife, Dr. Heera M.S for her

love and affections. Nothing can ever absolve me of my indebtedness to her sacrifices.

I would like to express my thanks to the Librarian & Staff for providing me

with necessary books during the study.

In addition there are numerous people who have helped me during the course

of this study, either directly or indirectly. My profound gratitude goes to all those

wonderful people too.

Above all I thank the Almighty for the blessings showered on me.

Dr.THUSHAR BABU

Date:

Place: Moodbidri

Contents 2014

CONTENTS

SL No: Topic PAGE No:

i. Key For Translation i

ii. List of Abbreviations ii

iii. List of Tables & Charts iii - iv

iv. List of Figures & Graphs v - vi

v. Abstract vii - viii

1. Introduction 1

2. Objectives 6

3. Review of Literature

i. Disease Review

a. Review on Sirajagranthi 7

b. Review on Varicose vein 14

ii. Review on Siravyadha 46

iii. Review on Sahacharadi Kashaya and Taila 71

4. Materials and Methods 78

5. Observations and Results 88

6. Discussion 115

7. Conclusion 129

8. Summary 131

9. List of References 134

10. Bibliography 142

11. Annexure 145

Key to Translations 2014

A Comparative study of Siravyadha and Sahacharadi Kashaya with Taila in the

management of Sirajagranthi W.S.R to Varicose Vein. i

KEY TO TRANSLATIONS

अ - a आ - ā इ - i ई - ī उ - u ऊ - ū ऋ - ṛ

ए - e ऎ - ai ओ - o औ - au अ - aṃ अ: - aḥ

क - ka च - ca ट -ṭa त - ta प - pa

ख - kha छ - cha ठ -ṭha थ - tha फ - pha

ग - ga ज - ja ड - ḍa द - da ब - ba

घ - gha झ - jha ढ - ḍha ध - dha भ - bha

ङ - ṅa ञ - a ण - ṇa न - na म - ma

य - ya र - ra ल - la व - va श - śa श - śa

स - sa ह -ha - kṣa - tra - a

Abbreviations 2014


management of Sirajagranthi W.S.R to Varicose Vein. ii

LIST OF ABBREVIATIONS

A.K Amara Kosa Si Siddhisthana

A.H Ashtanga Hridaya S.S Sushruta Samhitha

A.S Ashtanga Samgraha Su Sutrasthana

Arun Arunadatta Ut Uttara Tantra

B.P Bhavaprakasha Vi Vimanasthana

B.Rat Bhaishajya Ratnavali V.S Vangasena Samhitha

B.S Bhela Samhitha Y.R Yoga Ratnakara

C.D Chakradatta AT After Treatment

Ck Chakrapani BT Before Treatment

C.S Charaka Samhitha M D Mean deviation

Chi Chikitsasthana S D Standard deviation

Dal Dalhana S E Standard error

H.S Harita Samhitha % Percentage

Hem Hemadri e.g. Example

Kal Kalpasthana i.e. That is

K.S Kashyapa Samhitha

M.K Madhu kosha

M.N Madhava Nidana

Ni Nidanasthana

Sa Sarirasthana

Sh.S Sharngadhara Samhitha

List of Tables 2014


management of Sirajagranthi W.S.R to Varicose Vein. iii

LIST OF TABLES & CHARTS

Table

No: Name of Tables & Charts Page No:

1. Panchabhouthikatva of Rakta 46

2. Doshaja Rakta Dusti Lakshna 48

3. Enumeration of Sira according to its location 56

4. Vedya and Avedya Siras 58

5. Amount of blood to be removed in Siravyadha 64

6. Properties of Drugs 72

7. Properties of Drugs 75

8. Grading of Shoola 82

9. Grading of Kandu 82

10. Grading of Grathana 83

11. Grading of Shotha 83

12. Grading of Vaivarnya 83

13. Distribution of 40 patients according to Age 88

14. Distribution of 40 patients according to Gender 89

15. Distribution of 40 patients according to Religion 90

16. Distribution of 40 patients according to Socio-economic status 91

17. Distribution of 40 patients according to Occupation 92

18. Distribution of 40 patients according to Marital status 93

19. Distribution of 40 patients according to Appetite 94

20. Distribution of 40 patients according to Diet 95

21. Distribution of 40 patients according to Body weight 96

22. Distribution of 40 patients according to Bowel Habit 97

23. Distribution of 40 patients according to Duration 98

24. Distribution of 40 patients according to Affected Leg 99

25. Assessment of Shoola 100

26. Effect on Shoola in Group A 101

27. Effect on Shoola in Group B 101

28 Assessment of Kandu 102

List of Tables 2014


management of Sirajagranthi W.S.R to Varicose Vein. iv

29 Effect on Kandu in Group A 103

30 Effect on Kandu in Group B 103

31 Assessment of Grathana 104

32 Effect on Grathana in Group A 105

33 Effect on Grathana in Group B 105

34 Assessment of Shotha 106

35 Effect on Shotha in Group A 107

36 Effect on Shotha in Group B 107

37 Assessment of Vaivarnya 108

38 Effect on Vaivarnya in Group A 109

39 Effect on Vaivarnya in Group B 109

40 Immediate effect of treatment in Group A 110

41 Comparison of effect of treatment between two groups 111

42 Comparative percentage of relief between two groups 112

Chart

No: CHARTS

1. Formation of Rakta 47

2. Raktamokshana classification 50

3. Mode of action of Raktamokshana 125

List of Figures & Graphs 2014


management of Sirajagranthi W.S.R to Varicose Vein. v

LIST OF FIGURES & GRAPHS

Figure

No: Name of Figures & Graphs Page No:

FIGURES

1. Vascular System of lower limb 25

2. Superficial venous system 25

3. Deep venous system 25

4. Earliest depiction of Varicose veins 26

5. Leonardo’s Drawing of veins 27

6. Valve defects on Varicose vein 30

7. Pathology of Varicose veins 31

8. Varicose vein in lower limb 31

9. Materials used for Siravyadha 84

10. Procedure of Siravyadha 85

11. Drugs used for Taila Moorchana 86

12. Preparation of Taila 86

13. Preparation of Kashaya 87

14. Before Siravyadha 113

15. After Siravyadha 113

16. Before Treatment 114

17. After Treatment 114

Graph

No: GRAPHS

1. Distribution of 40 patients according to Age 89

2. Distribution of 40 patients according to Gender 89

3. Distribution of 40 patients according to Religion 90

4. Distribution of 40 patients according to Socio-economic status 91

5. Distribution of 40 patients according to Occupation 92

6. Distribution of 40 patients according to Marital status 93

7. Distribution of 40 patients according to Appetite 94

8. Distribution of 40 patients according to Diet 95

List of Figures & Graphs 2014


management of Sirajagranthi W.S.R to Varicose Vein. vi

9. Distribution of 40 patients according to Body weight 96

10. Distribution of 40 patients according to Bowel Habit 97

11 Distribution of 40 patients according to Duration 98

12 Distribution of 40 patients according to Affected Leg 99

13 Assessment of Shoola 100

14 Assessment of Kandu 102

15 Assessment of Grathana 104

16 Assessment of Shotha 106

17 Assessment of Vaivarnya 108

18 Comparative percentage of relief between two groups 112

Abstract 2014


management of Sirajagranthi W.S.R to Varicose Vein. vii

ABSTRACT

TITLE

“A Comparative Study of Siravyadha and Sahacharadi Kashaya with Taila in the

management of Sirajagranthi w.s.r to Varicose Vein”

BACKGROUND AND OBJECTIVE

Varicose vein is a condition where veins become elongated, dilated and

tortuous. Varicose vein is becoming a day to day problem particularly in 10- 20% of

middle aged and elderly people. They are most common in the superficial veins of the

legs like long and short saphenous veins. The aetiology of this condition is mainly the

incompetence of the valves. Varicose veins usually do not cause life threatening

problems, but conservative treatment is required when pain, itching, skin problems

and other complications arise.

The etio-pathogenesis and symptomatology of Sirajagranthi described by our

Acharya’s are similar to that of Varicose veins. Internal administration of

Sahacharadi Taila, Upanaha with Vatahara drugs, Vasti Karma and Siravyadha are

the treatment modalities indicated for Sirajagranthi in Ayurvedic classics. Acharya

Vagbhata has mentioned Sahacharadi Kashaya which is indicated for Vatavyadhis

pertaining to Adhah Kaya and it is specifically told that it should be taken along with

Taila.

Hence, here an attempt was made to study the individual effect of Siravyadha

and Sahacharadi Kashaya with Taila in the management of Sirajagranthi along with

their comparative effect.

Abstract 2014


management of Sirajagranthi W.S.R to Varicose Vein. viii

METHODS

40 patients diagnosed as Sirajagranthi were randomly selected and divided

into two groups, Group A patients received Siravyadha as treatment on 1st day

followed by Paschat Karma for 7days. Group B patients were treated with

Sahacharadi Kashaya with Sahacharadi Taila for 14 days. The patients were assessed

before treatment, 7th

day, 14th

day, 21st day and 28

th day and follow up of 30 days. The

effect of the treatments was assessed statistically on the basis of gradation of signs

and symptoms before and after treatment.

RESULTS

In this clinical study, both Group A and Group B showed significant results in

all attributes of Sirajagranthi. On comparison, there is no statistically significant

difference between Siravyadha and Sahacharadi Kashaya with Taila except in the

case of Shoola and Vaivarnya.

INTERPRETATION AND CONCLUSION

In Sirajagranthi, Siravyadha group showed more results in main attributes like

Shoola, Grathana and Vaivarnya, while Sahacharadi Kashaya with Taila was found

more prominent in reducing Kandu and Shotha.

Therefore it may be concluded that the total effect of Siravyadha was better

than Sahacharadi Kashaya with Taila in the management of Sirajagranthi.

Key Words- Sirajagranthi, Siravyadha, Sahacharadi Kashaya, Sahacharadi Taila,

Varicose vein.

Introduction

Introduction 2014


management of Sirajagranthi W.S.R to Varicose Vein. 1

INTRODUCTION

In the 21st century, continuous changing life styles, environment and dietary

habits have made man the victim of many diseases. In their busy life schedule they

have no time to take care of one’s own health. Today, a lot of occupations and

professions have sprung up where a person is require to either constantly stand up for

a long time or made to sit with legs hanging down for a considerable time. The

priceless value of the leg is not appreciated until the organ becomes affected with

diseases or loss of function threatens the day to day activities of a man.

Varicose vein is one such disease affecting the legs with its ugly appearance.

Computer professionals, nurses, waiters, bus conductors, security guards, traffic

policemen, salesmen, teachers and persons doing desk jobs are the worst sufferers of

varicose veins.

Abnormal dilated, elongated and tortuous alteration in the saphenous veins

and their tributaries are called as varicose veins. Varicose vein is a common condition

in India affecting up to 15% of men and up to 25% of women. Genetics, age,

overweight and the prolonged standing nature of the work are the main risk factors.

Sedentary and comfortable life styles, modern fashion like wearing tight jeans and

high heeled sandals, irregular standing and sitting postures have contributed to

increased incidence of this condition. Women suffer from this disease four times than

men. Pregnant females, menopausal age groups are usually prone to varicose veins

For many people, varicose veins may be simply a cosmetic concern. But for

some others, varicose veins can cause aching pain and discomfort. Sometimes the

condition leads to more serious problems. Varicose veins may also signal a higher risk

of other disorders of the circulatory system.

Introduction 2014



It is commonly assumed that, if the varicose veins are left untreated they will

continue to enlarge and ‘varicose processes’ will spread to involve other previously

‘normal’ veins. Venous disorders are associated with high morbidity and significant

mortality.

Varicose vein is becoming a day to day problem particularly in middle aged

and elderly people, claiming considerable portion of national economy because of

long time hospital stay of the patient or high costs of treatments, medical or surgical.

In spite of the tremendous advances made in the field of modern surgical

management, still certain diseases pose a problem to the surgeon. Among the various

treatment modalities for varicose veins in modern surgery like Sclerotherapy, Laser

Surgeries, Vein stripping etc. none of these are labelled as ideal since their failure to

give permanent cure and the recurrence rate is more.

Ayurveda, the very ancient science of life with its rich treasure of

medicaments still stands the test of the present day requirements. Its surgical

principles can contribute a lot for the management of certain surgical disorders. The

management of varicose veins is one such area where Ayurveda has multiple answers.

Keeping in view those who are getting affected with this disorder and who needs

minimum invasive techniques are looking for effective remedies available in

Ayurvedic system of medicine.

Knowledge of Siras and Dhamanis was in existence from the Vedic period.

This knowledge was improved at the time of Acharya Sushruta and further modified

at the time of Sharngdhara, who for the first time in history clubbed the functions of

the respiratory system with that of the circulatory system.

In Ayurveda there are various concepts for varicose veins such as

Sirajagranthi, Siraakunchana, Sirakutilata and Siragata Vata. Ayurveda has given a

Introduction 2014



great contribution in the management of such disorders, while describing the

management of Vata Vyadhi.

The etiology of the disease, its pathology, diagnosis and prognosis is dealt in

Sushruta Samhitha.1 But the treatment is not found in Sushruta Samhitha which

considers the disease extremely difficult to cure. Ashtanga Hridaya by Vagbhata also

describes the disease in much the same manner as Sushruta Samhitha but

Vagbhataacharya considers the disease curable and describes radical treatment for

early cases. 2

The etio-pathogenesis and symptomatology of Sirajagranthi described in

classics are similar to that of varicose veins, etiology of excessive exertion of lower

limbs, obstructive pathology and tortuous clinical appearance are some of the

examples. Various research works have been done including conservative treatment

such as external application of Sahacharadi Taila, Vasti and para surgical procedures

such as Jaloukavacharana and Siravyadha.

Shodhana, Shamana and Nidana Parivarjanam are the main treatment

modalities for any disease. Acharya Sushruta is the first to introduce the unique

treatment modality i.e. Siravyadha and it is considered as Ardha Chikitsa in Shalya

Tantra.3 Also Acharya Sushruta highlights Raktamokshana for Vata Prakopa in Sira,

Twak, Mamsa, and Rakta which was not encountered even after the treatment of

Panchakarma.4

Rakta is considered as the second Dhatu and fourth Dosha.5-7

The

main aim of the Raktamokshana is Dushta Rakta Nirharana.

In Ashtanga Hridaya, Sahacharadi Kashaya is mentioned in Vatavyadhi

chapter and is indicated for Vatavyadhis pertaining to Adhah Kaya. It is told that the

Kashaya should be taken along with Taila.8

Introduction 2014



In the treatment principle of Sirajagranthi, Acharya Vagbhata has told internal

administration of Sahacharadi Taila.9 Sahacharadi Taila is also mentioned in

Vatavyadhi Prakarana and is indicated for Vatavyadhis which are difficult to cure.

Hence, here an attempt was made to study the individual effect of Siravyadha

and Sahacharadi Kashaya with Sahacharadi Taila in the management of

Sirajagranthi along with their comparative effect. Pathya and Apathya are also been

advised to the patients.

PLAN OF STUDY

The whole study is divided into the following sections such as introduction,

objectives, review of literature, methodology, observation, results, discussion and

conclusion.

1. Introduction

2. Objectives

3. Review of literature

i. Disease review

Comprises of conceptual work on Sirajagranthi. The historical background,

Nirukti, Nidana, Poorvaroopa, Roopa, Samprapti, Upashaya, Pathya and Apathya of

Sirajagranthi is explained in this section. Various modalities of Chikitsa utilised for

the management are also discussed in this section. The modern review consists of its

symptomatology, correlation with varicose vein, its etio-pathogenesis and the

management.

ii. Review on Siravyadha

iii. Review on Sahacharadi Kashaya and Taila.

Introduction 2014



4. Methodology

Consists of materials and methods.

5. Observation and Results

The section comprises of observations, comparative study of both the groups

and the results are analysed statistically.

6. Discussion

The section deals with the discussion done on each study during the whole

work and probable mode of action of both the modalities on Sirajagranthi has been

mentioned.

7. Conclusion

In this section, the conclusion on the work done has been mentioned. Also the

limitations of the study and further recommendations have been mentioned.

8. Summary

In this section, the brief summary of the whole work done has been

mentioned.

Objectives

Objectives 2014



OBJECTIVES OF THE STUDY

Since antiquity, Sirajagranthi and its management has been a challenge for

physicians of all the systems of medicine. Varicose veins are said to be the penalty,

man pays for his erect posture, as this disease is virtually unknown in quadrupeds.

Keeping in view there is definitely a need of cost effective, result oriented and

easy to adopt methodology to manage this disorder and who cannot afford costlier

modalities.

Thus the objectives of the study are;

1. To study on Sirajagranthi and its comparison with varicose vein.

2. To assess the effect of Siravyadha in Sirajagranthi w.s.r to varicose vein.

3. To assess the effect of Sahacharadi Kashaya with Taila in Sirajagranthi w.s.r

to varicose vein.

4. To compare the effect of Siravyadha and Sahacharadi Kashaya with Taila in

Sirajagranthi w.s.r to varicose vein.

Review of Literature Disease Review Review on Siravyadha Review on Sahacharadi Kashaya &

Taila

Disease Review 2014



REVIEW ON SIRAJAGRANTHI

Sirajagranthi consists of two words- ‘Sira’ and ‘Granthi’

Concept of Sira

‘Saranath Sira’

Sira is a tubular structure where Sarana occurs i.e. flow of fluids. Here fluid

refers to Rasa, Rakta etc. All the Siras present in the body originate from the Nabhi,

and from there, they spread to all directions to provide nutrition to the body.

Concept of Granthi

Granthi is so called because of its genuine quality Grathana, i.e. the property

of accumulation or collection. It is as follows according to Shabda Kalpa Dhruma.1

Grath- Curved or curled in nature. Formation of knot or twist like structure by the

quality of curliness or coiling, rippling in action.

Grathitam- to twist into ringlets.

Granthi- Formation of knot like structure by the way of accumulation. It also means

swelling and hardening of the vessels.

Different Acharya’s explained Granthi in various Prakarana of their

Samhithas.

Acharya Charaka – Shotharoga Prakarana of Chikitsasthana

Acharya Sushruta – Granthi Prakarana of Nidanasthana

Acharya Vagbhata –Uttaratantra

Granthi was considered by Acharya Sushruta as a Sopha (swelling) which is

Vrutha (circular), Unnatha (elevated) and Grathitha (nodular). The pathology is

related to all the three Doshas, Mamsa and Rakta which vitiates Meda.2

Disease Review 2014



Granthi is classified as Vathika, Paithika, Kaphaja, Raktaja, Mamsaja,

Medaja, Asruja, Siraja and Vranaja by Acharya Vagbhata.3

Acharya Sushruta

classifies it as Vathika, Paithika, Kaphaja, Medaja and Siraja.4

Sirajagranthi is so termed only because it clinically manifests as a swelling in

Siras. The pathogenesis of Sirajagranthi mainly concerns with Vata.5

Description of Sirajagranthi

Among the Samhitha texts, Sushruta Samhitha stands first in describing

Sirajagranthi with its etiology, pathology, prognosis and physical signs.6 Acharya

Vagbhata in Ashtanga Hridaya has described the same thing with some modifications

in physical signs.7 But it is Vagbhata who has gone a step further in narrating the

treatment of this disease.8

In giving the features of the disease Madhavanidanakara

just follows Acharya Sushruta. Acharya Vangasena9 and Acharya Bhavaprakasha

10

explain the same as in Sushruta Samhitha including Sadhyaasadhyatha.

Nidana (Etiology)

The sole etiological factor precipitating Sirajagranthi according to Sushruta

Samhitha is excessive exertion by a person who is weak and emaciated. However, it

must be noted that Acharya Sushruta has not mentioned where, in which part of the

body Sirajagranthi will be clinically manifested, although he says other vitiating

factors of Vata also contributes much to the etiology.11

In Ashtanga Hridaya, it is mentioned that one who suddenly immerses or

wash the lower limb in cold water after walking a long distance, or one who does

excessive exercise is likely to be affected by Sirajagranthi.12

Although he has not told

the specific site of Sirajagranthi, by the description itself, one can assume that it is in

the lower extremities.

Disease Review 2014



Factors affecting the Vyana Vayu will affect the Sira because Vyana Vayu

circulates Rasa, eliminates Sweda and helps flow of blood, performs the five kind of

action Gati, Akshepana, Utkshepana, Nimesha and Unmesha. 13

Poorvaroopa

Charakacharya explains the Poorvaroopa of Sopha as Jwara, Davadhu,

Aayama of Sira.14

Samprapthi (Pathology)

Samprapthi comprises the relation between the Nidana, Dosha vitiation, and

manifestation of the disease along with its progression.

According to Acharya Sushruta, the etiological factors play a role in the

vitiation of Vata and this vitiated Vata directly affects the Sira Prathana (cluster of

veins) by Aakshepa and exposes them to Sampeedana, Samkochana and Vishoshana15

and produces Granthi which is protruding out. The same is explained in Vangasena

Samhitha also.16

Acharya Vagbhata further adds that the vitiated Vata playing main role, will

exert its influence on Siras and Raktadhatu, causing Sampeedana, Samkochana,

Vakreekarana (tortuosity) and Vishoshana of the Sira resulting in formation of

Granthi which is non-pulsating and painless.17

The explanation given by Charakaacharya has got a little difference that

because of the Nidana not only Vata but Kapha, Rakta and Pitta also get vitiated

which then enter the external blood vessels, get lodged there and produce obstruction

and spreads to the nearby areas causing oedema.18

According to Acharya Bhoja, when a weak person indulges in Vata Prakopaka

Disease Review 2014



Nidana’s, Vata gets aggravated and invades Sira which is already Durbala and leads

to Prathitha Akshipana and Parisoshana and result in painful Sirajala.19

Lakshanas (Symptomatology)

The clinical picture given by Acharya Sushruta is far from adequate. He

describes two types of Sirajagranthi - one which is painful and movable and another

which is painless, immovable and greatly enlarged.20

He says that Sirajagranthi can

occur in Marmasthanas also.21

According to him, Sirajagranthi presents as Vrutha

and Unnatha.22

Acharya Vagbhata modifies the physical signs. His addition of Vakreekarana

(tortuosity) makes the focus of the clinical picture clear. He also narrates that

Sirajagranthi will be Nishphura (non-pulsatile) and Neeruja (painless). And he did

not say as Sushruta have told that it will be Vrutha (circular).23

Sadhya - Asadhyatha (Prognosis)

The description of prognosis itself demarcates a difference between the

opinions of the two authors. Sushrutaacharya describes the painful variety as

Krichrasadhya (difficult to cure) and the painless variety that is bigger in size and

presenting at Marmasthanas as totally incurable. 24

Acharya Bhavaprakasha and Acharya Vangasena follow the same opinion of

Sushruta Samhitha.25, 26

Vagbhataacharya too is keen on the selection of cases. He, along with the

narration of this condition has told the treatment is indicated for cases which are

‘Nava’ (fresh).27

So in this context the understanding of what is meant by Nava

becomes important. Vagbhataacharya has not claimed the disease as Sukhasadhya

(easily curable) or Krichrasadhya (difficult to cure).

Disease Review 2014



Concept of Srotodushti

Although Siras and Dhamanis are functionally different, they come under

Raktavaha Srotas as primarily; both are engaged in transport of blood.28

So a keen

look into the concept of Srotodushti was found necessary.

In the classics, “Siras and Dhamanis” are described separately as the channels

for circulation of blood. The differentiation of Sira and Dhamani can be understood

by the following description as “Saranath Sira’” means through which blood flows

constantly without any pulsation, “Dhamanat Dhamani” means to pulsate. The

occurrence of a disease starts with Doshadushya Sammurchana, which takes place in

Srotas. Srotas can be regarded as the system through which all the metabolites are

transported. According to Charaka, Dosha, Dhatu and Mala are depended on their

respective Srotas for their formation, conduction and destruction. When Srotas gets

deranged, the physiological activity of Dosha, Dhatu and Mala also get deranged. The

derangement of Srotas is called “Kha Vaigunya” – Kha means a space or cavity. In

the classics, two Moolasthana have been assigned to each Srotas. If the Moolasthana

is affected, then the entire Srotas is deranged. The Moolasthana of Raktavaha Srotas

is Yakrit and Pleeha.29

Athipravruthi (excessive flow), Sanga (cessation of flow or obliteration of

passage), Siragranthi (swelling in Siras) and Vimargagamana (flow in opposite

direction) are the pathogenesis of Srotodushti according to Charaka.30

That means by

any of these features, one can identify the vitiation of the particular Srotas. In chronic

condition, Vimargagamana or regurgitation is noticed as an important symptom.

The Ashrayasthana of Siragata Vata is the Sira of the lower limbs. The

vitiation of Dosha particularly Vata occurs due to Apathya Ahara and Vihara, causing

obstruction in the flow of blood in Siras of the lower limb. Adho-Kaya is an important

Disease Review 2014



seat of Vata, where the Kutila Sira is manifested. So Tulya Dosha and Tulya Desha

make the disease Durupakrama i.e., not easily curable and the duration of the disease

becomes prolonged.

Rakta which is moving in their own Sira performs function such as supplying

nutrition to the tissue, colour, tactile sensation and many other functions. When it gets

vitiated, Rakta accumulates in its own Siras and manifests many diseases in the

body31

.

Striking similarities are met with the pathology of Sirajagranthi when viewed

in the light of pathology of Srotodushti. An astonishing degree of resemblance is seen

with the pathology of varicose veins in the modern parlance also with regards to

Srotodushti. All these facts concrete the idea that, Sirajagranthi occurs due to all

these types of Srotodushti.

Chikitsa (Management)

No other author except Vagbhata gives a clue for the treatment of

Sirajagranthi.

Methodology of management

Aiming at the methodology of management, one cannot forget the foundation

stone in the treatment principle of Ayurveda that, the treatment must be

Nidanaparivarjana32

(prevention of causative factors) as well as Samprapthi

Vighatana 33

(breaking the pathological process). If the treatment satisfies these two-

fold requirements, then only it can aptly be called scientific.

Specific Management of Sirajagranthi

Management of Sirajagranthi described by Acharya Vagbhata mainly aims at

Disease Review 2014



Samprapthi Vighatana.34

. It is described in Granthi - Apachi - Arbuda - Prathishedha

chapter of Utharasthana of Ashtanga Hridaya. It is indicated for Nava (fresh) cases.

Internal administration of Sahacharadi Taila,

Upanaha (poultice) with Vatahara drugs,

Vasthi Karma (medicated enema) and

Siravyadha (puncturing of the vein).

While explaining Jalookavacharana, Acharya Vagbhata says that it is highly

beneficial even in case of Avagada Doshas and in Granthi.35

Raktamokshana mentioned as the treatment for Siragata Vata in our classics36

can also be considered here, as the Samprapthi of both diseases being the same, and

varicosity of veins is definitely a Siraja Vyadhi.

Disease Review 2014



REVIEW ON VARICOSE VEIN

Structure of Veins:

The walls of the vein like those of the arteries are composed of three coats, the

tunica intima, the tunica media and the tunica adventitia. The main difference between

the wall of arteries and those of veins is that, in the latter, there is a comparative

weakness of the muscular layer and a much smaller proportion of elastic tissue. In

small veins these coats are difficult to distinguish.

The veins of the lower extremity can be grouped broadly into three-

1. Superficial venous system.

2. Deep venous system.

3. Perforator system.

SURGICAL ANATOMY OF THE VEINS OF LOWER LIMB 37

I. Superficial venous system38, 39

This is the venous system which lies in the subcutaneous system i.e., in the fat

between the skin and deep fascia being close to the latter. It comprises the long and

short saphenous vein and their tributaries. The peculiarity of the system is that its

middle coat (media) is much thicker than that of the other veins, consisting mostly of

smooth muscle, added with some elastic and fibrous tissue. Being lying in the fat,

these veins are loosely adherent to the muscles, and hence unprotected.

1. The Long Saphenous Vein.

This is the longest vein in the body commencing from the medial part of the

dorsal venous arch of the foot, courses in front of the medial malleolus and traces up

superficial to the deep fascia, through the posterior-medial aspect of the knee joint to

empty in the femoral vein at fossa ovalis. The opening is normally 3.8 cm. below and

Disease Review 2014



lateral to pubic tubercle. Long saphenous vein contains about 10-20 valves, which are

more numerous in the leg than in the thigh.

The surgical Anatomy

The surgical significances are as follows:

a) Tributary of small saphenous vein to its longer counterpart or its direct entry

to the latter.

b) Popliteal tributaries and short saphenous branch or Short Saphenous vein drain

to posteromedial and to long saphenous. Antero-lateral as well as accessory

saphenous vein also enters long saphenous. Short saphenous branch acts as

key collateral in deep femoral vein thrombosis. Antero-lateral and accessory

saphenous vein enlarges in varicosity because of proximity to skin.

c) Superficial external prudential, Superficial circumflex iliac, Superficial

inferior epigastria and Deep external prudential veins show versatility in

entrance to long saphenous and if not foreseen, high ligature Trendelenburg

operation will be failure.

d) Long saphenous vein's entry to the femoral vein might be more distant than

normal. Superficial veins draining to long saphenous might enter femoral vein

directly. This may be a trap to the surgeon.

e) Profounda artery might originate from femoral artery near sapheno-femoral

junction.

f) As Saphenous nerve is closely associated with long saphenous vein, its

exposure and protection during operation is necessary.

g) Long saphenous vein itself may be duplicated or it may lie below deep fascia.

h) In case of varicosity of the long saphenous vein, the small veins from the soles

of the foot and the ankle which drain in to this venous system through the

Disease Review 2014



medial marginal veins become dilated and this give rise to swelling of the

ankle, which is known as ‘ankle flare’.

2. The Short Saphenous Vein 40, 41

It begins posterior to the lateral malleolus, as a continuation of the lateral

marginal vein. In the lower third of the calf it ascends lateral to the tendo calcaneous,

lying on the deep fascia and covered only by the superficial fascia and skin. Inclining

medially to the midline of the calf it penetrates in to the deep fascia within which it

ascends on the gastronomies, only emerging between the deep fascia and

gastronomies gradually at about the junction of the intermediate and proximal thirds

of the calf. Continuing its ascent it passes between the head of the gastronomies, then

proceeds to its termination in the popliteal vein, 3-7.5 cm above the knee joint in the

Popliteal Fossa.

Its tributaries drain the calf muscles after piercing the deep fascia. This vein

possesses 7 to 13 valves, one of which is always found near its termination in the

popliteal veins. Its mode of ending is variable; it may join the great saphenous vein in

the proximal thigh or it may bifurcate, one branch joining the great saphenous, the

other joining the popliteal or deep posterior femoral veins. Sometimes it ends distal to

the knee in the great saphenous or deep sural muscular veins.

Surgical importance

Variations in its length, depth and communications are mandatory. It might

merge with the deep veins of the lower thigh or join the long saphenous. The general

rule that the more distally placed, the generous veins are valved, projected by Dodd

and Crockett might be of importance in the case of short saphenous vein. The venous

arches of posterior medial vein might connect the small saphenous vein with the long

Disease Review 2014



saphenous vein and hence venous hypertension may be transmitted to both the

systems if at all only one system is affected.

Attention to the association of the varicosity of short saphenous vein with

other tributaries of popliteal vein was brought into light by Dodd. Short saphenous

vein, in 90% of cases runs sub-facials course. In these cases, it must be made a rule to

explore the popliteal space to ligate its termination itself.

II. Deep venous system42, 43

The deep veins of the lower limbs accompany the arteries and their branches.

Plantar digital veins arise from plexuses in the plantar regions of the toes, connecting

with dorsal digital veins and uniting in to four plantar metatarsal veins. These run in

inter metatarsal spaces and connect by perforating veins with dorsal veins, then

continue to form the deep plantar venous arch, accompanying the plantar arterial arch.

From the medial and lateral plantar area veins run near the corresponding arteries and

after communication with the great and small saphenous veins.

Posterior tibial veins accompany the posterior tibial artery, receiving veins

from sural muscles, especially the venous plexus in the soleus, connecting from

superficial veins and the peroneal veins.

Anterior tibial veins is the continuations of the venous companions of the

dorsal pedal artery, they leave the extensor region between the tibia and fibula,

passing through the proximal end of the interosseous membrane, and unite with the

posterior tibial veins to form the popliteal vein at the distal border of the popliteus.

Popliteal vein ascending through the Popliteal fossa to an aperture in adductor

magnus, it becomes the femoral vein. Its tributaries are the small saphenous vein;

veins corresponding to branches of the popliteal artery and muscular veins. There are

usually four valves in the popliteal vein.

Disease Review 2014



Femoral vein accompanies its artery beginning at the adductor opening as the

continuation of the popliteal, and ending posterior to the inguinal ligament as the

external iliac. In the distal adductor canal it is posterior to the femoral artery more

proximally in the canal and in the distal femoral triangle.

The vein occupies the middle compartment of the femoral sheath. It has many

muscular tributaries about 4-12 cm distal to the inguinal ligament the vena Profunda

femoris joins it posteriorly and then the great saphenous vein, which enters anteriorly.

There are usually 4-5 valves in the femoral vein, the most constant being one just

distal to the entry of the Profunda femoris and one near the inguinal ligament.

Vena profunda femoris is anterior to its artery its tributaries connects distally

with the popliteal and proximally inferior gluteal veins. It has a valve just before its

end.

Surgical importance

When the leg is at rest, the soleus venous sinuses might contain more blood as

a result of the backward push due to the flow of blood from the perforating veins

because of the non-valvular nature of the former. Though this blood is not static, its

movement anyway is sluggish. In conditions of long-term bed rest etc., an ideal

condition precipitates for the formation of clots. Thrombus, of soleal blood banks may

extend to the perforating veins through posterior tibial veins. This destroys the valves

of the perforating veins and venous hypertension in result.

The resultant hypertension (in those of congenital valvular absence in external

iliac veins) in the upper saphenous system may present varicosities commencing at

the Sapheno-femoral junction to be transmitted down the vein.

The observation of Dodd and Crockett is interesting to be restated –“it can

thus be appreciated that in the erect position, the essential venous drainage of what is

Disease Review 2014



known as the 'ulcer bearing area' is taken directly into the deep veins and not into the

saphenous system."

III. The Perforator system 44

These are also called communicating veins in the sense that it communicates

the superficial and deep system of veins. The salient feature is that these contain

valves allowing blood only to flow from superficial to deep system under normal

conditions. This is achieved by the valves so positioned to prevent reflux. A limb in

action has a variable degree of high pressure inside the deep veins and a decreased

pressure in the superficial veins. But if the valves become inefficient, reverse flow of

blood occurs, shooting up the pressure of superficial veins causing varicose veins and

ulceration. Perforating veins can be direct or indirect.

Valves:

Unlike arteries veins possess valves through which the blood flows towards

the heart. The valves have two leaflets consisting of folds of intima reinforced with an

intervening layer of connective tissue.

There are no valves in the superior and inferior venae cave but there are valves

in the tributaries from both upper and lower limbs, the number of valves increasing

towards the periphery of each limb. Valves do not appear to play an important part in

controlling the circulation within the upper limbs and there is no equivalent of the calf

and thigh muscle pump in arm. The valves in the lower limb play an important role in

controlling the direction of blood flow.

There are no valves in the sinusoidal veins of the soleal muscles but the

venous arcade which drain the soleal and gastrocnemius muscles have numerous

valves. All the deep veins of the calf are densely valved with the valves occurring at

Disease Review 2014



approximately 2 cm. intervals.

The popliteal vein usually has two valves in the region of the knee joint;

damage to these valves may have serious consequences on the calf muscle pump.

There is a valve in the femoral vein just distal to its junction with the deep femoral

vein in 90% of all legs and a valve in the upper third of the popliteal vein just distal to

the adductor canal in 96% of the legs. There are eight to ten valves in the long and

short saphenous vein which is thought to be important in preventing reflux down the

long saphenous vein.

The valves in the communicating vein between the superficial and deep

venous systems of the leg are arranged so that blood flows from the superficial to the

deep vein.

Surgical importance

A) Indirect Perforator system

These are more or less insignificant superficial veins being drained into a

vessel in a muscle which in turn is drained to one of the deep veins. But Crockett

pointed out that few are the indirect perforators in the ankle region and drainage is

entirely dependent on direct perforators, contributing a significant factor in the

genesis of ankle ulceration.

B) Direct Perforator System

This consists of,

1. The long and short saphenous veins.

2. Smaller perforating veins.

The former has been already discussed. The smaller direct perforator veins are

vessels which are fairly constantly situated and have attained great surgical

significance ever since Dodd, H. and Cockett, FB described them.

Disease Review 2014



In the leg, the perforators lie under:

1. Constant medial perforators

2. Inconstant posterior perforators

The ankle perforating veins constantly found in the medial aspect of the leg

(internal ankle perforators) and those which are inconstantly placed lie in the lateral

aspect of the leg (external ankle perforators). Three constant medial perforators

(internal ankle perforating veins) are there placed so as to connect the venous arcades.

The upper two of those three perforators drain into the posterior tibia vein at

the exact level of the soleal venous sinuses entrance into the posterior tibia veins and

hence, a soleal clot can extend into these perforators through the intermediate

posterior tibial veins. Such a clot damages the valve causing varicosity.

Venous Pathophysiology45, 46

Blood enters the limb through the femoral arteries before passing through

arterioles in to the capillaries, which have a pressure of about 32 mmHg at their

arterial ends. This pressure is reduced along the course of the capillaries and is

approximately 12 mmHg at the venular end of the capillary.

The pressure continues to fall in the main veins and is as low as -5 mmHg at

the upper end of the vena cava where it enters the right atrium.

The venous pressure in a foot vein on standing is equivalent to the height of a

column of blood extending from the heart to the foot. To enable blood to be returned

against gravity in the standing position an auxiliary pump is required in the lower

limb. This is the calf muscle pump, which is augmented to a lesser extent by the thigh

and foot pumps. The deep veins of the calf are capacious and are joined by blind –

ending sacks called the soleal sinusoids, which force blood in to the popliteal and

sural veins during calf muscle pump contraction like walking. The foot pump also

Disease Review 2014



ejects blood from the plantar veins during walking. As the calf muscles contracts, the

veins are compressed and the valves only allow blood to pass in the direction of the

heart.

The pressure within the calf compartment rises to 200-300mmHg during

muscle contraction. During muscle relaxation the pressure falls and blood from the

superficial veins enter the deep veins through the saphenous junctions and the

perforating veins. Each time this occurs as the pressure falls in the superficial venous

compartment until a threshold is reached.

The veins are capable of constricting and enlarging and there by storing either

small or large quantities of blood and making this blood available when it is required

by the remainder of the circulation.

Blood from all the systemic veins flow in to the right atrium, therefore the

pressure in the right atrium is called the central venous pressure. The normal right

atrial pressure is about 0 mm Hg, which is about equal to the atmospheric pressure

around the body. It can rise to 20 to 30 mm Hg under very abnormal conditions. The

lower limit to the right atrial pressure is usually about -3 to -5 mm Hg, which is the

pressure in the chest cavity that surroundings the heart.

The normal pressure in the peritoneal cavity of a recumbent person averages

about 6 mm Hg, but at time it can rise to 15 to 30 mm Hg as a result of pregnancy,

large tumors or excessive fluid (ascites) in the peritoneal cavity. When this happens

the pressure in the veins of the legs must rise above the abdominal pressure before the

abdominal veins will open and allow the blood to flow from the legs to the heart.

Physiology of the lower limb circulation47

The valves in the lower limb veins are arranged so that the direction of the

blood flow can be only towards the heart. Consequently, every time a person moves

Disease Review 2014



the legs or even tenses the muscles, a certain amount of blood is propelled towards the

heart and the pressure in the vein is lowered. This pumping system is known as the

“venous pump” or “muscle pump”.

If a person stands perfectly still, the venous pump does not work, and the

venous pressures in the lower part of the leg will rise. The pressure in the capillaries

also increases greatly, causing fluid to leak from the circulatory system in to the tissue

spaces. As a result the legs swell, and the blood volume diminishes.

Blood is returned to the heart from the tissues, carried out by three different

processes.

1. Pressure of blood at the arteriolar end.

2. The negative pressure in the thorax.

3. Movement of blood by active exercise.

But the lower limb has got a specialized haemodynamics and the veins of this

area are arranged to suit accordingly and some other factors also supports it.

a) Importance of valvular mechanism

The blood from the superficial veins passes to the deep veins through the

perforators. This is made possible by the presence of valves inside the veins, which

allow blood to pass only in one direction. The vein contain sinuses which are

characterized by back-eddies present in them to create a closing pressure on the valve.

The veins have been overstretched by excess venous pressure lasting weeks or

months. Stretching the veins increases their cross-sectional areas, but the leaflets of

the valves do not increase in size. Therefore, the leaflets of the valves no longer close

completely. When this develops the pressure in the veins of the legs increases still

more owing to failure of the venous pump, this further increases the size of the veins

and finally destroys the function of the valves entirely, results the development of

Disease Review 2014



varicose veins.

b) Gravitational factor

The gravitational influence of the whole column of blood from heart to the

toes is directly acting on lower limb veins. However, in the presence of proper

valves, the gravitational factor is counteracted by the calf pump during exercise.

c) Histology of veins

Veins are much thinner than arteries, especially the media which is poorly

developed. The notable exception is that of the unsupported superficial veins of the

leg which has got a thick middle layer for acting as a reservoir of blood. The thin

nature of deep veins helps the pumping action of calf muscles more effectively.

d) Haemodynamics

In physiological conditions, the haemodynamics of lower limb can be:

1. That at rest

2. That at the time of exercise

At rest, in the recumbent position (horizontal), blood flows up the saphenous

vein and empties into the femoral vein because of absence of gravitational factor.

However, in a dynamic situation blood from saphenous vein passes into perforating

veins guarded by valves to prevent reflux and the blood thus drawn together squeezed

by the calf muscles into the deep veins which again is guarded by valves to prevent

regurgitation and thus, blood is drained to the heart.

The hydrostatic pressure of the blood in the superficial veins is equivalent to

the height of a column of blood between the foot and the right heart in normal

individuals standing erect at rest, as revealed by the pressure studies of Burnand et al,

(1977). Normally at rest it is 80 to 100 mm of Hg. and on exercise it falls to about 30

mm of Hg.

Disease Review 2014



Figure No: 1 - Vascular system of lower limb

Figure No: 2 - Superficial venous system Figure No: 3 - Deep venous system

Disease Review 2014



VARICOSE VEINS

Historical review

1550 B.C.

The first venous publication:

The Ebers papyrus was written in 1550 B.C. One section containing a

description of three types of lump. Together with advice that two types can be treated

surgically but certain serpentine windings – means varicose vein should not be

incised.

4th

century B.C.

A votive tablet found at the of the Acropolis in Athens where the first

illustration of varicose vein shows the medial side of a massive leg with a long

serpentine swelling which has all the characteristics of a varicose vein which was

dedicated to Doctor Amynos, who was the world’s first phlebologist.

Figure No: 4 - Earliest known depiction of varicose vein at the end of 4th

B.C.

A.D. 130-200

Galen – the beginning of varicose vein surgery:

Galen of Pergamum describes the treatment of ulcer and varicose vein by

Disease Review 2014



Venesection. He noticed that wall of the vein was always much thinner than the wall

of the arteries and that veins contain dark blood. He described the use of silk ligatures

and advised that varicose vein should treated by incision and tearing out with a blunt

hook. The masterly anatomical drawing of Leonardo da Vinci shows how clearly he

observed the venous system.

Figure No: 5 - Leonardo’s detailed drawing of veins of lower limb

A drawing of a valve, at last is believed to be the first recorded drawing of

valve in vein. It was published by Saloman Alberti in 1585 B.C.

Definition of Varicose Veins 48

When a vein becomes dilated, elongated and tortuous, the vein is said to be

‘varicose’.

Site-

The common sites of varicosity are:

Superficial venous system of lower limbs, affecting either the long saphenous

or the short saphenous veins or the both.

Oesophageal varix (affecting veins of the gastro oesophageal junction )

Varicosity of the haemorrhoidal veins (Piles)

Varicosity of the spermatic veins (Varicocele)

Disease Review 2014



The Etiology of varicose veins 48, 50

Theories themselves are debating as to what the causative factors for varicose

veins are. But studies conducted till date do not mark any single factor as being the

aetiology of varicose veins, The etiological factors can be congenital or acquired,

valvular or obstructive or both or none of these. They can be primary when there is

no evidence of venous obstruction or secondary, where evidence of obstruction to

venous drainage. Usually the iliac or femoro-popletial or calf muscle veins are met

with. The pathophysiology of varicose vein development is probably related to

defective connective tissue and smooth muscle in the vein and leading to a secondary

incompetence of the valves rather than to a primary defect in the valves.

Morphological factors

Varicose veins of the lower limb are the penalty that man has to pay for his

erect posture.

The veins have to drain against gravity.

The superficial veins have loose fatty tissue to support them and thus suffer

from varicosity.

There are three types of varicosity –

Primary varicose veins.

Secondary varicose veins.

Congenital varicose vein.

Primary varicose veins

This condition is mainly due to defect in the valves. The defect may be

congenital or acquired.

Disease Review 2014



Primary varicose vein occur due to the changes in the vein wall, progressive

venous dilatation, and valvular failure.

A congenital pre disposition combined with occupational influences leads to

the development of primary varicose vein i.e. work involving long periods of

standing still aggravates inherited weakness of valve structure

Defect in the saphenofemoral valves leads to varicosity of the long saphenous

vein.

Defect in the saphenopopliteal valves leads to varicosity of the short

saphenous vein.

Defect in the valves of the perforator’s leads to varicosity of either long

saphenous or short saphenous system.

Secondary varicose veins

It usually occurs due to venous obstruction like;

Mechanical factors like pregnancy or tumours in the pelvis (uterine fibroids,

ovarian cyst, cancers of the cervix, uterus, ovary or rectum)

Deep vein thrombosis and obstruction thereby damage to the valves.

Acquired damage to the perforator valves due to excessive calf muscle activity

Altered hormonal climate in the body (increase in circulating progesterone and

relaxin) as in pregnancy

Extensive cavernous Haemangioma

Acquired arterio-venous fistula

Retro peritoneal lymphadenopathy.

Local trauma causing local thrombo phlebitis which may destroy perforator

vein.

Disease Review 2014



Congenital varicose veins

Occasionally varicose veins may develop below 20 years of age; these cases

are mostly due to either congenital arteriovenous fistula or cavernous (venous)

haemangioma.

Pre-disposing factors

Some of the other factors that may predispose to the development of varicose

veins are:

i. Occupation - Prolonged standing

ii. Obesity

iii. Bowel habits

iv. Heredity

v. Pregnancy

vi. Old age

vii. Athlets & Rikshaw pullers

viii. Clothes.

Figure No: 6 - Valve defects on Varicose vein

Disease Review 2014



Figure No: 7 - Pathology of Varicose vein

Figure No: 8 - Varicose vein in lower limb

Disease Review 2014



Symptomatology51, 52

The clinical presentations of the varicose veins patients are varied and a

careful inspection and documentation of the site of the varicosities is extremely

important. Patients may present themselves with -

1. Asymptomatic, cosmetically unacceptable varicose veins.

2. Symptomatic varicosity.

3. Complications of primary or secondary varicose veins

4. Recurrent varicose veins.

5. Superficial Thrombo phlebitis.

6. The restless leg syndrome (Night cramps).

In India, it is rare for a patient to present with varicose veins simply because of

cosmetic unacceptability; younger women of the higher elite usually seek advice at an

early stage.

Clinical Features

Symptoms which varicose veins present are many:

The commonest symptom is tired and aching sensation in the affected lower

limb, particularly in the calf at the end of the day.

Sharp pain may be complained in grossly dilated veins.

Cramp in the calf shortly after retiring to the bed.

Dilated and tortuous veins of the leg.

There may be other complaints also like;

- Ankle swelling towards the evening

- The skin over the varicosity may itch and may be pigmented

- Eczema of affected skin

- Venous ulceration

Disease Review 2014



Patients concerned with the unsightly appearance of their varicose veins often

complain of discomfort but the severity of this discomfort is difficult to assess and

does not seem to be related to the size of the varices.

Aches and Pain:

Many patients do however, experience considerable discomfort which is

sometimes localized to the main varices, but is often a diffuse dull ache felt

throughout the legs which gets worse as the day passes and is exacerbated by

prolonged standing.

Worsening of the pain before a period is characteristic and pain is sometimes

accompanied by a severe ‘itch’ over the veins. Pain that is present at rest or in bed is

unlikely to be caused by varicose veins and another source must be sought. The

typical description of ‘venous’ pain is an ‘ache’ or ‘discomfort’. The presence of a

sharp or acute pain should suggest an alternative diagnosis.

Relief of the discomfort by wearing an elastic stocking provides good

circumstantial evidence that the pain is of venous origin. Elevation of the legs, bed

rest and walking all relieve venous pain, while standing still for prolonged periods

invariably makes it worse.

A history of a bursting pain during exercise (venous claudication) may

indicate venous outflow obstruction but is a rare symptom in patients with

uncomplicated varicose veins.

Night cramps are a common complaint and appear to be particularly frequent

in patients with varicose veins, especially after a long day of standing without

exercise.

Disease Review 2014



Ankle Oedema:

Oedema is not a common or prominent feature of varicose veins. It is usually

mild and only becomes noticeable at the end of the day. Incompetence of the lower

leg communicating veins in isolation or in association with post-thrombotic damage

of the deep veins can cause moderate oedema of the ankle and lower leg.

EXAMINATION OF VARICOSE VEINS 53

HISTORY

1. Age :

Though the varicose vein can affect individuals of all age groups, yet middle

aged individuals are the usual sufferers.

2. Sex :

Women are affected much more commonly in the ratio of 10:1

3. Occupation :

Certain jobs demand prolonged standing e.g. conductors and police men etc.

Varicose veins may also occur in individuals involved in excessive muscular

contractions e.g. rickshaw –pullers and athletes.

PAST HISTORY

Enquiry must be made if the patient had any injection treatment or operation

for varicose veins. Abdominal tumors, any serious illness or previous complicated

operation may cause deep vein thrombosis which is the cause of varicose vein now.

PERSONAL HISTORY

Women should ask about obstetric history, like details of previous

pregnancies. Use of contraceptive pills for quite long time, may cause for this.

Alcoholism and smoking may aggravate this condition.

FAMILY HISTORY

Disease Review 2014



It is not uncommon to find varicose veins to run in families. Often patient’s

mother and sister might have suffered from this disease.

PHYSICAL EXAMINATION 54

Local Examinations

INSPECTION

The following features can be found through inspection;

1) Varicosity

The vein become prominent when the patient stands up.

The varicosities may be wide spread or restricted to a single varix.

Assessment can be done whether long saphenous or short saphenous vein

is affected.

In case of long saphenous varicosity, a large venous trunk is seen in the medial

side of the leg starting from in front of the medial Malleolus to the medial side of the

knee and along the medial side of the thigh upwards to the saphenous opening.

In case of short saphenous vein varicosity the dilated venous trunk is seen in

the leg from behind the lateral Malleolus upwards in the posterior aspect of the leg

and ends in the Popliteal Fossa.

2) Swelling

Localized swelling may be due to the varicose veins of a segment of

superficial veins or superficial thrombophlebitis. Generalized swelling of the leg is

due to deep vein thrombosis.

3) Skin of the limb/ pigmentation

Local redness or marked discoloration can be noticed. Pigmentation is

mainly seen in the medial aspect of the lower part of the leg.

Skin is stretched and shiny due to oedema.

Disease Review 2014



4) Eczema or ulceration

Often seen on the medial aspect of the lower part of the leg.

Carefully inspect the toes to note if there is loss of hair or increased

brittleness of the nails due to chronic varicosity which may indicate

impending venous gangrene.

PALPATION

Examination of the varices is very important. The aim is to locate the incompetent

valves communicating the superficial and deep veins.

The dilated veins are particularly palpated and presence of cough impulse can

be elicited.

A few tests can be performed to know the details of varicose vein including

incompetent perforators.

1. Brodie-Trendelenburg test 55

This test is performed to determine the incompetency of the sapheno femoral

valve and other communication systems. This test can be performed in two ways. In

both the methods, the patient is first placed in the recumbent position and his legs are

raised to empty the veins. This may be hastened by milking the veins proximally.

The sapheno-femoral junction is compressed with the thumb of the clinician or

a tourniquet is applied just below the Sapheno-femoral junction and the patient is

asked to stand up quickly.

In first method, the pressure is released. If the varices fill vary quickly by a

column of blood from above, it indicates incompetency of the sapheno-femoral valve.

This is called a positive Trendelenburg test.

To test the communicating system, the pressure is not released but maintained

Disease Review 2014



for about 1 minute. Gradual filling of the veins during the period indicates

incompetency of the communicating veins. This is also considered as a positive

Trendelenburg test.

In case of short saphenous vein same test is done by pressing the sapheno-

popliteal junction.

2. Perthes test56

This test is primarily intended to know whether the deep veins are normal or

not. A tourniquet is tied round the upper part of the thigh, tight enough to prevent any

reflux down the vein. The patient is asked to walk quickly with the tourniquet. If the

communicating and deep veins are normal the varicose veins will shrink where as if

they are blocked the varicose veins will be more distended.

3. Schwartz test57

In a long standing case if a tap is made on the long saphenous varicose vein in

the lower part of the leg an impulse can be felt at the saphenous opening with the

other hand.

4. Pratt’s Test: 58

This test is performed to know the position of the leg perforators. Firstly an

Esmarch elastic bandage is applied from toes to the groin. A tourniquet is then applied

at the groin at the upper end of the elastic bandage. This causes emptying of the

varicose veins. The tourniquet is kept in position and the elastic bandage is taken off.

The same elastic bandage is now applied from the groin downwards. At the position

of the perforator, a ‘blow out’ or a visible varix can be seen. This is marked with a

skin pencil.

5. Fegan’s Method to Indicate the Sites of Perforators: 59

In the standing position the places of excessive bulges within the varicosities

Disease Review 2014



are marked with a pencil. The patient now lies down. The affected leg is elevated and

the heel is kept supported. Then palpate along the line of the marked varicosities

carefully, so that he can find gap or small pit in the deep fascia which transmits the

incompetent perforator. This is marked with ‘X’. This is the site of the perforator. It

should tally with the skin pencil mark of the venous bulge marked before.

6. Morrissey’s cough impulse test: 60

The limb is elevated to empty the varicose veins. The limb then put to the bed

and the patient is asked to cough forcibly. An impulse is felt in the long saphenous

vein particularly at the saphenous opening if the sapheno-femoral valve is

incompetent. Similarly a bruit may be heard on auscultation.

PERCUSSION

If the most prominent parts of the varicose veins are tapped, an impulse can be

felt by the finger at the saphenous opening. This is known as Schwartz test.

Sometimes the percussion wave can be transmitted from above downwards and this

will imply absent or incompetent valves between the taping finger and the palpating

finger.

AUSCULTATION

The importance of auscultation is limited to the arterio-venous fistula, where a

continuous machinery murmur may be heard.

Regional lymph nodes (inguinal) are only enlarged if there be venous ulcer

and this is infected. Examination of the abdomen is probably is the most important,

sometimes a pregnant uterus or intrapelvic tumour (fibroid, ovarian cyst, cancer of

cervix or rectum) or abdominal lymphadenopathy may cause pressure on the external

iliac vein and become responsible for secondary varicosity.

Disease Review 2014



OTHER EXAMINATIONS 61

A. Examination of abdomen

This is essential to exclude pregnancy or presence of any pelvic tumour as

the cause of varicosity.

Any dilated collateral veins should be noted as these veins develop due to

inferior venacaval obstruction, particularly thrombosis.

B. Vaginal and rectal examination – to exclude pelvic tumour

C. Peripheral arterial pulse should be examined – to exclude presence of arterial

insufficiency.

INVESTIGATIONS62

It is believed that the patient suffering from varicosities should undergo an

assessment by duplex scan. There is some evidence that this policy leads to more

accurate surgical approach and reduces the incidence of recurrence of the varicose

veins. Duplex scanning is, however not always available and clinical examinations

with tourniquet tests is still suffices in many settings.

Doppler ultrasonography

A Doppler flow probe can be used to exclude arterial diseases, to determine

the patency of a vein and a bidirectional probe is used to detect venous reflux.

A standard Doppler probe emits a sound when blood flows past the

transmitting and receiving crystals. A uniphasic signal indicates flow in one direction.

Biphasic signals indicate forward and reverse flow and are indicative of blood

refluxing down through incompetent valves. A Doppler probe is placed over the

saphenofemoral junction. A calf squeeze is carried out and if a biphasic signal is

obtained this confirms the presence of incompetence of the saphenofemoral junction.

Disease Review 2014



Duplex ultrasound imaging

The probe of a duplex scanner contains multiple emitting and receiving

crystals. These allow a gray-scale image to be obtained in which the veins are seen as

a black void in the subcutaneous and deep tissues. Directional flow can be shown as a

colour image (red or blue) superimposed on the gray scale image of the vessels.

Venography

Venography (also called phlebography) is a procedure in which an x-ray of

the veins, a venogram, is taken after a special dye is injected into the veins. The dye

has to be injected constantly via a catheter, making it an invasive procedure. Normally

the catheter is inserted by the groin and moved to the appropriate site by navigating

through the vascular system.

Venography can also be used to distinguish blood clots from obstructions in

the veins, to evaluate congenital vein problems, to see how the deep leg vein

valves are working.

Varicography63

A contrast is injected directly in to surface varices. The contrast is non-

thrombogenic, as it is nonionic and iso osmolar with blood. This allows detailed

mapping of varicose to their termination.

Plethysmography

Measures volume changes in the leg in response to a tourniquet applied around

the thigh.It provides useful information on venous outflow and can be used to

diagnose ileofemoral venous thrombosis.

Complications of Varicose Veins64

Das has mentioned the complications under separate entities

Thrombo phlebitis of the superficial veins.

Disease Review 2014



Pigmentation.

Eczema or Chronic infective dermatitis

Venous Ulceration.

Hemorrhage from rupture of varicosity.

Calcification of veins.

Ankle flare

Periostitis, in the case of long standing ulcer over the tibia.

Equines deformity.

Although, all these complications are not met with in everyday cases of

varicose veins, complications as Superficial Thrombo phlebitis, Pigmentation,

Eczema, Ulceration etc. are seen very frequently. Leg ulceration is more

associated with secondary varicose veins than with primary varicosity.

Ulceration due to repeated mitosis in unfavorable circumstances may

eventually undergo malignant change becoming a squamous cell carcinoma

and is termed 'Marjolin's Ulcer'.

Management of Varicose Veins65, 66

From time immemorial, wide scale research on management procedures were

conducted on varicose veins, but none of these techniques is better than the other and

the best method is yet to be derived. At present, the prevalent methods of treatments

are three.

1. Palliative treatment

2. Compression Sclerotherapy or empty vein injection technique

3. Operative procedure.

Disease Review 2014



1. Palliative treatment

It has limited scope and its indications are

Pregnancy

Those who don’t want operation

Those who are waiting for operation

Very early cases of varicosity

This treatment consists of:

Avoidance of prolonged standing

A crepe bandage or elastic stockings are applied from the toes to the thigh.it

should be worn all throughout the day and is only taken off during sleep.

Advice the patient to keep the leg in a raised position preferably above the

level of heart whenever he sits or sleeps.

Exercises like bicycle riding in the air while lying on the back, walking etc.

should be performed to strengthen the calf muscle.

2. Sclerotherapy (liquid or foam)

This procedure is performed under local anesthesia. Sclerotherapy involves

injecting a chemical into the varicose veins. This will damage the veins and close

them. Liquid sclerotherapy is often used to treat smaller veins below the knee. Foam

sclerotherapy is used to treat the larger veins. The legs will be tightly bandaged

afterwards or the patient may be asked to wear compression stockings.

Compression Sclerotherapy is a modification of the previously done

Sclerotherapy, and was postulated by Regan, The principle of the procedure aims at

injecting a sclerosant as Sodium tetra decyl Sulphate 3% into the dilations, which acts

by damaging the intimae of the veins to cause a thrombosis and later, endosclerosis.

The detergent destroys the lipid membrane of endothelial cells causing them to shed,

Disease Review 2014



leading to thrombosis, fibrosis and obliteration (sclerosis). After the treatment the

vein is rendered a fibrous cord. The success of the treatment lies in selecting the

minimum effective dose and this also should not be exceeded any one site.

Compression Sclerotherapy cannot be employed in pregnancy for fear of

abortion. It is never to be used in women on oral contraceptives because of the

possibility of pulmonary embolism. Following this procedure, unpredictable staining

may occur. It is not a radical cure in large varicosities, since the fibrous tissue may re

analyze in future. Many patients find a period of leg bandaging for six weeks, which

inevitably they have to follow after this therapy uncomfortable and irksome,

particularly in hot weather (Savage).

3. Ultrasound – guided form Sclerotherapy67

This has recently become an alternative to the ‘blind’ Sclerotherapy practiced

in the past and can be used to treat the main saphenous trunks. A needle is inserted in

to the vein that requires treatment under duplex ultrasound guidance and the

sclerosant is made in to form. The form is then injected under continued ultrasound

monitoring, which can image the form as it spreads up the vein. The top of the

saphenous vein should be compressed by the ultrasound probe, preventing the

majority of the form from entering the deep veins until the spasm in the main trunk

develops. The leg can also be elevated to reduce the spread of the form in to the axial

deep veins.

Repeat duplex imaging confirms the presence of occlusion and over 90 %

major trunks can be occluded by up to three treatments. As yet, there are no long term

results available for this technique and no controlled trials have been carried

comparing this technique with other techniques for saphenous obliteration.

Disease Review 2014



1. Operative procedure68, 69

Surgery is often the best option for bulging varicose veins visible beneath the

skin. It is usually most effective in the largest varicose veins which will be

completely removed. It is also effective for smaller varicose veins. Surgery will not

help thread or spider veins which are found within the most superficial layers of the

skin itself and cannot be physically removed.

Varicose vein surgery has been shown to be clinically effective as well as cost

effective. The benefits in terms of the improvement in the quality of life for patients

undergoing venous surgery was as great

The results of surgery for varicose veins will vary. In general, a detailed pre-

operative assessment followed by surgery targeted to the sources of reflux feeding the

varicose veins will produce a better result.

Indications are:

Positive Trendelenburg test

Sapheno femoral incompetence

Contraindications are

Pregnancy

Women taking contraceptive pills

Thrombophlebitis

The operative procedures include:

1. Ligation

Done in case of

Sapheno femoral incompetence

Sapheno popliteal incompetence

Disease Review 2014



2. Ligation and stripping

Ligation and stripping is done under general anaesthesia. It's used to remove

the long or short saphenous veins in the legs. Two cuts about 5cm long, one in the

groin and the second in the lower leg either close to the knee or ankle. Then the faulty

vein (this is called ligation) is tied off through the cut in the groin to stop blood

flowing through it. Using a thin flexible wire, the varicose vein will be carefully

pulled (strip) out through the cut in the knee or ankle.

3. Phlebectomy

Phlebectomy is used to remove the smaller surface veins that lie under the

skin. Small cuts about 5mm long is made on the leg and the affected veins are pulled

out by using hooks. This procedure may be done with ligation and stripping or with

the endovenous laser and radiofrequency techniques. It can be used on its own if the

patients only have surface veins treated.

Medical treatment of Varicose Veins

Although successful reports of medical treatments in Varicose Veins are not

yet seen published, drugs like Glyvenol, Aetoxisclerol and Dihydroergatomine have

been tried and the results published.

Review of Siravyadha 2014



REVIEW ON SIRAVYADHA

RAKTA

Word derivation:

The word Rakta is derived from the root renj, which means to give color.

(Shabdakalpadruma)

Synonyms of Rakta:

Raktam, Rudhiram, Rohitam, Asruk, Shonitam, Lohitam, Asram, Angagam,

Khajam, Charmajam, Twagjam, Kshatajam and Ranjakam. (Shabdakalpadruma)

Importance of Rakta:

Rakta is stated to be the Moola or root of the body, as it does Dharana, and

hence it is known as Dhatu1. The Kshaya and Vruddhi of Dathus depend on Rakta.

2

Thus Rakta needs to be cared and well protected as it is important as Jeeva and it is

one of the Pranayatana. Acharya Charaka says that Shudha Rakta is responsible for

Bala, Varna, Sukha and Ayushya.3

Rakta is the one which does Purana, gives Varna

Samsparsha Jnana and is considered as Shresta among the seven Dhatus.4

Sushrutacharya considers Rakta as Jeevatulya or Jeevarakta as it is present only in

live body.5

Properties and Panchabhoutikatva of Rakta:6

The properties like fleshy odor, fluidity, redness, movement and lightness of

Rakta represent Prithvi, Jala, Agni, Vayu and Akasha Mahabhutas respectively.

Panchabhouthikatva of Rakta

Table No:1

Sl. No Properties Mahabhuta

1. Visruta (characteristic fleshy odour ) Prithvi




2. Dravata (fluidity) App(Jala)

3. Ragata (redness) Teja

4. Spandana (movement) Vayu

5. Laghuta (lightness) Akasha

Formation of Rakta: 7, 8

Chart no: 1

Rasa Dhatu circulating in body reaches Yakrut & Pleeha

Teja attains red colour Rakta

Features of Shudha Rakta: 9, 10

The normal blood should have a bright red color and should neither be too

thick nor discoloured. Slightly sweet in taste, neither cold, hot, nor coagulated. The

colour of Shudha Rakta is correlated to gold (purified with Fire), Fire fly (Indragopa),

Red lotus and fruit of Gunja.

Characteristics features of person having Shudha Rakta:

Excellency of colour, acuity of the sense organs, good reception of objects,

unhindered digestive capacity, enjoyment of comforts, endowed with good nutrition

and strength.

Causes of vitiation of Rakta: 11

The Aharaja, Viharaja, Kala and Manasika factors vitiate Rakta.

Ahara

- Excessive intake of Ushna, Teekshana and Dusta Madhya.

- Excessive intake of Lavana, Kshara, Amla and Katudravyas.

- Excessive intake of Kulattha, Masha, Nishpava, Tilataila, Pindalu (potato),

Mulaka and Haritashaka.




- Excessive intake of meat of animals living in Jala, Anupa, Prasaha and

Vileshaya.

- Excessive intake of Dadhi, Dadhimastu, Amla Kangi, Sura and Souviraka.

- Excessive intake of Viruddha, Puthi (spoiled) Snigdha and Guru Ahara.

Vihara

- Sleeping during day time after taking liquids and heavy foods.

- Excessive exposure to the sun and fire

- Suppression of the Chardi Vega.

- Not undergoing Raktamokshana during Sarad Kala.

Manasika:

- Excessive Krodha, Shoka and Bhaya

Kalaja:

- By the very nature of the Sarad-Ritu it causes Rakta Prakopa

Rakta Dusti Lakshana: 12

The Lakshana of Rakta vitiated by different doshas is as follows:

Doshaja Rakta Dusti Lakshana

Table No: 2

Sl. No Dosha Lakshanas

1. Vata Aruna, Phenila, Krishna, Parusha, Shyava, Tanu, Vishada,

Askandana

1. Pitta Peeta Neela, Haritha and Shyava Varnatha, Visrata not liked

by Pipilika and Makshika.

3. Kapha Ishat Pandu or Gairikodaka Varna, Snigdha, Sheeta, Bahala,

Picchila, Mamsapeshivarna

4. Dwidoshaja Lakshana of involved two Doshas

5. Sannipataja Sarva Dosha Lakshana.




Acharya Charaka mentioned Vishudha Rakta Purusha Lakshana separately in

Sutra Sthana13

Raktaja Roga:

Mukhapaka, Akshiroga, Pootighrana, Aasyagandha, Gulma, Upakusha,

Visarpa, Raktapitta, Pramelaka, Vidradhi, Raktameha, Pradara, Vatashonita,

Vivarnya, Agnisada, Pipasa, Gurugatra, Santapa, Dourbalya, Aruchi, Siroshoola,

Vidaha, Tikta-Amla Udgara, Klama, Krodha, Moha, Lavanasyata, Sweda, Sareera

Dourgandhya, Mada,Kampa, Swarakshaya, Tandra,Nidra, Tamodarshana, Kandu,

Ruk, Kota, Pidaka, Kusta, and Charmadala. 14

TREARMENT FOR RAKTADUSTI 15

Raktapittahara Kriya’s

Virechana

Upavasa

Raktamokshana

RAKTA MOKSHANA

Definition:

Raktamokshana is made up of two words ‘Rakta’ which means – coloured,

dyed, tinged, painted, red, crimson, red blood and ‘Mokshana’ which is derived from

the root word ‘Moksha’ which means ‘to relieve’ or ‘to let out’ . Therefore letting out

of blood (vitiated) is known as Raktamokshana.

Raktamokshana is considered as one of the Sodhana therapy as per Sushruta

and Vagbhata. Raktamokshana is nothing but letting of blood outside the body, where

alone is equal to all measures described in the treatment of diseases caused by Rakta

as well as other vitiated Dosha. The main function of the Rakta is Jivana. It is a




synonym for Ayu or life.16

Paryayas:

Raktamokshana, Raktanirharana, Shonithamokshana, Raktasravana, Raktavasechana

and Raktaharana.

Classification:

Raktamokshana can be classified as follows, 17, 18, 19

Chart no: 2

The suitable method for bloodletting has to be adopted considering various

factors like Dosha, Rakta and Atura Avastha. In Vatadusti, Sringavacarana is

mentioned because Sringa of cow is Usna, Madhura, Snigdha which are opponents of

Sita, Ruksa of Vata. In Pittadusti, Jaloukas are selected as they are being in Jala they

are Sita and Madhura, opposite to Pitta. In Kaphadusti Alabu is selected as it is

having Katu Rasa, Ruksa, and Tiksna Gunas.20

According to Dosha and Avastha, that is if Dosha is Avaghaḍa [superficial]

then Praccanna, Jalouka, Alabu, Sringa etc. can be adopted. If there is Sarvadaihika

Raktadusti, Siravyadha is adopted.21

Depending on Atura Bala also different modalities of Raktamokshana are

selected. In case of Raja, Bala, Vrddha, Sukumara and Nari, Anusastravacarana can

SASTRA VISRAVANA ANUSASTRA VIDHI

PRACHANA

SIRAVYADHA

JALOUKA

SRINGA

ALABU

GHATEE YANTRA




be adopted and in others Sastravacarana can be adopted.22

HISTORICAL REVIEW

Atharvaveda has documentary evidence of knowledge of circulatory system, it

has been explained that there is intense flow of fluid, coloured “Aruna Rohita, Tamra,

Dhuma” upwards, downwards and peripheral towards “Jala-Sindhu”.23

Kausika Sutra

of Atharvaveda has references regarding Raktamokshana by Jalouka. Raktamokshana

by Sringa was done is case of Pravavata under the guidance of Buddha.24

It is one of the Shalya Tantra technique adopted by most of ancient Ayurvedic

scholars and practiced through ages by scholars such as Vaidya Satapatha Brahmana,

Aupadenava, Aurabhra, Pouskalavata, Karavirya, Vaitarana, Bhoja, Kritavirya,

Gopuraraksita, Bhaluki, Kapila, Goutami etc. Moreover Charaka, Sushruta,

Vagbhata and others have explained regarding Raktamokshana.25

In western medicine Siravyadha is referred to as phlebotomy or venesection, it

is also called as bloodletting procedure. “Phleb” is a Greek word which means vein

and –“otomy” is to cut. Hence phlebotomy is to put an incision on the veins. The

procedure of phlebotomy refers to dates back to the period of early Egyptian

(4000BC). Later it spread to Greeks, Romans, Arabs, Asians and then to Europe.

Hippocrates (460-370 BC) said that the imbalance of humors in the body is corrected

by removing the excess humors. One of the methods to remove humors is

bloodletting. Galen of Pergamum (129-200AD) declared that blood is the most

dominant humor and cause for much illness, which even more increased the practice

of bloodletting.

During this period there were three methods of bloodletting: (1) Venesection

or Phlebotomy (Siravyadha) (2) Cupping and (Sringa & Alabu) (3) Leech application

(Jaluka). For the purpose of venesection the instruments used are lancet and fleams.26




In period of 1200-1600 A.D extensive practice of parasurgical procedures were

practiced by Unani practioners and during 1300 A D in Europe. There is evidence of

Raktamokshana are available.27

During 18th century bloodletting was done to whom it was understood that all

other said treatments were helpless and the bloodletting was followed to maintain

physiological well-being.28

Importance of bloodletting greatly reduced by mid of 19th

century due the

evolving micro-organism theory, which considered micro-organisms are the cause for

the disease. This was aided by studies conducted by different people like Dr. Pierre

Louis (1782-1872) and others which said that the results of bloodletting were not

appealing as it was propagated.

Then onwards blood was drawn only to find the cause and not as cure.

Presently phlebotomy is done only in few cases such as Hemochromatosis,

Polycythemia Vera and Prophyria Cutanea Tarda.29

Out of all types of Raktamokshana as Siravyadha is taken up for study, hence

it is highlighted in detail.

SIRAVYADHA

Introduction:

Ayurveda the science of life holds an unmatched way of approach towards the

diseases. It gives equal importance to cure the diseases as well as to preserve the

health of a healthy person. The management of diseases aims at the radical removal of

the causative factors as to the restoration of Doshik equilibrium.

Importance of Siravyadha:

1. As Vasti has been mentioned as a dominant line of treatment in Kayachikitsa,




likewise Siravyadha has been mentioned in Shalya Tantra. It is also

considered as ‘Ardha Chikitsa’ of Shalya Tantra. As the Rogadhistana is

primarily Rakta, Raktamokshana by Siravyadha has got its own importance in

curing the Disease.30

2. Vagbhata also mentioned that Siravyadha is complete treatment in Shalya

Tantra as Vasti is the complete treatment in Kayachikitsa. As Rakta Dhatu is

the main causative factor in all Vikaras or diseases it is to be treated first by

Siravyadha Viddhi.31

3. Charaka has mentioned that if the Sadhya Rogas if does not get cured by Sita,

Usna, Snigdha, and Ruksa that is Vatahara, Pittahara and Kaphahara

Upakramas then it has to be considered as Raktaja Vyadhi and has to be

treated by Raktamokshana and Raktapittahari Kriyas.32

4. Raktamokshana by Siravyadha will be helpful to maintain good health by

causing Varna Prasannata, Indriya Prasannata, Agnidipti, proper Vega

Pravrtatha, Pusti, Tusti etc.33

5. Siravyadha is the supreme procedure amongst all Sodhana therapies. When

Snehadi, Lepanadi treatments have been failed Siravyadha is adopted.34

6. Sushruta has mentioned that repeated Raktamokshana if done at regular

intervals will avoid diseases of the skin, tumours, oedema etc.35

7. In Rakta Pradosaja Vikaras, Siravyadha is the procedure which gives

complete cure in relation to other types of Raktamokshana and Sodhana

therapies like Vamana-Virecana etc.

8. Siravyadha is the only method by which all the diseases will be cured from

their roots just like rice and other crops in the field die out completely by

removing the bunds of field.36




ETYMOLOGY OF SIRAVYADHA

“Sinuthauhi ithi Sira”

That which binds or a quantity bound together

Any tubular vessel of the body – nerve, vein, artery, tendon;

As they are binding the whole body together by transporting blood to all over

the body

“Vyadhanamiti Vyadha”

That which cuts

To pierce, to transfix, to hit, strike, wound

“Sarathyabhi Raktamiti Sira”. “Tasam Vyadha Siravyadha”

By which the blood is being taken all over the direction is ‘Sira’. Puncturing

of Sira is known as ‘Siravyadha’.

“Upakrama - Sirabhyaḥ Sastra Karmana Rakta Mokshanam”

It is a procedure in which using a Sastra the blood is removed from Sira. Here

initially vitiated blood flows out similar to the flow of yellow fluid from Kusumbha

Puspa37

.

SIRA:

Dhamani and Sira are differentiated throughout the classical period, though

some of them differ from the opinion that there is no basic difference in Sira,

Dhamani and Srotas, they are synonymous to each other. However, in Samhitas like

Sushruta, Charaka and Vagbhata there is a clear opinion about the differentiation

between Sira, Dhamani and Srotas.38, 39, 40

The fundamental difference between Dhamani, Sira and Srotas is act of

Dhamana or pulsation. The school of Sushruta observed that Sira ought to be

different from Dhamani due to its origin, function and properties.




‘Saranath sira’ 41

Sira is the tubular structure, where Sarana is performed. Sarana refers to flow

of fluids; here fluids are Rasa, Rakta etc. Srotas are the structures through which

Sravana occurs.

Sravana is the permeation of various fluids through the pores present in the

wall of Srotas. This explains the osmosis or permiasis, the veins spread in body like

venules in leaf. They nourish the body like river and streams in term of Jala-Harini.42

Origin of Sira:

All the Siras present in the body originate from the Nabhi, and from there,

they spread to all directions. Prana resides in the Siras of the Nabhi and the Nabhi is

the seat/residence of the Siras. The Nabhi is surrounded by Siras similar to the axle

hole being surrounded by spokes43

.

Siras are mainly ten in number located in Hridaya. They transport the Rasa

and Ojas to the whole body, all the activities of the body depends on them. They are

broad at their root and very narrow at their tips and spread upward, downwards

obliquely and divide into 700 in number, it appear like the lines of a leaf. These

branches of Siras provide nutrition to the body as the water carrying channels irrigate

a field.44

Types & Distribution of Siras:

Among these 700 Siras, Mula Siras are 40 in number. They are:

Vatavaha - 10 in number

Pittavaha - 10 in number

Kaphavaha - 10 in number

Raktavaha - 10 in number




These Siras, on reaching their respective seats divide themselves into 175. The seat of

Raktavaha Srotas is Yakrt and Pliha. Thus together they form 700 in number.45

Siras are four types namely.46

i.e.

1. Vatavaha - 175

2. Pittavaha - 175

3. Kaphavaha - 175

4. Raktavaha - 175

TOTAL - 700

Number of Sira according to specific location: 47

Enumaration of Sira according to its location

Table No: 3

Shaka Kostha Jatrurdha

Vatavahini Sira 100 34 41

Pittavahini Sira 100 34 41

Kaphavahini Sira 100 34 41

Raktavahini Sira 100 34 41

Swarupa of Siras: 48

The Vata carrying Siras are of crimson red colour and filled with Vata. Pitta

carrying Siras are warm and blue in colour. Kapha carrying Siras are white in colour,

cold and steady. The Rakta carrying Siras are red in colour and are neither very warm

nor very cold.

Vata, moving in its own Sira bestows non-hindrance of all activities, no

delusion in the functions of the mind and many other activities. When the aggravated




Vata accumulates in its own Sira, many diseases due to Vata develop in the body.49

Pitta moving in its own Sira attends to functions such as brightness of colour

of the skin, taste perception, keenness of digestive fire, absence of disease

(maintenance of health) etc. when aggravated, Pitta accumulates in its own Sira and

many diseases of Pitta origin develop in the body.50

Kapha moving in its own Sira bestows lubrication of the body, stability of the

joints, augmenting strength to the body etc. when aggravated, Kapha accumulates in

its own Sira and many diseases of Kapha origin develop in the body.51

Rakta, moving in its own Sira performs functions such as supplying nutrition

to the tissues, bestowing colour and tactile sensation to the skin etc. when aggravated,

Rakta accumulates in its own Sira and many diseases due to Rakta vitiation develop

in the body.52

Siras not only carry Vata, Pitta or Kapha also carries aggravated Doshas

intimately mix with each other and circulate in the Siras are sure to over run their

normal seats since they carry all the Doshas. Hence, all Siras are said to carry all the

Doshas.53

Bhavotpatti: 54

All the hard parts like Kesha, Smashru, Loma, Asthi, Nakha, Danta, Sira,

Snayu, Dhamani, and Retasa, are contributed by paternal Bhava. These are known as

Pitruja Bhava.

Vedhya and Avedhya Siras: 55, 56

Acharyas described Vedhya Siras as those where surgical procedures can be

performed. They present no serious complications, when handled properly. It is also

mentioned that through these veins only the safer bloodletting can be done for curing




various diseases. Avedhya Siras are those on which the injury or any surgical

interventions must be avoided.

Acharya Sushruta mentions specific and detailed description of Siravyadha as

well as Avedhya Siras for the first time in the history of medicine and surgery. He has

mentioned 98 Avedhya Siras which should be taken care by the physician or surgeon

at the time of Siravyadha or any other surgical condition.57

Vagbhata also mentioned the number of Avedhya Siras as Acarya Sushruta,

but he has slightly modified the knowledge of Avedhya Siras. His concept is that apart

from these 98 Avedhya Siras, those Siras which are oblique, short, and tortuous and

narrowly placed in the subject should also be included under this heading.58

Vedhya and Avedhya Siras

Table No: 4

Location

Total no.

of Siras Vedhya siras Avedhya Siras Reference

Extremities 400 - 16 Su. Vag

Trunk 136 - 32 Su. Vag

Urdhwajatru

(region above clavicles) 164 - 50 Su. Vag

Total 700 98

Yogya and Ayogya for Siravyadha:

Indications:

Diseases of the skin, tumors, swelling and diseases arising from blood will

never occur in persons who has undergone Siravyadha (generally in Sarad Ritu).59

Siravyadha is the method of treatment indicated in diseases caused due to the




vitiation of Rakta Dhatu like Visarpa (erysepelas), Vidradi (abscess), Pliha (Diseases

of Spleen), Gulma, Agnisadana (Dyspepsia), Jwara (Fever), Mukha Roga (Diseases

of mouth), Netra Roga (Diseases of Eye), Siro Roga (Diseases of Head), Mada

(Intoxication), Trisna (Thirst), Lavanasyata (Salty taste in the mouth), Kusta (Skin

diseases), Vatarakta, Raktapitta, Katu and Amlodgara (Pungent and Sour eructation),

Bhrama (Giddiness) etc.60

, if disease does not get cure by any other treatment.61

Contraindications: 62, 63

Siravyadha should not be done in Baala and Vriddha as the Dhatu are ill formed

and undernourished respectively.

Ruksa, Ksataksina (wounded and debilitated), as it may causes

“Vataprakopa”.

Bhiru (timid persons), as there will be “Tamobahulata”, they will faint by

seeing the blood.

Parisranta (tired persons), as Vata gets vitiated in such persons and will affect

the whole body.

Madyapa(alcoholics), as they will go to Murccha due to the intoxicated

condition.

Anuvasita (those who have undergone Anuvasanavasti), as there will be

Mandagni which leads to Agnimandya. In persons suffering from impotency,

Garbhini and who are affected with Kasa, Swasa, Shosha, Jwara, Akshepaka,

Upavasa, thirst, less strength is left; hence Siravyadha may further worsen the

condition.

In the persons who have underwent Vamana, Virechana, Niruha Basti,

Madyapana, not slept at night, Pakshagata, by performing Siravyadha Vata

further gets aggravated.




Siravyadha should not be done on invisible Vedana Yogya Siras and even after

tying the tourniquet if it is not visible.

The surgeon should make use of his Yukti according to his experience to select

the disease as well as patient. Raktamokshana should be done according to the

procedures.

It is left to the surgeon to do Siravyadha even in those Siras, which are

contraindicated for Vedhana as in case of poisoning and other emergency

conditions.64

Siravyadha should not be done on days which are very cold, very hot, with

heavy breeze and very cloudy and never in the healthy persons (except Sarad Ritu). 65

MATERIALS REQUIRED FOR SIRAVYADHA (Sambhara Sangraha)

For better performance of Siravyadha and for the management of the

complications, the following materials should be arranged prior to the procedure:

Cot, stools, pots of water, pieces of cloth (gauze piece, swabs), drugs like

Tagara, Ela, Sita, Siva, Kusta, Pata, Vidanga, Bhadradaru, Trikatu, Agaradhuma,

Haridra, Arkankura, Churna (slaked lime) etc. to promote bleeding; drugs like

Lodhra, Madhuka, Priyangu, Gairika, Rasanjana, Salmali, Sankha Churna, Yava,

Godhuma, Masa, Churna (slaked lime), Vata, Asvattha, Asvakarna, Palasa,

Vibhitaka, Sarja, Arjuna, Dhanvana, Dhataki, Salasara, bark of Arimeda, sprout and

latex of Tinduka, Srivestaka, Mrtkapala (potsherds), Mrnala, powder of Anjana

(Antimony sulphide), ashes of Ksauma, Laksa or powder of Samudraphena and also

any other substances useful to stop bleeding and its complications.66

Vastra Patta, Carma, Antarvalkala, Lata etc are used for the Yantrana of

Sira.67




1. Selection of Sira

Contraindicated Sira: 68

The Siras which are invisible and which are not prominent.

Out of 700 Siras, 16 Siras in the extremities, 32 in trunk and 50 in Urdwajatru are

regarded unfit for Siravyadha.

2. Vyadhana Kala (suitable time) for Siravyadha:

Three suitable times of Siravyadha are mentioned. During Varsa Ritu (rainy

season), it should be done on days which are not cloudy; during Grishma Ritu

(summer season) at the time which is cool; during Hemanta Ritu (winter season) at

mid-day.69

3. Contraindicated age:

Age below 16 years and above 70 years is contra-indicated for Siravyadha.70

4. Site of Siravyadha:

As per the diseases Acharyas told different sites for Siravyadha.71

5. Positioning the patient:

Acharya Sushruta has mentioned different position of patients in different

diseases for Siravyadha. The patients should be advised to have a comfortable

position with respect to the site of procedure.72

6. Sastra used

Vrihimukha Sastra: Vrihimukha Sastra is one of the sharp instruments

mentioned in classics for the purpose of Vyadhana. Vrihimukha Sastra is that

instrument whose tip is similar to Vrihi. It is held using thumb and index finger.

According to Vridha Vagbhata the Phala of Vrihimukha Sastra is Adhyardhangula.

According to Bhoja, Vrihimukha Sastra should be 6 Angula in length where 2 Angula

is the Vruta of the Sastra and 4 Angula Phala of the Sastra.73




Kutarika Sastra: Kutarika Sastra is similar to that of Kutarika (axe). The

Phala of Kutarika is ½ Angula and Vrnta is 7½ Angula and it is similar to Godanta. It

is used for Siravyadha in Asthi pradesha.74

7. Vyadhana Pramana (Size of Puncture):

In muscular areas, puncturing should be of the size of the Yava (barley grain)

in other areas it should ½ Yava or one Vrihi (rice) using a Vrihimukha Sastra.

Veins on the bones should be punctured to the size of ½ of Yava using a

Kutarika Sastra.75

SIRAVYADHA VIDHI (Procedure):

In Brihattrayis the procedure of Siravyadha is mentioned in a comprehensive

manner, there is no description about Vyadhana procedure with respect to different

parts of the body while. Chakradatta in Siravyadha Adhikara has given a detailed

description about the procedure of Siravyadha in different parts of the body.

Combining all the scattered information a procedure is given below.

Poorva Karma

Siravyadha should be conducted by a physician after assessing the strength of

the disease and patient, on the day which is neither very cold nor very hot.

Snehana and Swedana should be performed at the day of Siravyadha.

It is said that Doshas are diluted by the process of Snehana and Swedana. By

this process they pass in to the Siras. Therefore the patient should be prepared for

Siravyadha by Snehana and Swedana Karma to remove vitiated Rakta due to Doshas

from the body. The patient should be fed with Yavagu, Laghu Dravya before

venesection. Yavagu should be given to prevent the patients from fainting during the

procedure.76, 77




Pradhana Karma of Siravyadha 78, 79

The physician after making the patient perform all the auspicious ceremonies,

after determining the strength of disease and habit of the patient, should give him

either soup of meat of animals living in arid lands or a thick gruel mixed with fatty

materials (ghee or oil) as a drink; allow him to comfortably rest for about a Muhurtha

(48 minutes), either in the morning or in the afternoon. Afterwards he should be made

to sit on a soft stool of the height of the knee, placing his elbows on his knees and,

placing the feet together comfortably on the floor facing the sun. At the level of the

lower border of the hairs of the head, a tight bandage should be tied making use of

moist cloth, leather or inner bark of the tree. The patient is then asked to keep the

thumbs inside his fists, cover them with cloth and clench them as hard as he can,

accompanied with biting the teeth one over the other as hard as possible, inflating his

mouth.

Another person standing behind the patient should put a long piece of cloth

around the neck of the patient, make a knot around, with that cloth over the nape of

patient’s neck, twist the knot to tighten the knot around the neck taking care not to

block the respiration. This will be the method to control and raise the veins which are

facing inwards (in other words placed deep underneath the skin) and which are

forbidden.

Then the physician should raise the vein by tapping on it with his middle

finger triggered by the thumb. On finding that the vein has risen up, is pulsating and

full for touch, he should hold the Kutarika (axe) with his left hand and is kept in front

of the Vyadhana Sthana. A tap is given by releasing the middle finger held under

pressure by thumb.80




Strangling with the cloth, clenching the fist, grinding the jaws, inflating the

mouth, tapping on the vein are all meant to raise the pressure inside the veins.

Amount of blood letting:

The maximum of blood to be let out is one Prastha according to Acharya

Sushruta.81

According to Dalhanaacharya the amount has to be fixed according to the

strength of the patient, strength of the doshas, strength of the disease, and one

Prasta is 13 ½ Pala,82,83

Sharangadhara says small amount of Dusta Rakta

left after bloodletting will not cause any bad effects. Therefore little amount of

blood is to be kept unresolved.84

An intelligent surgeon should allow a part of the vitiated blood to remain

rather than drain it excessively. Alleviating measures should be followed to

pacify the remaining Dosha in the blood 85

.

Amount of blood to be removed in Siravyadha

Table No: 5

Uthama 1 Prastha 648 ml.

Madyama ½ Prastha 324 ml.

Heena ¼ Prastha 162 ml.

Siravyadha Lakshanas:

After Siravyadha following Lakshana has to be observed

a) Samyak Siravyadha Lakshanas

b) Durvidda Siravyadha Lakshanas

c) Atividda Siravyadha Lakshanas




Samyak Vyadha Lakshanas

When Siravyadha is done properly then the blood flows in a stream for a

period of one Muhurta and stops automatically after all Dusta Rakta flows out

without any external hindrance. 86, 87

After Samyak Viddha the following Laksanas are seen: Vedanasanti, Vyadhi

Vega Pariksaya and Manas Prasada.88, 89

Observation:

Siravyadha is a procedure to let out the Dooshita Rakta from the vein is

compared to the discharge of yellow juice which comes out by squeezing of Kusumba

flower, the excited and mobilized morbid factors are discharged out.90, 91

Asrava Dosha (Effect of Absence or Inadequate flow): 92, 93

Causes- If done in Durdina, in the presence of Sheetha Vata, if done without

Swedana if done immediately after Bhojana, if done in a person suffering from Mada,

Moorcha, Shrama, Vata, Vit, Moothra Sanga, Nidra (feeling sleepy) and if he is

Bheetha it leads to Ayoga.

When patient is unconscious, tired, improper position, puncturing of Avedhya

Sira or puncturing of the Sira by thin instruments also leads to inadequate flow of

vitiated blood.

Signs - It produces Kandu Shopa, Raga, Daha, Paka and Vedana, since the Dusta

Rakta is not removed. There will be little blood flow for a short period.

Atisrava Dosha (Effect of Excess flow): 94, 95

Causes- If done in Ushna Ritu, if excess Swedana is given and if done by an

inexperienced person and when the incision is made with an old instrument, which is

Shithila and not sharp.

Signs- It leads to excess flow which causes Shiroroga, Adhimantha, Andhatha,




Thimira Rogas and produces Dathu Kshaya, Akshepaka, Pakshaghatha, Ekangavata,

Trishna, Daha, Hikka, Kasa, Swasa, Pandu and also Mrithyu. There will be

Sashabdha Yuktha Srava, which stops with difficulty.

Dusta Vyadha (Improper puncturing):

Dusta Vyadha (Improper puncturing) is of twenty as follows:

Durviddha is that which puncture made by a minute sharp instrument, blood

flow being invisible and having pain and swelling.

Atividdha is that puncture which is more than the required measurement,

blood flow either goes inside the body of flows out in large quantity.

Kuncita is also similar to the above.

Picchita is that puncture which is made with a blunt instrument, the vein

attaining thickness.

Kuttita is that in which puncturing is done often, not getting blood and vein is

hurt by the instrument.

Aprasrta is that in which blood flow does not occur due to cold, fear or

fainting.

Atyudirna is that puncture made by a sharp and thick instrument.

Anteviddha is that puncture which causes scanty flow of blood.

Parisuska is that in which there is depletion of blood in the vein but it is filled

with air.

Kunita is that in which quarter portion of the vein is punctured and little

quantity of blood only flows out.

Vepita is that in which binding is made at improper place, puncturing done

with trembling hand, giving rise to tremors of the body and loss of

consciousness.




Anuthitaviddha is that in which the symptoms of Vepita occur.

Sastrahata is that in which the vein is cut, producing copious flow and

stoppage of functions of the body part.

Tiryakviddha is that in which the instrument is pushed into the vein through

its side and slightly.

Aviddha is that in which the instrument is used without making a wound (not

puncturing at all).

Avyadhya is that in which the puncture is not done by the instrument.

Vidruta is that in which the puncturing is done when the physician is

unsteady.

Dhenuka is that in which the body part is hit greatly many times to raise the

vein and flow of blood occurs again and again.

Punahpunarviddha is that in which the vein is punctured many times

because of using a small (minute) sharp instrument.

Sirasnayuasthisandimarmasu-Puncture done on ligaments, Bones, Veins,

Joints and Fatal spots (Marma) gives rise to pain, swelling, deformity or

Death.96

Treatment for the above is as same as Atisrava or Asrava condition.

Management of Durviddha97, 98

Ela, Karpoora, Kusta, Tagara, Pata, Devadaru, Vidanga, Chithraka, Trikatu,

Gruhadhooma, Haridra, Arkaankura and Karanja Rhala Gharshana of Choorna of

available drugs is done along with Lavana and Taila over the Vrana Mukha.

Lepa of the drugs like Vidanga, Shunti, Maricha, Pippali, Haridra, and Gruha

Dhooma with Lavana and Taila is done over the Vrana Mukha.




Management of Athi Yoga 99, 100

Choorna of drugs like Lodhra, Priyangu, Yastimadhu, Gairuka, Sarjarasa,

Anjana, Shalmali Pushpa, Masha, Yava and Godhuma is applied over the

Vrana Mukha, Gharshana is done and Vrana Mukha is pressed by a Anguli.

Avachoornana of the Bhasma got by burning the Kshouma Vasthra and

Choorna of the bark of Ksheeri Vriksha or Gharshana of Laksha and Samudra

Phena can be done over the Vrana Mukha. After this bandaging are done

using Karpasa and Kshouma Vasthra.

Sheetha Padartha Achadhana is done over that area. The person should use

Sheetha Bhojana, Pana and stay in a cool house.

Sheethala Oushadha Dravya Lepa and Sechana of the Kwatha of same drugs

are done over the area.

If still blood does not stop Kshara and Agni Karma is done over the site of

Sira Vyadha or Siravyadha is again repeated 3-4 Angula above the previous

site.

Internally Kakolyadi Gana Dravya Siddha Kwatha is given with honey and

sugar.

Rakta of Ena Harina is given for Pana, Dugdha and Yoosha is given with

Snigdha Bhojana

If the person faints in between the procedure the tourniquet is removed

immediately and fanning is done. If still he does not gain conscious then Moorcha

Nashana Oushadhi is given. After the patient regains conscious and normal stage

again Siravyadha is done, if he faints again then it is repeated after 2 to 3days.




Raktasrava Nirodha Karma (Methods of preventing bleeding):

There are four methods of preventing bleeding from the vein.

Sandhana – Joining the edges of the wound

Skandana – Promoting clotting

Pacana – Closing the surface

Dahana – Burning or Cauterization

Drugs which are astringent will join or unite the wound. Drugs which are cold

makes the blood to clot, Ash or Alkali drugs will adhere and closes the wound and

Cauterization will constrict the veins.101

Paschat Karma 102

Proper attention to Regimen:

After bloodletting it is washed with cold water. Then Bandhana is done. Later

the patient is administered with Brmhana Ahara because Rakta is Prana and on

removing this it may cause decrease in Agni and Vatakopa. The food or diet, which is

neither hot nor cold and is light, which can be easily digested, and that which

stimulates the digestion are recommended. If the food and drinks are extremely cold

then it impairs digestion and metabolism and if the food is too hot it creates instability

of the blood. The food, which consists of buttermilk with Yoosha, Yavagu, Peya must

be given to the patient.

Apathya after Siravyadha

Krodha, Bhaya, Ayasa, Divaswapna, Maithuna, driving, riding on vehicles,

study, exposure to cold, wind and water prolonged sitting in a single place,

Viruddahara, Asathmya Bhojana, Ajeerna Bhojana are contraindicated for one

month.103




Sesa Dosha Nirharana

If, even after reaching the maximum quantity of Srava Pramana the Doshas

are not evacuated then by using Samsamanadi Karmas these Doshas are pacified and

not by Atisrava of Rakta.104

Puna Siravyadha 105

If Ashuddha Rakta still remains even after letting the blood out once, then the

vitiated blood should be removed again either in the same evening or on the next day;

if the blood is found greatly vitiated it should be removed again after a fortnight, after

administrating oleation therapy to the body.

Review of Sahacharadi Kashaya 2014



REVIEW ON SAHACHARADI KASHAYA AND TAILA

For a treatment, either be a procedure or oral administration, drug is the at

most requirement. As told by Acharyas, Dravya is one among the four pillars of

treatment.1 It is not just any kind of Dravya, Dravya for treatment should possess the

quality of curing the disease, and availability should be in abundant, should be able to

be formulated into different Kalpanas and should possess the theoretical qualities

mentioned.

In Ashtanga Hridaya Chikitsastana- Vatavyadhi Prakarana Sahacharadi

Kashaya is mentioned and is specially indicated for Vatavyadhis pertaining to Adhah

Kaya.2 Acharya has told that the Kashaya should be taken along with Taila.

3

In the same contest, Acharya has also mentioned Sahacharadi Taila4,

especially indicated for Krichrasadhya Vatavyadhis and diseases like Vatakundalika,

Unmada, Gulma, Vridhi etc.

DRUGS IN SAHACHARADI KASHAYA

Sahacharadi Kashaya is a simple herbal formulation consisting of only three

ingredients: Sahachara, Devadaru and Nagara.

1. Sahachara

Botanical name : Barleria prionitis Linn.

Family : Acanthaceae

Synonyms : Saireyaka

Part used : Root & Leaves.

2. Devadaru

Botanical name : Cedrus deodara (Roxb.) Loud.

Family : Pinaceae




Synonyms : Bhadradaru, Surahwa, Suradaru

Part used : Bark, Heartwood, Oil.

3. Nagara

Botanical name : Zingiber officinale Roscoe.

Family : Zingiberaceae

Synonyms : Sunthi, Viswabheshajam, Sringavera.

Part used : Rhizome.

Table No: 6 - Showing properties of Drugs

DRUG RASA GUNA VIRYA VIPAKA KARMA

Sahachara Tikta,

Madhura

Laghu,

Snigdha Usna Katu

Kaphavata hara,

Kandughna,

Sothaghna

Devadaru Tikta,

Katu

Laghu,

Snigdha Usna Katu

Kaphavata hara,

Raktadosha hara,

Kandughna,

Sothagna

Nagara Katu Laghu,

Snigdha Usna Madura

Kaphavata hara,

Sothaghna,

Kashaya Preparation

Equal quantity of the above drugs was taken and made into coarse powder. 16 times

of water was added to the powdered drugs and made to boil on moderate fire till it

reduces to 1/8th

. 5, 6

DRUGS IN SAHACHARADI TAILA

Sahacharadi Taila is a Taila yoga mentioned especially for Vatavyadhis consisting of

11 herbal ingredients processed in Moorchitha Tila Taila as base.




1. Sahachara : same as above

2. Nata

Botanical name : Valeriana wallichii DC.

Family : Valerianaceae

Synonyms : Tagara, Kutila

Part used : Root

3. Vacha

Botanical name : Acorus calamus Linn.

Family : Araceae

Synonyms : Shadgrandha, Ugragandha

Part used : Rhizome

4. Salaparni

Botanical name : Desmodium gangticum DC.

Family : Fabaceae.

Synonyms : Stira, Guha, Amsumathi.

Part used : Whole plant

5. Kusta

Botanical name : Saussurea lappa C. B. Clarke.

Family : Asteraceae

Synonyms : Durnama,Vapya, Paribhavyam.

Part used : Root.

6. Devadara : same as above

7. Ela

Botanical name : Elettaria cardamomum Maton.

Family : Zingiberaceae




Synonyms : Trti, Triputa, Dravidi.

Part used : Seed

8. Usira

Botanical name : Vetiveria zizanioides (Linn.) Nash.

Family : Poaceae

Synonyms : Sevya, Sugandhamula, Amrnala.

Part used : Root

9. Silajit (Black Bitumen)

Synonyms : Kanmada, Adhrija

10. Satahwa

Botanical name : Anethum sowa Kurz.

Family : Apiaceae

Synonyms : Satapushpa, Misi, Karavi

Part used : Fruit

11. Rakta chandan

Botanical name : Pterocarpus santalinus Linn. F.

Family : Fabaceae

Synonyms : Raktavrksa, Tilaparna

Part used : Heartwood

12. Moorchita Taila

13. Goksheera

14. Sita




Table No: 7 - Showing properties of Drugs

DRUG RASA GUNA VIRYA VIPAKA KARMA

Sahachara Tikta,

Madhura

Laghu,

Snigdha Usna Katu

Kaphavata hara,

Kandughna,

Sothaghna

Devadaru Tikta,

Katu

Laghu,

Snigdha Usna Katu

Kaphavata hara,

Raktadosha

hara,

Kandughna,

Sothagna

Salaparni Tikta,

Madhura

Guru,

Snigdha Usna Madhura

Tridosha hara,

Sophagna,

Kusta

Tikta,

Katu,

Madhura

Laghu Usna Katu

Kaphavata hara,

Raktadoshahara,

Kandugna

Ela Katu,

Madhura

Laghu,

Ruksa Sita Katu

Kaphavata hara,

Vatanulomana

Sevya Tikta,

Madhura

Laghu,

Snigdha Sita Katu

Kaphapitta hara,

Raktadosha hara

Vaca Katu,

Tikta

Laghu,

Tiksna Usna Katu Kaphavata hara

Nata

Tikta,

Katu,

Kashaya

Laghu,

Snigdha Usna Katu

Tridosha hara,

Vedhanastapana,

Sothagna

Raktachandana Tikta,

Madhura

Guru,

Ruksa Sita Katu

Kaphapitta hara,

Raktadosha hara

Satahwa Katu,

Tikta

Laghu,

Tiksna Usna Katu Vatakapha hara

Silajit - Guru - -

Sothagna,

Shoolagna,

Sarva twakgada

nasanam




Goksheera Madhura Snigdha,

Guru Sita Madhura

Vatapitta hara,

Raktadosha hara

Sita Madhura - Usna Vatapitta hara,

Rakta Shodaka

Tila taila

Madhura,

Tikta,

Kashaya

Suksma,

Vyavayi,

Tiksna

Usna Madhura Kaphavata hara

Taila Preparation

Ingredients:

Kalka Dravya - Nata (root)

Vacha (rhizome)

Sthira (whole plant)

Kusta (root)

Surahwaya (bark)

Ela (seed)

Nalada (root)

Silajit

Satahwa

Rakta Chandana (Heart wood)

Kashaya Dravya – Sahachara

Sneha Dravya - Moorchita Taila

Goksheera

Sarkara




Kashaya was prepared by adding 16 parts of water to Sahachara and reducing

it to 1/4th part. Equal quantities of each of the drugs mentioned in Kalka Dravya were

taken and made into paste. Moorchita Tila Taila, Kalka and Kashaya were taken in

the proportion of 1:4:16 and Taila Paka was done. Later Goksheera and Sarkara was

added one by one and boiled until Paka Siddha Lakshanas were seen. Then it was

cooled and filtered into air tight container and stored.

Materials and Methods

Methodology 2014



MATERIALS AND METHODS

The present study was conducted by taking into consideration the conceptual

as well as the clinical importance of the disease and the specific modality of

management. Therefore the study in whole comprises of;

Conceptual study: In this part, effort was taken to understand the conceptual

background of Sirajagranthi, Siravyadha and Sahacharadi Kashaya with Taila based

on the references as per various Ayurvedic literary sources. The contemporary views

parallel to it were also studied.

Clinical study: In a view to prove or verify the statements given in the classics

through a scientific method, the best way of approach would be a clinical study.

Various modalities are mentioned in classics for the treatment of disease

Sirajagranthi. Here an attempt is made to clinically evaluate the efficacy of

Siravyadha and Sahacharadi Kashaya with Taila in the management of Sirajagranthi.

Source:

Literary source:

All the classical, modern literatures and contemporary texts including the

websites about the disease and the drug was reviewed and documented in the present

study.

Sample source:

40 patients diagnosed as Sirajagranthi were randomly selected from the O.P.D

& I.P.D of Alva’s Ayurveda Hospital, Moodbidri, other camps and referrals and were

grouped into two Groups A & B irrespective of their age, sex, religion, socio

economic status etc. Each patient was selected for the trial after voluntary consent.

Methodology 2014



Sample size:

40 patients diagnosed as Sirajagranthi were randomly divided into two equal

groups- Group A and Group B for the study.

Study design: Randomized comparative clinical study.

Selection Criteria:

The cases were selected strictly as per the pre-set inclusion and exclusion criteria.

Diagnostic Criteria

Clinical features of Sirajagranthi (varicose vein) viz. Sampeedana,

Samkochana and Vishoshana of Siras (dilated, elongated and tortuous veins)

will be taken as the criteria for diagnosis.

Brodie -Trendelenburg test

Multiple Tourniquet test

Perthes test

Inclusion criteria

Patient aged between 16-70 years of either sex.

Patient suffering from primary varicose vein.

Patient with Sirajagranthi (varicose vein) in lower limb only.

Exclusion criteria

Patient with Diabetes mellitus and other systemic diseases.

Patient with coagulopathy or bleeding diseases.

Varicosity associated with complications like deep vein thrombosis,

calcification, venous ulcer.

Congenital varicose vein.

Siravyadha Anarhas.

Methodology 2014



Investigations

Hb%, Blood sugar

CT and BT

Any other investigations if necessary.

Interventions:

Group A, 1st

day – Siravyadha

Up to 7th

day – Paschat Karma

8 to 28th

day – Observation period

Group B, 1st – 14

th – Sahacharadi Kashaya with Sahacharadi Taila

15 to 28th

day – Observation period

Assessment was done before treatment and on 7th

, 14th

, 21st and 28

th day, for both the

groups.

Follow up: Once in 15 days for one month after the study period.

Group A – Siravyadha

Materials used: Snigdha Yavagu, Moorchita Taila, Nadi Swedana Yantra, Kutarika

Sastra, adhesive plaster, kidney tray, antiseptic lotion.

Site: Maximum tortuous area will be selected for the Siravyadha.

Poorva Karma

Snigdha Yavagu is given to the patient.

Snehana is done locally with Moorchita Tila Taila.

Nadi sweda is given locally after Snehana.

Make the patient to stand comfortably.

Pradhana Karma

Tourniquet is tied above the site of Siravyadha.

Methodology 2014



Clean the site with the help of spirit.

Kutarika Sastra should be held in left hand and tapping should be given with

the help of right thumb and middle finger.

The stroke must be single, with enough force to eject a jet of blood.

Blood is collected in a measuring jar.

Paschat Karma

The tourniquet is removed.

After the complete stoppage of bleeding, Bandha is applied.

The food or diet, which is neither hot nor cold and is light, which can be easily

digested, and that which stimulates the digestion are recommended to be taken

for 7 days.

Follow up

Once in 15 days for one month after the study period.

Group B – Sahacharadi Kashaya with Taila

Drugs used: Sahacharadi Kashaya, Sahacharadi Taila.

Procedure of administration: Patient is advised to take 48ml Sahacharadi Kashaya

with 12ml Sahacharadi Taila twice daily, half an hour before food for two weeks.

Follow up

Once in 15 days for one month after the study period.

Assessment criteria:

Assessment of the condition was done based on a detail proforma adopting

different methods of scoring of subjective and objective parameters and was analysed

statistically.

Methodology 2014



Following scoring pattern was adopted for the study to observe the changes in

the signs and symptoms.

Subjective parameters:

Shoola (Pain) and Kandu (Itching sensation)

Table No: 8 - Grading of Shoola (Pain)

(McGill pain score index)

SHOOLA

Symptom Grading

None 0

Mild 1

Discomforting 2

Distressing 3

Horrible 4

Excruciating 5

Table No: 9 - Grading of Kandu (Itching sensation)

KANDU

Symptom Grading

No itching 0

Occasional itching sensation over varicosed

area of legs

1

Continuous itching sensation 2

Objective parameters:

Grathana (Hardening of Sira), Shotha (Swelling) and Vaivarnya

(Pigmentation).

Methodology 2014



Table No: 10 - Grathana (Hardening of the Sira)

GRATHANA

Symptom Grading

No hardening of Sira on palpation 0

Hardening of Sira on standing posture 1

Hardening is present throughout 2

Table No: 11 - Grading of Shotha (Swelling)

SHOTHA

Symptom Grading

No localized swelling 0

Swelling present after long exertion 1

Swelling present on standing posture 2

Swelling present throughout 3

Table No: 12 - Grading of Vaivarnya (Pigmentation)

VAIVARNYA

Symptom Grading

No discoloration 0

Reddish discoloration 1

Reddish blue discoloration 2

Total blackish discoloration with scaling 3

Statistical Analysis:

Mean, S.D, ‘t’ value and ‘p’ value were calculated. ‘Paired t’ test was used for

calculating the‘t’ value for pre and post-test. Unpaired t- test was applied to compare

between two groups.

Methodology 2014



Figure No: 9 - MATERIALS USED FOR SIRAVYADHA

12 No. Surgical Blade Artery Forceps

Preparing Kutarika Sastra

Spirit Tourniquet Bandage Distilled water

Kutarika Sastra

Methodology 2014



Figure No: 10 - PROCEDURE OF SIRAVYADHA

Tourniquet is tied Selecting the maximum tortuous site

Siravyadha using Kutarika Sastra Jet of blood

Bandaging is done

Amount of blood collected

Methodology 2014



Sahacharadi Taila

Varti Pareeksha

Figure No: 11 - DRUGS USED FOR TAILA MOORCHANA

nMooMOORCHANA

Figure No 12: PREPARATION OF SAHACHARADI TAILA

Drugs used for Taila preparation

Taila Paka

Methodology 2014



Figure No 13: PREPARATION OF SAHACHARADI KASHAYA

Observation and Results

Observations 2014



OBSERVATIONS

Observations were made before and after the treatment. In the present study,

40 patients fulfilling the inclusion criteria of Sirajagranthi were divided into two

groups and studied. Following pages contain the descriptive statistics and analysis of

the patients studied, along with the observation and results.

According to the proforma prepared for the present study, the observations

were made regarding the incidence of Sirajagranthi with regard to age, sex, religion,

socio-economic status, marital status, occupation, appetite, diet, bowel habit, body

weight, addictions, affected leg and duration of the disease.

OBSERVATIONS ON DEMOGRAPHIC PROFILE

1. DISTRIBUTION OF 40 PATIENTS ACCORDING TO AGE:

Age incidence of 40 patients suffering from Sirajagranthi showed, 35% of

patients were between the age group 41 to 50 years. 32.5% patients were between 31-

40 years followed by 25% between 51- 60years.

Table No: 13 - Showing the Distribution of 40 patients according to Age.

Age Group A Group B Total

No: % No: % No: %

21-30 0 0% 1 5% 1 2.5%

31-40 7 35% 6 30% 13 32.5%

41-50 4 20% 10 50% 14 35%

51-60 7 35% 3 15% 10 25%

61-70 2 10% 0 0% 2 5%

Observations 2014



Graph No: 1 - Showing the Distribution of 40 patients according to Age.

2. DISTRIBUTION OF 40 PATIENTS ACCORDING TO GENDER:

Gender wise distribution of patients showed 62.5% of males and 37.5% of

females.

Table No: 14 - Showing the Distribution of 40 patients according to Gender.

Sex

Group A Group B Total

No: % No: % No: %

Male 13 65% 12 60% 25 62.5%

Female 7 35% 8 40% 15 37.5%

Graph No: 2 - Showing the Distribution of 40 patients according to Gender.

0

2

4

6

8

10

12

14

16


21-30 yrs

31-40 yrs

41-50 yrs

51-60 yrs

61-70 yrs

0

5

10

15

20

25

30


Male

Female

Observations 2014



3. DISTRIBUTION OF 40 PATIENTS ACCORDING TO RELIGION:

Religion wise distribution of the patients showed that 23 out of 40 were

Hindus i.e. 57.5%, whereas 35% patients were Muslims and 7.5% were Christians.

Table No: 15 - Showing the Distribution of 40 patients according to Religion

Religion


No: % No: % No: %

Hindu 12 60% 11 55% 23 57.5%

Muslim 7 35% 7 35% 14 35%

Christian 1 5% 2 10% 3 7.5%

Graph No: 3 - Showing the Distribution of 40 patients according to Religion.

0

5

10

15

20

25


Hindu

Muslim

Christian

Observations 2014



4. DISTRIBUTION OF PATIENTS ACCORDING TO SOCIO-ECONOMIC

STATUS:

Maximum number of patients belonged to middle class i.e. 80% while 17.5%

belonged to poor class.

Table No: 16 - Showing the Distribution of 40 patients according to Socio-

economic status

Socio Economic

Status


No: % No: % No: %

High class 1 5% 0 0% 1 2.5%

Middle class 14 70% 18 90% 32 80%

Poor class 5 25% 2 10% 7 17.5%

Graph No: 4 - Showing the Distribution of 40 patients according to Socio-

economic status.

0

5

10

15

20

25

30

35


High class

Middle class

Poor class

Observations 2014



5. DISTRIBUTION OF PATIENTS ACCORDING TO OCCUPATION:

The incidence of nature of work revealed that, in the present study maximum

number of patients i.e. 55% were engaged in strenuous works, 35% in moderate work

and 10% in sedentary work.

Table No: 17 - Showing the Distribution of 40 patients according to Occupation

Nature of

Work


No: % No: % No: %

Sedentary 3 15% 1 5% 4 10%

Moderate 6 30% 8 40% 14 35%

Strenuous 11 55% 11 55% 22 55%

Graph No: 5 - Showing the Distribution of 40 patients according to Occupation.

0

5

10

15

20

25


Sedentary

Moderate

Straneous

Observations 2014



6. DISTRIBUTION OF PATIENTS ACCORDING TO MARITAL STATUS:

In the present study, out of 40 patients 95% (38) were married and only 5% (2)

were unmarried.

Table No: 18 - Showing the Distribution of 40 patients according to Marital status.

Marital Status


No: % No: % No: %

Married 19 95% 19 95% 38 95%

Unmarried 1 5% 1 5% 2 5%

Graph No: 6 - Showing the Distribution of 40 patients according to Marital status.

0

5

10

15

20

25

30

35

40


Married

Unmarried

Observations 2014



7. DISTRIBUTION OF PATIENTS ACCORDING TO APPETITE:

The incidence of appetite revealed that maximum number of patients i.e.

24(60%) patients had moderate appetite, 12(30%) patients had good appetite and

4(10%) patients had poor appetite.

Table No: 19 - Showing the Distribution of 40 patients according to Appetite.

Appetite


No: % No: % No: %

Good 6 30% 6 30% 12 30%

Moderate 12 60% 12 60% 24 60%

Poor 2 10% 2 10% 4 10%

Graph No: 7 - Showing the Distribution of 40 patients according to Appetite.

0

5

10

15

20

25

30


Good

Moderate

Poor

Observations 2014



8. DISTRIBUTION OF PATIENTS ACCORDING TO DIET:

Regarding dietary habits, maximum number of patients i.e. 77.5% (31

patients) consumed mixed diet. Only 22.5% (9 patients) were vegetarians.

Table No: 20 - Showing the Distribution of 40 patients according to Diet.

Diet


No: % No: % No: %

Mixed 15 75% 16 80% 31 77.5%

Vegetarian 5 25% 4 20% 9 22.5%

Graph No: 8 - Showing the Distribution of 40 patients according to Diet

0

5

10

15

20

25

30

35


Mixed

Vegetarian

Observations 2014



9. DISTRIBUTION OF PATIENTS ACCORDING TO BODY WEIGHT:

Incidence of body weight among 40 patients showed that majority of the

patients i.e. 32.5% had their body weight between 71-80Kg, and 30% of patients had

between 61-70 Kg and 20% had between 51- 60 Kg body weight.

Table No: 21- Showing the Distribution of 40 patients according to Body Weight.

Body Weight

(Kg)


No: % No: % No: %

41-50 2 10% 0 0% 2 5%

51-60 6 30% 2 10% 8 20%

61-70 4 20% 8 40% 12 30%

71-80 5 25% 8 40% 13 32.5%

81-90 3 15% 2 10% 5 12.5%

Graph No: 9 - Showing the Distribution of 40 patients according to Body Weight.

0

2

4

6

8

10

12

14


41-50

51-60

61-70

71-80

81-90

Observations 2014



10. DISTRIBUTION OF PATIENTS ACCORDING TO BOWEL HABIT:

The incidence of bowel habit revealed that maximum number of patients had

regular bowels i.e. 60% (24), whereas 40%(14) had constipated bowels.

Table No: 22 - Showing the Distribution of 40 patients according to Bowel Habit.

Bowel Habit


No: % No: % No: %

Regular 15 75% 9 45% 24 60%

Constipated 5 25% 11 55% 16 40%

Graph No: 10 - Showing the Distribution of 40 patients according to Bowel Habit.

0

5

10

15

20

25

30


Regular

Constipated

Observations 2014



11. DISTRIBUTION OF PATIENTS ACCORDING TO DURATION:

Incidence of duration among 40 patients showed that majority of the patients

i.e 87.5% had more than one year disease chronicity, whereas 12.5% had less than one

year disease chronicity.

Table No: 23 - Showing the Distribution of patients according to Duration of

disease.

Duration


No: % No: % No: %

Up to 1 yr. 2 10% 3 15% 5 12.5%

More than 1 yr. 18 90% 17 85% 35 87.5%

Graph No: 11 - Showing the Distribution of 40 patients according to Duration.

0

5

10

15

20

25

30

35

40


Up to 1 Yr

More than 1 Yr

Observations 2014



12. DISTRIBUTION OF PATIENTS ACCORDING TO AFFECTED LEG:

Among 40 patients selected for the study, the majority i.e. 57.5% patients were

affected with varicosities in both legs, whereas 27.5% patients were affected with

varicosity in the right leg and 15% in the left leg.

Table No: 24 - Showing the Distribution of patients according to Affected leg.

Affected leg


No: % No: % No: %

Right 5 25% 6 30% 11 27.5%

Left 2 10% 4 20% 6 15%

Both 13 65% 10 50% 23 57.5%

Graph No: 12 - Showing the Distribution of 40 patients according to Affected Leg.

0

5

10

15

20

25


Right

Left

Both

Results 2014



RESULTS

The observations procured on the assessment parameters of 40 patients before

treatment, 7th

, 14th

, 21st and 28

th day in Group A and Group B were statistically

analysed to determine the effect of the treatment Siravyadha in Group A and

Sahacharadi Kashaya with Taila in Group B.

The parameters consisted of Shoola, Kandu, Grathana, Shotha and Vaivarnya.

Statistical methods used were as follows:

Average was found using mean and standard deviation.

Pre- test and Post-test data was compared using paired ‘t’ test.

Comparison of two groups were done using unpaired ‘t’ test.

EFFECT OF TREATMENT ON SIGNS AND SYMPTOMS

1. Shoola

Table No: 25 - Assessment of Shoola

Mean BT 7D 14D 21D 28D

Mean Group A 3.0 1.2 0.75 0.55 0.20

Mean Group B 2.6 1.7 1.3 1.10 0.85

3

1.2 0.75 0.55

0.2

2.6

1.7 1.3 1.1

0.85

0

1

2

3

4

BT 7D 14D 21D 28D

Mean Group A Mean Group B

Graph No: 13

Results 2014



Effect on Shoola

Group A Table No: 26 No. of patients – 20

Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test

SD SE t value P value

3.0 7th

1.2 1.80 60% 0.616 0.138 13.077 <0.001

3.0 14th

0.75 2.25 75% 0.786 0.176 12.795 <0.001

3.0 21st 0.55 2.45 81.6% 0.887 0.198 12.352 <0.001

3.0 28th

0.20 2.80 93.3% 0.768 0.172 16.310 <0.001

The mean score of the symptom which was 3.0 before treatment was reduced

to 1.2 with the mean difference of 1.80 ± 0.616 on 7th

day, which further reduced to

0.75 with mean difference of 2.25 ± 0.786 during 14th

day, and again to 0.55 with

mean difference of 2.45 ± 0.887 during 21st day and to 0.20 with mean difference

2.80 ± 0.768 during 28th

day.

The change that occurred with the treatment is greater than would be expected

by chance; there is a statistically high significant change at P<0.001

Group B Table No: 27 No. of patients – 20

Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


2.60 7th

1.70 0.90 34.6% 0.553 0.124 7.285 <0.001

2.60 14th

1.30 1.30 50% 0.470 0.105 12.36 <0.001

2.60 21st 1.10 1.50 57.6% 0.688 0.154 9.747 <0.001

2.60 28th

0.85 1.75 67.3% 0.710 0.160 10.92 <0.001

Results 2014









1.75 ± 0.710 during 28th

day.



2. Kandu

Table No: 28 – Assessment of Kandu


Mean Group A 1.15 0.60 0.50 0.30 0.20

Mean Group B 1.25 0.50 0.30 0.20 0.10

1.15

0.6 0.5

0.3 0.2

1.25

0.5

0.3 0.2

0.1 0

0.2

0.4

0.6

0.8

1

1.2

1.4

BT 7D 14D 21D 28D


Graph No: 14

Results 2014



Effect on Kandu


Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.15 7th

0.60 0.55 47.8% 0.510 0.114 4.819 <0.001

1.15 14th

0.50 0.65 56.5% 0.489 0.109 5.940 <0.001

1.15 21st 0.30 0.85 73.9% 0.671 0.150 5.667 <0.001

1.15 28th

0.20 0.95 82.6% 0.686 0.153 6.190 <0.001







0.95 ± 0.686 during 28th

day.




Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.25 7th

0.50 0.75 60% 0.550 0.123 6.097 <0.001

1.25 14th

0.30 0.95 76% 0.605 0.135 7.025 <0.001

1.25 21st 0.20 1.05 84% 0.686 0.153 6.842 <0.001

1.25 28th

0.10 1.15 92% 0.671 0.150 7.667 <0.001

Results 2014









1.15 ± 0.671 during 28th

day.



3. Grathana

Table No: 31 - Assessment of Grathana


Mean Group A 1.35 0.85 0.70 0.65 0.60

Mean Group B 1.50 1.15 0.75 0.75 0.70

1.35

0.85 0.7 0.65 0.6

1.5

1.15

0.75 0.75 0.7

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT 7D 14D 21D 28D


Graph No: 15

Results 2014



Effect on Grathana


Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.35 7th

0.85 0.50 37% 0.513 0.115 4.359 <0.001

1.35 14th

0.70 0.65 48.1% 0.587 0.131 4.951 <0.001

1.35 21st 0.65 0.70 51.8% 0.571 0.128 5.480 <0.001

1.35 28th

0.60 0.75 55.5% 0.639 0.143 5.252 <0.001







0.75 ± 0.639 during 28th

day.




Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.50 7th

1.15 0.35 23.3% 0.489 0.109 3.199 <0.005

1.50 14th

0.75 0.75 50% 0.444 0.099 7.550 <0.001

1.50 21st 0.75 0.75 50% 0.444 0.099 7.550 <0.001

1.50 28th

0.70 0.80 53% 0.410 0.091 8.718 <0.001

Results 2014







day, and same is continued

during 21st day and to 0.70 with mean difference 0.80 ± 0.410 during 28

th day.



4. Shotha

Table No: 34 – Assessment of Shotha


Mean Group A 1.45 0.95 0.80 0.75 0.65

Mean Group B 1.35 0.80 0.65 0.55 0.50

1.45

0.95

0.8 0.75 0.65

1.35

0.8

0.65 0.55 0.5

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT 7D 14D 21D 28D


Graph No: 16

Results 2014



Effect on Shotha


Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.45 7th

0.95 0.50 34.4% 0.513 0.115 4.359 <0.001

1.45 14th

0.80 0.65 44.8% 0.587 0.131 4.951 <0.001

1.45 21st 0.75 0.70 48.2% 0.657 0.147 4.765 <0.001

1.45 28th

0.65 0.80 55.1% 0.616 0.138 5.812 <0.001







0.80 ± 0.616 during 28th

day.




Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.35 7th

0.80 0.55 40.7% 0.510 0.114 4.819 <0.005

1.35 14th

0.65 0.70 51.8% 0.571 0.128 5.480 <0.001

1.35 21st 0.55 0.80 59.2% 0.696 0.156 5.141 <0.001

1.35 28th

0.50 0.85 62.9% 0.671 0.150 5.667 <0.001

Results 2014









0.85 ± 0.671 during 28th

day.



5. Vaivarnya

Table No: 37 – Assessment of Vaivarnya


Mean Group A 1.20 0.75 0.55 0.45 0.40

Mean Group B 1.40 1.20 1.15 1.10 1.05

1.2

0.75

0.55 0.45 0.4

1.4

1.2 1.15 1.1 1.05

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

BT 7D 14D 21D 28D


Graph No: 17

Results 2014



Effect on Vaivarnya


Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.20 7th

0.75 0.45 37.5% 0.510 0.114 3.943 <0.001

1.20 14th

0.55 0.65 54.1% 0.587 0.131 4.951 <0.001

1.20 21st 0.45 0.75 62.5% 0.550 0.123 6.097 <0.001

1.20 28th

0.40 0.80 66.6% 0.523 0.117 6.839 <0.001






mean difference of 0.75 ± 0.550 during 21st day and to 0.40 with mean difference of

0.80 ± 0.523 during 28th

day.




Mean

of BT

Mean of Mean

difference %

Paired ‘t’ test


1.40 7th

1.20 0.20 14.2% 0.410 0.091 2.179 <0.05

1.40 14th

1.15 0.25 17.8% 0.444 0.099 2.517 <0.05

1.40 21st 1.10 0.30 21.4% 0.470 0.105 2.854 <0.05

1.40 28th

1.05 0.35 25% 0.489 0.109 3.199 <0.01

Results 2014









0.35 ± 0.489 during 28th

day.


by chance; there is a statistically significant change at P<0.01

IMMEDIATE EFFECT OF TREATMENT IN GROUP A

Table No: 40

Symptoms BT

mean

AT

mean

Mean

diff S.D S.E

‘t’

value

‘p’

value

Shoola 3.00 1.05 1.95 0.510 0.114 17.085 <0.001

Kandu 1.15 0.40 0.75 0.639 0.143 5.252 <0.001

Grathana 1.35 0.70 0.65 0.489 0.109 5.940 <0.001

Shotha 1.45 1.30 0.15 0.366 0.081 1.831 >0.05

Vaivarnya 1.20 1.10 0.10 0.308 0.068 1.453 >0.05

Results 2014



COMPARATIVE EFFECT OF TREATMENT BETWEEN TWO GROUPS

Table No: 41

Symptoms

BT-AT mean Difference

of mean

Standard

Deviation ‘t’

value

‘p’

value Group

A

Group

B

Group

A

Group

B

Shoola 2.80 1.750 1.05 0.768 0.716 4.472 <0.001

Kandu 0.950 1.150 -0.2 0.686 0.671 0.932 >0.05

Grathana 0.750 0.80 -0.05 0.639 0.410 0.295 >0.05

Shotha 0.80 0.85 -0.05 0.616 0.671 0.246 >0.05

Vaivarnya 0.80 0.35 0.45 0.523 0.489 2.809 <0.01

The difference in the mean values of the two groups in symptoms like Kandu,

Grathana and Shotha is not great enough to reject the possibility that the difference is

due to random sampling variability. There is not a statistically significant difference

between the two groups at P= >0.05.

The difference in the mean values of the two groups in symptoms like Shoola

and Vaivarnya is greater than would be expected by chance; there is a statistically

significant difference between the two groups at P = <0.01

Results 2014



COMPARATIVE PERCENTAGE OF RELIEF BETWEEN GROUP A &

GROUP B

Table No: 42

Signs and

Symptoms

Mean Difference Percentage Relief %

Group A Group B Group A Group B

Shoola 2.80 1.750 93.3% 67.3%

Kandu 0.950 1.150 82.6% 92%

Grathana 0.750 0.80 55.5% 53%

Shotha 0.80 0.85 55% 62.9%

Vaivarnya 0.80 0.15 66.6% 25%

Graph No: 18

93.30%

82.60%

55.50% 55%

66.60% 67.30%

92%

53%

62.90%

25.00%

Shoola Kandu Grathana Shotha Vaivarnya

Signs and Symptoms Group A Signs and Symptoms Group B

Results 2014



Figure No: 15 - AFTER SIRAVYADHA

Figure No: 14 - BEFORE SIRAVYADHA

Results 2014



Figure No: 16 - BEFORE TREATMENT

Figure No: 17 - AFTER ADMINISTRATION OF SAHACHARADI

KASHAYA WITH TAILA

Discussion

Discussion 2014



DISCUSSION

1. Discussion on Review of Literature

Many diseases of modern medicine are considered to be taken as

Sirajagranthi. Some translators of Ayurvedic texts go to the extent of interpreting

Sirajagranthi as aneurism. But the mention of excessive walking and washing of legs

in cold water after a long walk as etiological factors, Sampeedana of Siras and Rakta

by Vata followed by their Samkochana and Vishoshana in Samprapthi (Pathology),

the Lakshana (clinical presentation) of ' Neeruja ' (painless) and ' Nishphura ' (non-

pulsatile) swelling with 'Vakreekarana' (tortuosity) - all concretes the hypothesis that

Sirajagranthi is varicose veins itself and not any other disease.

A) Nidana - Samprapthi (Etio-pathological factors)

The disease is said to be due to Adhwa i.e. continuous walking, Vyayama of

Durbala (excessive exertion of a debile person) or due to sudden immersion of limb

in cold water after long distance walk. Many modern authors share the same view.

The precipitating factor of primary varicose vein is excessive exertion of lower limb

followed by a predisposing or inherent factor of defective venous or valvular

structure.

Vagbhata describes Samprapthi as Sampeedana, Samkochana, Vishoshana

and Vakreekarana by Vata in Siras and Shonitha. Although Sampeedana (stress) can

be a factor in both primary and secondary varicose veins. Vakreekarana is the sign of

foremost clinical significance. The main presentation of the disease itself is

Vakreekarana, i.e., tortuosity. As it is Vakra, the Siras form varices and hence the

term, varicose veins.

Discussion 2014



B) Lakshanas (Physical signs)

Vrutha (circular), Unnatha (elevated), Vigrathita & Sopha are the features of

any Granthi as per Sushruta. Acharya Vagbhata adds Nishpeedana, Samkochana and

Vakreekarana of the veins in cases of Sirajagranthi.

Unnathathwa is because of engorged veins, which is the effect of accumulated

blood inside the vessels. In fact this Unnathathwa (elevation) may be very much

local, causing the circular elevation or may be elongated one, leading to longitudinal

elevations of the veins.

Shotha is the result of stasis of the fluid in the sub dermal tissues and is the

byproduct of malfunctioning of venules and veins.

Shoola of the affected leg is the cardinal feature of Sirajagranthi. Vagbhata

explains that Vata is the first Dosha aggravated with Rakta followed by other Doshas

and he says Niruja (no pain) over the Granthi. Pain may be absent over the Grathita

part on palpation but the complaint of whole limb pain that the patient gets may be

due to weakened musculature, stasis of the blood, engorged vein, excessive exertion

and may be even due to occlusion in the deep veins.

Vaivarnya is primarily seen over the skin due to the process of congestion in

the vessels. This can be considered as hyperpigmentation where reddish brown to

black pigmentation is noticed. This is due to the deposition of haemosiderin from the

breakdown of R.B.C which may come out of thin walled veins. As this continues for

quite a long time there may be effect on the interstitial and intracellular compartments

of the tissues of vessels and the tissues around these producing Vaivarnya

(discoloration) along with Shotha (oedema). These factors also give rise to itching

sensation.

Discussion 2014



Kandu is due to the aggravation of Pitta and Kapha Dosha which is because of the

stagnation of blood as well as the necrosis of the tissue with improper circulations.

C) Srotorodha

As Siras are Raktavaha Srotas, an interconnected study with the Srotorodha

Lakshanas and the etiological factors of varicose veins are justifiable.

Athipravruthi (excessive flow), Sanga (cessation of flow), Siranam

Grathanam (swelling / hardening in Siras) and Vimargagamana (flow in the

abnormal direction) are the Lakshanas of Srotorodha.

Sanga is due to valve defects. As the excess blood accumulates in the

superficial veins, Grathana of Siras (hardening of veins) occurs.

Etiological factors like excessive exertion and long walk naturally causes the

increased rate of blood perfusion in the lower extremities, leading to high pressure

blood leak from the deep veins to the superficial veins causing venous hypertension

which is nothing but the ‘Athipravruthi’ in the Siras. If the same person indulges in a

sedentary work or a work which demands standing for several hours continuously,

results in the stasis of blood in veins causing ‘Sanga’. After such heavy exercise, if he

exposes his legs to extremely cold climate or plunging into cold water, it suddenly

causes the contraction of all tissues from superficial to deep layers. But one should

remember that due to the warmth generated during the exercises there will be

increased dilatation of veins and the sudden change in the local temperature leads to

the contraction of tissue around the vessels as well as the vessel walls. This is the true

cause for the sudden increase of tension inside the vessels. In normal young healthy

individuals, it may not show any immediate effect. But a continuation of such

episodes will definitely bring about the changes in the vessel walls which produce

features like dilatation or bleeding of veins, hardness, irregular shape or increased

Discussion 2014



pressure in them etc. which can be compared to a condition of “Siranam Granthi” i.e.

Grathana of Siras.

Yet again the condition ‘Sanga’ may give rise to the formation of clots. These

in turn obstruct the free flow of blood, which ends in the further engorgement of the

outer veins by a process known as ‘Vimargagamana’ i.e. flow in reverse direction

from the deep to superficial veins via communicating veins.

2. Discussion about Clinical study:

Study design is a randomized comparative clinical study. A special proforma

was prepared with all the points of history taking, physical examination and

investigations to procure the required data.

The study was carried out in 40 patients of Sirajagranthi, 20 patients in each

groups - Group A and Group B. Group A patients were treated with Siravyadha on the

1st day followed by Paschat Karma for 7 days. Group B patients were administered

with Sahacharadi Kashaya with Taila for 14 days.

Total patients registered for the study : 40

Patients intervened with Siravyadha : 20

Patients administered with Sahacharadi Kashaya with Taila : 20

3. Discussion on Observations:

Age: Analysis of age incidence of 40 patients suffering from Sirajagranthi

showed 35% patients between the age group of 41 to 50 years and 32.5%

between 31-40 years. This may be due to the reason that most of the patients

belonged to working class and progressive Vata Prakopa occurs normally with

advancing age.

Discussion 2014



Sex: Present study revealed that the maximum numbers of patients were

males. It may be thought that strenuous works, office work requiring long

hours of sitting and work that requires prolonged standing may be causative

factors in the predominance. However the sample is too small to convey a

definite conclusion.

Religion: In the present study, 57.5% patients were Hindus, 35% were

Muslims and 7.5% were Christians. This shows the geographical

predominance of Hindus & Muslim in this area.

Socio-economic status: Majority of patients belonged to the middle class

(80%). Demanding life style of middle class people and also less concern over

the health may be the reason for this observation.

Occupation: In the present study, maximum numbers of patients (55%) were

engaged with strenuous work. Prolonged standing and continuous strenuous

works affects the circulation of lower limbs resulting in varicose vein.

Marital status: Out of 40 patients, a majority of 38 (95%) were married.

Appetite: The incidence of appetite revealed that maximum numbers of

patients, (60%) had moderate appetite.

Diet: Regarding dietary habits, maximum number of patients from both

groups consumed mixed diet i.e. 77.5 %.

Body Weight: Out of 40 patients, majority of 62.5% patients between 61-80

Kg of body weight got affected by this disease. It may be due to the reason

that over weight is one among the etiological factors for varicose veins.

Bowel Habit: The incidence of bowel habit revealed that maximum number

of patients (60%) had regular bowel habit.

Discussion 2014



Duration of the disease: Majority of patients (87.5%) had more than 1 year

disease chronicity. This may be due to the negligence about the disease in its

prior stages which is almost asymptomatic.

Affected leg: Among 40 patients, a majority of 57.5% reported to have the

disease affected in both legs. During prolonged standing and strenuous works

equal pressure is exerted in both the legs.

4. Discussion on Results

Overall effect of treatment

In Group A, the effect of Siravyadha in various signs and symptoms of

Sirajagranthi as assessed on 7th

, 14th

, 21st and 28

th day showed sudden improvement

in clinical conditions and revealed statistically significant changes.

In Group B, the effect of Sahacharadi Kashaya with Sahacharadi Taila in signs

and symptoms of Sirajagranthi as assessed on 7th

, 14th

, 21st and 28

th day revealed a

clinically gradual improvement which was also statistically significant.

Effect on Shoola

In Group A, out of 20 patients, the mean score of Shoola before treatment was

3.0 which was reduced to 0.2 on 28th

day after treatment. This revealed a statistically

significant effect of Siravyadha on Shoola at P<0.001. This may be probably due to

the removal of stagnant vitiated blood which in turn reduces the intravascular

pressure.

In Group B, out of 20 patients, the mean score of Shoola before treatment was


day after treatment. This revealed a

statistically significant effect of Sahacharadi Kashaya with Taila on Shoola at

P<0.001. This may be probably due to the Vatahara and Vedanasthapana properties

Discussion 2014



of the drugs.

Effect on Kandu

In Group A, out of 20 patients, the mean score of Kandu before treatment was



statistically significant effect of Siravyadha on Kandu at P<0.001. Siravyadha acts on

Kandu by the removal of vitiated stagnant blood which had caused Sanga.

In Group B, out of 20 patients, the mean score of Kandu before treatment was



statistically significant effect of Sahacharadi Kashaya with Taila on Kandu at

P<0.001. This may be due to Raktashodhaka and Kaphahara properties of

Sahacharadi Kashaya and Taila, Sanga is removed which leads to relief in Kandu.

Effect on Grathana

In Group A, out of 20 patients, the mean score of Grathana before treatment

was 1.35 which was reduced to 0.60 on 28th


statistically significant effect of Siravyadha on Grathana at P<0.001. This may be due

to the removal of stagnant blood by Siravyadha, fresh blood flows through the veins

which reduce the tortuosity.

In Group B, out of 20 patients, the mean score of Grathana before treatment



statistically significant effect of Sahacharadi Kashaya with Taila on Grathana at

P<0.001. The drugs act on Grathana by its Kaphavatahara property which regains

Chala Guna of Vata and removes Srotorodha.

Effect on Shotha

In Group A, out of 20 patients, the mean score of Shotha before treatment was

Discussion 2014





statistically significant effect of Siravyadha on Shotha at P<0.001. By doing

Siravyadha, the intravascular pressure and volume is relieved which further reduces

Shotha.

In Group B, out of 20 patients, the mean score of Shotha before treatment was



statistically significant effect of Sahacharadi Kashaya with Taila on Shotha at

P<0.001. This may be due to the Shothahara property of the drug.

Effect on Vaivarnya

In Group A, out of 20 patients, the mean score of Vaivarnya before treatment



statistically significant effect of Siravyadha on Vaivarnya at P<0.001. This is due to

removal of haemosiderin through Siravyadha reduces Pigmentation.

In Group B, out of 20 patients, the mean score of Vaivarnya before treatment



statistically significant effect of Sahacharadi Kashaya with Taila on Vaivarnya at

P<0.01. This may be due to the Raktashodhaka and Twakdoshahara properties of the

drugs.

5. Discussion on the comparative effect of both groups:

While comparing both the groups there is statistically significant difference

between Group A and Group B in the case of Shoola and Vaivarnya [Shoola P=

<0.001, Vaivarnya P=<0.01] and no statistically difference in other signs and

symptoms of Sirajagranthi

Discussion 2014



6. Discussion on the Comparative Percentage relief of Group A and Group B

The comparative percentage relief in signs and symptoms of Group A and

Group B are as follows:

Shoola- In group A 93.3% relief and in Group B 67.3% relief was observed.

Kandu- In group A 82.6% relief and in Group B 92% relief was observed.

Grathana- In group A 55.5% relief and in Group B 53% relief was observed.

Shotha- In group A 55% relief and in Group B 62.9% relief was observed.

Vaivarnya- In group A 66.6% relief and in Group B 25% relief was observed.

Thus, Siravyadha showed more results in main attributes like Shoola,

Grathana and Vaivarnya, while Sahacharadi Kashaya with Taila was found more

effective in reducing Kandu and Shotha.

Thus the total effect of Siravyadha was better than Sahacharadi Kashaya with

Taila.

Follow Up

The improvement in the disease condition noted during the study period

persisted as such in both the groups in course of the follow up period except that-

In group A, 3 patients showed mild increase in symptoms like Shoola, Kandu

and Shotha due to Nidana Sevana especially prolonged standing as a part of

occupation.

In group B, 5 patients showed mild increase in symptoms like Shoola and

Shotha due to Nidana Sevana.

7. Discussion on mode of action of Siravyadha

“Siravyadham Ardha Chikitsa Shalyatantre Prakirtitah”

Siravyadha is considered to be the half or even some times the complete

treatment (depending upon the condition) in surgical diseases.

Discussion 2014



Siravyadha removes the Dusta Rakta and clears the pathway of Dosha. Rakta

Avasecana also helps to improve the proper nourishment of Uttarottara Dhatus.

Being a Shalya procedure it possess Asukari Guna providing immediate result in

relieving the symptoms. It also has an advantage of immediate relief in pain (Vedana

Shanti) which is one among the Samyak Vyadha Lakshanas.

As Siravyadha is a type of Sastravacharaniya Raktamoksana procedure, two

Sastra have been mentioned in classics for Vyadhana purpose. One is Vrihi Mukha

Sastra and the other is Kutarika Sastra, former to be used in Mamsala Pradesa and

later in Asthi Pradesa. In the present study Siravyadha was carried out using Kutarika

Sastra. By using Kutarika Sastra large amount of vitiated blood can be removed from

the maximum tortuous area which gives more symptomatic relief.

Siravyadha is a simple procedure and can be practiced even in OPD levels.

Probable mode of action of Siravyadha

In the disease Sirajagranthi, the main vitiated factors are Vata and Rakta. By

doing Siravyadha, the stagnant vitiated Rakta gets drained out which will

helps to retain the Chala Guna of Vata.

By removing the stagnant vitiated blood that had caused Sanga, Siravyadha

reduces intravascular pressure and volume hence relieving Shoola and Shotha.

Since the stagnant blood is drained out, the breakage of RBC gets reduced

which in turn reduce the pigmentation and itching over the part.

Vitiated Vata in Sira causes Siraakunchana (dilatation of the veins) and

stimulate release of substance P which gets collected in smooth muscle of

blood vessels causing pain. After doing Siravyadha, this is removed from the

blood thus causing relief in pain.

Vata Shamana is also done by Snigdha Ahara which is given at the time of

Discussion 2014



Paschat Karma.

Probable mode of action of Siravyadha on various steps of Pathogenesis of

Varicose veins

Chart no: 3

Pathogenesis Mode of action of Siravyadha

Incompetence of venous valve

Stasis of blood This can be removed by

Siravyadha

Chronic venous Decreases after Siravyadha

Hypertension

Defective microcirculation Improved by draining out the stagnant

blood

R.B.C. diffuses in tissue

planes Dead R.B.C. are removed

after Siravyadha

Lysis of R.B.C.

Release of haemosiderin Free iron can be utilized by fresh blood

Pigmentation It does not occur if there is no free

iron or haemosiderin

Dermatitis Removal of haemosiderin through

Discussion 2014



Siravyadha reduces dermatitis

Impairment of diffusion and After removal of stagnant blood

Exchange of nutrients fresh blood comes to flow through

Sira which helps in exchange of

nutrients

Severe anoxia This decreases when fresh blood

comes to flow through Sira.

If the above conditions are treated earlier, then various steps of complications

can be stopped, otherwise severe anoxia in the lower part of the leg and surrounding

tissue can lead to chronic venous ulceration.

Recurrent varicose veins are veins which have become varicose after the

previous treatment, which had once become ‘normal’ after the treatment. This occurs

when all the visible varicosities were treated but the underlying abnormality was not

corrected; the remaining ‘normal’ veins therefore continue to be subjected to

abnormal pressure and subsequently dilate.

8. Discussion on mode of action of Sahacharadi Kashaya with Taila

Sahacharadi Kashaya is a simple herbal compound in the form of a herb

processed decoction with three chief ingredients - Sahachara, Devadaru and Nagara.

All the three drugs acts as Kaphavatahara and possess Shothagna property. As a

combined effective formulation for Vatavyadhis, they help in alleviating the pain and

associated complaints caused by the vitiated Vata.

Sahachara: It pacifies the vitiated Vata and Kapha and hence alleviates the diseases

caused due to the morbid Vata, Twak Roga and Shotha. It also purifies and detoxifies

the blood.

Devadaru: Sushruta considered this drug among Vata Samana group. It has wide

range of actions like Shothagna, Vedanasthapana, Kushtagna, Kandugna,

Discussion 2014



Vranaropana, Rakta Prasadhana etc.

Nagara/Shunti: It is one among the best drugs for relieving Srotorodha. It pacifies

vitiated Kapha and Vata and act as Vedanasthapana, Vatanuloman, Shothahara,

Vranaropana and Kushtagna.

Sahacharadi Kashaya is said as “Taila Vimishritam Piban” – to be taken

along with Taila. Sahacharadi Taila consists of 11 drugs, most of which having

properties like Kaphavahara, Shothagna, Kandughna and Rakta Doshahara. It is

processed in Moorchita Tila Taila which also acts as Vatasleshmahara.

Probable mode of action of Sahacharadi Kashaya with Taila

From the above description of the properties of drugs it may be assumed that

Sahacharadi Kashaya with Taila acts on Sirajagranthi mainly by its

Kaphavatahara property.

By bringing the vitiated Vata and Kapha in the Siras to its normalcy helps to

relieve the Sanga and regain the Chala Guna of Vata thereby maintaining the

proper flow of blood through the Siras. This further helps in relieving Kandu.

Nagara has the property to remove the Srotorodha thereby relieving the Sanga

/obstruction in affected Siras.

Vedanasthapana and Shothahara properties help in relieving the pain and

swelling in the affected area.

The drugs also possess Raktashodhaka property which removes the Dushana

of Rakta thereby relieving the complications caused by Dusta Rakta.

The base Tila Taila possess Sukshma, Vyavayi, Tiksna properties which helps

in easy assimilation and penetration of the drug even into minute channels/

Srotas. The end result is that the medicine acts quickly on the affected area.

Discussion 2014



Problems faced during the period of study:

There were no much complications that occurred during the procedure.

Few patients belonging to Group ‘A’ showed prolonged bleeding after

Siravyadha which was managed by tight bandaging with wet saline pad.

2 patients in Group ‘B’ reported mild burning sensation all over the body

which was managed by increasing the dilution of Kashaya.

3 patients in Group ‘B’ reported mild purgation during intake of medicine.

This was managed by decreasing the dose of Taila.

Conclusion

Conclusion 2014



CONCLUSION

Based on the review of literature and observations made in this clinical study,

the following conclusions are drawn.

Sirajagranthi is a common clinical condition affecting the lower limbs and the

incidence being prevalent in this era owing to the busy life schedule.

Incidence of varicose veins was more in people belonging to the occupation

that involved prolonged standing.

Siravyadha is a simple cost effective OPD procedure which has miraculous

effect on varicose veins.

By using Kutarika Sastra large amount of vitiated blood can be removed from

the maximum tortuous area which gave more symptomatic relief, though

convincing the patient for Siravyadha was a difficult task.

Siravyadha showed immediate result in reducing the signs and symptoms of

Sirajagranthi especially in symptoms like Shoola and Kandu.

Sahacharadi Kashaya with Sahacharadi Taila also had significant results in

the conservative management of varicose veins.

Though palatability was a major concern for some of the patients,

Sahacharadi Kashaya with Taila showed gradual improvement in all the signs

and symptoms especially in reducing Kandu and Shotha.

In this clinical study, both Group A and Group B showed significant results in

all attributes of Sirajagranthi.

But on comparison there is statistically significant difference between the two

groups in Shoola (Group A 93.3%) and Vaivarnya (Group A 66.6%) and no

significant difference in other signs and symptoms of Sirajagranthi.

Conclusion 2014



Siravyadha group showed more results in main attributes like Shoola,

Grathana and Vaivarnya, while Sahacharadi Kashaya with Taila was found

more prominent in reducing Kandu and Shotha.

Therefore on the basis of the observations from the present study, it may be

concluded that the total effect of Siravyadha was better than Sahacharadi

Kashaya with Taila in the management of Sirajagranthi.

Limitations of the study

The study was limited to small sample of 40 patients, 20 in each group, thus

difficult to draw a generalised conclusion.

As study was conducted in OPD basis, Pathya may not be maintained

properly.

Abhyantara Snehapana was not done before Siravyadha, only Bahya Snehana

and Swedana was done.

The disease Sirajagranthi is difficult to cure completely due to its chronic

nature.

Scope for further study

Both the treatment modalities can be combined and studied under a single

group with large sample.

Classical Siravyadha after Abhyantara Snehapana can be conducted.

Duration of study can be increased to check the recurrence rate.

Summary

Summary 2014



SUMMARY

The present work entitled “A Comparative Study of Siravyadha and

Sahacharadi Kashaya with Taila in the management of Sirajagranthi w.s.r to

Varicose Vein” comprises of following sections.

1. Introduction

2. Objectives of the study

3. Review of literature

i. Disease review

ii. Review on Siravyadha

iii. Review on Sahacharadi Kashaya with Taila

4. Methodology

5. Observations and Results

6. Discussion

7. Conclusion

8. Summary

9. Bibliography

10. Annexure

Introduction:

Deals with prevalence of Sirajagranthi in present era, need for Ayurvedic

management and importance of present study. It includes plan of study in brief.

Review of literature:

The Review of literature comprises of the following fragments:

Summary 2014



I. Disease review: In this fragment a brief description of the historical

aspect of the illness from vedic era to the present time is dealt and is

entitled as historical review. It elaborates the general description of

Sirajagranthi which includes the etymological derivation, anatomy,

physiology etiology, pathogenesis, clinical manifestations, prognosis

and general principles of treatment of Sirajagranthi.

II. Review on Siravyadha: Comprises of general description of Sira and

Siravyadha and a brief description of the properties of Siravyadha and

the procedure followed.

III. Review on Sahacharadi Kashaya with Taila: Comprises of brief

description of the properties of Sahacharadi Kashaya and Sahacharadi

Taila. Followed by the composition of the indigenous compound drugs

in Sahacharadi Kashaya and Sahacharadi Taila. The properties of the

individual herbs used in the preparation of the medicinal compound are

briefed in the context.

Methodology:

The materials and methods of the present work with complete description of 40

patients of which 20 patients treated with Siravyadha and the other 20 with

Sahacharadi Kashaya with Taila along with their various criteria including

assessment criteria are presented here.

Observations:

The observations made during the clinical study are presented in order with tables

and graphs.

Results:

Statistical analysis of the findings and the results obtained are methodically

Summary 2014



presented in this section with suitable tables and graphs.

Discussion:

In this section, the observations and results obtained are critically analysed and

interpreted on the basis of facts established in various literatures to unravel the truth

of efficacy of the treatment taken for the study.

Conclusion

The final conclusions drawn from the present clinical research work are presented

in this fragment.

References

List of References 2014



LIST OF REFERENCES

REFERENCES OF INTRODUCTION

1) S.S Ni 11/8,9

2) A.H U 30/7

3) S.S Sa 8/23

4) S.S Ci 4/7

5) S.S Su 14/20

6) A.H Su 1/13

7) S.S Su 20/3

8) A.H U 30/7

9) A.H Ci 21/56

REFERENCES OF DISEASE REVIEW

1) Sabdha kalpa Druma Vol 2 P: 372

2) S.S Ni 11/3

3) A.H U 29/1

4) S.S Ni 11/3

5) S.S Ni 11/3

6) S.S Ni 11/8

7) A.H U 29/10,11

8) A.H U 30/7

9) V.S Vol 1 48/6,7

10) B.P Vol 2 44/16

11) S.S Ni 11/8,9

12) A.H U 29/10,11




13) S.S Ni 1/17,18

14) C.S Ci 12/10

15) S.S Ni 11/8

16) V.S Vol 1 48/6

17) A.H U 29/10,11

18) C.S Ci 12/8

19) S.S Ni 11/8 (commentary)

20) S.S Ni 11/9

21) S.S Ni 11/9

22) S.S Ni 11/9

23) A.H U 29/10,11

24) S.S Ni 11/9

25) B.P Vol 2 44/17

26) V.S Vol 1 48/7

27) A.H U 30/7

28) S.S Sa 9/3

29) S.S Sa 9/12

30) C.S Vi 5/24

31) S.S Sa 7/14,15

32) S.S U 1/25

33) C.S Su 1/5

34) A.H U 30/7

35) A.H Su 26/53

36) S.S Ci 4/7

37) S. Das 7th

ed, Chapter 16, pg no 256




38) S. Das 7th


39) Gray’s Anatomy 39th


40) S. Das 7th




42) S. Das 7th




44) S. Das 7th


45) S. Das 7th


46) Bailey & Love’s, 25th


47) Gayton & Hall 11thed, Chapter 15, pg no 178

48) S. Das 7th


49) S. Das 7th




51) S. Das 7th



ed, Chapter 54, pg no 927,928

53) S. Das, Clinical Surgery, 6th


















62) S. Das 7th





63) S. Das 7th






66) S. Das 7th




REFERENCES OF SIRAVYADHA

1) S.S Su 14/20

2) S.S Su 14/21

3) C.S Su 24/4

4) S.S Sa 7/14,15

5) S.S Su 14/8

6) S.S Su 14/9

7) C.S Su 24/25

8) S.S Su 14/6

9) S.S Su 14/22

10) C.S Su 24/22

11) C.S Su 24/5-10

12) C.S Su 24/20-21

13) C.S Su 24/24

14) C.S Su 24/11-16

15) C.S Su 24/18

16) A.H Su 12/5

17) S.S Su 14/25

18) C.S Su 29/35




19) A.H Su 26/53

20) S.S Hindi page no 43



23) A.V 10/2/11

24) Ayurveda ka brhat itihas Atridev page no 63

25) Ayurveda ka vijnaik itihas By Prof. P.V Sharma

26) B C medical journal vol 52 Jan & Feb 2010

27) Ayurveda ka vijnaik itihas By Prof. P.V Sharma

28) A text book of pathology by William boyd page no 1097

29) B C medical journal vol 52 Jan & Feb 2010

30) S.S Sa 8/23

31) A.S Su 36/4,5

32) C.S Su 24/17

33) C.S Su 24/24

34) S.S Sa 8/22

35) S.S Su 14/34

36) A.S Su 36/3

37) S.S Sa 8/12

38) C.S Su 30/12

39) S.S Sa 7/4

40) A.H Sa 3/39

41) C.S Su 30/12

42) S.S Sa 7/4

43) S.S Sa 7/5




44) A.H Sa 3/18

45) S.S Sa7/3,6

46) S.S Sa 7/7

47) S.S Sa 7/8

48) S.S Sa 7/8

49) S.S Sa 7/8,9

50) S.S Sa 7/10,11

51) S.S Sa 7/12,13

52) S.S Sa 7/14,15

53) S.S Sa 7/16,17

54) S.S Sa 3/33

55) A.H Sa 3/20-31

56) S.S Sa 7/22

57) S.S Sa 7/19

58) S.S Sa 7/20,21

59) S.S Sa 8/18

60) S.S Su 14/34

61) S.S Su 25/12-16

62) A.H Su 27/3-5

63) S.S Sa 8/3

64) S.S Sa 8/3

65) S.S Sa 8/5

66) S.S Sa 8/16,17

67) A.S Su 36/9

68) S.S Sa 8/5




69) S.S Sa 8/9

70) A.H Su 27/6-8

71) S.S Sa 8/9

72) S.S Sa 8/8

73) S.S Sa 8/6

74) S.S Sa 8/4,5

75) S.S Sa 8/6,7

76) S.S Sa 8/6-8

77) A.S Su 36/11

78) S.S Sa 8/8

79) A.S Su 36/12

80) Chakradatta Siravyadha Adhikara 8

81) S.S Sa 8/16

82) S.S Sa 8/16

83) A.H Su 27/42

84) Sa.S By Prof. K.R Srikantamurthy pg no 257

85) A.H Su 27/45

86) S.S Su 14/32

87) A.H Su 27/38

88) S.S Su 14/32

89) S.S Su 14/33

90) S.S Sa 8/12

91) A.H Su 27/37

92) S.S Su 14/35

93) A.H Su 27/35




94) S.S Su 14/36

95) A.H Su 27/34

96) S.S Sa 8/18,19

97) S.S Su 14/38

98) A.H Su 27/36-37

99) S.S Su 14/39-40

100) A.H Su 27/48-50

101) S.S Su 14/39,40

102) A.H Su 27/52

103) Yoga Ratnakara

104) Yoga Ratnakara

105) A.H Su 27/44

REFERENCES OF SAHACHARADI KASHAYA AND TAILA

1) C.S Su 9/3

2) A.H Ci 21/26

3) A.H Ci 21/26

4) A.H Ci 21/60

5) Sha.S. M. 2/1

6) H.S 3/1.

Bibliography

Bibliography 2014



BIBLIOGRAPHY

1. Agnivesa; Charaka Samhitha, revised by Charaka and Dridabala with Ayurveda

Dipika commentary by Cakrapanidatta, edited by Vaidya Yadavji Trikamji

Acharya, Published by Chaukhambha Prakasan, Varanasi, Reprint edition 2009.

2. Sushruta; Sushruta Samhitha, with commentaries Nibandha Sangraha of Dalhana,

edited by Vaidya Jadavji Trikamji Acharya, Chaukahamba Krisnadas Academy,

Varanasi, Reprint edition, 2008.

3. Vagbhata; Astanga Hridaya with the commentaries Sarvangasundara of Aruna

Datta and Ayurvedarasayana of Hemadri, published by Chaukhamba Sanskrit

Sansthan, Varanasi, edited by Pt.Hari Sadasiva Sastri Paradakara, Reprint edition

2009.

4. Cakrapanidatta; Ayurveda Dipika, English translation by Ramkaran Sarma and

Vaidya Bhagwan Das, Chaukhambha Sanskrit Series Office, Varanasi, Uttar

Pradesh, Edition 1997.

5. Cakrapanidatta; Cakradatta with Vaidyaprabha Hindi commentary by Dr.Indradev

Tripathi, Chaukhambha Sanskrit Bhavan, Varanasi, Uttar Pradesh, 1997.

6. Dr. B.D. Chaurasia, Human Anatomy, Published by CBS Publishers and

Distributors, Delhi 32, 3rd Edition, Vol. 11.

7. Guyton A. C. and Hall J. E.; Textbook of Medical Physiology, published by

Harcourt Publishers International Company and W. B. Saunders Company, 10th

edition 2001.

8. Hamilton and Bailey; Bailey and love’s short practice of surgery revised by

Charles Mann, Chapman and Hall 2-6 Shoin/Saunders Philadelphia, 25th edition.

9. Harding Rains A J & Charles V Mann; Bailey and Love’s Short Practice of

Surgery, 20th edition, ELBS, London.

Bibliography 2014



10. Harrison T R; Harrison’s Principles of Internal Medicine, Vol I and II, 14th

International edition, Mcgraw-Hill Book Co, Singapore, 1998.

11. Henry Gray; Gray’s Anatomy, edited by Peter C.Williams and Roger warick, 37th

edition 2005.

12. Hiremath Shobha; Textbook of Bhaisajya Kalpana, 1st edition, IBH Prakasana,

Bangalore, 2000.

13. Kasyapa Marica; Kasyapa Samhitha, Vrddah Jivaka Revatsya with Hindi Vidyotini

commentary by Satyapala Bhisagacarya, Chaukhambha Sanskrit Bhavan,Varanasi,

Uttar Pradesh, 1998.

14. Madhavakara; Madhava Nidanam with Madhukosa Vyakhya by Vijayaraksita and

Srikanthadatta, Vidyotini Tika by Ayurvedacarya Sri Sudarsana Sastri,

Chaukhambha Sanskrit Sansthan, Varanasi, Uttar Pradesh, 29th

edition1999.

15. Sarngadhara; Sarngadhara Samhitha Madhyama Khanda, English Translation by

Ayurved Vidvan Prof. K. R. Srikantha Moorty, Chaukhambha Orientalia,

Varanasi, Uttar Pradesh, 3rd edition, 1997.

16. Sushutha; Sushruta Samhitha with English translation of text and Dalhana’s

commentary along with critical notes by Dr.P.V.Sarma, First edition,

Chaukhambha Bharati Academy Varanasi, 1999.

17. Vagbhatacarya; Ashtanga Sangraha with Hindi Vyakhya by Kaviraj Tridev Gupta,

Krsnadas Academy, Varanasi, Uttar Pradesh, Reprint Edition, 1993.

18. Vangasena; Vangasena Samhitha, Chikitsa Sara Samgraha, 1st edition, edited by

Dr. Nirmal Saxena, Chowkhamba Krishnadas academy, Varanasi.

19. Williams Sir Monier; A Sanskrit English Dictionary, Motilal Banarasidas

Publishers Pvt. Ltd., Delhi, 2008 1st edition.

Bibliography 2014



20. Bhava Mishra; Bhavaprakasha. Edited by K.R.Srikantha Murthy, 2nd

edition.

Varanasi: Krishnadas Academy, 2001.

21. Bhelacharya; Bhela Samhitha edited by Dr.H.Krishnamurthy, 1st Edition

Chaukambha Vishvabharati Varanasi, 2000.

22. Dr. Somen Das; A Concise text book of surgery, 4th

edition, 2006.

23. Dr. Somen Das. A Manual on Clinical Surgery, 6th

edition, 2004.

24. Kaviraj Govind Das Sen; Bhaishajya Ratnavali with Sidhiprada hindi

Commentary, New Delhi, Chaukhamba Surbharati prakashan, 2007.

25. Oxford Concise Medical Dictionary, New York, Oxford University Press Inc 2008.

26. Gray’s Anatomy, The anatomical basis of clinical practice, Churchill Living stone,

Elsevier Ltd, 40th

Ed.

27. Raja Radhakantadeva, Sabdakalpadruma, Vol 2, Nag publication, Reprint 1988.

28. Yogaratnakara; Part-Two, published by Chaukhambha Visvabharati, Varanasi,

First edition:2010.

29. Dr. K.M. Nadkarni, Indian Materia Medica, Popular Prakashan Pvt Ltd, Reprint

1999, Vol: II

30. Dr Ashok D Satpute; Rasa Ratna Samuchaya, English translation, Chaukhamba

Sanskrit Pratishthan, Delhi ed 1st 2003.

31. Prof. D. Shanth Kumar lucas; Dravya guna Vijnana Vol 2, Chaukhambha

Visvabharati, Varanasi, Reprint 2012.

32. Prof. K.C. Chunekar; Bhavaprakasa Nighantu, Chaukhambha Bharati Academy,

Varanasi. ed :2010.

33. Bhaisajya Kalpana Vijnana, 1999, Chaukhambha Surabharati Prakasana,

Varanasi,Uttar Pradesh.

Annexure

Annexure 2014



CASE PROFOMA FOR DESSERTATION

‘A COMPARATIVE STUDY OF SIRAVYADHA AND SAHACHARADI

KASHAYA WITH TAILA IN THE MANAGEMENT OF SIRAJAGRANTHI

W.S.R TO VARICOSE VEIN’

NAME OF THE GUIDE : DR.MANJUNATHA BHAT M.S.(Ayu)

NAME OF THE SCHOLAR : DR. THUSHAR BABU B.A.M.S

1. Name of the patient : Case Sheet No :

2. Age : OPD No :

IPD No & Bed No

:

D.O.A :

D.O.D :

3. Sex :

4. Religion :

5. Occupation :

6. Economic Status :

7. Address : Phone No:

I. CHIEF COMPLAINTS: Duration

II. HISTORY OF PRESENT ILLNESS:

The complaints started with proceeding Present / Absent (+ --)

a) Pain

Department Of P.G. Studies in Shalya Tantra

Alva’s Ayurveda Medical College & Hospital

Moodbidri D.K. 574227

Annexure 2014



b) Thrombophlebitis

c) Trauma

d) No history

e) Other particulars.

III. HISTORY OF PAST ILLNESS: Present /Absent (+ --)

a) Pregnancy

b) Deep Vein Thrombosis

c) Other particulars

d) H/O Surgery

IV. FAMILY HISTORY:

V. PERSONAL HISTORY:

of standing for a long time

of washing lower limbs in cold water immediately after work

of smoking

Alcoholic consumption

Tea/Coffee Habit

Other Particulars

a) Diet: veg/mixed

b) Appetite: good/moderate/poor

c) Bowel: R/IR, constipated/loose stools

d) Sleep: sound/ disturbed

In women, dates of deliveries, if any

VI. TREATMENT HISTORY:

VII.OBS. /GYNAEC HISTORY:

Annexure 2014



VIII.GENERAL EXAMINATION:

(a) Nakha:

(b) Nayana:

(c) Jihvaa:

(d) Akruthi

(e) Pulse rate: (f) Rhythm:

(g) B.P:

IX. SYSTEMIC EXAMINATION:

i. Cardio Vascular System:

ii. Respiratory System:

iii.Central Nervous System:

iv.Gastro Intestinal System:

v.Other Systems:

X. EXAMINATION OF THE VEIN:

A. SAMAANYA PAREEKSHAA:

a) Darsana Pareekshaa:

(i) Aakruti:

(ii) Sankhyaa:

(iii) Sthaana:

(iv) Varna of the vein :

(v) Vrana:Present/Absent

(vi) Sotha on the surrounding area: Present/Absent

(vii)Visible color changes (Vivarnya):

b) Sparsana Pareekshaa:

(i) Size of the vein: Length

Breadth

Thickness

(ii) Touch: Rough/Smooth

(iii) Local rise of temperature Present/Absent

(iv) Sensation Normal/Altered

(v) Grathana : Hard/Soft (Katinya)

(vi) Tenderness: Present/Absent

Annexure 2014



c) Deep vein thrombosis Present/Absent

d) Any other examination (if required)

Sampeedana of sira : Present /Absent

Samkochana of sira : Present /Absent

Vishoshana of sira : Present /Absent

C. TESTS DONE

TEST POSITIVE/ NEGATIVE (+ -)

1. Brodie Trendelenburg Test

2. Multiple Tourniquet test

3. Perthes Test

Result

XII. Investigations:

Before treatment After treatment

Blood:

(a)Blood sugar

(b)ESR

(c)HB%

(d)T.C

(e)D.C

(f)C.T & B.T

DIAGNOSIS:

Sirajagranthi (Varicose Vein)

ASSESSMENT OF RESULTS

CLINICAL PARAMETERS

A.Subjective response

Parameters Day1/BT Day7 Day14 Day21 Day28

N__; L__: M__; B__; E__ N__; L__: M__; B__; E__

Annexure 2014



Shoola

Kandu( Itching

sensation)

B.Objective response

Day1/BT Day7 Day14 Day21 Day28

Grathana

Shotha

vaivarnya

C. FOLLOW UP

PARA METERS DAY 43 DAY 58

Shoola

Kandu

Grathana

Shotha

Vivarnya

Chikitsa:

Complications during the treatment:

Total effect of treatment:

Signature of the P G scholar:

Signature of Guide:

Annexure 2014



DEPARTEMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA

ALVA’S AYURVEDIC MEDICAL COLLEGE & HOSPITAL

MOODBIDRI, MANGALORE, D.K.

PATIENT CONSENT FORM

I __________________________________________ exercising my free power of

choice, hereby give you my complete consent to be included as a subject in the

Clinical trial on “A comparative study of Siravyadha and Sahacharadi Kashaya with

Taila in the management of Sirajagranthi w.s.r to varicose vein” I have been

informed to my satisfaction by the attending Doctor, the purpose of the Clinical Trial

and the nature of drug treatment, therapeutic procedures, follow-up and probable

complications. I am also ready to undergo necessary Laboratory and Radiological

Investigations to monitor and safeguard my body functions.

I am also aware of my right to opt out of the trial at any time during the course

of the trial without having to give the reasons for doing so.

£Á£ÀÄ, _________________________________ ಸಿರಜ ಗ್ರನ್ಥ ಿ gÉÆÃUÀzÀ aQvÉìAiÀÄ

¸ÀA±ÉÆÃzsÀ£ÁvÀäPÀ CzsÀåAiÀÄ£ÀPÁÌV aQvÉìUÉ M¼À¥ÀqÀ®Ä AiÀiÁªÀÅzÉÃ MvÀÛqÀPÉÆÌ¼ÀUÁUÀzÉ

¸ÀéAiÀÄA¥ÉæÃjvÀªÁV ¹zÀÞ¤zÀÄÝ, CzÀgÀ ¸ÁzsÀPÀ- ¨ÁzsÀPÀUÀ¼À£ÀÄß ªÉÊzÀågÀÄ £À£ÀUÉ ZÉ£ÁßV «ªÀj¹zÀÄÝ,

«eÁÕ£ÀzÀ ¨É¼ÀªÀtÂUÉ ªÀÄvÀÄÛ ¸ÀªÀiÁdzÀ M½wUÁV DUÀÄªÀAvÀºÀ F ¸ÀA±ÉÆÃzsÀ£ÉUÉ ¸ÀºÀPÀj¸À®Ä

§zÀÞ£ÁVzÉÝÃ£ÉAzÀÄ F ªÀÄÆ®PÀ zÀÈrüÃPÀj¸ÀÄvÉÛÃ£É. C®èzÉ ªÉÊzÀågÀ DzÉÃ±ÀzÀAvÉ EzÀPÉÌ ¨ÉÃPÁzÀ

gÀPÀÛ ¥ÀjÃPÉëUÉ ªÀÄvÀÄÛ EvÀgÉ ¥ÀjÃPÉëUÀ½UÉ ¸ÀºÀPÀj¸À®Ä £À£Àß M¦àUÉAiÀÄ£ÀÄß ¤ÃqÀÄwÛzÉÝÃ£É.

Signature of the Doctor Signature of the Patient/ Guardian

SL No

NAME

AG

E

SEX

REL

IGIO

N

S-E

STA

TUS

OC

CU

PA

TIO

N

CH

RO

NIC

ITY

AP

PET

ITE

DIE

T

BO

DY

WEI

GH

T

BO

WEL

AFF

ECTE

D L

EG

AM

OU

NT

OF

BLO

OD

R

EMO

VED

1 BHASKER SHETTY 58 M H MC MW >2YR G V 88 R BOTH 275ml

2 MUMTAZ 41 F M HC HW 1-2YR G M 68 R BOTH 270ml

3 SHRIDHAR SHETTY 52 M H MC BS >2YR G M 77 R BOTH 180ml

4 MOHANAN 62 M H PC MW 1-2YR M M 86 R R 250ml

5 SR. ALOYSIA 69 F C MC MW >2YR M M 52 R R 150ml

6 MAMATHA 40 F M MC HW I-2YR M M 60 C BOTH 200ml

7 SANGEETHA 38 F H PC HW 1YR M V 46 R L 230ml

8 GANAPATHI KINI 49 M H MC MW 2YR M V 58 R BOTH 250ml

9 P.V PRAKASH 52 M H PC MW >2YR G M 65 R L 245ml

10 RUKIYA RASHEED 55 F M MC HW >2YR M M 76 R BOTH 220ml

11 KHATIJA 39 F M MC HW >2YR G M 85 R BOTH 300ml

12 SANDEEP 38 M H MC MW 1-2YR G M 58 R R 250ml

13 KHATIJA YASMINE 38 F M MC HW >2YR G M 78 R BOTH 250ml

14 MANADEVAPPA 54 M H MC MW >2YR M V 74 R BOTH 275ml

15 APPI 45 M H MC MW 1-2YR M M 68 R BOTH 230ml

16 ABDUL 53 M M MC BU >2YR P M 61 C R 180ml

17 SADHASHIVA SHETTIYAR 40 M H MC MW >2YR M V 56 R R 240ml

18 PANDU RANGA ROA 60 M H PC MW >2YR M M 72 C BOTH 280ml

19 CHANDRAHAS SHETTY 50 M H MC BU <2YR M M 48 C BOTH 290ml

20 KHADAR 39 M M PC MW 1YR M M 52 C BOTH 210ml

OBSERVATIONS CHART OF GROUP A

OBSERVATIONS CHART OF GROUP B

M-Male, F- Female, H- Hindu, M-Muslim, C- Christian, PC- Poor class, MC- Middle class, MW- Manual worker, HW- House wife, Bu-

Business, G- Good, V- Veg Diet, M- Mixed Diet, R- Regular, C- Constipated, Rt- Right, Lt- Left

INCIDENCE CHART OF GROUP A

SUBJECTIVE OBJECTIVE

SLNo NAME SHOOLA KANDU GRATHANA SHOTHA VIVARNYA

BT 7D 14D

21D

28D

BT 7D 14D

21D

28D

BT 7D 14

D 21D

28D

BT 7D 14D

21D

28D

BT 7D 14D

21D

28D

1 BHASKER SHETTY 4 3 2 1 1 2 2 1 1 1 2 2 1 1 1 1 0 0 0 0 2 1 1 1 1

2 MUMTAZ 4 2 1 1 0 1 0 1 0 0 1 1 1 1 1 2 1 1 1 1 2 2 1 1 1

3 SHRIDHAR SHETTY 2 0 0 0 0 1 1 0 0 0 1 1 0 0 0 3 2 2 2 2 1 0 0 0 0

4 MOHANAN 3 2 2 2 1 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 0 0 0 0 0

5 SR. ALOYSIA 2 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1

6 MAMATHA 4 2 1 0 0 2 1 1 1 0 2 2 2 1 1 2 2 1 1 1 2 1 0 0 0

7 SANGEETHA 3 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 1 1 0 2 1 1 1 1

8 GANAPATHI KINI 3 1 1 1 0 2 1 1 0 0 1 1 1 1 0 2 1 1 0 0 1 0 0 0 0

9 P.V PRAKASH 4 2 1 1 1 1 0 0 0 0 2 1 2 2 2 2 1 1 1 1 0 0 0 0 0

10 RUKIYA RASHEED 3 1 0 0 0 1 1 1 1 0 1 0 0 0 0 1 0 0 0 0 1 1 0 0 0

11 KHATIJA 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 2 1 1 1 0 0 0 0 0

12 SANDEEP 4 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 2 1 1 1 1

13 KHATIJA YASMINE 3 2 1 0 0 2 1 1 0 0 2 1 1 1 0 1 1 1 1 1 1 1 1 0 0

14 MANADEVAPPA 2 1 1 1 0 1 0 0 0 0 1 1 1 1 1 2 2 2 2 2 0 0 0 0 0

15 APPI 3 1 0 0 0 2 1 1 0 0 1 0 0 0 1 1 1 1 1 1 1 1 1 0 0

16 ABDUL 4 2 2 1 1 2 1 1 1 1 1 1 1 1 1 0 0 0 0 0 2 1 1 1 1

17 SADHASHIVA 3 1 0 0 0 0 0 0 0 0 2 1 0 0 0 2 1 1 1 1 1 1 0 0 0

18 PANDU RANGA ROA 3 0 0 0 0 1 0 0 0 0 2 2 1 1 1 2 1 1 1 1 2 2 2 2 1

19 CHANDRAHAS 2 0 0 0 0 1 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0

20 KHADAR 3 1 1 1 0 0 0 0 0 0 2 1 1 1 1 1 1 1 1 0 2 1 1 1 1

OBSERVATIONS CHART OF GROUP A

SL No

NAME

AG

E

SEX

REL

IGIO

N

S-E

STA

TUS

OC

CU

PA

TIO

N

CH

RO

NIC

ITY

AP

PET

ITE

DIE

T

BO

DY

WEI

GH

T

BO

WEL

AFF

ECTE

D L

EG

1 SHIVA SHANKER 24 M H MC MW 1-2YR G M 65 R L

2 KUCHADI POVAPPA 53 M H MC MW >2YR M M 74 R BOTH

3 JAYANANANTHA CHOUTA 48 M H MC BU >2YR M M 80 C BOTH

4 HAMATHA 41 F H PC HW 1YR M V 68 R R

5 MUMTHA 36 F M MC HW 2YR M M 65 R R

6 KRISHNA MOGARAYA 52 M H MC MW >2YR M V 72 C BOTH

7 GERALD COSTA 44 M C MC MW >2YR M M 66 R L

8 SUBRAMANYA 48 M H MC MW >2YR G M 80 C BOTH

9 ASWANTH 38 M H MC MW >2YR G M 60 R BOTH

10 SHAJAHAN 45 M M MC MW 1YR M M 75 C BOTH

11 RAZIA 44 F M MC HW 1-2YR M M 78 C BOTH

12 NAJITHA 48 F M MC HW 1-2YR M M 58 C R

13 UMESH 40 M H MC MW 2YR M M 66 C BOTH

14 KHATHIJA 49 F M MC HW >2YR G M 74 R BOTH

15 CELINA PINTO 37 F C MC HW 1-2YR G M 68 C L

16 ANANTH RAO 38 M H PC MW >2YR G M 70 C R

17 MANAS 36 F M MC HW 8M M M 66 C R

18 VANITHA 42 F H MC HW >2YR M V 86 R BOTH

19 SADANAND 49 M H MC MW 1-2YR P V 78 R R

20 MUHAMMAD KHALIF 53 M M MC MW >2YR P M 87 C L

M-Male, F- Female, H- Hindu, M-Muslim, C- Christian, PC- Poor class, MC- Middle class, MW- Manual worker, HW- House wife,

Bu- Business, G- Good, V- Veg Diet, M- Mixed Diet, R- Regular, C- Constipated, Rt- Right, Lt- Left

INCIDENCE CHART OF GROUP B

SUBJECTIVE OBJECTIVE

SLNo NAME SHOOLA KANDU GRATHANA SHOTHA VIVARNYA

BT 7D 14D

21D

28D

BT 7D 14D

21D

28D

BT 7D 14

D 21D

28D

BT 7D 14D

21D

28D

BT 7D 14D

21D

28D

1 SHIVA SHANKER 3 2 2 2 1 2 1 0 0 0 1 1 1 1 0 2 1 1 1 1 1 1 1 1 1

2 KUCHADI POVAPPA 4 3 2 2 2 1 0 0 0 0 2 1 1 1 1 1 0 0 0 0 2 2 2 2 2

3 JAYANANANTHA 3 2 2 1 1 2 1 1 0 0 2 2 1 1 1 2 1 1 1 1 2 1 1 1 1

4 HAMATHA 2 2 1 1 1 1 0 0 0 0 1 1 0 0 0 1 1 1 1 1 3 3 3 2 2

5 MUMTHA 2 1 1 1 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 1 1 1 1 0

6 KRISHNA 3 3 2 2 1 2 1 1 1 0 2 1 1 1 1 3 2 2 1 1 0 0 0 0 0

7 GERALD COSTA 1 0 0 0 0 1 0 0 0 0 2 2 1 1 1 2 1 1 1 1 2 1 1 1 1

8 SUBRAMANYA 2 2 1 1 1 0 0 0 0 0 2 1 1 1 1 1 1 0 0 0 3 3 3 3 3

9 ASWANTH 4 3 2 1 1 2 1 1 0 0 1 1 1 1 1 2 1 1 0 0 1 1 1 1 1

10 SHAJAHAN 3 2 2 2 2 1 1 0 0 0 1 1 1 1 1 2 1 0 0 0 0 0 0 0 0

11 RAZIA 3 1 1 1 1 2 1 1 1 1 1 1 0 0 0 1 0 0 0 0 1 1 1 1 1

12 NAJITHA 2 2 1 1 1 2 0 0 0 0 2 1 1 1 1 1 1 1 1 1 2 2 2 2 2

13 UMESH 1 0 0 0 0 1 1 1 1 0 2 2 1 1 1 0 0 0 0 0 1 1 1 1 1

14 KHATHIJA 2 1 1 0 0 0 0 0 0 0 1 1 1 1 1 3 2 2 2 2 0 0 0 0 0

15 CELINA PINTO 3 2 2 2 2 1 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 0 0

16 ANANTH RAO 2 1 1 1 0 1 0 0 0 0 2 1 1 1 1 1 1 0 0 0 2 1 1 1 1

17 MANAS 2 0 0 0 0 2 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 0 0 0 0

18 VANITHA 3 2 1 0 0 1 0 0 0 0 2 2 1 1 1 0 0 0 0 0 2 2 2 2 2

19 SADANAND 4 3 2 2 1 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 2 2 2 2 2

20 MUHAMMAD KHALIF 3 2 2 2 2 2 1 0 0 0 2 1 1 1 1 1 0 0 0 0 1 1 1 1 0

OBSERVATIONS CHART OF GROUP B

Dr Thushar Babu - Dissertation.pdf

Documents

Transcript of Dr Thushar Babu - Dissertation.pdf