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Line 4,466: − − ===''Tattva Vimarsha'' === − − • The marma are the vital points as prāna (life force) resides in them. Among the ten prānāyatana, three marma i.e., śira, hr̥daya and basti have been given importance.12 − • If doṣha affect these three marma, they will have impact on the prāna. Hence their pro-tection, for management of disorders is crucial. − • Udāvarta means abnormal upward movement of vāta doṣha. Commonly this condition is caused due to the suppression of natural urges and vāta aggravating factors.13 Udavarta hampers digestion and retains the toxic elements to cause various diseases. − • Symptoms of udavarta are also seen in pakvashaya gata vata, kostagata vata, gudagata vata, purisavrita vata and gulma. Vitiation of vata is common in all the above men-tioned diseases. − • Ashmari (lithiasis) is caused by either increase in prithvi mahabhuta or decrease of jala mahabhuta or both. Excessive exercise, food having ruksha (dry), ushna (hot) potency like alcoholic preparations cause absorption and thus depletion of jala mahabhuta whereas aetiological factors like eating flesh of animals residing in marshy land; fish etc are the one which increases prithvi mahabhuta. − • Site of doṣha aggravation is important. As like in jwara, if patient is suffering from sama sannipataj mutrakrichra then first treat vata dosha as sthansamshraya (site of collection of morbid doṣha) of the disease is in vatasthana (seat of vata doṣha), followed by treat-ment of pitta and lastly kapha. Whereas, in visham sannipataj mutrakricchra, depending on the predominant doṣha do the treatment i.e. if kapha is dominant vaman, if pitta is dominant virechana and if vata is dominant then basti. − • Relationship exists between krimi, annavahasrotas (gastrointestinal tract) and heart dis-ease. In Ca. Vi. 7/12 Diet such as milk, sesame, fish etc leads to kaphaja krimi which have origin in amashaya (gastrointestinal tract) and ‘hridaychara’ a type of kaphaja krimi can cause chest discomfort.14 − • If chest pain increases just after food intake and relieved during digestion and on empty stomach than it is kapha dominant whereas, if pain aggravates during digestion it is pitta dominant and if pain increases after digestion or on empty stomach it is vata dominated. − • Treatment for samasannipataja hridroga (heart disease), in which all three doṣha are equally vitiated, in such a case heart being in kapha dominant seat, first do the langhana (fasting therapy) and other kapha pacifying treatment followed by treatment of pitta and lastly treatment of vata. In vishamsannipataj hridroga depending on predominant doṣha chikitsa should be done. − • Pratishyaya (rhinitis) has also been mentioned in rajyakshma chikitsa chapter but there it is classified as one of the symptom of rajyakshma disease whereas over here it is men-tioned as independent disease.15 − • Exaggerated doṣha should be removed from the nearest site i.e. if doṣha are in amashaya (above navel area) vaman (emetic therapy) should be administered, if in pitta sthana (around navel area) virechana (purgation therapy) should be administered and basti (en-ema therapy) for doṣha in vata sthana (below navel area). − Vidhi Vimarsha: − This chapter explains the treatment of diseases effecting three vital systems (cerebrovascular, cardiovascular and renovascular system) and not the organs themselves. − Brain, heart and kidney axis support each other in maintaining the homeostasis. Declining car-diac function is associated with a spectrum of compensatory mechanisms to preserve cardiovas-cular homoeostasis. Two of the major participants in the neurohormonal system that are intri-cately intertwined in order to achieve stability are (i) the Autonomic nervous system and (ii) the Renin–angiotensin–aldosterone system (RAAS). A reduction in cardiac output activates afferent stimuli from the baroreceptors to the central nervous system cardio-regulatory centres, which in turn leads to an activation of the sympathetic nervous pathway. Reduced renal perfusion, sec-ondary to reduced forward flow activates the RAAS system via renin release. Importantly, renin facilitates the conversion of angiotensinogen to angiotensin I. Angiotensin-converting enzyme subsequently converts angiotensin I to angiotensin II. Although angiotensin II has a central ef-fect on increasing sympathetic activity, it is also involved in sodium and water retention and has a systemic vasoconstrictive effect. It is noteworthy that these compensatory mechanisms are initially important to maintain cardiac outputbut over the long term are detrimental through their adverse impact on the structural adaptive response of the heart. Heightened sympathetic tone modulates heart rate, enhances AV conduction, as well as myocardial contractility, but when sustained over time it is associated with reduced cardiac sympathetic neuronal density and responsiveness. Sympathetic activation in turn increases the vasoconstrictor tone, accompanied by activation of the RAAS and the endothelin 1 and vasopressin system, which may be respon-sible for peripheral organ dysfunction and damage in the setting of congestive heart failure.16 − Thus, a functional interrelationship is essential for homeostasis as well as disease condition. Diseases such as diabetes mellitus have an impact on all the three system and they in turn have impact on each other. Similarly, Acharya Charak observed udavarta, a disease of gastrointesti-nal tract origin and dominated by vata doṣha to have impact on this trimarma. In other words, these marma have to be protected especially from Anila (vāta), as vāta is the main cause for the aggravation of pitta and kapha and also is the cause of prāna (Life force).17 − Vāta gets vitiated due to the vātaja aggravating factors and especially retaining or unnecessarily provoking the natural urges. Caraka in Vimānasthāna mentioned that diet if consumed without following the rules of proper dietary intake can lead to manifestation of disease by vitiating doṣha and deteriorating the healthy status of dhātu.18 (5-10) − The toxins retained due to retention of mala due to impaired apana can lead to various diseases. The impaired apana has first impact on agni to hamper the metabolism. The impaired metabo-lism leads to impaired gut microbiome and the latest research has shown that impaired gut mi-crobiota can lead to various disorders, from heart disorders to psychological disorders which the Acharya have mentioned in verse 9-10. − It is generally observed that patient exaggerate pressure to evacuate the faecal matter which is not easily passed in case of udavarta. This increases the intra rectal pressure which can lead to arsha (piles), parikartika (fissure). The continuous increased pressure can further lead to bleed-ing leading to anaemia (pandu). As discussed in shwas adhyaya, pandu is cause of shwas (dysp-noea). Shwas has its impact on hridaya (heart) as it is seat of pranvahasrotas. Hridaya may also get involved due to pandu. Involvement of hridaya opens the gate for various disorders from brain to kidneys. Increased rectal pressure further leads to increased abdominal pressure which has been recorded as cause for TIA/ CVA in elderly individuals. Increased abdominal pressure has impact on movement of diaphragm which further increased the thoracic pressure. Restless-ness attained due to improper evacuation of faeces increases the irritability and non attentive-ness leading to psychological distress. Some Acharyas have accepted guda as a sthana of mana. (6-10) − It is also observed that due to impaired digestion and absorption, nutritional deficiency occurs especially folic acid etc which lead to increased homocystine levels, another cause for various serious diseases of three marma. − Therefore, one finds explanation of udavarta which as a disease alone only has impact of ab-dominal discomfort but later on may be the basic pathogenic factor for various diseases related to three marma. Hence Caraka explained udavarta as a disease of gastrointestinal tract prior to the explanation of diseases like mutrakrichra, hridroga and shiroroga. − The method of preparation of suppository is to be followed as described in verse 12. Then gen-tly insert the pointed tip of suppository first into lubricated rectum of the patient for downward movement of vāta and treat the retention of stool, flatus and urine which is caused by udāvar-ta.[11-14] https://infoayushdarpan.wordpress.com/2017/01/15/%e2%80%8bmy-approach-why-udaavarta-is-mentioned-in-trimarmiya-chikitsa-adhyaaya-of-charak-samhita/ − All drugs mentioned in the verse possess vāta pacifying quality and therefore useful in the erad-ication of the symptoms. Here Yavakshāra can play a significant role in the treatment as men-tioned in siddhisthān. − Yavakshāra is useful in hrudroga – heart diseases, pāndu – anemia, grahani – malabsorption syndrome, pleeha – enlargement of spleen, ānāha – bloating, constipation, galagraha – obstruc-tion in throat, kāsa – coughing and kaphaja arsha – piles of shlaismika variety. − Alkali preparations (kshāra) in general are sharp, hot, light, unctuous, softening, carminative, corrosive, caustic, digestive stimulant and depletive. (11-14). − Importance of sneha in udavarta: − As discussed in pathogenesis, ruksha guna is the one that gets increased during metabolism (katuvipaka) and opposite of ruksha is snigdha guna. It helps in lubrication and pacifying the vitiated vata. The lubrication softens the stool thereby helping downward movement. Further due to its quality to enter the lipid membrane of cell wall it helps in removing the toxins i.e. remove the vilina doṣha. Snigdha guna also helps to maintain the strength (bala). Thus, oleated suppository, medications prepared of oily substances having laxative/ purgative properties have been mentioned. Even in decoction enema (niruha basti) oil is always added which gives the essential oleation that is needed. − The main etiology for udāvarta is vitiated vāta; the aggravated vāta inturn can aggravate the other two doṣha, pitta and kapha, therefore medicated enemas as a line of treatment for each aggravated doṣha causing udāvarta is described in the verse. [15-17]. − Purgation therapy should be followed with the gap of seven days of administration of niruha basti.20 [19] − Hingvastaka or Lavanbhaskarchurna are the substitutes for Dviruttara-hingvadi-churna. − Anaha (bloated abdomen especially upper half) is a type of udāvarta which has specific etiolo-gy, signs and symptoms. [26] − Among sneha, eranda taila is more effective in udavarta or in any such condition where the gati of vata is impeded by kapha, pitta, meda, rakta or by ruksha guna of vata itself. Snigdha and anuloma action of eranda taila helps in normalizing the movement of vata dosha. 26-31 − In human beings mutrakrcchra (dysuria) is of eight types which are as follows; − Dysuria caused due to aggravated vāta, pitta, and kapha individually, and all the doṣha aggravated simultaneously (sannipatika) [33-35]. Dysuria caused due to calculus in the urinary tract. [36-39] − 6. Dysuria caused due to sarkara (granules) [39] − 7. Dysuria caused due to diseases of semen [40-43] − 8. Dysuria caused due to kshata (trauma) to urinary tract.ver. [43-44] − − Vataj mutrakriccha may be compared with various crystaluria which result in painfull and diffi-culty in micturation. Pittaj mutrakriccha can be compared with infective cystitis or various UTI whereas kaphaj can be compared with non infective cystitis. Sannipatik is a mixture of above three. Spermaturia can be understood as shukraja mutrakricchra. Spermatorrhoea is a condition of excessive, involuntary ejaculation it may be cause for spermaturia. − Raktaj mutrakrichhra: Kshata (skin breaching/ trauma) and abhighat (not bridging skin) along-with kshaya (depletion of body tissues) to be the cause for raktaj mutrakrichhra. Kshata and abhighata although both have common meaning i.e. trauma yet Acharya has used both the words to explain that both external trauma and internal trauma may be the cause of bleeding. Further, in kshatakshina adhyaya while explaining prodormal features raktamutratvam has been explained. Haematuria may occur due to kshat (trauma) as well as kshaya (shukra oja kshaya).34 Renal tuberculosis is one of the causes for haematuria. Various cancers of the kidney, prostate or bladder and benign prostatic hyperplasia, in older men, especially those over 50 is cause for haematuria. − Some causes of dysuria are explained below.35 − Drugs and irritants (tikshna aaushada) − Chemical Irritants, e.g., soaps, tampons, toilet paper − Drugs, e.g., anticholinergics, NSAIDs − Crystalluria is considered as one of the side effects of sulfonamides and penicillins − Genital − Benign prostatic hyperplasia (male) − Endometriosis (female) − Prostatic cancer (male) − Prostatitis (male) − Vaginitis (female) − Urinary Tract − Chlamydia − Cystitis − Hemorrhagic cystitis − Kidney stones − Malignancy, i.e., bladder cancer, prostatic cancer, or urethral cancer − Prostatic enlargement, i.e., benign prostatic hyperplasia (male), prostatic cancer − Prostatitis (male) − Pyelonephritis − Sexually transmitted disease − Trichomoniasis − Urethral stricture − Urethritis − Urinary schistosomiasis − Urinary tract infection (UTI) caused by bacterial infection − Other − Diverticulitis − Hypotension − Mass in the abdomen − Reactive arthritis − (https://en.wikipedia.org/wiki/Dysuria) − The most common causes of hematuria are: − Urinary tract infection with bacteria. The vast majority of UTIs are caused by Escherichia coli, with a smaller percentage due to Klebsiella pneumonia and Staphylococcus saprophyt-icus − Nephrolithiasis: stones in the kidney, bladder or ureter − Polycystic kidney disease − Trauma − Cancer of the kidney, prostate or bladder − Benign prostatic hyperplasia, in older men, especially those over 50. − Vigorous exercise- Exertion and excessive exercise (vyayama) increases peripheral circula-tion and reduces central circulation as per demand thus glomerular filtration is reduced re-sulting in less production of urine reducing the pH of urine causing burning and painful uri-nation. Further in athletes it is seen that high-intensity exercise can occasionally cause he-maturia. http://www.sjzkidney.com/faq/1674.html − No cause found − Other, less common causes of hematuria include: − Glomerular bleeding: e.g.: IgA nephropathy ("Berger's disease"), Alport syndrome, thin basement membrane disease − Sickle cell disease − Schistosomiasis (caused by Schistosoma haematobium) - a major cause for hematuria in many African and Middle-Eastern countries − Recent instrumentation of the urinary tract − Prostatitis − Urethritis − Kidney diseases − Arteriovenous malformation of the kidney (rare, but may impress like renal cell carcinoma on scans as both are highly vascular). − Rare causes include: − Paroxysmal nocturnal hemoglobinuria - a rare dis-ease where hemoglobin of hemolyzed cells is passed into the urine − Arteriovenous malformation of the kidney (rare, but may impress like renal cell carcinoma on scans as both are highly vascular) − Fibrinoid necrosis of the Glomeruli (as a result of malignant hypertension) − Vesical varices may rarely develop secondary to obstruction of the inferior vena cava − Allergy may rarely cause episodic gross hematuria in children − Left renal vein hypertension, also called "nutcracker phenomenon" or "nutcracker syn-drome," is a rare vascular abnormality responsible for gross hematuria − Ureteral Pelvic Junction Obstruction (UPJ) is a rare condition beginning from birth in which the ureter is blocked between the kidney and bladder. This condition may cause blood in the urine − March hematuria secondary to repetitive impacts on the body, usually the feet − Athletic nephritis secondary to strenuous exercise − Alport syndrome − Others signs that resemble hematuria include: − Medications can cause red discoloration of the urine, but not hematuria. Some examples in-clude: sulfonamides, quinine, rifampin, phenytoin − consumption of beets ("beeturia") − menstruation http://www.sjzkidney.com/faq/1674.html − In general terms though we find that mutraghata is described as condition with suppression or less production of urine and mutrakricchra as dysuria, not all conditions described under mut-raghata are characterized by oliguria or reduced output. Most of the conditions seem to be pre-dominated by retention or bladder distension. Mutrasaada, mutraukasaada and ushnavata may be considered as scanty urination or oliguria; Mutrakshaya may be equated to oliguria or anuria. Mutrakricchra is a condition of dysuria and others like vatabasti, mutratita, mutrajathara seem to occur due to voluntary withholding of the urge of micturition resulting in physiological blad-der atony as in mutratita or retention with pain as in vatabasti and atonied distended bladder in mutrajathara all progressive conditions of the same pathological process. Bastikundala also seems to be a condition of bladder atony but with superadded cystitis due to severe physical stress and states of dehydration. In vatashthila and mutragranthi there seems to be an obvious anatomical growth which causes obstruction to the urine pathway which may be considered as prostatomegaly and vesical tumors respectively. The condition of vatakundalika, though from the aetiological factors seems to be similar to the conditions of withholding the urge of urina-tion, due to the symptoms seems more or less like urethral stricture. Mutrotsanga seems to be a condition of acute urethritis or cystitis where there is stranguary, dysuria, and hesitancy along-with haematuria. Vidvighata clearly seems a case of recto vesical or rectourethral fistula.36 [43-44] − Summer season regimens are described in sutra /6:27-32 in detail. Oily, cold, sweet and liquid dominated diet should be taken. Alcohol should be avoided or should be taken in very less quantity and with more of water. Food dominated with salt, sour and spicy taste and exercise should be avoided so also sexual intercourse.37 [49] − In verse 77 common causes of all hridroga has been explained whereas in Sutrasthan 17 chapter aetiological factors specific to the type of hridroga have been explained. If one analyzes the aetiological factors as mentioned in Chikitsasthan they are more like exaberating factors (sadyo nidana) rather than etiological factors mentioned in Sutrasthan which do cause hridroga in long duration (kalantara nidan).38 − Excessive exercise/ exertion, explains the increased demand on already compromised heart. Strong and excessive virechan and/ orbasti which will induce loose motions in excess will re-duce water content leading to reduced fluid volume (hypovolaemia) and inturn hypotension. Thus, to maintain the blood pressure, heart will need to pump blood but due to reduced fluid volume the heart may be unable to pump or if the heart is already compromised and may not be able to bear the excessive workload. Further loss of fluid volume due to strong virechan and basti can also cause electrolyte imbalance leading to arrhythmia and hence heart disease. − Chinta (excessive thinking) bhaya (fear) explain the adrenaline influx which causes tachycardia which may again lead to heart disease in a compromised heart. − Chakrapani has mentioned that vaivarnya (discoloration) etc are seen after hridroga which manifest in some cases as presenting symptoms. Vaivarnya explains the discoloration with which the patient may present. Cyanosis is general presentation in cardiac diseases but other cutaneous presentation may also help in diagnosing cardiac involvement for eg; lupuspernio, a pink discoloration on the tip of nose and face etc which is generally a feature of sarcoidosis wth cardio-pulmonary involvement.39 − Livedo reticularis, is characterized by mottled, erythematous discoloration of the skin, which blanches on pressure. Livedo reticularis is the most common dermatologic manifestation ofArteriosclerosis (cholesterol emboli).40 − Erythema marginatum occurs in 10% of children with their first attack of acute rheumatic fever (ARF). Erythema marginatum is a flat to mildly elevated, pinkish, nonpruritic, transient erup-tion found primarily on the trunk and proximal extremities. Overall, it occurs in less than 5% of patients with rheumatic fever. − Subcutaneous nodules are also rare in rheumatic fever but are associated with more severe car-ditis, as they usually present many weeks after the onset of disease; they are generally found over bony prominences and are usually painless because it can involve the pericardium, epicar-dium, myocardium, and endocardium. − Xanthelasma is Yellow flat plaques over the upper or lower eyelids, most often near the inner part of the eye.Xanthelasma palpebrarum is observed in patient with hyperlipidemia. − Eruptive xanthomas are characterized by crops of 1- to 5-mm yellow-orange papules with sur-rounding erythema, most commonly on the extensor surfaces of extremities and the buttocks. This condition is most strongly associated with hypertriglyceridemia − Conjunctival pallor; Pallor in a patient with a prosthetic valve may be indicative of hemolytic anemia. − Janeway lesions are associated with acute endocarditis, of which S aureus is the most common cause. Osler's nodes are associated with subacute bacterial endocarditis and S viridans. Osler's nodes are painful, erythematous nodules most commonly found on the pulp of fingers and toes. − Other cutaneous manifestations of infective endocarditis include splinter/subungual hemorrhag-es.Thus a variety of colour changes (vaivarnya) may be observed in cardiac patient.41 http://csccm.org.cn/?p=9963 − Murcha (Syncope): Cardiac syncope may be due to arrhythmias or structural cardiac diseases that cause a decrease in cardiac output leading to acute global impairment of cerebral blood flow. − Cough (Kasa), hiccups (hikka) and dyspnea (shwas) have been discussed in Hikka shwas chikitsa adhyaya. It is caused due to cardio-pulmonary relationship. − Anorexia (Aruchi and aasya vairasya): Cardiac disease of any cause can cause hepatic dysfunc-tion through elevated hepatic vein pressure (congestive hepatopathy), decreased hepatic blood flow (ischemic hepatitis), or hypoxemia. Further cardiac dysfunction can lead to secondary re-nal injury through reduced renal blood flow (low cardiac output), renal venous congestion, and impaired renal autoregulation. In both the organ (liver and kidney) injury alongwith anemia caused due to cardiac disorders anorexia and unpleasant taste is the common feature. In conges-tive cardiac failure, Accumulation of fluid in the liver and intestines may cause nausea, ab-dominal pain, and decreased appetite. − Anorexia nervosa can complicate heart disease as patients with anorexia loose weight, they loose muscle mass, both of the skeletal and cardiacmuscle mass, They can develop mitral valve prolapse which can present as sharp pain beneath the sternum. − Cardiac vomiting [chardi]: Left ventricular receptors which appear to signal intramyocardial tension cause bradycardia and vasodilatation, and increase urine flow. They are probably im-portant in blood volume control and in adjusting the circulation during exercise. When strongly stimulated they cause nausea and reflex vomiting. They may be involved in the autonomic dis-turbances at the onset of myocardial infarction, syncope in aortic stenosis, vasovagal syncope, and fluid retention in heart failure.42 − The extra fluid in the body may cause increased urination, particularly at night which can lead to increase thirst [trishna]. [78] − Vataj Hridroga: As mentioned in sutrasthana the, grief, fasting, excessive exercise, intake of unctuous, dry and inadequate quantities of food, causes, vāta vitiation and affects the heart. 43 − Excruciating pain, trembling, cramps, stiffness, darkness, feeling of sense of emptiness, worsen-ing of pain after the digestion of food are the symptoms mentioned in Sutrasthana while ex-plaining the heart disease.44 [79] − Vataj Hridroga: Vata is necessary for the coordinated functioning of heart. If vata gets vitiated the conduction defects may occur. Tachycardia and bradycardia are the two main classification of impaired cardiac conduction. Dara or dardarika as explained by Chakrapani or hrudrava as explained by Yogindranath Sen explains the tachycardia. − Various rhythmic and arrhythmic tachycardia have been described by Modern science eg. Sinus tachycardia, which originates from the sino-atrial (SA) node, near the base of the superior vena cava, Atrial fibrillation, Atrial flutter, AV nodal reentrant tachycardia, Accessory pathway me-diated tachycardia, Atrial tachycardia, Multifocal atrial tachycardia, Junctional tachycardia, Ventricular tachycardia, any tachycardia that originates in the ventricles, any narrow complex tachycardia combined with a problem with the conduction system of the heart, often termed "supraventricular tachycardia with aberrancy", A narrow complex tachycardia with an accesso-ry conduction pathway, often termed "supraventricular tachycardia with pre-excitation" (e.g. Wolff–Parkinson–White syndrome). https://en.wikipedia.org/wiki/Tachycardia − Hridstambha explains the bradycardia. Stoppage, obstruction, suppression are various meaning of stambha. Sinus bradycardia, Sick sinus syndrome, AV block etc explain the condition of slow heart rate. Asystole, also known as flatline, is a state of no electrical activity from the heart and therefore no blood flow. It results in cardiac arrest. It may also be noted that tachycardia may later convert into asystole. Thus various conditions resulting into tachy and bradycardia may be considered in vataj hridroga.Near-fainting or fainting (murcha), dizziness, confusion or memory problems (pramoha/ sam moha) are the symptoms other then chest pain, Fatigue and Shortness of breath − Hritshunyata explains the emptiness due to non filling of the heart chambers, desolate is also meaning of sunyata or it may also be understood as akinesia wherein no movement (asystole) is observed. − Pittaj Hridroga: Acharya gives specific features and causes in Sutrasthana like intake of hot, sour, salty, alkaline (caustic) and pungent foods, taking food during indigestion, excess of alco-hol, anger, exposure to Sun, vitiates pitta located in the heart and gives rise to the symptoms like heartburn, bitter taste in the mouth, eruptions with bitter and sour taste, exhaustion, thirst, unconsciousness, dizziness, perspiration.45 [80] − Pittaj hridroga includes infective conditions of cardiac diseases like infective endocarditis/ my-ocarditis/ pericarditis, infective cardiomyopathy. Further alcohol, chemotherapeutic drugs, heavy metals like arsenic etc induced heart disease has similarity with pittaj hridroga. − A small number of patients present with fulminant myocarditis, with rapid progression from a severe febrile (jwar) respiratory syndrome to cardiogenic shock that may involve multiple organ systems, leading to renal failure, hepatic failure (cause for yellowish discoloration (pittata)), and coagulopathy. The cardiogenic shock leads to cardiac syncope (tamo darshan/ moha). The myalgia due to infection leads to distress (santras). Breakdown of haemoglobin may also be the cause for yellow discoloration alongwith hepatic involvement. In tuberculous pericarditis, fever, night sweats (sweda), and weight loss, were commonly noted. Acute pericarditis presents as burning pain sensation (daha). − Aetiological factors like excess use of saltexplains the vitiated increase of blood (rakta) which leads to hypervolaemia contributing to hypertension and thereby hypertensive cardiac disease. − Kaphaja Hridroga: Excessive intake of food, intake of heavy and unctuous food, inadequate mental exercise, sedentary habits, excessive sleep which gives rise to symptoms like, bradycar-dia, lesser activities of heart, stiffness and heaviness of the heart, drowsiness and anorexia. The patient feels as if he is loaded with stones.46 [80] − Kaphaja hridroga: stabdha, supta and stimita are the three symptoms mentioned by Caraka. The Sanskrit meaning of the word stabdha is firmly fixed, stiff, rigid, immovable, paralyzed, senseless, dull, solidified, tardy, slack, slow whereas supta means insensible, dull, resting, la-tent, inactive and stimita means fixed, rigid, unmoved, motionless, steady; paralysed, flowing gently along. − It means heart is motionless, inactive, slow, solidified, and rigid, these three words extend the scope of kaphaja hridroga from non infective cardiomyopathy to cardiac tamponade. − Pulseless electrical activity (PEA), also known by as electromechanical dissociation, refers to cardiac arrest in which a heart rhythm is observed only on the electrocardiogram. Pulseless electrical activity leads to a loss of cardiac output, and the blood supply to the brain is inter-rupted. As a result, PEA is usually noticed when a person loses consciousness (suptata) and stops breathing spontaneously. The cool touch resembles stimitata and the heaviness felt is ashmavrita. Alternately as there is no pulse, it may be explained as the suptata as Chakrapani defines suptata as motionless (niskriyata). The contractility of myocardium is reduced, resem-bling the stabdhata and due to collection of fluid the steady motionless condition wherein the apex beat is not palpable explains stimitata. − Sannipatika hridroga: This type of heart disease is caused by the combined vitiation of all the three doṣhas. This can be diagnosed by the existence of the various signs and symptoms of all the three types of heart diseases. This type of heart disease is very painful and difficult to cure. http://easyayurveda.com/2014/05/04/diseases-head-heart-abscess-charaka-samhita-sutrasthana-17/ − Rheumatic Fever should be correlated with pran avrita udan which may be the reason of tridosha involvement therefore multiple features appear like carditis, chorea etc are manifested. In this patient, dyspnea is common feature but chest pain is also severe complaint. − Rheumatic Fever if not corrected with appropriate antimicrobial drug in time is complicated as Rheumatic Heart Disease (RHD) where Aschoff nodules (granthivat jayate) are present in endo-cardium leading to endocarditis and inturn valvitis. Mitral valve is commonly affected followed by aortic valve involvement. It resembles the same explanation wherein Sannipataj hridroga patient when consumes diet favourable for krimi converts into krimija hridroga. − After explanation of five types of hridroga Charaka has explained differential diagnosis of chest pain. Cardiac and non cardiac chest pain do exist which present the symptoms at different phas-es of digestion such as stable angina pectoris usually develops gradually with exertion, emo-tional excitement, or after heavy meals. Similarly, chest discomfort due to esophageal reflux is worsened by post prandial recumbency and relieved by antacids so is the case with gall bladder disease wherein chest discomfort may follow meal whereas chest discomfort due to peptic ulcer is relieved with food and antacid. − Dust, smoke, excessive sexual intercourse, indigestion, contact with cold water are some com-mon aetiological factors between pratishyaya and hikka shwas which explains that these factors have impact on local immunity of pranvaha srotas (respiratory system). As previously discussed in hikka shwas chapter these factors stimulate the immune response leading to secretion from the nasal cavity (pratiśyāyamudīrayēttu). Śītairavaśyayā47 (cold dew drops) has been mentioned as one of the cause wherein avashyaya means water drops which may be compared with dew drops, fountains or in present era coolers and air conditioners which have been found to be common aetiological factors even in present era. (104-105) − All the pratishyaya if not treated and if aetiological factors are not avoided the pratishyaya dis-ease converts into dusta pratishyaya (persistent rhinitis). It may complicate into various disor-ders from hairloss to asthama, epistaxis etc disease. (107-109) − Caraka has mentioned that 64 various diseases of mukhroga. Depending on the seat of disease (lips, gums etc), symptoms, nomenclature etc but as the root cause of all these diseases is three dosha therefore these 64 diseases can be classified in to four groups such as vataj, pittaj, kaphaj and sannipataj and accordingly treatment has been mentioned. [122-123] − One of the causes of anorexia is atilobha; here it means repeated use of only one type of food which can cause aruchi (anorexia). [124-126] − − − − − − − − CHARTS − 1. Pathophysiology of udavarta and its complication − Food predominant in Kashaya, Katu, Tikta Rasa − Ruksha bhavad (Ca. Su. 26/60) − Katu Vipaka (Ca. Su. 26/58) − Increase of vitiated vata and Increase ruksha guna − Impaired peristalsis and increased absorption of fluid content as a feature of vikarvighat bha-va − Difficulty in passing/ retention of mutra (urine), purisha (faeces), vata (flatus) and retasa − Further vitiation of movement of vata − If takes tiryak gati Gulma − Vitiated vata if takes upward direction − − Further hampers digestion process Reduced nutrition − Retention of toxic factors Leads to ama visha − Dushit aahar rasa Nutritional Disorders (aandhya, badhirya) − − Ama janya vikar depending on sthana like hridroga, rajyakshma, mutragata etc (Ca. Ci 15/) − − − 2. Comparative pathology between Ischemic heart disease and Vatik Hridroga − Coronary Atherosclerosis Hridayasta Dhamani Pratichaya − Thrombosis Grathita Rakta − Narrowing of coronary vessel Srotosanga/Avarodha − Myocardial Ischaemia Apatarpana (Hridayastha) − Chest Pain Vataprakopa − I.H.D. Hrithshool (Chest Pain) − Vatik Hridroga − − − − − − − − − − 3. Pathology of vatika hridroga − − − − − − − − − − − − − − − − − − − − Role of excessive salt intake, stress leading to diseases related to trimarma − − − − − − − − − − 4. Relationship between Sannipatik and Krimija Hridroga: − Congenital cause (sahaja nidan) of Valvular disease − − Vitiate tridosha. − − Sannipatik hridroga − − with intake of krimija aahar − Krimija hridroga. − In CHD Secondary Infective Endocarditis may arise (Krimija hridroga) − − − − − − − − − − − − − − 5. Pathogenesis explaining how aortic stenosis causes chest pain and dyspnoea − − Rheumatic fever is one of the causes of Aortic Stenosis − Aortic Stenosis Systolic murmur − S2 – Loud − Ejection Sound − Lt. Ventricular Out flow Obstruction − Sanga − − C.O. Bhrama, Aayasena Shwas − − Vimargagaman − − Pranavaha Srotodushti Lt. Ventricular hypertrophy − Shwasadi Demand − Hridayagata vata − Chest pain − − − − − − − 6. Physiological Relationship between trimarma − − Courtesy: http://eurheartj.oxfordjournals.org/content/35/2/77 − − 1. udāvarta (उदावर्त- udAvarta): Abnormal condition characterized by retention of feces, urine and flatus, associated with pain and leading to or caused by anti-peristaltic move-ments in the body by vata. − 2. pravāhikā (प्रवाहिका- pravAhikA): spurious feeling of the need to evacuate stools with straining. − 3. asthilā (अष्ठील AShThIla): stony hard tumour − 4. śīta jwara (शीतज्वर- shItajwara) fever with external cold touch. − 5. vartiṁ (वर्ति-vartiM): Anal suppository − 6. pradhamēt (प्रधमेत्तु - pradhamett): Insufflations- powder is blowed up with the pipe/ tube in to the oleated anal canal − 7. prasannā (प्रसन्ना- prasannA): clear top portion of alcohol − 8. guḍasīdhu (गुडसीधु –guDasIdhu): wine prepared out of jaggery. − 9. dadhimaṇḍa (दधिमण्ड- dadhimaNDa): upper liquid portion of curd/ curd-scum − 10. ānāha (आनाह-AnAha): bloated abdomen above navel area − 11. bradhna (ब्रध्ना- bradhna): inguinal swelling − 12. mūtrakr̥cchra (मूत्रकृच्छ्र- mUtrakRucchra): Dysuria − 13. tripuṭ (त्रिपुट्य- tripuT): prismatic i.e. having three layers − 14. sēvanī (सेवनी- sevanI): perineum- suture below the pudendum and between two testicles. − 15. ccharkarā (च्छर्करा-ccharkarA): Graveluria − 16. aṇḍa stabdham (अण्डयोःस्तब्ध aNDa stabdham): stiffness of the testicles − 17. drava (द्रव-drava): palpitation/ tachycardia − 18. dūyana (दूयन- dUyana): giddiness − 19. santrāsa (सन्त्रास- santrAsa): distress − 20. stimita (त्स्तिमितं- stimita): timidity of heart − 21. vikartikā (विकर्तिका- vikartikA): cutting pain in this chapter it is related to Angina pain − 22. pratiśyāya (प्रतिश्याय-pratishyAya): Chronic rhinitis − 23. śirōbhitāpa (शिरोभिताshirobhitApa): excessive exposure of head to the heat − 24. duṣṭapratiśyāya (duShTapratishyAya): vicious coryza − 25. pratīnāha (प्रतीनाह- pratInAha): nasal obstruction − 26. parisrava (परिस्रवौ- parisrava): excessive discharge from the nose − 27. pūti ghrāṇa (पूतिघ्राण- pUtighrANa) foul smell in nostrils (ozena), − 28. apīnasa (अपीनस- apInasa- ) chronic rhinitis − 29. nāsāpāka (पाक- nasApAka) inflammation (suppurative rhinitis), − 30. nāsāśōtha (शोथा- shotha) swelling (oedematous rhinitis), − 31. nāsārbuda (अर्बुद- nasArbuda) growth/nasal tumor, − 32. pūyarakta (पूयरक्ताः- pUyaraktA) purulent and sanguineous rhinitis, − 33. arūṁṣi (अरूंषि- arUMShi) furunculosis − 34. vaisvarya (वैस्वर्ये- vaisvarye): hoarseness of voice − 35. śr̥ṅgāṭak (शृङ्गाट- shRu~ggATak): vital spot where the junction of vessels supplying nourishment to eye, nose and ear takes place. − 36. avapīḍaka (वपीडकः-avapIDaka): juice extracted after squeezing − 37. kavalagrahaḥ - (कवलग्रहः-kavalagrahaH): gargling or holding paste of drugs in mouth. − 38. gr̥hadhūmō (गृहधूमो- gRuhadhUmo): Kitchen shoot deposited after burning wood of various plants. − 39. Rasakriyā (रसक्रिया-rasakriyA): the decoction of daruharidra when solidified is called rasakriya. − 40. biḍālakaḥ (बिडालकः-biDAlakaH): application of drugs in paste form on the closed eye lids excluding eye-lashes. − 41. Āścyōtana (आश्च्योतनं- Ashcyotana): eye douche − 42. khālityē (खालित्ये- khAlityA): alopecia − 43. palitē (पलिते- palite): Graying of the hair − 44. Vali (वलि- vali): appearance of wrinkles over the face − 45. visūcikā (विसूचिका-visUcikA) diarrhea with pricking pain in abdomen − − − − − 1. https://www.cdc.gov/heartdisease/facts.htm, https://www.cdc.gov/nchs/fastats/stroke.htm, https://www.cdc.gov/nchs/fastats/deaths.htm − 2. Ca.Ci. 25/121 − 3. Ca. Ci. 25/6 − 4. Cakrapani Ca. Ci.26/1 − 5. Su. Sa. 6/15 − 6. Dr. Harsh Arvind July 2015 − 7. Dalhana Tika Su. Sa. 6/2 − 8. Su. Sa. 6/42 − 9. Ca. Su.11/48 − 10. Tanya Lewis Jan 2015 − 11. Ca.Si.9/5 − 12. Ca.Su.29/3 − 13. Su. Ut. 55/3 − 14. Ca. Vi. 7/12 − 15. Cakrapani Ca.Ci.26/104-106 − 16. http://eurheartj.oxfordjournals.org/content/35/2/77 − 17. Ca.Si.9/7 − 18. Ca Vi, 1/7 − 19. Ca.Su. 27/306 − 20. Ca. Si. 1/26 − 21. Su.Ut. 56/24-26 − 22. Su. Ni 3/1-28 − 23. Ca.Si 9/29 − 24. Ca.Si 9/32 − 25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4525130/ − 26. Fad diets and their effect on urinary stone formation:Antonio Nouvenne, Andrea Ticinesi, Ilaria Morelli, Loredana Guida, Loris Borghi,and Tiziana Meschi: PMID:9883212) − 27. Ibid − 28. Ibid − 29. Ibid − 30. Ibid − 31. Ibid − 32. Ibid − 33. Ibid − 34. Ca. Ci.11/11 − 35. https://en.wikipedia.org/wiki/Haematuria − 36. Dr.Ravishankar Shenoy 2015 − 37. Ca. Su. 6/27-32 − 38. C. Su. 17/34 − 39. https://en.m.wikipedia.org/wiki/Lupus_pernio − 40. http://en.m.wikipedia.org/wiki/Livedo_reticularis − 41. http://reference.medscape.com/features/slideshow/ci-card − 42. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC482594/pdf/brheartj00185-0013.pdf − 43. Ca.Su.17/30 − 44. Ca.Su.17/31 − 45. Ca.Su.17/32-33 − 46. Ca.Su.17/34-35 − 47. Ca.Ci.17/13 − − REFERENCE BOOKS − 1. CHARAK SAMHITA by AGNIVESHA edited by Yadavji Trikamji Acharya-Munshiram Mano-harlal Publishers Pvt. Ltd. 4th Edition. − − 2. SUSRUTA SAMHITA of SUSRUTA edited by Yadavji Trikamji Acharya- Chaukhamba Orien-talia, Varanasi- 6th Edition. − − − 3. ASTANGA HRUDAYA by vagbhat-chaukhamba publication − − 4. Caraka Samhita (Text with English translation & critical exposition based on Cakrapani Datta Ayurved Dipika) by R K Sharma and Bhagwan Dash, Chowkhamba Sanskrit Series Office, Va-ranasi. − − 5. HARRISON’S PRINCIPLES OF INTERNAL MEDICINE –Mc Graw Hill Medical Publication- 17th Edition (Volume I & II) − <div id="BackToTop" class="noprint" style="background-color:#DDEFDD; position:fixed; − bottom:32px; left:2%; z-index:9999; padding:0; margin:0;"><span style="color:blue; − font-size:8pt; font-face:verdana,sans-serif; border:0.2em outset #ceebf7; − padding:0.1em; font-weight:bolder; -moz-border-radius:8px; "> − [[#top| Back to the Top ]]</span></div>
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44. Vali (वलि- vali): appearance of wrinkles over the face
44. Vali (वलि- vali): appearance of wrinkles over the face
45. visūcikā (विसूचिका-visUcikA) diarrhea with pricking pain in abdomen
45. visūcikā (विसूचिका-visUcikA) diarrhea with pricking pain in abdomen