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An ayurvedic management of gastric polyp

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DrVishwajit Rajput

Ayurveda Specialists, INDIA

Efficacy of Kshara Application in the Management of Internal HemorrhoidsA Case Study
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Abstract A 59-year-old male patient came to the Outpatient department, CSMSS Ayurved Mahavidyalaya, Aurangabad, with complaints of prolapsing pile mass during defecation and bleeding while passing stool. The case was diagnosed as “Raktarsha” – 11 & 7 „o‟ clock position II degree internal hemorrhoids, deeply situated, projecting one and caused by pitta and rakta; with bleeding tendency. Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia. The pile mass and per rectal bleeding resolved in 7 days and the patient was relieved from all symptoms within 21 days. No complications were reported after the procedure. The result of the Pratisarneeya Kshara karma showed marked relief. Keywords: Arshas, Kshara karma, internal hemorrhoids, piles. Introduction Kshara is a derivative of plant drug ashes in the form of solutions, powder or crystals, all of which have the basic quality of being alkaline in nature. Acharya Sushruta has explained in detail regarding Kshara by dedicating a separate chapter which no other author has made. The prepared drug substance is called Kshara because it causes Ksharana (Destruction of tissue) to Mamsa and other Dhatu. Acharya Sushruta defines the Kshara as the substance possessing Ksharana and Kshanan (Destruction) properties and told that Kshara have Chedana (Excision), Bhedana and Lekhana (Scrapping) properties and also has Tridoshahara (Equilibrium of Vaata, Pitta and Kapha) properties and he has narrated Kshara considering its scope in Shalya Tantra. The classification of Kshara can be done in various ways on the basis of administration i.e. Paneeya and Pratisaraneeya, concentration i.e. Mrudu, Madhyama and Teekshna.[10] Kshara karma measures for hemorrhoids are mentioned in classical Ayurvedic texts, but it is not widely practiced in all over India. Therefore, this paper is being written to document the typical features of and outcomes of Kshara karma in management of hemorrhoids. Hemorrhoids occur in everyone; gradually, they become large and cause problems in only 4% of the general population and their prevalence peaks in people over 50 years of age.[1] Hemorrhoids that cause problems are found in 2 : 1 ratio of men and women.[2] Different treatment modalities are available like expectant medical therapy, injection treatment, rubber band ligation, manual dilatation, cryosurgery, infrared coagulation, and operative treatments like formal hemorrhoidectomy.[3] However, the risk of recurrence or of developing an infection of the wound after the operation is high.[4] Risk or complications of Milligan-Morgan hemorrhoidectomy are pain – varies virtually nil to very severe, retention of urine – 7% of patients required catheterization, secondary hemorrhage – 1.2% patients, development of abscess or fistula.[5] Also, the patient requires longer hospitalization in some of the procedures. Kshara karma (application of Pratisaraneeya kshara): It is a non-surgical procedure of Ayurveda indicated for the management of hemorrhoids. A medicine (alkaline in nature) derived from a combination of various herbs is applied to the pile mass with the help of a special slit proctoscope.[6] It is Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.64 a type of chemical cauterization. The Kshara karma method and preparation of the herbal combination of treating piles has been described in detail in the ancient text Sushruta Samhita. And also, the superiority of kshara over sharp instruments (sastras) and accessory sharp instruments (anusastras) has been mentioned in Sushruta Samhita.[9] 10 Kg of Achyranthes aspera (Apamarga) is burnt to get 1 kg of ash. One Kg of ash is mixed with six times of water to form a solution, which is filtered using a sterile cloth. The filtrate was boiled slowly to reduce it to 2/3 of quantity, followed by addition of 100 g of Oyster or Pearl (shukthi) shell powder. The solution is again boiled slowly. To this solution, 10 g of powdered Plumbago zeylanica (Citraka), Gloriosa superba (Langali), Acorus calamus (Vacha), and Coral (Pravala) are added to get semisolid, brownish-colored paste; this is collected and stored in dry glass bottle. Acharya Sushruta has narrated Kshara as an Anushastra [6] and one of the Upakrama for abhyantar arsha[7] and it has been proved to be effective in treating many disorders like Dushta Vrana, Bhagandara, Vrana, Charmakeela. Case Report A 59-year-old male patient came to the Outpatient department, CSMSS Ayurved Mahavidyalaya, Aurangabad, with complaints of prolapsed pile mass during defecation, but mass returns spontaneously to the anal canal and occasional bleeding twice in a week during defecation since 11 months. Proctoscopic examination confirmed the diagnosis as a case of 11 & 7 „o‟ clock position second-degree internal hemorrhoids. The patient was under allopathic treatment for the above complaints and did not try any other system of medications. After careful interrogation of the patient, the following causative factors were identified as mentioned in classical texts. i.e., daily two-wheeler riding (utkata, kathina visamasana), intake of more spicy (vidahi), sweet (madhura) and cold (sita) food, irregular food habits (ajirna bhojana), and straining to pass stool (pratata atipravanhana) habitually. This is a primary disease (Svatantra vyadhi), with impaired digestion (agnimandya) as the underlying pathogenesis. The patient was not willing to undergo modern surgery and requested Ayurvedic treatment. Hence, Kshara karma procedure was offered. This particular case was treated by Kshara karma because it was having symptoms of „Raktarsha‟ (bleeding piles) with soft-elevated, well-defined mass. The bleeding was also noted during proctoscopic examination. The Kshara karma application in treating “Raktarsha” has been indicated in the ancient text Susruta-Samhita[8] Before planning treatment, Complete blood count and other tests were done to rule out conditions like Anemia, Clotting disorder, other infective disorder, Human immunodeficiency virus, Diabetes Mellitus, and Hepatitis. The patient was kept in lithotomy position then lubricated Arshoyantra (proctoscope) was introduced in anal canal (under local anesthesia) and the selected pile mass was arrested in the slit and cleaned thoroughly with gauze piece. Pratisaraniya kshara was applied on 11 and 7 „O‟ clock position internal hemorrhoids one after the other. After 2 minutes minutes when samyak dagdha lakshana appear the Kshara was washed out from the pile mass with nimbu swaras and Yashtimadhu ghrita was applied to overcome the burning sensation. It was observed that the pile mass has reduced in size and its color has turned to blackish brown (pakva jambu phalavarna in shatamatrakala).[7]. The patient was discharged on the same day after 3 hours of observation, as there was no postoperative bleeding. Patient was asked to attend surgical clinic for anal examination once a week for 4 weeks. Diet and lifestyle guidelines and corrections were suggested to the patient and patient was expected to follow these guidelines for at least 3 months. For this one-month period, following medications were prescribed to cure digestive impairment (agnimandya), to reduce pain and inflammation and promote healing. Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.65 Orally: Haridradi Kashayam (50 ml with honey, twice in a day after meal), Gandharv Haritaki 4 gm with lukewarm water was given daily at bed time. Lukewarm sitz bath(triphala quath avgah) was advised after each defecation twice in a day. After sloughing out of pile mass (usually in 3-5 days) Jatayadi taila(5ml twice a day) was applied in anal canal for healing purpose. . During each follow-up visit, signs and symptoms were assessed. There was moderate to mild pain, tenderness, inflammation, and brownish black discharge on first visit and second visit. During the third and fourth visit, there was no pain, tenderness, discharge, or anal stricture and the internal hemorrhoids had completely resolved Table 1 Table 1- Follow-up observation form Follow-up observation form To assess pain in this particular case, following criteria were adopted: Severe – To relieve from pain, analgesic injections are required/Pain or discomfort dose not reduce after oral analgesics. Moderate – To relieve from pain, oral analgesics are required. Mild – Feeling discomfort within tolerable limit, no requirement of analgesic either orally or in other route. Nil – No discomfort in any manner in the site, no analgesics. Discharge – Severe – Changing sanitary pads or cotton pads minimum 2 times a day Moderate – Changing of pads once a day only Mild – No requirement of pads Nil – Area is completely dry Tenderness standard assessment Severe – Patient feeling pain by touching perianal area. Not possible to perform P/R examination. Moderate – Little finger P/R can be done, patient feeling very much tolerable pain Mild – Index finger P/R done with very much tolerable pain Nil – Index finger insertion to anal canal without any pain or discomfort Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.66 Discussion Pratisaraneeya kshara was applied to the internal hemorrhoids. It was observed that the Pile mass became black in 50 seconds as described in the Sushruta Samhita. nimbu swaras (citric acid) was used to neutralize the kshara after proper burning of pile mass. Pratisaraneeya kshara causes coagulation of Hemorrhoid plexus (cauterization of pile mass), necrosis of tissue followed by fibrosis of plexus, adhesion of mucosal, submucosal coat helps in prevention of further dilatation of veins and prevents prolapse of regional mucosa of anus. This makes permanent radical obliteration of Hemorrhoids. Detailed action of Pratisaraneeya kshara from the time of application up to 21 days are shown in Table 2. The whole treatment that was given to the patient is presented below as a flow chart. Table 2- Action of Pratisaraneeya kshara In present day practice, application of Kshara is found to be a safe, efficacious, and costeffective method for management of internal hemorrhoids. Compilation of case reports and clinical studies are needed to standardize the treatment protocol and define outcome measures. In this way, comprehensive treatment guidelines can be formulated. Conclusion Pratisaraneeya kshara was found effective in obliterating the hemorrhoid mass within 21 days of application. The patient was followed up regularly and proctoscopic examination did not reveal any evidence of recurrence of the hemorrhoids. The patient was on active treatment for only a period of one months. Diet restrictions were followed for another year. This case study shows that a combination of kshara karma, conservative treatment (samana aushadhis), diet restrictions, and life style modifications administered over a period of 3 months is effective in obliterating the pile mass as well as preventing recurrence on a long-term basis. Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.67 References 1. Goligher J, Duthie H, Nixon H. Surgery of the Anus, Rectum and Colon. Vol. 1. New Delhi: A.I.T.B.S. Publishers and Distributors; 2004. p. 98. 2. Goligher J, Duthie H, Nixon H. Surgery of the Anus, Rectum and Colon. Vol. 1. New Delhi: A.I.T.B.S. Publishers and Distributors; 2004. p. 105. 3. Ssat.com [Internet]. Beverly: ssat.com is an online, Thesocity for surgery of the alimentary tract Foundation, Inc. 2011. Available from: http://www.ssat.com/cgi-bin/hemorr.cgi . 4. Goligher J, Duthie H, Nixon H. Surgery of the Anus, Rectum and Colon. Vol. 1. New Delhi: A.I.T.B.S. Publishers and Distributors; 2004. pp. 137–9. 5. Paradakar HS, editor. Ashtanga Hridaya. Varanasi: Chaukhambha Surbharti Prakashan; 2007. p. 643. 6. Acharya JT, editor. Sushruta Samhita. Varanasi: Chaukhambha Surbharti Prakashan; 1997. p. 48. 7. Paradakar HS, editor. Ashtanga Hridaya. Varanasi: Chaukhambha Surbharti Prakashan; 2007. p. 355. 8. Acharya JT, editor. Sushruta Samhita. Varanasi: Chaukhambha Surbharti Prakashan; 1997. p. 45. 9. Acharya JT, editor. Sushruta Samhita. Varanasi: Chaukhambha Surbharti Prakashan; 1997. p. 430. 10. Acharya Sushruta, Sushruta Samhita, Dalhana. Nibandhasangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya, Chaukhambha Sanskrit Sansthan, Varanasi, Reprint, Sutrasthana 2013; 11(3/4/6/11):45-47; 8(15):41

Abstract A 59-year-old male patient came to the Outpatient department, CSMSS Ayurved Mahavidyalaya, Aurangabad, with complaints of prolapsing pile mass during defecation and bleeding while passing stool. The case was diagnosed as “Raktarsha” – 11 & 7 „o‟ clock position II degree internal hemorrhoids, deeply situated, projecting one and caused by pitta and rakta; with bleeding tendency. Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia. The pile mass and per rectal bleeding resolved in 7 days and the patient was relieved from all symptoms within 21 days. No complications were reported after the procedure. The result of the Pratisarneeya Kshara karma showed marked relief. Keywords: Arshas, Kshara karma, internal hemorrhoids, piles. Introduction Kshara is a derivative of plant drug ashes in the form of solutions, powder or crystals, all of which have the basic quality of being alkaline in nature. Acharya Sushruta has explained in detail regarding Kshara by dedicating a separate chapter which no other author has made. The prepared drug substance is called Kshara because it causes Ksharana (Destruction of tissue) to Mamsa and other Dhatu. Acharya Sushruta defines the Kshara as the substance possessing Ksharana and Kshanan (Destruction) properties and told that Kshara have Chedana (Excision), Bhedana and Lekhana (Scrapping) properties and also has Tridoshahara (Equilibrium of Vaata, Pitta and Kapha) properties and he has narrated Kshara considering its scope in Shalya Tantra. The classification of Kshara can be done in various ways on the basis of administration i.e. Paneeya and Pratisaraneeya, concentration i.e. Mrudu, Madhyama and Teekshna.[10] Kshara karma measures for hemorrhoids are mentioned in classical Ayurvedic texts, but it is not widely practiced in all over India. Therefore, this paper is being written to document the typical features of and outcomes of Kshara karma in management of hemorrhoids. Hemorrhoids occur in everyone; gradually, they become large and cause problems in only 4% of the general population and their prevalence peaks in people over 50 years of age.[1] Hemorrhoids that cause problems are found in 2 : 1 ratio of men and women.[2] Different treatment modalities are available like expectant medical therapy, injection treatment, rubber band ligation, manual dilatation, cryosurgery, infrared coagulation, and operative treatments like formal hemorrhoidectomy.[3] However, the risk of recurrence or of developing an infection of the wound after the operation is high.[4] Risk or complications of Milligan-Morgan hemorrhoidectomy are pain – varies virtually nil to very severe, retention of urine – 7% of patients required catheterization, secondary hemorrhage – 1.2% patients, development of abscess or fistula.[5] Also, the patient requires longer hospitalization in some of the procedures. Kshara karma (application of Pratisaraneeya kshara): It is a non-surgical procedure of Ayurveda indicated for the management of hemorrhoids. A medicine (alkaline in nature) derived from a combination of various herbs is applied to the pile mass with the help of a special slit proctoscope.[6] It is Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.64 a type of chemical cauterization. The Kshara karma method and preparation of the herbal combination of treating piles has been described in detail in the ancient text Sushruta Samhita. And also, the superiority of kshara over sharp instruments (sastras) and accessory sharp instruments (anusastras) has been mentioned in Sushruta Samhita.[9] 10 Kg of Achyranthes aspera (Apamarga) is burnt to get 1 kg of ash. One Kg of ash is mixed with six times of water to form a solution, which is filtered using a sterile cloth. The filtrate was boiled slowly to reduce it to 2/3 of quantity, followed by addition of 100 g of Oyster or Pearl (shukthi) shell powder. The solution is again boiled slowly. To this solution, 10 g of powdered Plumbago zeylanica (Citraka), Gloriosa superba (Langali), Acorus calamus (Vacha), and Coral (Pravala) are added to get semisolid, brownish-colored paste; this is collected and stored in dry glass bottle. Acharya Sushruta has narrated Kshara as an Anushastra [6] and one of the Upakrama for abhyantar arsha[7] and it has been proved to be effective in treating many disorders like Dushta Vrana, Bhagandara, Vrana, Charmakeela. Case Report A 59-year-old male patient came to the Outpatient department, CSMSS Ayurved Mahavidyalaya, Aurangabad, with complaints of prolapsed pile mass during defecation, but mass returns spontaneously to the anal canal and occasional bleeding twice in a week during defecation since 11 months. Proctoscopic examination confirmed the diagnosis as a case of 11 & 7 „o‟ clock position second-degree internal hemorrhoids. The patient was under allopathic treatment for the above complaints and did not try any other system of medications. After careful interrogation of the patient, the following causative factors were identified as mentioned in classical texts. i.e., daily two-wheeler riding (utkata, kathina visamasana), intake of more spicy (vidahi), sweet (madhura) and cold (sita) food, irregular food habits (ajirna bhojana), and straining to pass stool (pratata atipravanhana) habitually. This is a primary disease (Svatantra vyadhi), with impaired digestion (agnimandya) as the underlying pathogenesis. The patient was not willing to undergo modern surgery and requested Ayurvedic treatment. Hence, Kshara karma procedure was offered. This particular case was treated by Kshara karma because it was having symptoms of „Raktarsha‟ (bleeding piles) with soft-elevated, well-defined mass. The bleeding was also noted during proctoscopic examination. The Kshara karma application in treating “Raktarsha” has been indicated in the ancient text Susruta-Samhita[8] Before planning treatment, Complete blood count and other tests were done to rule out conditions like Anemia, Clotting disorder, other infective disorder, Human immunodeficiency virus, Diabetes Mellitus, and Hepatitis. The patient was kept in lithotomy position then lubricated Arshoyantra (proctoscope) was introduced in anal canal (under local anesthesia) and the selected pile mass was arrested in the slit and cleaned thoroughly with gauze piece. Pratisaraniya kshara was applied on 11 and 7 „O‟ clock position internal hemorrhoids one after the other. After 2 minutes minutes when samyak dagdha lakshana appear the Kshara was washed out from the pile mass with nimbu swaras and Yashtimadhu ghrita was applied to overcome the burning sensation. It was observed that the pile mass has reduced in size and its color has turned to blackish brown (pakva jambu phalavarna in shatamatrakala).[7]. The patient was discharged on the same day after 3 hours of observation, as there was no postoperative bleeding. Patient was asked to attend surgical clinic for anal examination once a week for 4 weeks. Diet and lifestyle guidelines and corrections were suggested to the patient and patient was expected to follow these guidelines for at least 3 months. For this one-month period, following medications were prescribed to cure digestive impairment (agnimandya), to reduce pain and inflammation and promote healing. Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.65 Orally: Haridradi Kashayam (50 ml with honey, twice in a day after meal), Gandharv Haritaki 4 gm with lukewarm water was given daily at bed time. Lukewarm sitz bath(triphala quath avgah) was advised after each defecation twice in a day. After sloughing out of pile mass (usually in 3-5 days) Jatayadi taila(5ml twice a day) was applied in anal canal for healing purpose. . During each follow-up visit, signs and symptoms were assessed. There was moderate to mild pain, tenderness, inflammation, and brownish black discharge on first visit and second visit. During the third and fourth visit, there was no pain, tenderness, discharge, or anal stricture and the internal hemorrhoids had completely resolved Table 1 Table 1- Follow-up observation form Follow-up observation form To assess pain in this particular case, following criteria were adopted: Severe – To relieve from pain, analgesic injections are required/Pain or discomfort dose not reduce after oral analgesics. Moderate – To relieve from pain, oral analgesics are required. Mild – Feeling discomfort within tolerable limit, no requirement of analgesic either orally or in other route. Nil – No discomfort in any manner in the site, no analgesics. Discharge – Severe – Changing sanitary pads or cotton pads minimum 2 times a day Moderate – Changing of pads once a day only Mild – No requirement of pads Nil – Area is completely dry Tenderness standard assessment Severe – Patient feeling pain by touching perianal area. Not possible to perform P/R examination. Moderate – Little finger P/R can be done, patient feeling very much tolerable pain Mild – Index finger P/R done with very much tolerable pain Nil – Index finger insertion to anal canal without any pain or discomfort Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.66 Discussion Pratisaraneeya kshara was applied to the internal hemorrhoids. It was observed that the Pile mass became black in 50 seconds as described in the Sushruta Samhita. nimbu swaras (citric acid) was used to neutralize the kshara after proper burning of pile mass. Pratisaraneeya kshara causes coagulation of Hemorrhoid plexus (cauterization of pile mass), necrosis of tissue followed by fibrosis of plexus, adhesion of mucosal, submucosal coat helps in prevention of further dilatation of veins and prevents prolapse of regional mucosa of anus. This makes permanent radical obliteration of Hemorrhoids. Detailed action of Pratisaraneeya kshara from the time of application up to 21 days are shown in Table 2. The whole treatment that was given to the patient is presented below as a flow chart. Table 2- Action of Pratisaraneeya kshara In present day practice, application of Kshara is found to be a safe, efficacious, and costeffective method for management of internal hemorrhoids. Compilation of case reports and clinical studies are needed to standardize the treatment protocol and define outcome measures. In this way, comprehensive treatment guidelines can be formulated. Conclusion Pratisaraneeya kshara was found effective in obliterating the hemorrhoid mass within 21 days of application. The patient was followed up regularly and proctoscopic examination did not reveal any evidence of recurrence of the hemorrhoids. The patient was on active treatment for only a period of one months. Diet restrictions were followed for another year. This case study shows that a combination of kshara karma, conservative treatment (samana aushadhis), diet restrictions, and life style modifications administered over a period of 3 months is effective in obliterating the pile mass as well as preventing recurrence on a long-term basis. Aayushi International Interdisciplinary Research Journal (AIIRJ) UGC Approved Sr.No.64259 Vol – IV Issue-IX SEPTEMBER 2017 ISSN 2349-638x Impact Factor 3.025 Email id’s:- [email protected],[email protected] I Mob.09922455749 website :- http://www.aiirjournal.com l UGC Approved Sr.No.64259 Page No.67 References 1. Goligher J, Duthie H, Nixon H. Surgery of the Anus, Rectum and Colon. Vol. 1. New Delhi: A.I.T.B.S. Publishers and Distributors; 2004. p. 98. 2. Goligher J, Duthie H, Nixon H. Surgery of the Anus, Rectum and Colon. Vol. 1. New Delhi: A.I.T.B.S. Publishers and Distributors; 2004. p. 105. 3. Ssat.com [Internet]. Beverly: ssat.com is an online, Thesocity for surgery of the alimentary tract Foundation, Inc. 2011. Available from: http://www.ssat.com/cgi-bin/hemorr.cgi . 4. Goligher J, Duthie H, Nixon H. Surgery of the Anus, Rectum and Colon. Vol. 1. New Delhi: A.I.T.B.S. Publishers and Distributors; 2004. pp. 137–9. 5. Paradakar HS, editor. Ashtanga Hridaya. Varanasi: Chaukhambha Surbharti Prakashan; 2007. p. 643. 6. Acharya JT, editor. Sushruta Samhita. Varanasi: Chaukhambha Surbharti Prakashan; 1997. p. 48. 7. Paradakar HS, editor. Ashtanga Hridaya. Varanasi: Chaukhambha Surbharti Prakashan; 2007. p. 355. 8. Acharya JT, editor. Sushruta Samhita. Varanasi: Chaukhambha Surbharti Prakashan; 1997. p. 45. 9. Acharya JT, editor. Sushruta Samhita. Varanasi: Chaukhambha Surbharti Prakashan; 1997. p. 430. 10. Acharya Sushruta, Sushruta Samhita, Dalhana. Nibandhasangraha commentary, Edited by Yadavji Trikamji Acharya and Naarayana Ram Acharya, Chaukhambha Sanskrit Sansthan, Varanasi, Reprint, Sutrasthana 2013; 11(3/4/6/11):45-47; 8(15):41

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