Atisara – Charaka Chikitsa Sthana 19th Chapter

The 19th chapter of Charaka Samhita Chkitsa Sthana is Atisara Chikitsa Adhyaya. It deals with symptoms, types and treatment of diarrhea and dysentery.

Chapter 19
We shall now explore the chapter on the treatment of Atisara (diarrhea, dysentery). Thus said Lord Atreya [1-2]

Prologue
Lord Atreya was sitting on the northern slope of Himalayas surrounded by sages, after completing his daily worship and oblations to the fire, Agnivesha approached him, offered his salutations and asked him to kindly expound the origin, etiology, signs and symptoms, and treatment of Atisara for the well-being of humanity. [3]

Mythological origin of Atisara

Hearing to the plea of Agnivesha, lord Punarvasu said “O! Agnivesha, hear me. I shall explain every topic of your query in detail”.
In ancient times, the sacrificial animals were released soon after the recitation of the Sacrificial Mantras, and these animals were not actually killed during the course of the sacrifice (yajna).
However, in later times, Daksha Prajapati, the sons of Manu, like Narisyan, Nabhaga, Iksvaku, Nrga and Saryathi started actually assassinating these sacrificial animals during the performance of Yajna (Sacrificial ritual) thinking that it was so ordained in the Shastras (Scriptures) or being pressed by the animals themselves [as it was felt that the animals associated during the sacrifice will directly attain heaven].
Subsequently, it became quite impossible to get other animals in the required number, and Prushadhra who was performing a sacrifice (Yajna) or long duration, started sacrificing even bulls and cows. After observing this, the living creatures were bewildered. The meat of the scarified bulls and cows proved to be too heavy, too hot and too harmful. Person par-taking that meat started suffering from the loss of the power of digestion and loss of mental equilibrium. Thus, Atisara (diarrhea) originated from the sacrifice (Yajna) performed by Prushadhra. [4]

Vataja Atisara Nidana, Samprapti, Lakshana

Causes for Vataja Atisara:
As a consequence of the above mentioned primordial causative factor, at later stage [Vatika type of Atisara is manifested] if a person having Vatika type of constitution resorts to the following factors:
Vatala vata aatapa vyayama atimatra- Exposure to the excessively strong wind, hot sun and physical exercise
Ruksha alpa – Indulgence in dry food or pramitasana- less quantity of food or irregular meals or Teekshna madya – strong alcoholic drinks or Vyavaya – excessive sexual intercourse and
Suppression of natural urges

Vataja Atisara Samprapti: Pathogeneisis:
Because of the aforementioned factors, Vata Dosha gets aggravated and the power of digestion (Agni) gets afflicted.
The aggravated Vata, forcefully brings down the urine and sweat (moistness in the body) to the colon (Purishashaya), and with the help of these (urine and sweat) liquefies the stool, causing diarrhea thereby.

The signs and symptoms of the Vataja type of Atisara, when associated with Ama
1. Vit jalam amam – The stool is slimy and mixed with Mucus (Ama)
2. The stool floats on water
3. The stool when placed over the earth, gets soaked
4. Ruksham dravam – The stool is rough and liquid
5. Sa shula aamagandha – defecation is associated with colic pain
6. The stool smells like undigested food
7. Defecation is associated with less of sound or no sound at all
8. It is associated with non-voiding of flatus and urine and
9. The aggravated Vayu (flatus) moves in the Kostha (gastro intestine tract) obliquely along with gurgling sound, while causing colic pain.

Signs and symptoms of Pakwa Vataja Atisara:
1. the patient voids hard stool in small quantities
2. The voiding of stool is associated with sound and colic pain
3. The stool is frothy and slimy
4. The patient suffers from griping pain, horrification, groaning, dryness of the mouth, pain in the lumber region, things, sacral region, knees, back and sides of the chest, and prolapsed of the rectum and
5. He voids granular (grathita) stool frequently.

According to some physicians, this type of diarrhea is also called Anugrathita-Atisara because of the voiding of Scybalous stool. [5]

Pittaja Atisara Nidana, Samprapti, Lakshana

Causes for Pittaja Atisara:
A person of Paittika contribution indulging in the following factors gets type of Atisara (Diarrhea):
1. Excessive intake of Amla (sour), Lavana (salt), Katu (pungent), Kshara (alkaline) Ushna (hot) and Teekshna (sharp) ingredients.
2. Pratata Agni Surya Santapa ushna marutopahata gatrasya – Affliction of the body by excessive expose to the heat of strong (pratata) fire, hot rays of the sun and hot wind; and
3. Krodha irshya bahula – Excessively wrathful and jealous disposition
By the above mentioned factors, Pitta gets aggravated.

Paittika Atisara Samprapti: pathogenesis:
This aggravated Pitta on account of this liquidity suppresses the power of Agni (power of digestion), and having arrived at the colon, disintegrates the stool because of its heat liquidity and mobility thereby causing Paittika type of Atisara (Diarrhea).

The signs and symptoms of Paittika Atisara:
1. Haridram, haritam, nilam, krshnam purisham -The patient voids frequent loose motions which are either yellow, green blue or black in color
2. Rakta pitta upahita, ati durgandha purisham – The stool is mixed with blood and bile, and it is excessively foul smelling and
3. The patient suffers from Trishna (excess thirst), Daha (burning sensation), Ati sweda(excessive sweating), Murcha (fainting), Shula (colic pain) and Santapa (hot sensation) and
4. There is suppression of the anus [6]

Kaphaja Atisara Nidana, Samprapti, Lakshana

Causes for Kaphaja Atisara:
A person of Kapha type of constitution indulging in the following factors gets Kaphaja type of Atisara (diarrhea)
1. Guru madhura shita snigdha ahara sevana – Intake of heavy, sweet, cold and unctuous ingredients in excess
2. Inactivity of the mind, lethargy and
3. Diva swapna – Habitually sleeping during the day time

Kaphaja Atisara Samprapti: Pathogenesis:
Because of the above mentioned factors, Kapha gets aggravated, by nature, Kapha is heavy, sweet, cold and unctuous. It moves downwards (because of its heaviness, etc). And afflicts the agni (power of digestion) because of its natural cooling property. Thereafter, having arrived at the colon, it liquefies the stool to cause diarrhea.

The signs and symptoms of Kaphaja Atisara:
1. The patient voids stool which is Snigdha (unctuous), Shwetam (white), Picchila (slimy), fibrous, mixed with mucus as well as undigested food particles, Guru (heavy), Durgandham (foul- smelling) and mixed with phlegm
2. Badhha shoola – The patient suffers from continuous pain.
3. Alpam abhikshnam atisara – He voids stool, frequently in small quantities
4. Pravahikam – The voiding of stool is associated with griping pain
5. Guru udara guda basti vankshana shoola- The patient suffers from heaviness in the abdomen, in the region of urinary bladder and in the pelvic region
6. The patient feels the urge for passing another bout of stool even after evacuation and
7. He suffers from Loma harsha (horripilation), Utklesha (Nausea), Ati nidra (excessive sleep), Aalasya (indolence), Sadana (prostration) and Anna dveshi (dislike for food). [7]

Sannipatik Atisar Nidan, Samprapti

Causes for Sannipatika Atisara (diarrhea caused by the simultaneous vitiation of all the 3 Doshas)
1. Intake of Ati sheeta (excessive cold), Snigdha (unctuous), Ruksha (dry), Ushna (hot) Guru (heavy), Khara (coarse) and Kathina (hard) ingredients
2. Intake of Vishama aahara(irregular meals), Viruddha (ingredients of food having mutually contracting properties) and unwholesome food.
3. Abhojana – Avoiding intake of food.
4. Kalaateeta bhojana – Intake of food long after the scheduled time
5. Yat kinchat abhyavaranat – Intake of food without caring for its wholesomeness or otherwise
6. Pradusta madya paniya pana – Drinking of alcohol and other drinks which are polluted
7. Ati madyapana – Drinking of alcohol in excess
8. Samshodhana pratikarma – Not resorting to elimination therapies[ in appropriate seasons]
9. Inappropriate administration or non-administration of therapies
10. Vishama gamana, anupa chara jvala aditya pavana salila sevana – Excessive exposure to fire, hot rays of the sun, strong wind and bath, etc., in strong current of water
11. Ati svapna vega – Not sleeping or sleeping in excess
12. Vega vidharana – Suppression of natural urges
13. Not resorting to appropriate regimens during different seasons.
14. Over daring attitude
15. Shoka, udvega – Excessive exposure to fear, grief and anxiety and
16. Krsha due to Krimi, Jvara,sosha – Excessive emaciation due to worm- infection, consumption, fever and piles bleeding
Because of the above mentioned causative factors, the Agni (power of digestion) gets vitiated as a result of which all the 3 Doshas get aggravated. These aggravated Doshas, in their turn, further afflict the Agni, and having entered into Pakvashaya (colon), cause Atisara(diarrhea) in which the signs and symptoms of all the 3 types of Atisara(viz, Vatika,Paittika and kaphaja Atisara, described before) are manifested. [8]

Signs and symptoms of Sannipatika Atisara
The 3 aggravated Doshas (referred to above cause excessive vitiation of Dhatus (Tissue elements) like Rakta (blood) resulting in the manifestation of different colors [in the stool]. The nature of these colors depends upon the nature of the vitiated Dhatus and Doshas. If the Dhatus like Rakta are excessively vitiated, then the following signs and symptoms are manifested
1. The patient voids stool having yellow (like the color of turmeric), green, blue, reddish (like the meat is Manjistha), pink (like the color of water in which meat is washed), red black, white and yellowish (like the color of the pig-fat) in color.
2. The patient suffers from continuous pain or he may be free from any pain [in the abdomen]
3. Sometimes, the patient may void scybalous stool, sometimes it may be mixed with mucus (Ama) and sometimes, the stool may be free from Mucus (Pakva).
4. There is diminution of the muscle tissue, blood and strength
5. The power of digestion (Agni) of the patient is suppressed and
6. There is impairment of the taste in the mouth of the patient
Such a patient is Kricchra-Sadhya (difficult of cure).

The patient becomes Asadhya (incurable) if the Diarrhea is associated with the colors and complications as follows:

1. The patient voids stool having the color of digested blood, (Mealena), piece of liver, washing of fat or flesh, curd, ghee, bone- marrow, oil, muscle fat (Vasa) milk and Vesavara (minced meat).
2. The color of the stool is excessively blue, red, black, transparent like water or tar- colored
3. The stool is exceedingly greasy
4. The color of the stool is a mixture of green, blue and brown (Kashaya)colors
5. The stool is variegated in color(Karbura), dirty, slimy, fibrous, mixed with mucus and spotted with Candraka (colored patches circular in shape like moon)
6. The stool has exceedingly bad smell like that of a dead body or it is exceedingly putrid in smell or the stool bears the smell of undigested products or it is like(raw) fish
7. The stool attracts flies in excess
8. The stool contains sloughs (Kuthita) and tissue elements in excess
9. The stool contains less or no fecal matter
10. The patient continuously suffers from Trshna(excess thirst), Daha (burning sensation), Jwara (fever), Pralapa (giddiness), Murcha (fainting), Hikka (hiccup), Shvasa (asthma), Tivra shoola (excessive pain) or no pain
11. There is prolapsed and inflammation of the anal canal or the rectum sphincters come out of their sites or the whole of the rectum comes out (mukta- Nala)
12. There is excessive loss of strength, muscle tissue and blood,
13. Parva asthi shoola – There is pain in all the joints and bones
14. The patient suffers from excessive form of Aruchi (anorexia), Arati (dislike for every thing), Pralapa (Delirium) and Sammoha(unconsciousness), and
15. There is sudden cessation of the signs and symptoms of the disease.
Such a patient is rejected.
These are the characteristic features of Sanipatika type of Atisara (Diarrhea). [9]

Atisara Chikitsa – Treatment

The patient who has not yet reached the state of absolute incurability is properly treated after the examination of causative factors, Upashaya (treatability) and nature of the aggravation of specific Doshas.
In this condition, the most aggravated Dosha is treated in the beginning followed by the treatment of the less aggravated Doshas. [10]

Agantuja Atisara

The exogenous type of Atisara (Diarrhea) is of mental origin, and is of 2 types.
1. Bhayaja – fear and
2. Shokaja – grief
Their signs and symptoms are similar to those of the Vatika type of Atisara. [11]

Management of Exogenous (mental) Diarrhea:
Because of fear and grief, Vayu gets aggravated instantaneously. Therefore, for the treatment of these 2 varieties of Diarrhea, Vayu-alleviating drugs and therapies are administered.
The patient suffering from diarrhea caused by fear (Bhayaja) is exhilarated, and the patient suffering from Diarrhea caused by Shoka (grief) is consoled for their cure.
Thus, 6 types of Atisara (Diarrhea) are described above, the curable varieties of these is treated. Therefore, the methods of their treatment will be described seriatim. You (addressed to the disciples) should understand these methods appropriately. [12-13]

Atisara Chikitsa Sutra

Atisara Line of treatment:
When the diarrhea is caused by the aggravated Doshas impelled by Vidagdha (Undigested) food, the patient is given laxative to eliminate these Doshas. It is not desirable to give laxatives in the beginning in the Ama (primary or immature) stage of Diarrhea.
When ama is not there in the initial stage, administration of such bowel-binding therapies (Sangrahana chikitsa) obstructs the movement and elimination of the already aggravated Doshas which gives rise to several diseases (complications) like
Dandakalasaka (obstruction to intestinal peristalsis),
Adhmana (flatulence),
Grahani (sprue syndrome)
Arshas (Piles),
Bhagandara (Fistula- in Ano),
Shotha (Oedema),
Pandu (Anaemia)
Pliha (Splenic disorders),
Kushta (obstinate skin diseases including leprosy),
Gulma (phantom tumor),
Udara (obstinate abdominal diseases including ascities) and
Jwara – fever.
Therefore, the physician should ignore the downward movement of the already detached (Utklista) morbid matter which is moving downwards on its own.
By implication, diarrhea is allowed to continue and should not be stopped by constipative medicine.
If the Diarrhea is associated with griping pain (difficulty in voiding), then Haritaki – Harad is given as a mild laxative.

When the morbid matter is eliminated through downward movement [as suggested above], then it gets cured, the body becomes light and the l Agni (power of digestion) becomes strong.
If the Doshas are moderately aggravated, then Pramathya (a type of decoction of drugs) which simulates the power of digestion (deepana) and which is carminative (Pachana) is administered.
If the Doshas are only slightly aggravated and causing Diarrhea, then Langhana (fasting therapy) is very useful. [14-19]

Recipes of Pramathya

These recipes of Pramathya which are useful in the treatment of Diarrhea are as follows:
1. Pippali – Piper longum, Nagara – Zingiber officinale, Dhanya,Bhutika, Abhaya – Terminalia chebula and Vacha – Acorus calamus [According to the commentary, the decoction or Pramathya prepared of these herbs is useful for Vatika Diarrhea]
2. Hrivera – Pavonia odorata, Bhadramusta, Bilva – Aegle marmelos, ginger and coriander [According to the commentary, the pramathya prepared of these herbs is useful in Paittika type of Diarrhea] and
3. Prishniparni – Uraria picta, Svadamshtra – tribulus, Samanga – Rubia cordifolia and Kantakari – Solanum xanthocarpum [According to the commentary, the Pramathya prepared of these herbs is useful in Kaphaja Diarrhea].
The decoctions of the following ingredients are also useful for the treatment of Diarrhea:
1. Vacha (Acorus calamus Linn.) and Prativisha [ According to the commentary, the decoction of these herbs is useful in Vatika Diarrhea]
2. Musta – Cyperus rotundus and Parpataka[According to the commentary, the decoction of these herbs is useful in Paittika Diarrhea] and
3. Hrivera – Pavonia odorata and Shringavera – Ginger – Zingiber officinale [According to the commentary, the decoction of these herbs is useful for Kaphaja Diarrhea]. [20-22]

Diet for Atisara

In appropriate meal time, when the patient is hungry, he is given light food to eat. By this, he develops appetite for food, his Agni (power of digestion) gets stimulated, and his strength is promoted immediately.
In the beginning, depending upon the wholesomeness (Satmya), the patient is given [the above mentioned light food] along with butter-milk, Avanti-Soma or Kanji (a sour drink), Yavagu (thick Gruel), Tarpana (Roasted flour of cereals mixed with water), alcoholic drink.
Thereafter, the patient is gradually given Yavagu (thick gruel), Vilepi (a sticky gruel), Khada (a sour appetizer), Yusha (vegetable soup) and boiled rice mixed with meat soup which is prepared by doing digestive stimulants and astringent (constipative) herbs. [23-25]

Group of herbs Useful in Diarrhea
Shala-Parni – Desmodium gangeticum
Prsni –Parni – Uraria picta
Brihati – Solanum indicum
Kantakari – Tribulus terrestris
Bala – Country mallow (root) – Sida cordifolia
Svadamstra – Tribulus terristeris
Bilva – Aegle marmelos
Patha – Cissampelos pareira
Nagara – Zingiber officinale
Dhanyaka – Coriandrum sativum
Sati – Hedychium spicatum
Palasha – Butea monosperma
Hapusa – Juniperus communis
Vacha (Acorus calamus Linn)
Jiraka – Cuminum cyminum
Pippali – Long pepper fruit – Piper longum
Yavani – Carum copticum
Pippali – Long pepper fruit – Piper longum-Mula
Chitraka – Leadword – Plumbago zeylanica
Hasti-Pippali – Long pepper fruit – Piper longum
Vrikshamla – Garcinia morella,
Sour Dadima – Pomegranate – Punica granatum
Hingu – Asa foetida
Vida
Saindhava- these ingredients are appropriately used in processing food preparation. Herbs belonging to this group alleviate Vata and Kapha.
These are
Dipana (digestive stimulant)
Pachana (carminative)
Grahi (constipating)
Balya (Promoter of strength)
Rocana (Appetiser). Therefore, these herbs are useful for the patient suffering from Atisara (Diarrhea). [26-29]

Diarrhea with pain management

Management of Diarrhea Associated with Griping Pain
After the maturity of Ama(product of indigestion), if the patient voids loose motions along with scybalous stool associated with colic pain and mucus very frequently in small quantities, and if there is griping pain, then he is given food along with the soup of
Mulaka – Raphanus sativus,
Badara – Zizyphus jujuba,
Upodika,
Ksheerini – Mimosops hexandra,
Yavani – Carum copticum,
Vastuka
Suvarcala,
Cancu (Nadica),
Leaves of Avalguja,
Sati – Hedychium spicatum,
Karkaruka,
Jivanti – Leptadenia reticulata,
Cirbhata (karkati),
Linika
Patha – Cissampelos parriera or
Suska-saka (susa or Kasamarda according to Chakrapani).
These soups is cooked along with curd (yogurt) and Dadima – Pomegranate – Punica granatum, are added with ghee (fat) in the profuse quantity. [30-33]

Treatment of Pravahika

Khada (a type of soup) is prepared by adding the paste of tender fruits of Bilva – Aegle marmelos, equal quantity of the paste of Tila – Sesame (Sesamum indicum), cream of sour curd and profuse quantity of ghee. Intake of this Khada cures Pravahika (griping pain) [34]
Treatment of Varcah-Ksaya (Scanty Formation of Stool)
If there is Varcah Ksaya (scanty stool) and Sushka mukha (dryness of the mouth), then the patient is given
Dhanya- Yusha (a type of soup prepared of cereals and Pulses) made of
Yava – Barley (Hordeum vulgare),
Mudga – Vigna radiata
Masha
Shali type of rice,
Sesame seeds
Kola and
Tender fruits of Bilva – Aegle marmelos, sizzled with Yamaka (ghee and oil) taken together, curd and the extract of Dadima – Pomegranate – Punica granatum.
Along with this soup he should take boiled Shali type of Rice [35- 36]

If there is Varcah-kshaya (Scanty stool), then the patient is given the following:
1. Cream of curd sizzled with ghee and oil, and mixed with Jaggery and Sunthi – Zingiber officinale. This is used as Vyanjana (a side dish)
2. Alcohol sizzled with ghee and oil. This is given as Vyanjana (side-dish)
3. Sour fruits sizzled with ghee and oil. This is used as Vyanjana (side-dish)
4. Soup of Grnjanaka, soup of the meat of Kacchapa added with ghee and sour ingredients or the soup the meat of Barhi, Tittiri, Daksha or Vartaka. These soups is used as Vyanjana (side- dish)
5. Red variety of Shali rice boiled by adding ghee and sour ingredients and
6. The decoction of the meat taken from the trunk of sheep is added with its blood, and sizzled by saddling the extract of Dadima – Pomegranate – Punica granatum, Dhanya, ghee and Nagara – Zingiber officinale. This soup is used for boiling red variety of Shali rice. Intake of this cooked rice and drinking this soup make the patient free from the ailments caused by varcah- Ksaya(scanty stool).[37-41]

Prolapse of Rectum

If there is prolapse of rectum and colic pain, and if the Diarrhea is free from Ama, then the patient is given sour-ghee (medicated ghee to be described below). Such a patient may also be given Anuvasana type of medicated enema [with this type of sour ghee].

Changeri Ghrita and Chavyadi Ghrta

Ghee is cooked with the juice of Changeri, decoction of Kola and sour curd, and the paste of Nagara and Kshara (alkali preparation). Intake of this medicated ghee cures ailments caused by prophase of rectum.
Thus, ends the description of Changeri-Ghrta.
Ghee is cooked with the sour ingredients (juice of Changeri- Oxalis corniculata, decoction of Kola and sour curd), and the paste of Chavya – Piper retrofractum, Pippali – Long pepper fruit – Piper longum, Maricha – Black pepper fruit – piper nigrum, Vida and Dadima – Pomegranate – Punica granatum. Intake of this medicated ghee along with Dhanya, Ajaji and Chitraka – Leadword – Plumbago zeylanica in appropriate quantity [cures prolapsed of rectum].
Thus, ends the description of Chavyadi- Ghrta for prolapsed rectum. [43- 44]

Anuvasana basti

Anuvasana Type of enema for Prolapse Rectum

For the treatment of Prolapse rectum, Anuvasana therapy is administered with the following recipes:
1. Dasha-Mula cooked with fat
2. Bilva – Aegle marmelosa cooked with fat
3. Sati – Hedychium spicatum, Shatahva or Bilva – Aegle marmelos cooked in fat
4. Vacha (Acorus calamus Linn.) cooked with fat
5. Chitraka – Plumbago zeylanica cooked with fat
Thus ends the description of the Anuvasana type of enema for prolapsed rectum. [45]

Management of Strangulated Prolapsed Rectum

If the prolapsed rectum becomes stiff of strangulated, and does not go inside of its own, then oil is applied over it and fomentation is given. Thereafter, when the prolapsed rectum is well fomented and it has become soft, then with the help of a cotton pad (or pad made of thick cloth), it is pushed inside and restored to its original place. [46]

Ksheerayoga

Ksheerayoga – Use of Medicated Milk
If the movement of flatus and stool is arrested, if the patient suffers from acute colic pain or gripping pain, if the patient voids blood and mucus, and if the patient is thirsty, then profuse quantity of milk is administered. Such a patient is given Yamaka (ghee and oil mixed together), and thereafter, lukewarm milk collected directly from the udder (dharosna) is given.
Milk boiled with the root of Eranda – Ricinus communis or tender fruit of Bilva – Aegle marmelos may also be given in the above mentioned condition.
By the intake of the recipes of medicated ghee mentioned above, bleeding mucus discharge from the anus stops. These recipes also cure colic pain, griping pain and constipation. [47-49]

Treatment of Paittika Atisara

If Paittika type of Atisara(Diarrhea) is associated with Ama which can be determined by causative factors, Upashaya (homologation), signs and symptoms, then the patient is given Langhana(fasting therapy) and Pachana (carminative therapy) appropriate to the strength of the patient.
If he is thirsty, then such a patient is given the decoction of
Musta (Cyperus rotundus),
Parapataka – Fumaria parviflora
Ushira – Vetiver – Vetiveria zizanioides,
Sariva – Indian Sarsaparilla – Hemidesmus indicus,
Chandana – Santalum album
Kirata tiktaka – Swertia chirata and
Udicya to drink
After the fasting therapy is administrated, during meal time, the patient is gradually given Yavagu(thick gruel), manda (a type of thin gruel) and the Niryuha(decoction prepared according to the procedure suggested for Sadanga-Paniya (vide commentary on Chikitsa 3 : 145-146] of Bala – Country mallow (root) – Sida cordifolia, Atibala – Abutilon indicum, Surpa- Parni(mudga- Parni and Masha-Parni), shala-Parni – Desmodium gangeticum, Prsni- Parni – Uraria picta, Brihati – Solanum indicum, Kantakari – Solanum xanthocarpum, Shatavari – Asparagus racemosus and Svadamstra – Tribulus terristeris
His Agni (power of digestion) is stimulated gradually with the vegetable soup of
Mudga – Vigna radiata
Masura
Harenu – Pisum sativum
Makustha – Phaseolus aconitifolius and
Adhaki – Cajanus cajan or
With the soup of the meat of
Lava,
Kapinjala,
Sasa – Rabbit
Harina,
Ena and
Kalapuccha
These vegetable soups and meat soups may be slightly sour or may not be sour.
If the Paittika type Diarrhea continues in site of the above mentioned measures, then the patient is treated with recipes which are
Dipaniya (digestive stimulant),
Pacaniya (carminative),
Upasamaniya (Dosha- alleviator) and
Sangrahaniya (constipating) [50]

Ayurvedic medicines

Ayurvedic Medicines for Paittika Atisara
The following recipes are useful for the patient suffering from Paittika type of Atisara (diarrhoea)
1. The fruit and bark of Vatsaka (Holarrhena antidysenterica Wall.) is added with Ativisa—Aconitum heterophyllum and honey. Intake of this along with rice-water (tandulodaka) cures Paittika atisara.
2. Powder of Kirata- Tiktaka – Swertia chirata, Musta (Cyperus rotundus), Vatsaka (Holarrhena antidysenterica Wall.) And Rasanjana (Aqueous extract of Berberis aristata)
3. Powder of Bilva – Aegle marmelos,Daru-Haridra (turmeric – Curcuma longa),Tvak,Hribera – Pavonia odorata and Duralabha – Fagonia arabica
4. Powder of Chandana (Sandalwood – Santalum album),Mrnala, Nagara – Zingiber officinale, Lodhra (Symplocos racemosa) and Utpala (Nymphaea alba)
5. Powder of tila, mocha-Rasa,Lodhra (Symplocos racemosa),Samanga – Rubia cordifolia,kamala and Utpala (Nymphaea alba)
6. Powder of Utpala (Nymphaea alba),Dhataki – Woodfordia fruticosa(flower),Dadima – Pomegranate – Punica granatum,Tvak and Mahausadha and Katphala – Myrica nagi, Nagara – Zingiber officinale, Patha- Cissampelos pareira, seed-pulp of Jambu – syzygium cumini and Amra – mango – Mangifera indica and Duralabha – Fagonia arabica

The above mentioned 6 recipes (nos- 2-7) are taken along with appropriately cooked meat-soup added with constipating herbs.

Administration of milk
Administration of goat-milk to the patient having strong power of digestion cures Paittika type of Atisara (Diarrhea), and promotes strength as well as complexion.
If because of excessively aggravated Doshas, the Paittika type of Diarrhea is not cured and if the patient has strong power of digestion and vitality, then he is given laxative therapy with milk.
He is given the decoction of the fruits of Palasa – Butea monosperma along with milk. Thereafter, depending upon the strength of the patient, he is given luke- warm milk to drink. This will restore bowel movement as a result of which Diarrhea will be controlled.
On the above lines Trayamana – Gentiana kurroo can also be administered for the cleansing of the bowel. [57-60]

Anuvasana type of medicated Enema
If in the course of Samsarjana- Karma (gradual administration of light to heavy food) [after the administration of the laxative therapy], the colic pain recurs, then to such a patient (from whole body the morbid matter is already eliminated) the appropriate Anuvasana (a type of medicated enema) therapy is administrated immediately.
Ghee is cooked by adding 1/4th (in quantity) of oil, decoction of Shatavari – Asparagus racemosa and Madhuka– Licorice – Glycyrrhiza glabra, and [the paste of] Bilva – Aegle marmelos. This medicated ghee is used for giving Anuvasana type of medicated enema. [61- 62]

Piccha basti

Piccha-Basti (Mucilaginous Enema)
If Diarrhea persist in spite of the administration of Anuvasana type of medicated enema and the administration of Samsarjana karma (gradual administration of lighter to heavier food), then Piccha-Basthi (Mucilaginous type of medicated enema) is given thereafter.
Green stalks of Salmali – Salmalia malabarica is covered with green Kusa (Desmostachya bipinnata), and tired. This bundle is smeared with the mud of black soil and placed over cow- dung fire. After the mud is dried up, the stalks of Shalmali – Salmalia malabarica is removed. These stalks are then triturated in a pestle and mortar. One Musti (ala or handful) of this paste is mixed with 1 Prastha of boiled milk and filtered. In this milk, oil and ghee, and the paste of Madhuka– Licorice – Glycyrrhiza glabra is added in adequate quantities. This recipe is used for medicated enema to be given to the patient after his body is massaged with oil. After the ingredients of enema come out of the rectum, the patient should take bath, and there after, take food along with either milk or the soup of the meat of animals inhabiting jangala area (thin forest).
This Piccha-basthi (mucilaginous enema) cures
Paittika type of Diarrhea,
Jwara – fever
Shotha – oedema
Gulma (phantom tumor), chronic Diarrhea,
Grahani (sprue syndrome) and the acute complications of Purgation as well as Asthapana (a type of medicated enema containing decoction etc) therapies [63-68]

Raktatisara (Hemorrhagic Diarrhea)

If the patient suffering from Paittika diarrhea does not follow the above mentioned therapeutic measures, and on the other hand, resorts to such food and drinks which cause aggravation of pitta, then the exceedingly aggravated Pitta causes Raktatisara (hemorrhagic Diarrhea) and instantaneous vitiation of Rakta (blood). This leads to serious complications like excessive thirst, colic pain, burning sensation and suppuration of the anus. [69- 70]

Raktatisara Chikitsa:
Treatment of Hemorrhagic Diarrhea
In a hemorrhagic Diarrhea, goat’s milk is very useful. It is used, when cooled, with honey and sugar for drink, along with food, and for washing the anal region.
Boiled rice of red variety of Shali is given to the patient to eat along with the Goat’s milk.
The boiled rice may also be given along with the soup of the meat of Paravata etc. Sizzled with ghee and mixed with sugar. The soup of the meat having cooling effect like that of rabbits, birds and deer inhabiting deserts is sizzled with ghee, mixed with sugar an given to such patients. It may be ensured that these soups are free from any sour ingredients.
For this ailments the blood of deer or goat, sizzled with ghee is also very useful.
The soup of the fruits of kashmarya, made slightly sour and mixed with sugar is also useful in this condition.
The powder of Nilotpala, Mocharasa, Samanga – Rubia cordifolia and Padmakesara is administered along with the goat’s milk. After the digestion of this potion, the patient is given rice with milk. If the patient is weak, then food can be given to him even before the above mentioned potion is digested.
To the patient suffering from hemorrhagic diarrhoea, butter along with honey and sugar may be given before meals. [71-76]

Recipes for hemorrhagic Diarrhea
After taking ghee collected from the cream of milk along with milk, the patient is the soup of Kapinjala. During this therapy, he should take milk [in adequate quantity]. This cures hemorrhagic diarrhea in the 3 days.
While taking milk as food (drink), the patient should take the paste of Shatavari – Asparagus racemosus mixed with milk. He may also take boiled with paste of Shatavari. Both these recipes cure hemorrhagic Diarrhea.
Intake of ghee cooked by adding the paste of the fruits of Kutaja – Connessi (Holarrhena antidysenterica Wall.), along with the scum (upper part) of the Yavagu and intake of Peya (thin gruel) thereafter, alleviates Rakta or blood (stops bleeding). [77-79]

Darvyadi Ghrita

Ghee is cooked by adding the 6 herbs, viz, the bark of Daru-haridra – Berberis aristata, fruits of Kutaja – Connessi (Holarrhena antidysenterica Wall.), Pippali – Long pepper fruit – Piper longum, Shringavera – Ginger – Zingiber officinale, Draksha – Raisin – Vitis vinifera and Kutuka-Katukarohini – Picrorhiza kurroa. Intake of Peya (thin gruel) and Manda (very thin gruel) along with this medicated ghee cures serious types of Diarrhea even if caused by Sannipataja (simultaneous aggravation of all the 3 Doshas). [80-81]

Hemostatic Recipes
Medicines and herbs to stop bleeding:
Intake of Krsna-Mrt (black earth), Madhuka– Licorice – Glycyrrhiza glabra, Sankha, Rudhira (blood or Kesara) and rice- water mixed with honey can stop bleeding instantaneously.
The paste of Priyangu (Callicara macrophylla) is added with rice- water (Tandulambu). Intake of this, while taking the soup of the meat of animals inhabiting arid zone, in food, stops bleeding instantaneously.
1 part of the paste of the black variety of Tila – Sesame (Sesamum indicum) is added with 4 parts of sugar. Intake of this potion along with the goat’s milk stops bleeding instantaneously. [82-84]

Intake of the decoction of the seeds of Vatsaka (Holarrhena antidysenterica Wall.) while taking meat-soup as food cures Paittika type of Diarrhea (Jatharamaya- abdominal diseases).
Intake of Chandana along with rice-water, mixed with sugar and honey cures burning sensation, excess thirst, Prameha (obstinate urinary diseases including diabetes) and bleeding [85- 86]

Gudapaka treatment

Treatment of Gudapaka – Anal Suppuration

The Anus may get suppurated by the aggravated Pitta on account of the frequent voidance of stool. The anus of such a patient is sprinkled with the following recipes:
1. Exceeding cold decoction of Patola – Trichosanthes dioica and Madhuka- Madhuca longifolia
2. Decoction of Pancha-Valkala (barks of Nyagrodha – Ficus bengalensis,Udumbara – Ficus racemosa, Asvattha – Ficus religiosa, Parisa – Ficus racemosa and Plaksa – Ficus lacor) or sugar cane juice and
3. Milk or ghee of goat or cow mixed with sugar and honey. [87- 88]
The paste of herbs mentioned above for washing (sprinkling over) the anus may be mixed with ghee and applied over the suppurated anus
The powder of the above mentioned herbs may also be used for Pratisarana (dusting) over the suppurated anus.
The powder of Dhataki – Woodfordia fruticosa and Lodhra (Symplocos racemosa), taken in equal quantities, may be used for dusting over the suppurated Anus.
The bleeding stops, and the suppuration as well as pain subside soon after the anal region is dusted with the above recipes.
If there is excessive bleeding (from the anus), the cold decoction of the above mentioned herbs is impregnated with ghee, and sprinkled over the anal region, pelvic region, lumber region and thighs.
To stop excessive bleeding, a cotton pad is soaked with Chandanadya-Taila (described in Chikitsa3; 258) or Shata- Dhauta- Grtha (ghee washed with cold water for the 100 times), and the oil or ghee is sprinkle by squeezing this pad over the Anal and pelvic regions. [89- ½ 93]

Picchabasti for griping Pain
When the movement of the aggravated Vata(Flatus) gets obstructed or its movements is not smooth or when there is absolutely no movement of this Vata, then the patient voids blood frequently in small quantities which is associated with pain. To such a patient, Piccha-Basthi (Mucilaginous enema) is administered. Recipes of this type of medicated enema are already described (in the verse nos. 63-68)
The above mentioned type of medicated type of patient is given Anuvasana type of medicated enema with the medicated ghee prepared by cooking with Prapaundarika (Nymphaea lotus) – red variety.
Because of chronic Diarrhoea, the Anus of the patient generally becomes weak. Therefore, (cotton soaked in) medicated ghee (described above) is inserted into his anus frequently (or be may be given Anuvasana type of medicated enema with this medicated ghee.). [93 ½ – ½ 96]

Basti, Lehayoga

Basti, Lehayoga: Medicated Enema and Recipes of Linctus
The above aggravated Vata becomes stronger in its own location, (i.e colon which is afflicted by Diarrhea). For the alleviation of this aggravated Vayu associated with Pitta (which takes place in hemorrhagic diarrhea), Basti or medicated enema (both the Anuvasana and Niruha types) is the best therapy.
If bleeding takes places along with the stool before voiding stool or after voiding stool in hemorrhagic type of Diarrhea, then the patient is given Shatavari-Ghrta(vide Cikista 30 : 64-69) in from of a Linctus.
Intake of freshly collected butter along with ½ quantity of sugar and 1/4th in quantity of honey cures the above mentioned ailments. While taking this potion, the patient should take wholesome food.
Adventitious roots of Nyagrodha – Ficus bengalensis, Udumbara – Ficus racemosa and Ashvattha- Ficus religiosa is crushed and kept soaked in hot water for 24 hours. Ghee is cooked along with this water. This medicated ghee is added with ½ the quantity of sugar and 1/4th in quantity of honey, and taken in the form of linctus. This cures hemorrhagic Diarrhoea associated with bleeding wither before or after the voiding of stool. [96 ½ – ½ 101]

Suppuration of Anal Sphincters
If the patient who has become weak because of hemorrhagic indulges in Pitta-aggravating ingredients out of ignorance, then the anal sphincters gets suppurated. This is a serious condition leading to instantaneous death [101 ½ – ½ 102]

Treatment of Kaphaja Atisara

For the treatment of Kaphaja type of Diarrhea, in the beginning, fasting (langhana) and carminative (Pachana) therapies is administered.
Similarly, the group of herbs which stimulates the power of digestion (Dipana- Gana) as described earlier (in verse nos- 26-29), and which are prescribed for the treatment of Ama- Atisara is given.
If, in spite of the Dipana and Pachana therapies, and despite of the administration of Langhana therapy, Kaphaja type of does not subside, then the patient is given Kapha- alleviating therapies. [102 ½- ½ 104]

Recipes for Kaphaja Atisara
Administration of the decoction of the following 4 recipes cures Kaphaja type of Atisara:
1. Bilva – Aegle marmelos, Karkatika, Musta (Cyperus rotundus), Abhaya – Terminalia chebula and VisvaBheshaja – ginger
2. Vacha (Acorus calamus Linn.),Vidanga – Embelia ribes, Bhutika, coriander and DevaDaru – Cedrus deodara
3. Kushta – Saussurea lappa, Ativisha – Aconitum heterophyllum,Patha – Cissampelos parriera, Chavya – Piper retrofractum and Katuka-Katukarohini – Picrorhiza kurroa and
4. Pippali – Long pepper fruit – Piper longum, Pippali Mula – Long pepper fruit – Piper longum, Chitraka – Leadword – Plumbago zeylanica and Gaja-Pippali – Long pepper fruit – Piper longum
The above mentioned 4 recipes also promote Kayagni (the power of digestion and metabolism). [104 ½ – 107 ½]

Administration of the recipe containing 1 part each of black variety of Patha – Cissampelos parriera, nagara – Zingiber officinale and Maricha – Black pepper fruit – piper nigrum, and 2 parts of Dhataki – Woodfordia fruticosa, along with profuse quantity of lime- juice cures Kaphaja type of Atisara. [107 ½ – ½ 108]

1 part each of Rasanjana (Aqueous extract of Berberis aristata), Ativisha – Aconitum heterophyllum and fruits of Kutaja – Connessi (Holarrhena antidysenterica Wall.), and 2 parts of Dhataki – Woodfordia fruticosa is added with honey and ginger. This potion is given to a patient suffering from Kaphaja Atisara to drink. [108 ½ – ½ 109]

Khada preparation

For the treatment of Kaphaja Atisara, the following 4 recipes is given in the form of Khada (a type of sour drink which stimulates the power of digestion):
1. Dhataki – Woodfordia fruticosa, Nagara, Bilva – Aegle marmelos, Lodhra (Symplocos racemosa) and Padma-Kesara
2. Bark of Jambu – Syzygium cumini, Nagara – Zingiber officinale, Dhanya, Patha – Cissampelos parriera, Moca-Rasa and Bala – Country mallow (root) – Sida cordifolia:
3. Samanga, Dhataki – Woodfordia fruticosa, Pulp of Bilva and bark of Jambu and Amra – mango – Mangifera indica and
4. Kapittha (Feronia limonia), Vidanga – Embelia ribes, Nagara and Maricha – Black pepper fruit – piper nigrum
The above mentioned recipes is added with the sour juice of Changeri and kola and butter- milk and given to the patient after adding ghee and salt. [109 ½ – 1/ 112]

Leha for diarrhea:
Intake of the pulp of Kapittha (Feronia limonia) along with Ginger, long pepper, black pepper, honey and sugar, or Katphala – Myrica nagi along with honey cures abdominal diseases(Kaphaja type of Diarrhea) [112 ½- ½ 113]

Long pepper with honey and buttermilk:
In take of Pippali – Piper longum along with honey, or butter-milk added with the powder of Chitraka – Leadword – Plumbago zeylanica or the powder of the fruits of Bilva cures abdominal diseases (diarrhea). [113 ½ – ½ 114]

Bael fruit

If the movement of Vayu (flatus) is obstructed resulting in colic pain and griping pain, then the patient is given tender fruits of Bilva – Aegle marmelos, Jaggery, oil, Pippali – Piper longum and Sunthi – Zingiber officinale. He is given diet prepared with Vayu- Alleviating ingredients along with the vegetable soup, meat soup and Khada (a type of sour drink) described earlier for the treatment of Vatika Atisara.
Similarly, to this patient is given the sour medicated ghee described earlier (in verse no. 43 with the title) Changeri ghrta or Satpala Ghrta (vide Chikitsa 5: 147) or (ten years) old ghee mixed with Yavagu (thick gruel) and (thin gruel). [½ 114- 116]

Piccha Basti and Anuvasana basti: (enema therapy) –
If Vayu and Kapha are obstructed [in the colon], if there is excessive voiding of Kapha (mucus) and if there is colic pain as well as gripping pain, then Piccha- basti (mucilaginous enema) is administered. This Piccha- Basti is prepared of the paste of pippali – Piper longum, Bilva – Aegle marmelos, Kushta – Saussurea lappa, Shatahva and Vacha (Acorus calamus Linn.) by adding salt. After the ingredients of this Piccha-basti come out of the anus and the patient feels comfortable, he is given bath. Thereafter, he is given food. In the after –noon, he is given Anuvasana type of enema with lukewarm Bilva Taila (Vide Siddhi 4: 4-7).
The Anuvasana type of medicated enema can also be given frequently with the oil cooked with the paste of Pippali – Long pepper fruit – Piper longum, Bilva – Aegele marmelos, Kushta – Saussurea lappa, Shatahva and Vacha – Acorus calamus
Administration of the above mentioned recipes cures the ailments (Diarrhea) abused by Kapha and Vata. [117- 120]

Need for Immediate Treatment
When Kapha gets reduced because of the above mentioned therapies measures, the Vayu undoubtedly gets aggravated in its own location (colon), this aggravated Vayu may cause instantaneous death: hence its treatment is attempted without delay. [121]

Sannipatika Atisara treatment

It is caused by sannipataja (simultaneous aggravation of all the 3 Doshas), then in the beginning, the aggravated Vayu is alleviated followed by the alleviation of the aggravated Pitta, and thereafter, alleviation of kapha. Alternatively, or the 3 Doshas, the most aggravated one is treated (alleviated) first of all (which is to be followed by the treatment of the remaining 2 Doshas). [122]

To sum up
In this chapter, the following topics in respect of the patient suffering from Atisara (Diarrhea) are described:
1. Mythological origin of Atisara
2. Etiology of different types of Atisara
3. Signs and symptoms of Atisara
4. Curability and incurability of Atisara and
5. Effective treatment for different stages of Atisara. [123]
Thus, ends the nineteenth chapter in chikitsa—Sthana (section on the treatment of diseases) dealing with the treatment of Atisara (Diarrhea) in the work of Agnivesha as redacted by Charaka.