Shalya Tantra - Complete Answer Sheet

Q1 - ARSHA (Hemorrhoids / Piles)

A. Treatment & Instrument

• Ksharasutra - the primary para-surgical instrument; a medicated thread prepared with Snuhi latex, Apamarga kshara, and Haridra powder applied over multiple coatings. It causes chemical cutting and healing simultaneously.
• Shalaka - for Kshara application
• Sanku / Sandhansa (toothed forceps / holding forceps) - used to grasp and hold the pile mass during surgery
• Scalpel (Vriddhi-patra or Karapatra) - for excision in Shastrakarma
• Arsha Yantra - a proctoscope-type instrument to visualize and expose the pile mass

B. Pre / Peri / Post-Operative Care

• Snehana (internal oleation) and Swedana (fomentation) for 3-7 days
• Mridu Virechana (mild purgation) to empty bowel
• Patient should fast on the day of procedure
• Pariksha (examination) - inspection, per rectal digital examination
• Shave the perianal area, clean with Panchavalkala Kashaya
• Administer Abhayarishta / Haritaki Churna the previous night

• Lithotomy position (Uttanasana)
• Use of local anesthesia (modern) or Madhu + Saindhava packing (classical)
• Expose pile with proctoscope/Arsha Yantra
• Apply Kshara with Shalaka for 1 Matra Kala (approx. 45 seconds), then neutralize with acidic wash (Sour liquid like lemon juice)
• In Ksharasutra: ligation of pile mass at its base

• Sitz bath with Triphala Kashaya or Panchavalkala Kashaya
• Jatyadi Taila or Nimba Taila local application
• Soft, easily digestible diet - Yusha (soup), Yavagu (gruel), avoid spicy/dry food
• Regular mild laxatives (Haritaki, Triphala)
• Avoid prolonged sitting, straining at stool
• Follow-up wound inspection every 7 days (for Ksharasutra)
• Ksharasutra is changed weekly until the pile falls off

C. Indications / Contraindications

• Sahaja Arsha (congenital piles) - Shastrakarma preferred
• Vataja, Pittaja, Kaphaja, and Sannipataja Arsha - based on Dosha, respective treatment
• Prolapsing piles (2nd, 3rd, 4th degree equivalent)
• Bleeding piles not responding to medical management
• Pedunculated pile masses
• Arsha with Srava (discharge)

• Garbhini (pregnant women)
• Balaka (very young children) and Vriddha (very old/debilitated)
• Severe anemia, bleeding disorders
• Medo Rogi (obese patients) - relative contraindication for surgery
• Patients with uncontrolled diabetes or cardiac disease (modern addition)
• Arsha in very high positions (difficult access)
• Kshara is contraindicated on Guda Vali (anal sphincter area) - risk of sphincter damage

Q2 - BHAGANDARA (Fistula-in-Ano)

A. Treatment & Instrument

• Ksharasutra - medicated thread (No. 20 surgical linen thread coated with Snuhi latex x11, Apamarga Kshara x7, Haridra powder x3 - total 21 coatings). This is the definitive therapeutic instrument.
• Probe (Shalaka/Eshani) - to locate and cannulate the fistulous tract
• Grooved director (Shanku) - to guide the thread through the tract
• Button probe - to find internal opening
• Curved scissors / Teekshna Shastra - for fistulotomy in some cases
• Artery forceps - to hold thread while threading
• Syringe with dye (methylene blue/modern) - to delineate tract

1. Examination under anesthesia - identify internal and external openings
2. Pass probe from external to internal opening
3. Thread the Ksharasutra through the groove of the probe
4. Tie the thread in a loop (not tight - it cuts slowly by chemical + mechanical action)
5. Thread is changed every 7 days (one rotation = 1 cm cutting per week approx.)
6. Continues until entire tract is cut and healed

B. Pre / Peri / Post-Operative Care

• Same as Arsha - Snehana, Swedana, bowel prep
• Methylene blue / H2O2 injection to identify tract
• CBC, coagulation profile, blood sugar
• Written informed consent
• Bowel preparation (enema or laxative night before)
• NPO from midnight (if GA/spinal)

• Position: Lithotomy
• Anesthesia: Spinal / local (Saddle block preferred)
• Identify internal opening with probe
• Thread Ksharasutra through the tract
• Secure the thread ends with a button to prevent slippage

• Sitz bath twice daily with Triphala/Panchavalkala Kashaya
• Local application of Jatyadi Taila
• Thread change every 7th day
• Monitor for: cutting speed, secondary infection, recurrence
• High fiber diet, adequate fluids
• Avoid straining, heavy lifting
• Haritaki or Triphala Churna at bedtime
• Complete wound assessment at each visit
• Treatment duration: 6-8 weeks typically

C. Indications / Contraindications

• All types of Bhagandara (Vataja, Pittaja, Kaphaja, Sannipataja, Agantuja)
• Simple low-level fistula (intersphincteric, low transsphincteric)
• Recurrent fistula after conventional surgery
• High fistula (where cutting seton approach is needed)
• Horseshoe fistula (with modifications)
• Patients unfit for major surgery

1. Shataponaka - resembles 100 holes
2. Ustragriva - camel-neck shaped
3. Parisravi - profuse discharge
4. Shambukaavarta - spiral / snail-shell shaped
5. Unmargi - with multiple tracts

• Crohn's disease-associated fistula (relative)
• Active perianal abscess (needs drainage first)
• Carcinoma in the fistulous tract
• Very high (suprasphincteric, extrasphincteric) fistula - staged approach needed
• Immunocompromised patients - caution
• Inflammatory bowel disease
• Radiation-induced fistula

Q3 - AGNIKARMA in VATAKANTAKA (Plantar Fasciitis / Heel Spur)

A. Instrument (Dahanopakarana)

• Panchadhatu Shalaka - rod made of 5 metals (gold, silver, copper, iron, tin/lead alloy) - most commonly used; conducts and retains heat well
• Lauha Shalaka - iron rod (used when strong stimulation needed)
• Pippali - dried long pepper fruit (for Twak/skin level burns)
• Godanta / Godanti - cow's tooth (for Mamsa/muscle level)
• Shara - reed/arrow stalk (for Snayu/ligament level)
• Shalaka (gold/silver) - for Asthi (bone) level

B. Types of Dagdha (Burns)

• Bindu Dagdha - single point burn (used in Vatakantaka - most common)
• Vilekha Dagdha - linear scratch burn
• Pratisarana Dagdha - spreading circular burn
• Varti Dagdha - wick-shaped
• Ardhachandra Dagdha - half-moon shaped

C. Post-Operative Measures (Paschatkarma)

• Apply Ghrita (clarified butter) or Madhu (honey) + Ghrita mixture immediately over the burnt area (Sadya Snehana)
• Sarpi (Ghee) dressing to prevent secondary infection and promote healing
• Rest - avoid weight bearing for 24-48 hours post procedure
• Warm sesame oil massage (Abhyanga) around the area after initial healing
• Foot soaking in warm Saindhava + Tila Taila water
• Repeat sitting after 7 days if pain persists (up to 5-7 sittings may be given)
• Avoid: cold water exposure, cold food, excessive walking for 1 week
• Dietary advice: Vata-pacifying diet (warm, unctuous, Snigdha Ahara)
• Monitor for: adequate burn, secondary infection, excess charring (over-burn)
• Shoe modification / heel pad advised concurrently

Q4 - PATIENT WITH PROFUSE BLEEDING

A. Instrument Used for Profuse Bleeding (Ayurvedic Context)

• Sandhana - approximation and bandaging
• Skandana - with astringent drugs
• Pachana - using digestive drugs
• Dahana - cauterization (Agnikarma Shalaka - red-hot rod applied to bleeding point)

B. Artery Forceps (Modern Surgical Instrument)

• Mosquito forceps (Halsted) - small, fine-tipped; for small vessels
• Crile's forceps - slightly larger; general use
• Kelly's forceps - for medium vessels
• Rochester-Pean forceps - large vessels
• Right-angled (Mixter) forceps - for dissection around vessels before ligation

1. Applied across the bleeding vessel to crush and occlude it
2. Vessel then ligated with suture (Ligature) - silk / vicryl
3. Or electrocoagulation applied through the forceps tips (bipolar/monopolar diathermy)

C. Cells That Help in Blood Clotting

1. Primary hemostasis: Platelets adhere to damaged endothelium (via von Willebrand factor), then aggregate (platelet plug formation)
2. Secondary hemostasis: Platelet phospholipid surface (PF-3) activates coagulation cascade
3. Coagulation cascade activates Factors → ultimately Thrombin → converts Fibrinogen to Fibrin → stable clot

• Endothelial cells - release von Willebrand factor, tissue factor
• Red blood cells - contribute to clot viscosity and thrombin generation
• Mast cells - release histamine (vasoconstriction in early phase)

Q5 - BANDH (Bandaging) - Ankle and Wrist Joint

A. Which Bandage?

• Ankle: Figure-of-8 bandage / Crepe bandage in figure-8 pattern
• Wrist: Spica bandage / Crepe bandage

B. Indications

• Ankle sprain (Gulpha Marmabhighata)
• Post-operative support after ankle surgery
• Varicose veins around ankle
• Edema of ankle joint
• Fractures (immobilization support)
• Joint instability

• Wrist sprain
• Post-operative wound on wrist
• Manibandha Shotha (wrist swelling)
• Fractures of distal radius / carpal bones (supportive)
• Painful conditions of wrist (Vata Vyadhi)

• Vrana (wound) management
• Fracture/dislocation
• Bleeding control
• Joint stability
• Post-surgical dressing support

C. How to Perform (Procedure)

1. Patient seated, ankle in neutral/slight dorsiflexion (90°)
2. Start with 2 circular anchoring turns around the mid-foot
3. Bring bandage diagonally upward across the dorsum of the foot
4. Circle behind the ankle (below the malleoli)
5. Cross again over the dorsum - forming the "8" pattern
6. Continue alternating figure-8 loops, moving proximally up the lower leg
7. Secure with clip or adhesive
8. Check: Two fingers should slide under the bandage (not too tight)
9. Check distal circulation (toe warmth, color, sensation)

1. Start distal anchor at palm/metacarpals
2. Spiral proximally in overlapping turns (each turn covers 1/2 to 2/3 of previous)
3. Cover the wrist joint completely
4. Anchor proximally above the wrist
5. Secure end

• Samyak Baddha - neither too tight nor too loose
• Desh-Kala - appropriate for body part and season
• Snigdha - smooth surface
• Sthira - stable, non-slipping
• Check and change every 24-48 hours or when soiled

Q6 - MARMA: KRUKATIKA MARMA

A. Identification with Location

• Number: 2 (bilateral - one on each side of the neck-head junction)
• Pramana (size): ½ Angula (approx. half the width of one's own middle finger)
• Modern anatomical correlation: Atlanto-occipital joint + surrounding ligaments and membranes (posterior atlanto-occipital membrane, atlanto-occipital capsule)

B. Classification

1. Sadyaspranahar - immediate death
2. Kalantarapranahara - delayed death
3. Vishalyaghna - death on removal of weapon
4. Vaikalyakara - causes deformity/disability ← Krukatika belongs here
5. Rujakara - causes only pain

• Sakthi (lower limb) - 11 × 2 = 22
• Bahu (upper limb) - 11 × 2 = 22
• Udar-Uras (trunk) - 12
• Prushtha (back) - 14
• Shiro-Greeva (head-neck) - 37 ← Krukatika is here

C. Condition if Krukatika Marma is Injured

• Meaning: Instability and involuntary trembling/shaking of the head
• The head becomes unstable, unable to be held steady
• Involuntary oscillation of the head (resembles essential tremor or torticollis)

• Atlanto-occipital joint disruption → cervical instability
• Injury to posterior atlanto-occipital membrane → loss of joint stability
• Damage to suboccipital muscles and ligaments → inability to control head posture

• Whiplash injury (RTA)
• Atlanto-occipital dislocation
• Suboccipital neuralgia
• Cervicogenic headache
• Torticollis (Manyastambha)
• Cervical spondylosis affecting C1-C2
• Occipital nerve compression

• The patient does not die immediately
• But suffers permanent disability - the head tremor/instability can be lifelong
• Medico-legal significance: classified as grievous injury in Ayurvedic jurisprudence