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Management of Amavata with Amavatari rasa and Valuka sweda - A clinical evaluation, Vijayendra. G. Bhat, PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa.

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Amavata k c006kop

  1. 1. BY Dr. VIJAYENDRA.G.BHAT B.A.M.S. (R.G.U.H.S, Bangalore) Dissertation submitted toRajiv Gandhi University of Health Sciences, Karnataka, Bangalore in partial fulfillment of the requirements for the degree of “Ayurveda Vachaspati” [M.D.] in KAYACHIKITSA GUIDE Dr. Rashmi Rekha Mishra M.D(Ayu), (U.U) Prof. Dept. of KayachikitsaDEPARTMENT OF POST GRADUATE STUDIES IN KAYA CHIKITSA A.L.N.RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE,KOPPA – 577126, CHIKMAGALUR DISTRICT, KARNATAKA, INDIA MARCH - 2006
  2. 2. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYA CHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Declaration I here by declare that this dissertation entitled “Management of Amavata with Amavatari rasa and Valuka sweda - A clinical evaluation” is a bonafide and genuine research work carried out by me under the guidance of Dr. Rashmi Rekha Mishra, Prof., Department of Post Graduate Studies in Kaya Chikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa. Date: Dr. Vijayendra. G. Bhat Place: Koppa P.G.Scholar, Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  3. 3. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYA CHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Certificate This is to certify that the dissertation entitled “Management of Amavata with Amavatari rasa and Valuka sweda - A clinical evaluation” is a bonafide research work done by Dr. Vijayendra.G.Bhat in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (M.D.) in Kaya Chikitsa, of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. Date: Guide: Dr. Rashmi Rekha Mishra Place: Koppa M.D(Ayu), (U.U) Prof. Dept. of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  4. 4. Department of Post Graduate A.L.N.Rao Memorial AyurvedicStudies in KAYA CHIKITSA Medical College, Koppa – 577126 Dist: Chikmagalur Endorsement This is to certify that the dissertation entitled “Management of Amavata with Amavatari rasa and Valuka sweda - A clinical evaluation” is a bonafide research work done by Dr. Vijayendra.G.Bhat under the guidance of Dr Rashmi Rekha Mishra, Prof., Department of Post Graduate Studies in Kaya Chikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P.G. Centre, Koppa. Date: Dr.Jagadeesh Kunjal M.D. (Ayu) Place: Koppa Principal, A.L.N.Rao Memorial Ayurvedic Medical College, Koppa –577126, Dist: Chikmagalur
  5. 5. COPYRIGHT I here by declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate this dissertation inprint or electronic format for academic/research purpose. Dr. Vijayendra.G.BhatDate: P.G.Scholar,Place: Koppa Dept. of Kaya Chikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126© Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. ACKNOWLEDGEMENT I am obliged to my beloved Parents, niece Vaibhava and family members fortheir constant efforts, encouragements and inspiration through out the work. On the completion of this thesis work, I extend my sincere gratitude to myrevered Guide Dr. Rashmi Rekha Mishra M.D (Ayu); who was the vital and kineticforce of this thesis; with out her initiation this piece of work would not have beenaccomplished in stipulated time. I owe my sincere regards and boundless gratitude to Dr. Taruni KantaMohanta, M.D, PhD (Ayu), for his constant encouragement and valuablesuggestions. I am grateful to Sri. Aroor Ramesh Rao, President, A.L.N. Rao MemorialAyurvedic Medical College, Koppa for giving me an opportunity to do my post-graduate studies. My immense thanks to Dr. Jagadeesh Kunjal, M.D (Ayu), Principal, A.L.NRao Memorial Ayurvedic Medical College, Koppa, for his help and support incompleting this work My sincere gratitude to all my respected teachers in the Dept. of Kayachikitsa;HOD Prof. P.K Mishra, MD(Ayu), Dr. Narayana Sharma, M.D(Ayu), andDr. C.B Singh, M.D(Ayu). I am obliged to my friends Dr Prashanth B K and Dr Harvin George for theirguidance, valuable suggestions and moral support. My special thanks to Dr Ramesh P V for his valuable suggestions, whichbecame the base for my study.
  7. 7. I remain grateful forever to Dr.Shyamalan (Ph.D) and my senior Dr.ChristyJ.T for their complete in the statistical work. I am obliged to the respected teachers of Dept. of Rasa shastra and Bhaishajyakalpana; Dr. D.K Mishra, M.D (Ayu) and Dr. Galib, M.D (Ayu) for their guidance. My earnest gratitude to the respected teachers of the faculty of Dravya guna:Dr. Lucas M.D (Ayu), FRAS (Lon), Dr. Sanjaya K.S, M.D (Ayu) and Dr. Sreedhar,M.D (Ayu) for their extensive help in the drug review along with Dr. H.R Pradeep,M.D (Ayu) and Dr. Sathish Sringeri, M.D (Ayu). I am glad to express my sincere thanks to Dr. Rajesh Kumar, M.D (Ayu) fromthe Dept. of Shalakya, Dr.Banmali das from dept of roga vijnana. and P.N.HegdeDept of Sanskrit. I will always treasure the guidance and support given by Dr. Ramohan,Dr.Ramesh N.V, Dr. Lalitha Bhasker, and Dr. Sreenivas, Dr. Abhinetri Hegde;Consultant Physicians of Ayurvedic college hospital for their support during variousstages of my work. I am ever grateful to my friend Dr Manoj S Panicker, for his continuousmotivation and valuable suggestions through out the course of my work. It will be reprehensible if I do not extend my gratitude to my seniors Dr.Purushotham K.G, Dr. Leeladhar, Dr. Prashant Bhat, Dr. Clarence, Dr. Anil PVarkey, and Dr. Pradeep K.V, for their support. With amicable gratitude, I thank the librarians, lab technicians, pharmacystaff and college office staff for providing me the technical support. I will be failing in my duties if I do not express my immense gratitude to myclassmates Dr.Sarat Babu, Dr. Raviganesh, Dr. James chacko, Dr. Parthasarathi,
  8. 8. Dr.Pradeep Dr. Prathibha Hullur, Dr. Binu A, Dr. Roshy, Dr.Vishwanath, Dr.Krishna kishore, Dr. Sanjeev, Dr. Suja, Dr. Kavitha, and Dr.Pankaj. With immense pleasure, I extend my heart full thanks to my good friends Dr.Mani jose, Dr. Sachin zadbukhe, Dr. Ratheesh, Dr. Guru, Dr. Dayanand R.D, Dr.vinod joshi and Dr. Harihara Prasad with out whose support this thesis work wouldnot have been complete. I will always cherish the love and consideration extended by my dear friendsDr. Murali Rao, Dr. Raju Kulkarni, Dr.Vijith, Dr. Sreejith, Dr. Prasanna K.G, Dr.Shreepathi E Nagol, Dr.Krishnaprashanth, Dr.Vishwanath Hegde Dr. MadhusudhanKulkarni, Dr. Manjunath Adiga, Dr. Yashwanth, Dr. Nagesh Puranic, and Dr.Chethan. I am grateful to all the patients who were included in the study. My thanks to Dr. Raghuram, Dr. Susheel Shetty, Dr.Manoj, Dr.Chandrakala, and Dr.Rita for their moral support. My special thanks to PG juniors, House surgeons, 2nd year U.G students(2002 batch) especially Jagadeesh Maiyya & Manjunath Bhat and others for theirconstant support. Finally I thank all those who helped me directly or indirectly to complete thiswork.Date :Place : Koppa Dr. Vijayendra.G.Bhat
  9. 9. LIST OF ABBREVIATIONS 1. A.H : Astanga Hridaya 2. A.K : Amarakosha 3. A.S : Astanga Sangraha 4. B.P : Bhava Prakasha 5. B.R : Bhaishajya Rathnavali 6. Basa : Basavarajeeyam 7. C.D : Chakra Datta 8. C.M.P : Concise Medical Physiology 9. C.S : Charaka Samhita A10. Ckr : Chakrapani.11. D.G : Dravya Guna Vijnana12. D.N : Dhanvantari Nighantu13. D.P.P.M : Davidson’s Practice and Principles of Medicine.14. Dl : Dalhana15. G.N : Gada Nigraha16. H.P.I.M : Harrison’s Principle Of Internal Medicine17. H.S : Harita Samhita.18. M.N : Madhava Nidana19. Madhu : Madhukosha20. R.P.B.D : Robin’s Pathologic Basis Of Disease21. R.R.S : Rasa Ratna Sammuchaya22. S.K.D : Shabda Kalpa Druma23. S.S : Sushruta Samhita24. Sh.S : Sharangadhara Samhita25. Vag : Vagbhata
  10. 10. 26. Vang : Vangasena27. W.I : The Wealth Of India28. Y.R : Yogaratnakara ABBREVIATIONS OF STHANAS OF SAMHITA 1. Chi : Chikitsa sthana 2. Ind : Indriya sthana 3. Ka : Kalpa sthana 4. Ma.Kha : Madhyama Khanda 5. Ni : Nidana sthana 6. Po.Kha : Poorva Khanda 7. Sha : Shareera sthana 8. Si : Siddhi sthana 9. Su : Sutra sthana
  11. 11. ABSTRACT “Angamarda, angashunyata, gatrastabdhata and jwara” are the cardinalsymptoms of Amavata, usually associated with raga, daha, shoola, sthaimithya, kanduand all the ama lakshanas since it is tridoshaja. It is a growing global problem,hampering the daily life movements of the affected individual and the treatment forthis is said to be krichrasadhya. Still, this disease can be managed with some formulations which can break thesamprapti of the disease, has inspired to witness the efficacy of the drug and toestablish its efficacy.Objectives: 1. Management of Amavata with trial drug Amavatari rasa individually and along with valuka sweda on randomly selected patients. 2. To establish the safe, economical and effective medication for Amavata without side effect, formulated as explained in the classical. 3. Detailed study of disease and trial drug covering classical and modern literature.
  12. 12. Methods: In this clinical study, 40 patients were selected for the study coming underinclusion criteria and randomly categorized into two groups.Group A – Administered Amavatari rasa 750mg twice daily in empty stomach for 30days, with hot water as anupana, followed by dietary measures.Group B – Administered Amavatari rasa 750mg with hot water as anupana, twicedaily in empty stomach for 30 days with Valuka sweda for 21 days with same dietarymeasures. Severity of the disease was assessed by subjective and objective parameters.Interpretations and results:After the therapy, it was observed that the group A treated with Amavatari rasa gavebetter result in relieving the two stnika main symptoms i.e, daha and raga andassociated symptom apaka, but a better and sustained relief of all the symptom wereobserved in group B which is treated with combined therapy.Conclusion: Amavatari rasa helps in the management of Amavata by pachana of ama, clearing the srotas, reduces the inflammation along with vitiated vata and kapha and also does the dhatu poshana. Treatment administered with Amavatari rasa along with valuka sweda showed more efficacy in all above said features with quick and long standing result.Key words:Amavata, Amavatari rasa, valuka sweda, Trika sandhies, Shoola, Gatrastabdhata.
  13. 13. INDEX Page No.Chapter - I INRODUCTION 1-5Chapter - II OBJECTIVES 6Chapter - III REVIEW OF LITERATURE A) Disease review Historical review 7-9 Nirukti, Paribhasha, Paryaya 10-11 Nidana 12-22 Samprapti 23-29 Poorvaroopa 30 Roopa 31-35 Classification of Amavata 36-37 Upadrava 38-39, Upasaya anupasaya 39 Sadhyaasadyata 40 Chikitsa 41-48 Vyavachedaka nidana 48-50 Pathya apathya 51-52 Modern disease review 53-61 Concept of Valuka sweda 62-68 B) Drug Review 69-77Chapter - I METHODOLOGY Materials and Methods 78-85 Observations 86-103Chapter - IV RESULTS 104-124Chapter - V DISCUSSION 125-142Chapter - VI CONCLUSION 143-144 SUMMARY 145-146 REFERENCES BIBLIOGRAPHY ANNEXURES
  14. 14. List of Charts Name of charts Pg no: Scheme of Samprapti 29 Effect of valuka sweda 140 List of tablesSl No Name of tables Pg No. 1 Samanya lakshana 33 2 Pravradaha lakshanas 34-35 3 Line of treatment 46 4 Different yogas 46-48 5 Differential diagnosis 48-50 6 Pathyapathya 52 7 Scoring chart 81 8 Age wise distribution 86 9 Sex wise distribution 87 10 Religion wise distribution 88 11 Marital status 89 12 Occupational status 90 13 Educational status 91 14 Socio-economical status 92 15 Family history 93 16 Diet wise distribution 94 17 Adductions 95 18 Deha prakrithi 96 19 Satwa wise distribution 97 20 Incidence of kosta agni 98 21 Nidana 99 22 Sarva dihika main symptoms 100 23 Sthanika main symptoms 101 24 Associated symptoms 102 25 Sroto dusti lakshanas 103 26 Effect of Amavatari rasa on sarvadihika lakshana after 104 therapy 27 Effect of Amavatari rasa on sarvadihika lakshana after 104 follow up 28 Effect of Amavatari rasa on sthanika lakshana after therapy 105 29 Effect of Amavatari rasa on sarvadihika lakshana after 105 follow up 30 Effect of Amavatari rasa on associated symptoms after 106 therapy 31 Effect of Amavatari rasa on associated symptoms after 106 follow up 32 Effect of Amavatari rasa on sroto dusti lakshana after 107 therapy
  15. 15. 33 Effect of Amavatari rasa on sroto dusti lakshana after 107 follow up34 Effect of Amavatari rasa with valuka sweda on 108 sarvadaihika lakshana after therapy35 Effect of Amavatari rasa with valuka sweda on 108 sarvadaihika lakshana after follow up36 Effect of Amavatari rasa with vauka sweda on sthanika 109 lakshana after therapy37 Effect of Amavatari rasa with vauka sweda on sthanika 110 lakshana after follow up38 Effect of Amavatari rasa with valuka sweda on associated 110 symptoms after therapy39 Effect of Amavatari rasa with valuka sweda on associated 111 symptoms after follow up40 Effect of Amavatari rasa with valuka sweda on sroto dusti 111 lakshana after therapy41 Effect of Amavatari rasa with valuka sweda on sroto dusti 112 lakshana after follow up42 Over all effect of Amavatari rasa after treatment 11243 Over all effect of Amavatari rasa after follow up 11344 Over all effect of Amavatari rasa with valuka sweda after 114 treatment45 Over all effect of Amavatari rasa with valuka sweda after 114 follow up46 Comparative effect of therapies on sarvadaihika symptoms 115 after treatment47 Comparative effect of therapies on sarvadaihika symptoms 116 after follow up48 Comparative effect of therapies on sthanika symptoms 117 after treatment49 Comparative effect of therapies on sthanika symptoms 118 after follow up50 Comparative effect of therapies on associated symptoms 119 after treatment51 Comparative effect of therapies on associated symptoms 120 after follow up52 Comparative effect of therapies on sroto dusti lakshana 121 after treatment53 Comparative effect of therapies on sroto dusti lakshana 122 after follow up54 Comparison of therapies b/w Group A & B after treatment 12355 Comparison of therapies b/w group A & B after follow up 124
  16. 16. List of GraphsSl no: Name of graphs Pg no:1 Age wise distribution 862 Sex wise distribution 873 Religion wise distribution 884 Marital status 895 Occupational status 906 Educational status 917 Socio-economical status 928 Family history 939 Diet wise distribution 9410 Adductions 9511 Deha prakrithi 9612 Satwa wise distribution 9713 Incidence of kosta agni 9814 Nidana 9915 Sarva dihika main symptoms 10016 Sthanika main symptoms 10117 Associated symptoms 10218 Sroto dusti lakshanas 10319 Comparative effect of therapies on sarvadaihika 115 symptoms after treatment20 Comparative effect of therapies on sarvadaihika 116 symptoms after follow up21 Comparative effect of therapies on sthanika symptoms 117 after treatment22 Comparative effect of therapies on sthanika symptoms 118 after follow up23 Comparative effect of therapies on associated symptoms 119 after treatment24 Comparative effect of therapies on associated symptoms 120 after follow up25 Comparative effect of therapies on sroto dusti lakshana 121 after treatment26 Comparative effect of therapies on sroto dusti lakshana 122 after follow up27 Comparison of therapies b/w Group A & B after 123 treatment28 Comparison of therapies b/w group A & B after follow 124 up
  17. 17. Introduction INTRODUCTION Amavata is a condition where simultaneously aggravated vata and Amaassociated with each other, settles in trika sandhies and is characterized by immensepain in joints with inflammation, fever and ultimately stiffness of the joints, causingthe temporary or permanent disability of joints and it hampers daily working capacityand runs a chronic course. Though the two main causative factors of disease ‘ama’ and ‘vata’ have equalimportance, the cause of Ama and its role in manifestation of disease requires specialattention. The improper digestive mechanism which is the basic cause of the diseaseproduces the incomplete ahara rasa or ‘ama’. This Ama acts as poisonous substancefor body and sets in different types of disorders. Among them, Amavata has uniqueimportance due to its gravity of problems with severe pain like ‘scorpion bite’. In early stages only the joint involvement can be seen with cardinal featureslike angamarda, aruchi, alasya, jwara and angashoonata etc. but if it is not treated withsystemic treatment procedures, then through the madyama roga marga, it will lead tocardiac damage and further complications like involvement of gastro- intestinal,cardiovascular, nervous, urinary and respiratory systems also. In its chronic phase,frequent aggravation of its entities concludes as cripplers for human being. Vedas also mention about the various disorders which leads to impairment ofmovement. But Amavata, as a disease entity is not available even in Brihatrayees.This is first recognized and described in detail by Madhavakara in 9th century. He Page 1
  18. 18. Introductionexplained trika sandhi or bigger articular joints like knee, elbow etc. as the most pronejoints. Though no particular age group is mentioned in Ayurvedic texts, affliction ofthis disease is confined to children and young adults mostly. Amavata can be compared to Rheumatoid arthritis which is a systemic chronicinflammatory joint disorder which affect predominantly to synovial joints. Cardiacinvolvement, symmetrical involvement of joints along with pain, stiffness andswelling with number of systemic complications resembles the disease Amavata. Theopinion regarding the correlation with rheumatic fever also cannot be ruled out, due tomany similarities with Amavata. There is no specific line of treatment in contemporary science which bringssolace to the patients. Allopathic system can manage this with its various potentremedies capable of suppressing or controlling the disease activity and gives relief tothe patient. But none of them gives a permanent cure and lastly advices prolongedpenicillin therapy instead. Nowadays, it is being observed that in OPD and IPD level, the number ofpatients increasing day by day suffering with this dreadful disease may be due tomodern way of life style with consumption of incompatible food and less physicalexercises and mental stress. However, definite approaches of specific remedies arestill required. The line of treatment in Ayurveda commonly used in all the diseases issamshodhana and samshamana. Samshodhana indicates the dosha eliminating Page 2
  19. 19. Introductionprocess, whereas samshamana gives knowledge regarding the palliative procedure ofdosha inside the body. For the samshodhana purvakarma, pradhana karma and afterthese careful diet procedures i.e. samsarjana karma are mentioned in Ayurvedicclassics. In purvakarma, oleation and sudation is mentioned to bring the dosha fromthe tissue level upto the koshta so that after this, eliminative procedure will be easy toconduct. After this procedure, samshamana therapy is adopted. Each type ofprocedure is having its equal importance in their respective way. For Amavata also, Acharya Chakradutta have given emphasis on a therapeuticprogramme in terms of chikitsa sutra instead of single therapy for complete cure,without reoccurrence or to manage this disease. That includes langhana, ama pachanafollowed by virechana, snehapana and kshara basti. It is advised that the valuka swedaas rukshana chikitsa, externally has excellent role in amapachana, in local sandhies.Same treatment is suggested by Yogaratnakara, Gada nigraha and Bhava prakashawith special importance to ruksha sweda and upanahas. On this disease, various research works in different institutions of Ayurvedahas been conducted time to time, to find out definite solution. Some of them are listedbelow: 1. Jala Jagisha – a clinical study on Virechana and dashamulakshara basti in management of Amavata. Gujarat Ayurveda University, Jamnagar 1995. 2. K.P. Reddy – A clinical and immunological study on role of langhana in management of Amavata and its treatment with Bhallataka Rasayana. Banaras hindu university, Banaras. 1995. Page 3
  20. 20. Introduction 3. Lakshmikantham. K – Management of Amavata with special reference to Simhanada guggulu. Govt. College of Indian medicine, Mysore 1990. 4. Shrinivasalu.M – A clinical study of the effect of Gandharvahastadi kwata in Amavata. Govt. Ayurvedic College, Hyderabad 1983. 5. Namboodiri P.K.N – Clinical study of Amavata and to assess its Ayurvedic treatment with special reference to the role of swedanakarma . University of Calcutta 1979. It has been observed that in some conditions shodhana and in some others, shamanachikitsa has given the significant results. Keeping on view, all its prevalence and for better management of the disease,this research work is taken as a clinical evaluation of Amavatari rasa with thereference of Bhaishajya ratnavali Amavata chikitsa Adhyaya, which fulfills deepana,pachana and anulomana like properties with its special combination of herbo- mineralingredients, alone and along with valuka sweda which is easy for administration, withno side effects and cost effective, in the management of the disease Amavata. Present work also includes theoretical aspects of Amavata like brief historicalbackground, definition, synonyms, nidana panchakas along with classification asexplained by different classical treatises which are discussed here in detail. Thepratyatmaka lakshanas, upadravas, vyavachedaka nidanas, sadhya- asadhyata of Page 4
  21. 21. IntroductionAmavata, line of treatment and probable mode of action of selected treatment therapyare also expounded in detail. Group wise random selection of patients for clinical trials, case study, adoptedtreatments and its methods with subjective and objective parameters, results,discussion and conclusion are dealt at the end.The entire work has been documented chapter wise in the following manner - Chapter I – Introduction Chapter II – Objectives Chapter III – Review of literature Chapter IV – Methodology Chapter V – Results Chapter VI – Discussion Chapter VII – Conclusion Chapter VIII _ Summary References Bibliography Annexure Page 5
  22. 22. Objectives Objectives Objective of the present study are: 1. Management of Amavata with trial drug Amavatari rasa individually and along with valuka sweda on randomly selected patients. 2. To establish the safe, economical and effective medication for Amavata without side effect, formulated as explained in the classical. 3. Detailed study of disease and trial drug covering classical and modern literature.HYPOTHESISNull Hypothesis –Amavatari rasa alone or along with Valuka sweda is ineffective against the disease Amavata.Alternate Hypothesis – Amavatari rasa alone or along with Valuka sweda is effective against the disease Amavata. Page 6
  23. 23. Review of literature HISTORICAL REVIEW History is chronologically arranged records of past events. Ayurveda hashistory of more than 2500 years. The quest for medicine with few achievements musthave been existing even much before the beginning of human race. The main sourcefor all sciences as well as Indian medicines are four Vedas, which are considered asoldest treatise of knowledge.Vedas: Ayurveda is considered as upaveda of Atharvaveda. There are no directreferences for Amavata in Vedas. In Atharvaveda there are few references regardingjoint disorders also, in the name of vishakhanda, which means disorganized joints. Itis stated that “destroy the balasa seated in organs and joints which is responsible forloosening of joints”1.About the defect of body parts, there are some references sayingthat “I shall remove the visha causing debility in majja and sandhies”2Puranas: In Puranas there are collections of matters pertaining to sharira. Agni Purananarrates the total number of joints and explained the pathyas for vata rogas concernedto joints3.Brihatrayee: In Brihatrayee also, there is no description about the disease Amavata. Theterm Amavata has been mentioned in Charaka Samhita which may date back to 1000B.C, possibly to denote the relation of Ama with vata. However the term Amavata is Page 7
  24. 24. Review of literatureincluded in some of the therapeutic indication of drug compounds, Kamsahareetaki4,Vishaladi phanta of Pandu chikitsa5 are described to be effective in Amavata. Further while illustrating the vata vyadhi chikitsa, Amavata word is used todenote avarana of vata by ama and also as a symptom6. In addition to this, a gooddeal of description regarding etiology, pathology, clinical manifestation and effectivetreatment for amapradosha is found7 . In Susruta Samhita (700-600 B.C) only the description of ama is found. In Astanga Sangraha (400 A.D) and Astanga Hridaya (500 A.D) there is nodescription about Amavata but the description about ama is available.Bhela Samhita: (800-700 B.C)In this treatise, the term Amavata is not available, the word amashayagata vata isfound.Harita Samhita: (800-700 B.C) Amavata description is found in this treatise. Here ‘angavaikalya’ is given aslakshana and ‘khandashaka’ as nidana. Treatment for Amavata is also available in thistext.Madhava nidana: (800 A.D) First description of Amavata as an independent disease is explained inMadhava Nidana by Madhavakara. The clear explanation of nidana, samprapti, roopa,upadrava and sadhyasadhata is available.Gada Nigraha: (1200 A.D) The description of Amavta and its treatment is explained in this treatise.‘Vikunchana’ is explained as lakshana of Amavata. Page 8
  25. 25. Review of literatureVanga Sena: (1300 A.D) Amavata description is found in this text. Author specially mentioned that“takra tulya mootra” is lakshana in Amavata.Vijayarakshita: (1300 A.D) In his Madhukosha commentary on Madhava Nidana, has mentionedsankocha, khanjatwa etc as the upadravas of Amavata.Rasa Ratna Sammuchaya: (1300 A.D) Author Rasa Vagbhata has mentioned different yogas for Amavata.Sarangadhara samhita: (1300 A.D) In his treatise description about classification about Amavata is available andhe suggested the use of ‘naga’ in this disease.Basavarajeeya: (1400 A.D) Author has specially explained the ‘peetamootrata’ as lakshana of Amavata.Bhavaprakasha: (1500 A.D) Author Bhavamishra has described Amavata in detail. Indication of ‘erandabheeja’ is mentioned in this text.Yogaratnakara: (1600 A.D) In this text the complete description of Amavata is available. Many aushadayogas for it are also mentioned in this treatise.Bhaishajya Ratnavali:(1800 A.D.) Author Govindadasa explained nidana and elaborately discussed about veritiesof chikitsa also. The disease Amavata seems to be not found in vedic and samhita period. Aftermedieval period it started dominating and nowadays it is very common dreadfuldisease. As the condition changes with the change in times, disease that were onceprevailing became rare and those that were rare or unheard became very common andeven went the extent of becoming a menace to the society. Page 9
  26. 26. Review of literature NIRUKTI, PARIBHASHA AND PARYAYA OF AMAVATAThe nirukti of Amavata can be defined in two ways: “Amena sahita vata iti Amavata” “Amascha vatascha iti Amavata”As per Shabdhakalpadruma, “The Amavata indicates its samprapti”. Because Ama is nothing but the improper end products of food stuffs due tothe impairment of jattaragni. It is also accepted that the main source of all type ofdisorders are on account of its poisonous properties. Even if it is poisonous, it has nocapacity to produce any disease with out the association of vata. As it is told that – “Pittapangu kaphapangu pangavo mala dhatavaha Vayunayatra niyate tatra gachati meghavat” Following this principle the disease Amavata gets manifested when Amacomes in contact with vitiated vata and while moving all around the srotus due to khavaigunyata in sandhi stana it gives some specific symptoms like sandhi shotha, rucha,anga mardha, aruchi and trushna etc which is diagnosed as ‘Amavata’ as per ourauthors description. So that, according to Sabdhakalpadruma, ‘Amavata indicates its samprapti’; isjustified. Page 10
  27. 27. Review of literature According to Sabdastoma Mahanidhi, “Amayati peedayati iti ama” Amayati means to be afflicted; peedayati means torment or annoy. In otherwords it means that, which causes many diseases, discomforts and pain in body isknown as Ama.Definitely Ama is known as root cause for all types of ailments.Paryayas of Amavata: In classical texts the paryayas of amavata are not envisaged. Gananath Senji in his Siddhanta nidana, has mentioned rasavata. He saysthat Amavata and rasavata both are same. The term rasa denotes normal or pure rasa. The pure rasa is not capable toproduce a disease. So pure rasa along with vata do not produce Amavata. For theformation of the disease Amavata, there must be ama. Hence the term Rasavata maynot be considered as synonyms of Amavata. The term Ama maruta and samavata are correlated withAmavata as synonyms by some recent authors. These terms do not imply thecondition of Amavata. Therefore this term may not be taken as synonyms ofAmavata. Page 11
  28. 28. Review of literature NIDANA Nidana is defined as a particular factor which has a capacity or tendency toproduce a disease8.In other words, nidana means the exact etiology of the disease. Nidana has been classified under various headings with different views.Among them one classification is bahya hetu and abhyantara hetu. Factors like ahara,vihara and kala are considered as bahya hetus. Where as abyantara hetu or intrinsicfactor mainly comprises of dosha and dooshya. The classification of the causes of disease is also very important. Theclassification of nidana such as sannikrista, viprakrista, vyabhichari, pradhanika etcguides the physician to study the history of the patient in detail. Dosha prakopa is thesannikrista nidana for all diseases. The causative factor for dosha prakopa is theviprakrista nidana and they may vary according to the disease. Virudhaahara is mentioned as one of the cause for Amavata. If we go throughwith the list of virudhahara, we find that ingestion of fish and milk is considered asvirudhahara. But many such people in taking that may not suffer from any of illnessfor years. ‘Vyabhichari’ is the name given in the texts for such type of unstrengthenedcausative factor of the disease. However such causes can alter dosha and dhatus of thebody and helps other causes to produce disease. Page 12
  29. 29. Review of literature The word Amavata indicates the main two internal cause of the disease that is‘ama’ and ‘vata’. Knowledge of these two important internal causative factors isabsolutely necessary for understanding the disease, and for the prevention andtreatment of disease. Hence its etiological factor ama is discussed here:CONCEPT OF AMA: • Eshad amyate pachyate Apakwe Vaidyakokte9 • Rogamatra, rogabheda Malavaishamya roga10 • Amyate eshad pachyate Eshad pakwe, asiddhe, pakarahite Ama + karane. Rogamatre11. • Raw, uncooked, unbaked, un annealed, unripe, immature, undigested12.Ama is an Asatmya substance in the body. In general the term ama means unripe, uncooked, immature and undigested. Inthe context of Ayurveda, however, this term refers to event which arises as aconsequence of impaired function of kayagni or dhatwagni or bhootagni . Page 13
  30. 30. Review of literature The concept of ama is a fundamental one in roganidana .The basicdoctrine of Ayurveda denotes that, most of the diseases which are included underkayachikitsa are having their origin from ama. Hence ‘Amaya ‘has been considered asa synonym of vyadhi . The description of ama is as follows: According to Vagbhata, “due to the hypo functioning of ushma ( agni ) , theannarasa is not properly formed and this rasa undergoes fermentation or putrefactionbeing retained in amashaya . This state of rasa is spoken as ama”13 Vijayarakshita , commenting on Amavata , in his Madhukoshacommentary , has quoted a number of definitions and descriptions of ama . They areas follows: • In the view of some, due to the impairment of kayagni , the annarasa and in this state it is known as ama . • The incompletely digested food which is not composed properly having bad odour and sticky in nature, produces sadana in the body is known as ama . • Some hold the view that, due to poor strength of jatharagni a residue of ahara rasa is not digested properly and produces apakwa rasa . This is known as ama , which is the root cause of all disease . • It is stated that the food which is not properly digested is ama. Yet others describe the accumulation of malas in the body as ama . • There is also the view that the first stage or phase of dosha dushti is ama14. Page 14
  31. 31. Review of literature According to other authorities, quoted by vagbhata , the impaired vatadidoshas become mixed up with one another , leading to the formation of ama verymuch like the production of visha from the spoiled kodrava15 . The food components are to be converted into bodily elements by bothjatharagni and dhatwagni . If either of the two is impaired , production of ama occurs . Most of the references cited elsewhere in this chapter are mainlyconcerned with jatharagni. Because in the quoted references ‘amashayagatam’and‘jatharanaladourbalyat’ have been used these factors refer to jatharagni mandyajanyaama . The impairment of dhatwagni also can yield ama. The commentatorDalhana commenting on ‘apakwa rasa’ says that even if rasas is not digested bydhatwagni , then it deserves to be called as dhatwagni mandya janya ama 16. In brief ama may be defined as an intermediary substance which is notuseful for healthy body, instead causes impairment of health and is produced owing tothe impaired function of either jatharagni or dhatwagni . By virtue of qualities and actions, the ama produces both acute andchronic diseases.CAUSES OF AMA: The cause of production of Ama is mainly agnimandhya. When there isagnimandya even a small quantity of light food does not get digested. The undigestedfood attains shuktatwa (fermentation) leading to the onset of toxic states, that is ama.The causative factors of agnimandhya can be classified as: Page 15
  32. 32. Review of literature 1. Aharaja 2. Viharaja 3. Manasika1. Aharaja:Various factors causing aharaja agnimandhya are: a) Abhojanam :- If no food is taken, fasting etc. By this agni gets impaired. Food is necessary for the maintenance of agni. b) Ajeerna bhojanam :- Food taken above the undigested food leads to impairment of agni. c) Athi bhojanam :- Over eating d) Vishamasanam :- Irregular dietary habits e) Asatmyaharam :- Ingestion of unfamiliar food f) Gurubhojanam :- To eat substances which are not easily digestible g) Seetha bhojanam :- Ingestion of food which is too cold or chilled h) Athi rooksha bhojanam :- Dry food with a negligible amount of water or food without ghee oil etc. i) Samdushta bhojanam :- Unclean and contaminated food j) Vishtambhi bhojanam :- Food which produces distention of the abdomen. k) Dagdhama bhojanam :- Fried and raw food intake. l) Vidahi bhojanam :- Food which produces vidaham in the abdomen. m) Sushka bhojanam :- Dry food intake. n) Akala bhojanam :- Ingestion of food at improper time . o) Athyambupanam ;- Excessive water intake. Page 16
  33. 33. Review of literature p) Virechana vamana shena vibhramam :- Maleffects of improper sodhanam ie takeing Virechana drugs without previous snehanam and swedanam and breakingof post treatment regimen.2. Viharaja: a) Desa kala ritu vaishamyam :- States brought about by fault changes in place, climate or season. b) Vega vidharanam ;- Suppression of natural urges c) Swapna viparyayam :- Late night alert and day time sleep. d) Prajagara :- Suppression of natural sleep.3.Manasika: a) Sokam :- grief b) Krodham :- anger c) Chinta :- worry d) Dukha sayya :- Unsuitable bed for sleepingPROPERTIES OF AMA: Arunadutta in his commentary on Astanga Hridaya describes the properties ofama as: 1. Dravatvam 2. Gurutwam 3. Snigdhatvam 4. Pichilatwam 5. Nana varnamPATHOLOGICAL SYMPTOMS: In general, this ama produces some pathological symptoms in the body. Theyare as follows 17 Page 17
  34. 34. Review of literature• Srotorodha:- Srotases are the channels of circulation, in which bodily elements or the others are transported. Ama obstructs anywhere in any srotus due to its pichilata property so that transportation of bodily elements gets hampered.• Balabramsha:- General weakness or loss of strength. Due to obstruction of srotases nutritions does not circulates, hence nutrition of dhatus get hampered and this cause balabramsha.• Gourava:- A feeling of heaviness. Guru, manda and pichila qualities of ama produce the feeling of heaviness in the body.• Anila moodata:- Due to srotavaroda, proper movement of vata do not takes place.• Alasya:- Lethargy, a feeling of laziness, lack of initiation.This is due to the impairment in the activities of vata; because vata is responsible for all activities in the body.• Apakti:- Indigestion; due to agnimandya, the digestive juices are not properly secreted and hence the digestion of ingested food does not takes place.• Nisteeva:- This term posses two meanings . 1. Excessive salivation. 2. Sticky mucous. Both this states are considered under kapha dusti.• Malasanga:- Constipation. Srotorodha and anila moodhata may cause the malasanga.• Aruchi:- Lack of taste. This may be due to vikruti of bodhaka kapha. Page 18
  35. 35. Review of literature • Klama:- Weakness of indrias. Due to improper supplementation of required nutrients to the dhatus. SAMA : As regards Sama , Vagbhata describes it as a condition in which tridoshasand saptadhatus as well as malas become permeated with ama . Diseases which arisein consequence are spoken of as Sama type of diseases. The settlement of ama duringits circulation through the channels of body is important in the production of adisease18. In this context, the next important point which gains much attention isvata associated with ama. Due to various factors vata gets prakupita and associatedwith ama to manifest condition called “samavata” which also have similar qualitieslike Amavata.Causes of vatakopa:Aharajam: 1. Regular intake of rooksha, ushna sheeta and laghu food stuffs. 2. Alpha bhojanam- inadequate intake of food. 3. Abhojanam - Fasting. 4. Ingestion of food which are predominantly tikta, katu and kashaya rasas.Viharajam: 1. Jagaranam - Sleep evasion 2. Vegadharanam - Suppression of natural urges. 3. Vegodheeranam - Forcible act of natural urges. 4. Ativyayama - Over exertion. 5. Ativyavayam -Excessive sexual indulgence. Page 19
  36. 36. Review of literatureManasika: Bhaya, krodha,chinta etc emotional factors also does the prakopa of vata. When vata becomes abnormal, it afflicts the body with diverse types ofdisorders. It impairs strength, complexion, happiness and span of life. It perturbs themind, affects all the senses. It destroys, deforms the fetus or prolongs the period ofgestation. It gives rise to fear, grief, stupefaction, humility and delirium. It obstructsthe vital function19. When both ama and vata gets conjoin together and moves all over the bodyand stagnant in Trika sandhis with many symptoms, produces a disease calledAmavata.Causes of Amavata as mentioned in Madhava nidanam and Bhavaprakasam are- 1. Virudhahara cheshta :- Ingestion of unwholesome food is one of the important causes of Amavata. Some dietary articles when mixed in a particular way with a particular food cause diseases instead of doing their normal functions. Virudha can be defined as that which provokes the doshas not expels them out of the body. Acharya Charaka described the factors which are responsible for the incompatibilityof food. Those are given below with one example:- 1. Desha virudha: Intake of snigdha and sheeta dravya in anoopa pradesha. 2. Kala virudha: Intake of sheeta ,rooksha druvyas in sheeta kala. 3. Agni virudha: Guru, sheeta druvyas in mandagni. 4. Matra virudha: Intake of equal quantity of madhu and sarpi. 5. Satmya virudha: Intaking unwholesome food. Page 20
  37. 37. Review of literature 6. Dosha virudha: Taking opposite quality food that of individual’s prakruti. 7. Samskara virudha: Intake of incompatibly prepared food. 8. Veerya virudha: Intake of mixture of sheeta and ushna veerya food. 9. Kosta virudha: Intake of heavy food by mrudu kosta persons. 10. Avastha virudha: Intaking kaphakara ahara after sleep. 11. Karma virudha: Intaking food before feeling hunger. 12. Parihara virudha: Intaking hot things after intake of boar meat. 13. Upachara virudha: Intake of sheeta guna druvya after intaking ghruta. 14. Paka virudha: intaking uncooked or over cooked food. 15. Samyoga virudha: Incompatibility of combination like,sour substances taken with milk. 16. Hrud virudha: Unpleasent tasted food intaking. 17. Sampad virudha: Quality less food like, unripe or over ripe or putrified. 18. Vidhi virudha: Incompatibility of rules of eating like, eating in solitary place20.Like virudhahara, virudhavihara also causes disease amavata. Examples are: 1. Exercise after taking food. 2. Sleeping at daytime. 3. Suppression of natural sleep. 4. Taking bath immediately after taking food. 5. Suppression of natural urges. 2. Mandagni:- Mandagni is the most important causative factor of amavata. Mandagni is nothing but agnimandhya which can immediately produces ama. If agni is very powerful even virudhahara cannot do any harm. Actually agnimandhya is the root cause for this disease. Page 21
  38. 38. Review of literature 3. Nishchala:- A sedentary habit is responsible for agnimandya as well as for producing hinayoga of the karmendriyas. It therefore produces sthana vaigunaya in the joints. This is a vyadhi hetu of the disease. 4. Exercise after the ingestion of snigdhahara: Actually the use of internal sneha is very much essential formaintaining the agni. However if proper rest is not taken after snigdha ahara which isguru, and indulging in heavy bodily works immediately, agni gets disturbed and it isunable to digest the food properly. So production of ama takes place here. Quite sometime agni is required for pakakriya and hence swasthavritha advises to take some restafter meals: If sufficient rest in not taken there is chance of vata prakopa. Bhavaprakasha, Vangasena, Gadanigraha and Yogaratnakar have alsoexplained about nidana of Amavata as same as Madhava nidana. Only Harita includedone more extra word ‘khandashaka’ which again gives the same meaning of intakingof likely food heavily without doing exercises. Even though causes mentioned for theproduction of Amavata are plenty, it is also noteworthy that all the causes are notnecessary to produce the disease always. Some of the cause may be sufficient for theproduction of a disease. Page 22
  39. 39. Review of literature SAMPRAPTI Samprapti is nothing but the detailed description of all the morbid process thattakes place in different stages of the disease. It is the period of pathogenesis takingplace in the body from the period of nidana sevana to the period of vyadhivyaktavastha. The factor of nidana vitiates doshas in some particular fashion. Suchvitiated doshas start accumulating in their respective areas and by continuousindulgence in nidana sevana, the accumulated doshas travel through srotas and getlodged, where there is a kha vaigunya and thus, manifestation of disease takes place. This complex process which involves sanchayadi avasthas is explained undersamprapti. Regarding the samprapti of Amavata all the authors who have dealt with ithave given the same opinion. Ama plays an important role in the formation of thedisease Amavata. According to vagbhata,the samprapti is again classified into five types. Theyare Sankhya,Vikalpa, pradhanya, Bala and Kala samprapti. These indicates regardingthe number of classification of particular disease, the very minute causative factor,predominant dosha involved in it’s manifestation, the strength of the disease andtiming of aggravation and alleviation of disease respectively21. Page 23
  40. 40. Review of literature The picture of satkriyakala, regarding samprapti of the any disease seems to bemore useful to know the different stages of disease and to select the appropriatetreatment procedures for them22.Here according to satkriyakala, the samprapti of Amavata is explained as follows-Sanchayavasta: Etiological factors of Ama cause the agnimandyata.. This condition leads tothe ama. The ama gets accumulated in amashaya. On the other hand, vata also getsvitiated by its own causes. This stage may be considered as ‘sanchayavasta’. In Amavata nidana, production of ama takes place not only in amashaya, butalso in all the shleshmastanas like ura, kanta, sandhis simultaneously, due tocontinuous indulgence of nidana.Prakopavasta: The ama which is accumulated in sleshma sthana gets instigated by vitiatedtridosha and becomes vidagdha. Accumulation of more and more vidagdha ama inamashaya and all other shleshma stanas which indicates ‘swa sthane vruddhi’ whichby itself prakopavasta. As agnimandya takes place in amashaya, primarily rasadhatwagni followed byall the dhatwgnis, also gets mandavasta.and tridoshaprakopa takes place here, amastarts producing and accumilating in rasadhatu also. Page 24
  41. 41. Review of literaturePrasaravastha: In classics it is stated that ama proceeds to shleshma sthanas. Uras is ashleshma sthana & hridaya is situated in uras. On the basis of this, it can be knownthat the ama comes in contact of hridaya also. As the ama and rasa mixes in hridaya, from the hridaya ama along withvitiated rasa, carried through all srotas of the body by the vitiated vata. This stage isconsidered as “prasaravastha”.Sthanasamshraya: Due to the kha vaigunya in sandhies ama along with vitiated rasa and vatasettles in sandhies. Madhavakara says that the vitiated doshas along with ama entersinto trikasandhi. The description of trikasandhi is as follows. The commentator VachaspatiVaidya commentating on trikasandhi says “kati manyamsa sandhi”. For kati, sacralregion can be compared. Dalhana commenting on trika says “shronikanda bhage trikam praseedam”23.This denotes that shronikanda bhaga is considered as trika. Amsa sandhi may also be considered as trika sandhi. Here the connection ofthree bones is present i.e. akshakasthi, amsaphalaka & pragandasthi. In Amavata, the sandhies are affected, probably due to the specific affinity ofama towards sandhies. Sandhies are supported by snayu and peshi. The inner side ofsandhi is covered by shleshmadhara kala (synovial membrane). Inside theshleshmadhara kala there will be secretion of shleshaka kapha (synovial fluid). This Page 25
  42. 42. Review of literatureshleshaka kapha is responsible for easy movements of sandhies. Ama and vitiated rasacause the vitiation of snayu and peshi. This condition leads to the vitiation ofslheshmadhara kala of sandhies. The ama located in shleshmadhara kala causesabhishayndha. As a result of this, the shleshaka kapha gets increased and blocks vatamarga. Due to avarodha, the ama lodges in sandhis. This may be considered as“sthanasamshraya”Vyaktavasta: Due to avarodha, the accumulated kapha will not be reabsorbed into srotas,and hence causes shotha and shoola, followed by all the lakshanas of Anavata. Thismay be considered as “Vyaktavasta”.Bhedavasta:If it is not treated in all these five stages, then the stage called “Bhedavasta” starts.This includes all the upadravas. This stage is difficult to treat also.This is the samanya samprapti.Vishista samprapti: In vishista samprapti of amavata, the involvement of particular dosha willtakes place. The predominance of dosha produces its own lakshana. The predominance of vata causes severe shoola in sandhies. Daha and raga areobserved in sandhies due to the predominance of pitta. The predominance of kaphaproduces sthaimitya, gaurava and kandu24. Page 26
  43. 43. Review of literatureSamprapti ghatakas:1. Dosha: a) Vata: Samana vayu helps for pachana, vivechana etc. In Amavata these kriyas are lessened. Vyana vayu also gets vitiated in Amavata. b) Pitta: Among five types of pitta, pachaka pitta is involved. The functions of pachaka pitta are impaired. c) Kapha: Kledaka kapha and sleshaka kapha are involved. Kledaka kapha moistens, breaks the food and produces dravata. These functions are impaired in Amavata. Shleshaka kapha gets vitiated and accumulated by the influence of ama. This results in sandhi shotha and shoola.2. Dushya: Dushya is rasa. By the contact of ama, rasa gets vitiated. Vitiated rasa and ama circulates throughout the body and produces amalakshanas. Because of affinity and kha vaigunya in sandhies the vitiated rasa and ama settles in sandhies and produce shotha and shoola.3. Agni: Mandata of jataragni and rasadhatwagni is observed in Amavata.4. Ama: Ama is produced by mandata of jataragni and rasadhatwagni.5. Srotas: Rasavaha srotas is affected in Amavata. The ama circulates through the rasavaha srotas. Page 27
  44. 44. Review of literature6. Dushti prakara: Due to the impaired function of rasadhatwagni, the rasa is not formed properly. This is attributed to sanga.7. Udbhava sthana: Udbhava sthana is amashaya. Ama is an important factor in the causation of disease. The production of ama occurs in amashaya.8. Sanchara sthana: Ama along with vitiated rasa travel through srotas and get lodged in sandhies.9. Roga marga: Roga marga is madhyama roga marga. The ama and vitiated rasa goes to hridaya. From hridaya, ama and vitiated rasa goes to asthi sandhies. As a result of this condition, shotha and shoola occurs in sandhies. Hridaya and sandhies comes under madhyama roga marga.10. Adhishtana: Ama settles in sandhies because of affinity and kha vaigunya in sandhies. This condition leads to shotha and shoola. Hence sandhies can be considered as adhishtana for Amavata.11. Vyakta sthana: In Amavata shotha and shoola occurs in sandhies due to ama. Hence sandhies can be considered as vyakta sthana. Page 28
  45. 45. Review of literatureChart no:1Scheme of Samprapti: Consumption of virudha ahara etc nidanas. Agni mandhya Ama Ama in all Sleshama stanas ( like amashaya, sandhi, ura, sira, kanta) {sanchayavasta} Ama gets ‘vidagdha’ by tridosha prakopa. {prakopavasta} Vidagdha ama starts moving in dhamanis from hrudhya to all over the body. {prasaravasta} Sroto rodha by shleshaka kapha of trikasandhis. Yugapath kupita vata and sleshama (ama) enters into ‘trika sandhi’ were kha vaygunya has taken place. {stanasamshraya} Produces symptoms of Amavata. {vyakthavasta} Page 29
  46. 46. Review of literature POORVA ROOPA The vitiated doshas in the stage of sthanasamshraya will produce thesymptoms of forthcoming disease. Such symptoms are called as poorva roopas orpremonitory symptoms. These are the indications of impending disease25. One more quotation from Madhavakara about poorvaroopa is, these are thefeebly manifested symptoms of forth coming disease. The poorva roopa of Amavata has not been mentioned in texts. Some of thesymptoms like dourbalya, aruchi, alasya, gaurava, trishna, angamarda can beconsidered as poorva roopas. In addition to these the other symptoms of Amavatawhich are incompletely manifested may be considered as poorva roopa. Page 30
  47. 47. Review of literature ROOPA The term roopa implies the signs and symptoms by which disease is identified.This is the fifth stage of samprapti i.e. vyaktavastha25. According to the signs and symptoms, roopa can be classified as follows- 1. Pratyatma lakshanas (Cardinal signs & symptoms) 2. Samanya lakshanas ( General signs & symptoms) 3. Vishishta lakshanas (Distinguishing features of doshanubandha) 4. Pravriddha Amavata lakshanas 1. Pratyatma lakshanas: a) Sandhi shotha- Generally the shotha is in symmetrical shape. There will not be any pitting on pressure. There will be ushna sparsha and the shotha increases in sheeta kala i.e. during night and early morning. b) Sandhi shoola: Usually shoola is felt in sandhies all the times. It increases during night and early morning owing to sheeta nature of night and early morning. Character of shoola in pravriddha avastha is described as “Vyavidfha iva vruschikaihi” (like scorpion bite). Commentator Vachaspati Vaidya described shoola as “Rijyate”, “Tujjate”. Shotha and shoola shift from one joint to another. In classics the phrase “Karotisarujam shotham yatra doshaha prapadhyate” has been used. This means where the Page 31
  48. 48. Review of literaturevitiated doshas and ama travels, there shotha and shoola takes place. As the diseaseprogresses, there is tendency for it spread to the sandhies of hastha, pada, shiras,gulfa, trika, janu and ooru. Shotha and shoola gets decreased in ushna kala.c) Gatrasthabdhata: This means stiffness of the body. As sandhdies are restrictedthe normal movements of the body also gets restricted.Samanya lakshanas: a) Angamarda- Angamarda means feeling of mardanavat peeda (crushing type of pain). This occurs due to rasa dhusti caused by ama 26 b) Aruchi- The bhodaka kapha, which is situated in jihwa, gets vitiated by the ama and leads to condition of aruchi, where the patient does not find food palatable. c) Trishna- Ama produces sroto rodha of udakavaha srotas. As a result of this patient craves for water. d) Gaurava- It is the feeling of heaviness. Guru and picchila gunas of ama, which have prithvi and jala mahabhootas, leads to rasa dhusti and produce gaurava. e) Alasya- It means inactiveness. Due to gaurava and srotovarodha, patient becomes unenthusiastic. f) Jwara- Ama and vitiated doshas expel the agni from its normal place resulting in santapa. g) Apaka- Hypo functioning of rasadhatwaghni arises as a consequence of impaired function of jataragni. This condition leads to apaka. Page 32
  49. 49. Review of literature h) Shoonatanga- This is nothing but sandhi shotha.Table No.1Samanya lakshanas of Amavata: Samanya M.N G.N H.S R.R.S lakshanas Angamarda + + _ _ Aruchi + _ _ _ Trishna + _ _ _ Alasya + _ _ _ Gaurava + _ _ _ Jwara + _ + _ Apaka + _ _ _ Agnimandhya + _ + + Sandhishoola _ _ _ +Yoga Ratnakara, Vangasena & Brihat yoga tarangini also mentioned the symptoms assaid by Madhavakara.Vishishta lakshana24: These symptoms indicate the anubandha of doshas. Those are: a) Vatanubandha- Predominantly shoola is found in the affected sandhies. b) Pittanubandha- Raga and daha will be predominant in the affected sandhies. c) Kaphanubandha- Sthaimitya, bahukandu are the predominant symptoms. Page 33
  50. 50. Review of literaturePravriddha Amavata lakshanas: As the disease progresses, due to the involvement of tridoshas, a number ofother symptoms will develop with complications. The different opinions mentioned invarious texts are follows:Table No.2Pravriddha lakshanas of Amavata: Pravriddha M.N H.S B.R Amavata lakshanas Sandhi shoola + + _ Sandhi shotha + + _ Agnimandhya + _ _ Praseka + _ _ Aruchi + _ _ Gaurava + _ _ Utsaha hani + _ _ Asyavairasya + _ _ Daha + _ _ Bahumootrata + _ _ Page 34
  51. 51. Review of literature Kukshi katinata + _ _ Kukshi shoola + _ _ Nidra viparyaya + _ _ Trishna + _ _ Chardi + _ _ Bhrama + _ _ Moorcha + _ _ Hridgraha + _ _ Malabhaddata + _ _ Jadya + _ _ Antrakoojana + _ _ Anaha + _ _ Grahani dosha _ _ _ Anga vaikalya _ + _ Peeta mootrata _ _ + Takra tulya _ _ + mootra Vasa tulya motra _ _ + Gada nigraha, Bhava Prakasha, Brihat yoga tarangini, Vangasena and YogaRatnakara have mentioned the same features as said in Madhava Nidana. Page 35
  52. 52. Review of literature CLASSIFICATION OF AMAVATA The disease Amavata has been classified on the basis of anubandha ofdosha, severity and mode of manifestation of the disease. A) Classification according to anubandha of dosha57 : On the basis of anubandha of dosha it has been classified into the following varieties; 1. Anubandha of one dosha: a) Vatanuga b) Pittanuga c) Kaphanuga 2. Anubandha of two dosha : a) Vata-pittanuga b) Vata-Kaphanuga c) pitta-kaphanuga 3. Involvement of all the three doshas : Tridoshaja The symptoms of three varieties of one dosha anubandha Amavata isexplained in vishista lakshanas of Amavata previously. Mixed symptoms are seen inother types of Amavata according to the dominance of dosha. B) Classification according to the severity of the disease : On the basis of severity, it may be classified into two stages. 1. Samanya amavata (prarambavasta) 2. Pravriddha Amavata. (pravrudhavasta) Page 36
  53. 53. Review of literature In the samanya Amavata stage, the symptoms are more or less general, andless severe and not associated with upadrava, contrary to the stage of pravridhaamavata. C) Classification according to the clinical manifestation : A unique classification of Amavata is explained by Harita based on presentation of the disease58. Those are as follows: 1. Vistambi 2. Gulmee 3. Snehi 4. Pakvama 5. Sarvanga 1. Vistambi : This type is present with constipation, feeling of heaviness in the abdomen, flatulence pain in the basti area. 2. Gulmee Amavata : Audible peristaltic sounds, squeezing type of pain in the abdomen simulating gulma are the symptoms 3. Snehi Amavata : Unctuousness in the body, inactivity, loss of appetite, passing of unctuous, undigested and dehydrated stools59. 4. Pakvama : The symptoms are passing the yellowish black or dark dullish dehydratedpakvama from the anus, fatigue, exhaustion. The condition is not associated with bastishoola60. 5. Sarvanga Amavata : Page 37
  54. 54. Review of literature Pricking type of pain in kati-prushta and vaksha region, pain in the bastiregion, audible peristaltic sounds, swelling, heaviness in the head, excessive excretionof ama are the symptoms61. UPADRAVA The disease which appears as a continuation of and after the completemanifestation of the original disease is called “upadrava”. Or in other words, theoccurrence of other disease in the wake of primary disease, as a complication isknown as “upadrava”27. According to Madhavakara, it is a secondary disease or complication,produced by the same dosha which is responsible for the formation of main disease28. There exists some difference of opinion regarding the upadrva of Amavata.Vachaspati opines that the symptoms of advanced stage of Amavata are itself theupadrava. According to Vijayarakshita, sankocha and khanjata are the upadravas.Vachaspati considered different vata vyadhis dealt in vata vyadhi nidana chapter asadditional upadravas. Hartita mentioned angavaikalya as the lakshana of Amavata,which can be considered as upadrava of disease. The following upadravas are dealt inAyurvedic literature- 1. Sankocha: Inability to extend the limb or abnormal flexed state of limb is termed as sankocha29. Yogaratnakara explained this as “Vikunchana”. Sankocha can occur in any srotas or any part of the body where ama and vitiatedvata travels. 2. Khanjata: Patients gait is altered because of pain, caused by akshepana ofkhandara, which is situated in the sakthi by katigata vata30. Page 38
  55. 55. Review of literature 3. Vataroga: Vachaspthi opines all vatavyadhis are the upadravas which mayleads to ‘stabda gatrata’ i.e., restricted movement of joints, or anga vaikalya i.e.,deformity of joints. 4. Hridaya vikruti: Heart is involved before the manifestation of disease, as amaproduced in amashaya reaches the hridaya, before moving towards the joints.Sankocha and also stabdhata can also manifest in some parts of hridaya. This vikaramay be cited as an example of angavaikalya. UPASHAYA – AANUPASHAYA In classics there are no direct references regarding Upasha and Anupashaya ofAmavata except Hareeta who mentioned that cold water bath increases the condition.Ama is the important factor in the production of Amavata .Hence the dravyas whichare antagonistic to the nature of ama, are to be considered as Upashaya of Amavata.So katu rasa, rooksha guna and ushna veerya drugs, rooksha sweda, rooksha upanahaalong with this, langhana and ushna kala are reckoned to be Upashayas. Bhavamishra, while describing the Samavayu stated that, Samavayu getsincreased by the use of sneha dravyas, during cloudy seasons, night and earlymorning. This principle is applicable to Amavata also. Dravyas having guru guna,sheeta guna and madhura rasa cause the aggravation of Amavata. Along with this, allnidanas of Amavata are also anupashayas of Amavata. Page 39
  56. 56. Review of literature SADHYA – ASADHYATA Regarding the sadhyasadhata of Amavata all the authors have considered onlythe number of doshas involved and the extension of shotha to all the sandhies. If thedisease Amavata involves only one dosha, it can be considered as sadhya. It becomesyapya if it involves two doshas. If all the sandhies are affected by shotha and all thethree doshas are involved in Amavata, with its upadrava, then it is said to beasadhya31. If Amavata is of recent onset, it is curable with minimum efforts. If it becomeschronic, it becomes krichrasadhya or yapya probably due to extensive damage orirreversible structural changes. Such condition may either disable the patient or leadto be accompanied with some complications. The disease Amavata is considerd as krichrasadhya only because sandhies areconsidered as adhistana and vyaktasthana in Amavata. As the disease Amavataprogresses, there is a tendency for it to spread to the sandhies of hasta, pada, shiras,gulfa, trika, janu and ooru. In classics it is said that “sakashtaha sarvaroganam yadaprakupito bhavet”. This denotes that, among all the diseases, Amavata is difficult tomanage in its advanced stage. Page 40
  57. 57. Review of literature Page 41
  58. 58. Review of literature AMAVATA CHIKITHSA In Ayurveda, there is emphasis on a therapeutic programme for managing thepatients of Amavata instead of a single drug therapy. This therapeutic programme ismore or less etiologically oriented and aimed at samprapti vighatana. This line oftreatment depends a good deal on the stage of the disease process. Chakradatta was the pioneer book in describing the principles of treatment forthe disease, which are: Langhana, svedana, administration of drugs having tikta, katurasa and deepana action, virechana, snehapana and basti. Same line of treatment is adopted in Yoga ratnakara and Gada nigraha,Yogaratnakara and Bhava prakasha have added ruksha upanaha to these therapeuticmeasures32.LANGHANA Langhana is adopted first in the management of Amavata. Following conceptssubstantiate the usefulness of langhana in Amavata. All types of langhana arebeneficial in rasaja vikaras33Rasadhatu is mainly involved in Amavata. Langhana treatment is advised in amashayotta vyadhi34. Ama in Amavata has its origin from amashaya. Langhana also pacifies theamavikaras35.Langhana is also indicated in samavata, samapitta, and samakapha conditions36. Page 41
  59. 59. Review of literature After examining desha, kala, dosha etc. these measures can be adopted inamaja vikaras. In alpa dosha condition –langhana, Madhya dosha condition –langhana and pachana and in prabhuta dosha condition – shodhana. In Amavata, ama is involved in prabhuta matra and has samavata condition, forwhich langhana should be done first. Because it has been described that samadoshacannot be eliminated until and unless ama attains the pakva form37 which can beattained by langhana Langhana in the form of upavasa is advised in cases of amajanya vikaras38.SWEDANA The therapy which does nigraha, gaurava nigraha, sheeta nigraha along withthe production of sweda is known as “swedana”. In Amavata, ruksha sweda has been advocated in the form of valuka putaka39this can be substantiated by Charaka’s vision that if vitiated vatadosha locates inkapha sthana first rooksha sweda should be done40. Swedana help in cleaning the doshas and thus aids in the transportation ofdoshas from shaka to kosta.It has been indicated in the condition of stamba, gourava, sheeta and shoola41 whichconstitutes the predominant feature of Amavata. Swedana is also advised in the line of treatment of samadosha, which hasspread through out the body, to attain niramavastha, to facilitate shodhana42. Page 42
  60. 60. Review of literature In Amavata as doshas take stanasamshraya, in sandhis and disease process is confined to joints, stanika sweda can be given and if there is involvement of sarvashareera, sarvanga sweda can be done. TIKTA, KATU AND DEEPANA DRUGS The rationality behind usage of tikta, katu and deepana drugs are as follows: Tikta rasa has rooksha and laghu gunas. It does lekhana as well as deepana and pachana. It is beneficial in conditions like, aruchi thrushna, moorcha and jwara. It absorbs the kleda and shleshma43. Katu rasa is having laghu, ushna and rooksha gunas. It also has properties like deepana pachana and rochana so it dilates the srotases. It dries up sneha, kleda and mala and is beneficial in shotha44. As agni vikriti is the main factor for Amavata, so administration of deepanadrugs helps to increase the appetite. These drugs have theeksna, ushna, langhana andagneya properties. These tikta, katu and deepana drugs are proved to be effective in the diseaseAmavata, which is due to their ama pachana property. VIRECHANA After the administration of langhana, swedana and tikta, katu and deepanadrugs, the patient should be subjected to virechana therapy becouse the doshas renderednirama by these therapeutic measures require elimination from the body by shodhana45.Shodhana should be adopted in prabhutha ama condition46. Page 43
  61. 61. Review of literature The virechana drugs expel the sanghata doshas after liquefying them byreaching through dhamanis due to their properties like ushna, teekshna, sukshma,vyavayee, vikasi and adhobagahara prabhava47. The virechana drug acts by following manner. Sara guna causes anulomana,sukshma guna is responsible for reaching minute channels. Teekshna guna producesrapid dosha sravana and ushna guna eliminates soumya dravyas48. The virechana does the adhomarga anulomana and vimarga nirharana ofvata49. It also produces agni deepti, dhatu sthirata, increase in bala and sroto shudhi50. Thus virechana has advantage on ama, vata and agni.SNEHAPANA After langanadi therapies, the patient should be subjected to snehapana, topacify the vata, but only after attaining nirama avastha51. Snehapana has been stated to augment the agni, as it influences the digestionby softening the food and stimulating the agni52 which is the primary requirement inAmavata. Further more, sneha is said to be supreme in the treatment of vata predominantdisorders53. Page 44
  62. 62. Review of literatureBASTIIn Amavata both anuvasana as well as niruha basti have been advocated. Chakradattaadvised saindhavadi taila for anuvasana and kshara basti for niruha. Administration ofanuvasana basti followed by niruha basti by various snehas has good control onAmavata.Shodhana bastis are considered to be beneficial in ama condition51. The administered basti dravyas reaches nabhi- kati- parshava and kukshi. Bystaying there itself, it acts through its veerya and spreads to different parts of body,quickly through the srotasas and is able to eliminate or palliate the doshas54.As vata is responsible for the location of diseases in shaka, koshta, marma anddifferent avayavas, basti is considered as best one to control the vata.Basti can be adopted in conditions like stabdhata, sankocha, sandhi muktata, vigrahitapurisha, shoola, aruchi and in conditions where vata is present in shakas. In shudhavata condition anuvasana basti is indicated. Besides this, niruha basti does the sroto shuddhi and is useful in all stages ofthe disease55.It facilitates lekhana along with shodhana and expels the dravikrita doshas56. Page 45
  63. 63. Review of literatureTable No. 3Line of treatment according to different texts: Name of the C.D B.P Y.R B.Y.T B.R treatment Langhana + + + + + Swedana + + + + + Tikta + + + + + Deepana + + + + + katu + + + + + Virechana + + + + + Snehapana + + + + + Basti + + + + +Table No.4Different Yogas for Amavata mentioned in different texts: Name of the Yoga C.D B.P Y.R Bh.R Kwathas Rasonadi kashaya + Rasna panchaka kwatha + + + + Pippalyadi kwatha + + Shatyadi kwatha + + + + Rasna saptaka kwatha + + + + Maharasnadi kwatha + + Rasnadi dashamoola kwatha + + + Rasna dwadasha kwatha + Dashamooladi kwatha + + Shuntyadi kwatha + + Punarnava kashaya + Choornas Nagara choorna + + + + Panchakola choorna + + + Page 46
  64. 64. Review of literatureAmritadi choorna + +Vaishvanara choorna + + +Alambushadi choorna + + +Shatapushpadi choorna +Hingwadi choorna + + +Pathyadi choorna + +Pippalyadi choorna +Chitrakadi choorna + + +Punarnavadi choorna + +Apeetaka choorna +Palatrikadi choorna +Panchasama choorna +Ajamodadi choorna +Bhallatakadi choorna +Trivritadi choorna + GhritasShunti dhanyaka ghrita +Shunti ghrita + + + +Kanjikadhya ghrita +Shringaberadya ghrita +Amrita ghrita +Kanji shatpala ghrita + TailasEranda taila + +Prasarini taila + +Dwipanchamoola taila +Brihat saindhavadi taila + + +Saindhavadi taila + KalkaShatyadi kalka + AvalehyaKhandashunti avalehya + + GutikasAjamodiadi vati + + +Yogaraja guggulu + + +Simhanada guggulu + + +Brihat simhanada guggulu + Page 47
  65. 65. Review of literature Vatari guggulu + Shiva guggulu + Amavatari vatika + Brihat yogaraja guggulu + Rasayogas Amavata vidhwamsini rasa + Amavatari rasa + Vata gajendra simha rasa + Amavateshwara rasa +Vyavachedaka Nidana Usually diseases are recognized by their signs and symptoms. But it is oftenseen that a few particular signs and symptoms appear in more than one disease. Insuch conditions, to avoid error in adopting the line of treatment, the differentialdiagnosis can be done on the basis of few points such as difference in nidana,samprapti, lakshana etc.Table No.5Differential Diagnosis for Amavata: Particulars Amavata Vatashonita Sandhigata vata Age Mainly children Generally between Generally and young adults 20-40 years over 40 years Onset Acute rarely, Gradual but Always Gradual sometimes acute gradual Causative factors Ama and vata Vata and rakta Vata alone Joints primarily Joints in which Small joints like Any of the involved three bones meet metacarpals and weight i.e. large joints like metatarsals bearing joints knee, elbow etc. specifically leg toe Page 48