Evaluation and Efficacy of Hingavadi Guggulu in Amavata (with special reference to Rheumatoid Arthritis), JI Hiremath, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG
CONTENTS Acknowledgement List of Photographs List of Tables List of Diagrams AbbreviationsChapter Name Page No.1. Introduction. 1–92. Review of Literatures 10–1033. Materials and Methods 104–1204. Observation and Results. 121–1435. Discussion 144–1626. Summary & Conclusion 163–168 • Bibliography • References • Appendix
ACKNOWLEDGEMENT “Love Is The Only Inspiration” This work caries some sweet memories to express and record about some distinguish personalities with whom I had inspired during the course of this thesis. I express my obligation to my honorable guideDr. Ch. Ranga Rao . M . D. (Ayu) Head of the departmentof Kayachikitsa, D.G.M. Ayurvedic Medical Collegeand post graduate and research centre, Gadag for hiscritical suggestions and expert guidance for thecompletion of thesis. I am extremly grateful and obliged to my Co-guide Dr.Ashok Kumar Panda, lecturer postgraduatedepartment of Kayachikitsa, PGARC, D. G. M.Ayurvedic Medical College, Gadag. Under whoseguidance, inspiration, supervision and valuablesuggestions. I have been able to complete this researchwork. I express my obligation to my principal Dr. G. B.Patil for his encouragement for studying M. D. as well
as providing all necessary facilities for this researchwork. I express my deep gratitude to Dr. Siva RamPrasad Kettamakka. M . D . ( A y u ) ( O S M ) , Reader inKayachikitsa, PGARC, D. G. M. Ayurvedic MedicalCollege, Gadag for his advice and encouragement atevery step of this work. I have much pleasure to appreciate Dr. M. C.Patil , Reader, PGARC, D. G. M. Ayurvedic MedicalCollege, Gadag for his whole hearted Co-operation &suggestion in this study. I express my sincere appreciation to Dr. S. A.Patil, RMO . D.G.M. Ayurvedic Medical College, Gadagfor his inspiration, relevant suggestion and supportduring my post graduate study and research. I am grateful to Dr. S. H. Doddamani , lecturerPGARC D. G. M. Ayurvedic Medical College, Gadagfor his co-operation & advise in this study. I am grateful to Dr. C.M. Sarangamath, Dr. U.V. Purad, Dr. C. S. Hiremath, Dr. P. C.Chappanmath, Dr. G. S. Hiremath, Dr. R. K.
Gachhinmath and Dr. B. G. Swami for their wholehearted co-operation and advise. My sincere thanks are extended to Dr M.EswaReddy , Dr S.S. Hiremath, Prof. SidduYapalparvi, Dr S.G. Hiremath, Dr. A.S. Prashant, DrG.C Hiremath, Dr Marideva Sharma T.H.M. Dr G.RVastrad, Dr Shoba Hiremath Dr. Madhava DiggaviDr.N. Anjaneyamurthy, Dr. S.R. Hiremath and DrJayashree for their encouragement and suggestion. I am glad to express my heartiest thanks to Dr.Venkatesh S. Karanth , radiologist for his co-operationand suggestion. I thank to Mr B.S. Tippanagoudar ,Lab technician, and Mr. Basavaraj x-ray technician fortheir help in the diagnosis of disease. Let me thanks to Sri. V.M. Mundinamani ,librarian assistant S.B. Sureban for providing manyvaluable books during my post graduation. I tender mythanks to Nandakumar , statistician, Dr. M.V. Achar,Dr. S.N. Karur and Dr V.C. Shirol for their help Co-operation, and suggestions.
I wish to express thanks to my colleagues Dr.Ragavendra, Dr. Shashi, Dr. Yashoda, Dr. VireshKottrushetter, Dr. Shiva Kumar, Dr. Patil, Dr.Rajashekar, Dr. Vivek, Dr. Anilkumar, Dr. Mulkipatil,Dr. Girish, Dr. Suresh, Dr. SyalKumar Dr. SeetharamPrasad Dr. Anand Adi Dr. Hadimani and Dr. Yasmeenand other PGTS of my institute. I acknowledge my patients for their wholeheartedconsent to participate in this trial and co-operationduring the follow-up in this research work. I express my thanks to Zuber (vision solutionsurfing center), for completing this type mattersincerely correctly in due time Lastly. I acknowledge to my Father Irayya S.Hiremath , elder brother Ningabasayya , sistersJayashree , Rajeshwari and Sujata for their silent helpduring my postgraduate regarding various problems.I express my thanks to all the persons who have helpedme directly and indirectly with apologies for myinability to identify them individually. Jagadish. I. Hiremath
LIST OF PHOTOGRAPHSPhoto No. Name of the Photo1. Hingu L: Ferula narthex2. C a v ya Piper retrofractum3. Vidalavana4. Sunthi L: Zingiber officinale5. Pippali L: Piper longum7. Krishnajeeraka Carium carvi8. Puskaramula L: Inula Racemosa9. Guggulu L: Commiphora Mukul10. Administration of Valukasweda
LIST OF TABLETable No. Name of the Tables Page No.I. Age and sex distribution of thirty treated patients 122II Distribution of Religion of thirty patients 123III Distribution of Patients according to the occupation 124IV Distribution of Patients according to economical status 125V Distribution of Patients according to the Diet habit 126VI Presenting symptoms of Thirty cases. 127VII The Duration of chronicity in treated 30 patients 128VIII a) The table showed the affected joints of Thirty patients 129 b) Showing the types of Amavata 130IX Agni bala of thrity treated cases. 131X Prakruti of treated thirty cases. 132XI Clinical symptoms before and after treatement of Group ‘A’ 133XII a) Clinical symptoms before and after treatment Group ‘B’ 133 b) Statistical analysis of clinical symptoms before and after treatment 135XIII Statistical analysis of objective parameters Group ‘A’ Patients 136XIV Statistical analysis of objective parameters Group ‘B’ Patients 137XV Laboratory investigations in thirty patients 138XVI Statistical analysis of laboratory parameters of Group ‘A’ Patients. 138XVII Statistical analysis of Laboratory parameters of Group ‘B’ Patients 139XVIII Comparative Overall assessment of therapeutic responses of trial and control group. 140XIX Statistical comparision between two groups after treatment relation to there clinical response 142
LIST OF DIAGRAMSDiagram No. Name of the Diagram PageNo.1. Age & sex distribution of thirty treated patients 1222. Distribution of religions in thirty patients 1233. Distribution of 30 patients according to the occupation 1244. Distribution patients of economical status of thirty patients 1255. Distribution of patients according to diet habit 1266. The chief complaints of thirty patients 1277. Duration of suffering of patients 1288. a. Affected joints of thirty patients 129 b. Types of Amavata 1309. Agnibala of thirty treated cases 13110. Prakruti of treated thirty cases. 13211. Overall assessment of therapeutic responses of trial and control group 14012. Comparative assessment of response in percentage. 142
ABBREVIATIONS1. A. D. : Atanka Darpana Commentary by Vacaspati on Madhava Nidana.2. A. N. : Anjana Nidana.3. A. H. Ci : Astanga Hridaya cikitsa Sthana.4. A. S. : Astanga Sangraha.5. B. P. : Bhava Prakasha6. B. R. : Bhaisajya Ratnavali7. C. Ci. : caraka cikitsa Sthana.8. C. Ni. : Caraka Nidana Sthana.9. C. Sa. : Caraka Sarira Sthana.10. C. Su: Caraka Sutra Sthana.11. C. Vi : Caraka Vimana Sthana.12. C. D. : Cakra dutta13. Dh. : Dalhana Commentary in Susruta Samhita14. M. K. : Madhu kosha commentary by, Vijayarakshita and Srikantha datta on Madhava Nidana.15. M. Ni.: Madhava Nidana.16. R. P. : Ranavir Prakasha.17. H.S. : Harita Samhita.18. S. Su : Susruta sutra Sthana.19. Y. R. : Yoga Ratnakara.20. C.Vi. :s Caraka Vimana Sthana21. Ch. : Carakasamhita22. Su. : Susrutasamhita
INTRODUCTION Ayurveda has been considered as the mother ofscience. It aims at preserving and promoting health aswell as preventing and curing diseases. A study ofclassical definition of the term ‘Ayurveda’ will confirm theconcept of “total health cure” which says ‘Ayurveda’ is thescience of life where in the happy and unhappy life. Goodand bad of life. What is wholesome and unwholesome oflife are described says charaka1. Further more Ayurvedadefines ‘Swastha’ (a healthy one) as one whose physicalphysiological, spiritual, social and environmental aspectsare in a good harmony2. Acharyas have taken maximum care to considereven routine events of the day-to-day life in view of theirvital role in promoting health and preventing diseases.Almost every source of life and matter surrounding humanbeing has been used in some form or treat the disease. Amavata is a chronic progressive, systemic,inflammatory disorder that primarly target the joints ofmiddle-aged adults. Its prevalence and destructivepotential impact a substantial risk for morbidity, disability,even mortality. This clinical study reviews all theliteratures of Ayurveda and modern and try to treat thepatients with Hingavadi guggulu. The goal of modern
theraphy per patients with Amavata are to relif pain. Theunderstanding of Ayurveda cannot be similar with theunderstanding of modern medicine. Rheumatoid arthritis can be compared with Amavatatypically, rheumatoid arthritis manifests as a symmetricarthritis involving numerous small and large jointsarticular symptoms may be accompanied by otherinflammatory symptoms such as fatigue, articularstiffness, anorexia, and fever. Rheumatoid arthritis doesnot appear to have existed before the industrial age, thishistorical evidence suggests that unknown environmentalexposures may account for the risk of rheumatoid arthritisin the modern world. Although rheumatoid arthritis usually developsbetween the ages of 30 and 50 years the disease can alsodevelop in childhood or old age. The signs of jointinflammation-pain, swelling, erythema and warmth aremost evident early in the disease. However, withestablished synovitis and disease chronicity, erythema orwarmth may be absent. Pain is reffered as a predominantsymptom followed by visual joint swelling progress in theunderstanding of this disease will lead to the developmentof safer medicine and more biologically specific agent tobetter control the disease improve the patient out come.
The discovery of the cause of rheumatoid arthritis willgive rise to a programes aimed at disease prevention butit is not yet start to invent more efficient preventivetherapies. On the contrary Ayurveda not only relif the painbut also preserve the function, reduce the inflammation,protect the joints and controle the disease progression.Their are varities of modlities available to treat thedisease in Ayurveda. The overall prevalance of Amavata in Indianpopulation is about 1% with a female to male ratio is 3:1NEED FOR THE STUDY:1. The current available medical intervention cannotsatisfy the objectives of a ideal theraphy. The availablepain-reliving agents associated with substantial risk ofgastrointestinal ulceration and bleeding.2. The real therapeutic intervention is to relif pain,preserve functions, reduce inflammation, protect thearticular and extra- articular structures controle thedisease progression and systemic complication and avoidtherapy related to adverse events.3. There is a need to judiciously combine the varioustherapeutic and rehabitative measures to give an effectivetreatment in a short time.
4. It is essential that the treatment adopted must havesome authentic background, either described in classicsor based on the experience of a successful treatment bysome physician or research scholars.5. Herbal medicines are safe and time tested their isno any substantial adverse effect in the praposedtherapeutic intervention.6. Analgesic may also be achieved with topical heatand cold applications. The application of heat is ofteneffective at relieving joint stiffness or muscle spasm or intreating contracture or limited range of motion.7. In the present context all the above views havebeen kept in the mind and the treatment adopted for thisstudy has classical reference and also useful in Amavata.AIMS AND OBJECTIVES OF THE STUDY :1. To evaluate the efficacy of Hingvadi Guggulu inAmavata.2. To compare the efficacy of Hingavadi guggulu andvaluka sweda in addition with Hingavadi guggulu, inAmavata.3. To study the etiopathalogical manifestation ofAmavata.4. To study the salient features of Amavata withModern Scientific knowledges.
HISTORICAL ASPECTS OF AMAVATA: Science is a continually altering stream ofKnowledge - based on logic, the conclusions of which arelike a pilgrim stranger tarrying for a while awaiting hisdestination. As new observations are added to the totalbody of knowledge, some of the older observations losetheir relevance or their significance. Ayurveda is noexception to this rule, and particularly this holds good inthe case of Amavata. The surveillance of the Ayurvedicliterature reveals the progressive evaluvation of Amavatathrough the ages. There is no reference to this disease inVedic literatures scattered nominal mention is found inclassical period elaborate description in the medievalperiod and above all an in depth study of the problembased on the revolutionary changes in the understandingof disease process brought about by the leap in toelectronic era of twenty first century. As mentioned earlier, there is no mention ofAmavata in vedic literature, the prime documented sourceof knowledge of Indo- Aryans, though scattereddescriptions of pathological factors like vata, pitta, andBalasa are available, However, some of the recentscholars have tried to attribute the visa mentioned inVedic literature here to the Ama concept of Ayurveda3.
The elaborate description of in this disease as aseparate entity is not available in caraka samhita.However, the term Amavata is included in some of thetherapeutic indications of drug compounds. Kamsa-haritaki4 of svayathu chikitsa and visaladi-phanta ofpandu-chikitsa5 are described to be effective in Amavata.Further in the 28th chapter while illustrating the Avarana-chikitsa, Amavata word is used to connote Avarana of vataby Ama, and also as a symptom6. In addition to this agood deal of description regarding etiology, pathology,clinical manifestation and effective treatment of Ama, andAmpradosa is found. These form the root cause of a chainof disorders7. It is worth, noting here that, the treatmentof sariragata Ama, as explained in Grahani chikitsa, ismuch the same as Amavata chikitsa laid down byBhavamishra i.e. langhana, pachana, oral administrationof pancakola decoction, snehapana, Basti and virecana 8. Susruta and kasyapa-samhita are also in accordwith caraka samhita there is no description of the diseaseas a separate entity, although, mention of this term isseen few and far between. Much the same in Bhelasamhita also distinct description of this disease is absent.Still the tenth chapter of Sutrasthana deals with
Amapradosa, which is analogous to Amavata to someextent. In Harita samhita, a complete chapter is devoted toAmavata roga. In this he has given an account of theetiology, clinical manifestation prognosis, treatmentaspect and dietetics at large. The classification of thisdisease is unique, and not followed in any of the laterworks in this field9. Anjana-nidana is another work, whichis claimed to be written by Acarya Agnivesa, where vividdescription of the disease is found, which incorporatesetiology, premonitory symptoms, clinical manifestationcomplications etc. It should be here noted that the ancestry of Anjana-nidana and Harita Samhita is questionable, as evidencedby the knowledge it incorporates, style of ellucidation andtextual material. Astanga sangraha and Astanga Hridaya also do notcontain description of Amavata-albeit the term is includedin the therapeutics index of drug compounds-vatsakadiyoga10 and vyosadi yoga11. After vagbhatcarya, his son Tisatacarya also avoidsmention of this disease in his work ‘Cikitsa Kalika’. In sofar as the jejjata commentary on susruta is concerned it isalso in line with the above work.
“Nidana viniscaya” which subsequenty becamefamiliar by the name ‘Madhava Nidana’ in honour of itsillustrous author Sri.Madhavacarya turns over a new leafin the history of joint diseases. A complete chapter hasbeen devoted to ellucidate this disease entity at length12.Later on Cakradatta an outstanding work pertaining to thetreatment of diseases, contributed the line of treatmentand effective drug remedy for this disease. The othercontemporary works vrinda madhava, vangasena followedMadhava Nidana, the latter with the addition of treatment. The other works like Bhavaprakasa, Yogaratnakara,Bhaisajaya Ratnavali followed the above texts with fewaddition of yogas in the form of decoctions, pills andpowders etc. In the modern period, maha mahopadhyayaGananath Sen compiled all the joint diseases with somenew nomenclatures. He coined the word Rasavata forAmavata. Later on this disease has been considered asrheumatoid arthritis (Upadhyaya Y. N. 1955) in modernparlance. On the basis of the findings in the Egyptianmummies, the antiquity of the disease rheumatoid arthritishas been traced to the very beginning of civilization. It isbelieved that the description of this disease was initiatedby Hippocrates (6th century BC) in the realm of medical
science. But in the right perspective, the first clinicaldescription was given by Arteus (100 A.D.) Rheumatismword was coined by Galen (199 A.D.) who also referredthe word arthritis to indicate the joint diseases. Baillow(1538- 1616) distinguished acute arthritis from gout.Further Sydenham (1629–89) classified the rheumatoidarthritis. Since then there is little change in the clinicalpicture of this classical disease.
Review of Ayurvedic Literature AMAVATA The nomenclature of the diseases can be done inmany ways. Some nomenclatures are based on thesubjective and objective symptoms, others are based oninvolved dusaya and its causative factors. The diseaseAmavata signifies the underlaying pathalogical conditionin its nomenclature. It is formed by union of two wordsAma and vata.Defnition of Amavata: “Amam Ca Vatam Amavatam” According to this derivation, the word Ama and vataunites to form Amavata. According to madhava nidana,highly vitiated Ama and vata mixed to gether with otherdosas enters the Trika sandhi, leading to the disease 13Amavata . Another description is “Amena Samhito vatahAmavatah", that is the vata Dose associated with Amacreating a disease Known as Amavata. In other wordsAma circulates in the whole body propelled by the vitiatedvata dosa causing srotorodha and then located in thesandhi and giving rise to Amavata14. From the above description it can be decided that aclear understanding of Ama and vata is necessory fordetailed study of this disease.
CONCEPT OF AMA: Ama occupied a dominent place in the pathogenesisof disease in general. So that the synonym “Amaya” hasbeen coined for disease in general. Sama roga,samadosa, samadhatu, samamala and samavastha aresome of the words widely used in the classics, which referto the association of Ama.ETYMOLOGY OF AMA: The word Ama is derived from the root ‘Am’ with thesuffix ‘Ninj’ which means “ A m ya t e Gamyatep a k a d ya r t h a m I t i A m a h ” T h e s u b s t a n c e w h i c h u n d e r g o e sa typical change in the processes of digestion is known asA m a ( A m a r K o s a ) “ A I s a t A m a y a t a p a c ya t e I t i A m a h ”means that which is subjected to incomplete digestion isAma. (Vacaspatyam) “Amyate pidyate SrotosamuhoAnena Iti Amah” i.e. Ama is that which is obstruct thegroup of channels and produce pain and misery (AmaraKosa). In Sanskrit literature the word Ama is also used toindicate a person, substance and an unnatural state. Butit cleared that Ama is the unnatural form or unriped formof a substance or a person in both the genders.
D e f i n i t i o n o f A m a: Various definitions of Ama is available in theAyurvedic literatures are as follows:1. The abnormal initial Rasa dhatu produced in theAmasaya, on account of the hypo functioning of the Usmaor Jatharagni is called as Ama15.2. A substance which is undigested, unformed, foulsmelling and more viscous, rendering sluggishness, in thebodily functions is understood by the name Ama16.3. The residue of Ahara Rasa, which is undigested andresultant from the hypofunctioning of Agni, forming theroot cause of all the somatic diseases is termed as Ama17.4. Some scholars refer the undigested food as Ama, somehold that the accumulation of metabolic waste in the bodyas Ama, while some others opinion that the first stage ofDosa Dusti as Ama18.5. The other meaning of this word in Ayurvedic literatureincludes incompletely fermented unriped19. Unbaked, incompletely developed20 unprocessedsubstance21.On the basis of the foregoing Ama maybe classified asfollows:I. Ama produced as a Consequence to the hypofunctioningof Agni,
1. Ama produced by Jatharagni-Mandya.2. Ama produced by Dhatvagni-Mandya.3. Ama produced by Bhutagni-Mandya.4. Accumulation of Mala.II. Ama produced irrespective of the action of Agni.1. Formation of the toxic Ama by the interaction ofvirulently vitiated Dosas.2. First phase of dosic vitiation.Vata in Amavata: Movements in the body both voluntary andinvoluntary are largely under the control of Vata Dosa –allivate other factors contribute to this to some extent. InAmavata though other functions of vata are alsodisturbed, it is the stabdhata and sandhigraha leading tothe restricted movements of the joints, and that isprimarily responsible for the crippling effect seen in thepatients. Thus the predominance of Vata Dosa in thepathogensis of Amavata is well illustrated. Forth comingpages carry a brief description of Vata Dosa.The term Vata is derived from the root ‘Va gatig a n d h a n a yo h ’ i . e . t o m o v e , t o e n t h u s e , t o m a k e k n o w n ,and to become aware of (Sabda Stoma). In the classics itis also referred by other names like anila, pavana, marutaetc.
Ruksa, Sita, Lagu, Suksma, Cala, Visada and Saraare the Guna (qualities) of this Dosa. Though it is presentin the whole body, still large intestine (Pakvasaya),bladder (Basti), ear (srotra), skin (Tvak), sole (pada)waist (Kati), lower limbs (Sakthi) and bones areconsidered as its chief sites.In its normal state it performs the following functions:a) Sustaining all the organs of the body.b) Inspirationc) Expiration.d) Restraining and impelling mental activity.e) Bringing about all bodily actions.f) Co-ordination of sense organs and perception ofobjects.g) Bringing about compactness of Dhatu.h) Union of body parts.i) Prompting speech.j) Organisation of touch and sound.k) Causative factor of joy and sorrow.l) Stimulation of digestive power.m) Absorption of Dosa’s.n) Excretion of mala.o) Creation of gross and minute srotas.p) Moulding the shape of embryo andq) Indicator of continuity of life22.
It is classified into five types, viz. Pranavayu,Udanavayu, Samanavayu, Vyanavayu and Apanavayu. Pranavayu is located in the head and moves aboutin the chest and throat23. According to caraka, tongue,mouth and nose are also the sites of pranavayu24. Itsupports the intellect (Buddhi), heart (Hridaya), Senseorgans (Indriya) and mind. It brings about salivation,belching, sneezing, expiration and ingestion of food25. Chest is the abode of Udanavayu and it movesabout the umbelicous, nose and throat. Articulation ofspeech, initiation of body activities, enthusiasm, bodystrength, complexion of the skin and memory are thefunctions are Udana Vayu26. Samana vayu is located closely to the Agni andregulates its functions. Moreover, sweda, dosa andAmbuvahi srotas are also considered as its sites. SamanaVayu facilities digestion27.Hridaya is the chief abode of vyana vayu and it moves allover the body. It brings about circulation of Rasa Dhatuand all kinds of body activities – like flexion and extentionof the limbs, closure and opening of eyes28 etc. Sandhi isalso considered as the site of vyana vayu by somescholars29.
Apana vayu is present in pelvis, thigh, scrotum,penis, bladder, umbelicus, rectum, excretion of stools,voiding of urine, delivary of baby these are caused byApana vayu30.S ym p t o m s o f V a t a V r i d dhi : Roughness of voice, emaciation, blackishdiscolouration, fasciculations (Gatrasphurana), debility,insomnia, affliction of sense organs, giddiness, delirium(pralapa), indigence (Dinata), loss of consciousness(samjna nasa) pain in the bones, dryness of majja dhatu(majjasosa), fear, confusion (moha), greed, Atopa – theseare the symptoms produced by vitiated vata dosa.S ym p t o m s o f V a t a K s a ya : Slowness of activity (manda cesta), lesstalketiveness (Alpa vak), laziness (Apraharsa), stupor(Mudha samjna), excessive salivation, anorexia, nausea,impaired appetite, and disorders of Agni – these areproduced by vata ksaya31.S ym pt o m s P r o d u c e d b y V a t a P r a k o p a : Ptosis and dislocation (Sramsa), dilatation (Vyasa),Vyadha, numbness (Svapa), sada, pain (Ruk) pin pricksensetion (Toda), piercing pain (Bheda), obstruction(Sanga) Angabhanga, contructure (Sankoca), round shape(Varta), Harsa, dryness of mouth (Trsa), Tremor (Kampa),
hardness (Parusya), Sousirya, emaciation (Sosa),pulsation (Spandana), cramps (Vestana), cala, stiffness(Stambha), astringent taste in the mouth, blackish redcolour (Aruna syava varna), these are the symptomscaused by vata prakopa32. In Amavata the incriminatory effects of Ama areexclusively manifested by virtue of vitiated vata dosa. Thelatter renders circulation of deleterious Ama throughoutthe body. It reinforces the virulence of Ama associationwith the other two dosas. Vata blended with Ama displaysa number of symptoms characteristic of Amavata. In otherwords vata Dosa is a predominant part of samprapti inAmavata. Thus an appraisal of vata Dosa helps inunderstanding the pros and cons of pathogenesis inAmavata.
Sandhi: Locomotion is made possible by the presence ofjoints in the body. Affliction of sandhi is the central eventin the samprapti of Amavata. Though Sandhi cannotes thejunction of any two or more anatomical structures, still itmainly refers to the Asthi Sandhi in the present context33. It is reckoned to be the Upadhatu of Medodhatu andthe origin (mula) of majjavaha srotas34. The function ofthe Sandhi is sustained by slesmaka kapha and snayu theformer imparts lubrication to the joint and the latter bringsabout stability. On the basis of mobility joints are of sthira(fixed) or cala (mobile) types35. Out of these two the latteri.e. Cala Sandhi is chiefly involved in Amavata. On the basis of approximate shape of the joint it isclassified as under:1. Kora Sandhi: Ex. Finger joints, wrist, ankle, knee,elbow.2. Ulukhala Sandhi: Ex. Hip joints, joint between toothand bone.3. Samudga Sandhi: Ex. Shoulder, Symphysis andNitambha Sandhi.4. Pratana Sandhi: Ex Pristha Sandhi (Vertebral column).5. Tunnasevani Sandhi: Ex. (Suture) skull and Pelvis.6. Vayasatunada Sandhi: Ex. Temperomendibular joint.
7. Mandala Sandhi: Ex. Trachea, neck, chest, eye.8. Sringhataka Sandhi: Ex. Srotra, Sringhataka36.Amavata and its Incidence: The onset of the disease may occur at any stage oflife. Approximately in 70 percent of patients the onset ofthe disease occurs between third and seventh decade,with the peak occuring among the age group of 35 yearsto 45 years. About 59 percent of patients show geneticpredisposition. No particular predisposition to any race isobserved. More patients were reported fromtemperatezone and the onset of the disease is morefrequent during the spring. (Harrison. 1981). Amavata occurs throughout the world and in allethnic groups. Climate, altitude and geography do notappear to influence its prevalence but a higher proportionof patients in western and urban communities have moresevere and disabling disease. The overall prevalence ofRA in caucasian populations is about 1% with a female tomale ratio of 3:1 but the sex incidence of severe diseaseis almost equal since males appear more liable to thesystemic manifestations of the disease. Annual incidenceof new cases of about 200 per million per year, 5% ofwomen and 2% of men over the age of 55 years areaffected.
The Indian incidence of RA is not clearlydocumented. Approximately 30% of the population havesymptoms of arthritis and low back pain. Among the twothird of the patients have symptoms severe enough tocause them to seek medical care. RA is clearly a diseasethat shortens survival and produces significant disability.Approximately 50% of patients will be functional class IIIor IV within 10 years of disease onset over 33% of RApatients who were working at the time of onset of theirdiseases will leave the work force within 5 years. Inaddition, the standardized mortality ratio is 2 - 2.5 to 1compared to people of same sex and age without RA.Overall, RA shortens the life span of patients by 5-10years. This disease increased the mortality of the patients.The U.S. study noted that 42% of RA cases havecardiovascular involvement, 9% infectious diseases likepneumonia and 14% developed cancer and lympho-proliferative malignancies. Only 0.5% people are totallydisabled from arthritis. Only 0.02% patients are died fromthis disease. The cost of musculoskeletal disorder expenditure inhealth care expenditure and lost of wages is very high. Itloses our active manpower and rational product over 30%
of working of age persons aged (18-64) year with RA areeither unable to work or cannot work in their usualoccupation due to thier diseases.Amavata Nidana: Ayurveda believed in the three humours (vata, pittaand kapha), which is said to be the fundamental unit ofbody. These humours are controlled by the ahara andvihara of a individual. Every effect is associated with cause like thatdisease is associated with cause know as Nidana. N i d a n a h a s b e e n d e f i n e d a s “ S e t i k a r t h a v ya t h a k o ”and “Rogothpadaka hetu”. Which means that all suchfactors which deranging dynamic state of doshicequilibrium provokes the disease is Nidana. The knowledge of Nidana or hetu guides us todecide the line of treatment as well as the prognosis ofthe disease. In Amavata it is necessary to discuss theabove to conclude the therapeutic and prognostic values. The nidana of Amavata is multifaceted. VariousAcharaya’s mentioned their different views for theproduction of Ama in Amavata. According to madhava nidana, unwholesome diet(Viruddha Ahara), erroneous habit (viruddha cestha),diminished Agni (Mandagni) Sedentary habit (Avyayama),
and exertion immediately after the intake of unctous foodare the etiological factors of Amavata37. Besides theseintake of heavy food articles excessive intake of tubers(kanda, Saka) and excessive exertion are reckoned to beetiological factors by Harita38. The author of Anjana Nidana has also included thefactors, which vitiate vata, pitta and kapha in this list39.All these etiological factors can be categorised intounwholesome diet and erroneous habits.Unw holesome Diet (Viruddha Ahara): All drugs and diets, which provoke the Dosas butnot expel them out of the body, are considered to beunwholesome40.Acarya caraka has categorised these unwholesome dietsinto eighteen types.Viz.1. Desa (place/habitate) Viruddha.2. Kala (time) Viruddha.3. Agni (power of digestion) Viruddha.4. Matra (Quantity) Viruddha.5. Satmya Viruddha.6. Dosa Viruddha.7. Samskara (Mode of preparation) Viruddha.8. Virya (Potency) Viruddha.
9. Kostha (Bowel) Viruddha.10. Avastha (State of Health) Viruddha.11. Krama (Order) Viruddha.12. Parihara (Proscription) Viruddha.13. Upacara (Prescription) Viruddha.14. Paka (Cooking) Viruddha.15. Samyoga (Combination) Viruddha.16. Hrit (Palatability) Viruddha.17. Vidhi (Rules of eating) Viruddha.18. Samapada Viruddha41. In addition to the above a long list of unwholesome 42diet has been described in Caraka samhita . Besides theconsumption of food without taking into consideration theeight factors known as “Astha Vidha Ahara Visesaayatana” are also reckoned to be unwholesome diet.These include(a) Nature of Food articles (Prakrati).(b) Method of processing (Karana).(c) Combination (Samyoga).(d) Quantity (Rasi).(e) Habitate (Desa).(f) Time. i.e. stage of the disease or the state of theindividual (kala).(g) Rule governing intake of food (Upayoga Samstha).
(h) Wholesomeness to the individual who takes it 43.(Upayoga)Erroneous Habits (Viruddha Cest a): This includes a wide variety of Causative factorslike Sedentary habit, exertion immediately after the intakeof unctous food44 day sleep, keeping awake at knight,excessive execrise, excessive sex indulgence, horseriding etc. after meals. Suppression of natural urges45,cold water bath, exposure to east breeze and sleeping ona uneven bed. These factors may directly hamper thefunction of Agni, or Cause vitiation of Dosas, thusproducing Amavata.M i s c e l l an e o u s C a u s e s : In spite of the above said causes, in theperspective of Astrology, in any persons horoscope, ifGuru is placed in the 8th house (R.N.) or if surya in theKarka Rasi has got full aspect of Budha, that indicatesforth coming Amavata46. Unwholesome diet (Viruddha Ahara) is abroad term,which includes a wide variety of etiological factors asseen earlier. The list of unwholesome diets given in aclassic is said to cause a number or disease includingAmavisa, which is contended to be incriminatory as far asAmavata is concerned. But it is the prevailing notion that
not all these factors listed under the unwholesome dietcause Amavata, rather some particular unwholesome dietis the causative factor. At this juncture, it is appropriateto point out that not all the habits mentioned by Carakaare in Vogue today amidst the general public. Not onlythat response produced in any given individual depends toa large extent in idiosyncrasy.
Samprapati: In state of pre-existing mandagni if the person isexposed to etiological factors then Ama is formed in theAmasaya along with vitiation of Vata Dosa. This morbidAma circulates obliquitously on the body propelled byvitiated vata with the predilection for slesma-sthana. Hereby the action of Vata Dosa Ama becomes more virulentand reaches dhamanies. Before long in the Dhamanies itblends with vata, pitta and kapha and consequentlycauses varigative colour, becomes heavy and viscous.These qualities facilitaes sroto-Abhisyandana andsrotorodha. These changes in the srotas, enduressthanasamsraya, leading to the manifestation of symptomslike Hridgaurava, Hrid-dourbalya and in the sandhisotha,sula etc. If kapha and pitta are also involved along withthe above symptoms, specific symptoms of these doseswill also manifest47. In the process of disease manifestation a vastnumber of factors invariably take part and accordinglycontribute for the pathogenesis. These are collectivelycalled as samprapti Ghataka. For the properunderstanding of any disease, consideration of thesefactors is quite essential. The following smprapti
Ghatakas will be discussed in detail in relation to Amavataviz.1. Udbhava sthana2. Sancara sthana,3. Adhisthana4. Vyakti5. Marga6. Agni7. Ama8. Dosa9. Dusya10. Srotas11. Bhedha prabhedha12. Vyadhi svabhava1) Udbhava Sthana: As cited earlier in samprapti, Ama as well as vatadosa are the predominent pathogenic factors. Ama stemsout from Amasaya, while the vata dosa from pakvasaya.Accordingly it can be inferred that Amasaya andpakvasaya both are the udbhava sthana of Amavata.2) Sancara Sthana: In the first stage of the pathogenesis the Ama andvata gets accumulated in their respective abode insubstantial quantities. Before long, it in the next stage i.e.
prakopa stage both together will undergo some changeand are up to circulate in the body consequently. Amaspreads throughout the body, propelled by the vitiatedvayu, along the Rasavaha srotas, with the predilection forslesma sthana ie. Rasa, urah, kantha, siras and sandhi. Inthe next stage the sthana Samsraya of Dosas will takeplace. From the foregoing description it can beconjenctured that sancara sthana of the dosas comprisethe whole body in this disease.3) Adhisthana: In the pahthogenesis of any disease, dosas lodge ata particular site in the body and leads to manifestation oflocal or constitutional Symptoms. This particular site istermed as Adhisthana. In so far as Amavata is concernedDosas get lodged in the slesma sthana in general andSandhi in particular. Sandhisula, Sandhi Graha, Sandhisotha etc. Symptoms will develop when the dosas arelodged in Sandhi, while in Hridaya, kantha and siras theygive rise to hridgraha, pipasa and murcha symptomsrespectively.4) Vyakta: Sandhi Sula, Sandhi Sotha, Sandhi Stabdhata arethe silent features of the disease and the manifestation ofthese lead to the diagnosis of Amavata. By this it can be
implied that Vyakti Sthana in this particular disease isSandhi.5) Marga: The affliction of the Sandhi is the chief feature inAmavata. So it stands to reason that this is a disease ofmadhyama Roga marga. However, trivial involvement ofAbhyantara Roga marga also should be considered.6) Agni and Ama: The generation of Ama in Amavata is largely if notslowly rests on hypofunctioning of Jatharagni. The Amathus produced is responsible for the srotorodha and thelatter is inevitable for the sthanasamsraya of Dosas. Inaddition to this as functional sequelae of hypofunctioningof Jatharagni, Dhatvagni Mandya may occur, which giverise to Dhatu Ksaya. From the above it is clear that, bothJatharagni and Dhatvagni are involved in the production ofAma at two different stages.7) Dosa: The predominance of Vata in the pathogenesis ofAmavata is Unequivocal. Nevertheless the involvement ofpitta and kapha Dosa are also significant. On the basis ofpresenting signs and symptoms it can be inferred that allthe five varieties of Vata are vitiated. Sandhi sula, Sandhigraha and othe symptoms are caused by Vyana Vayu.
Along with other factors vitiation of vayu contributes forthe production of Ama. The cardi a symptom seen inadvanced stage of Amavata referes to vitiation of Udanavayu. Murcha, Sirasula, Praseka and other symptoms arecaused by prana vayu and Vibandha, Bahumutra,Antrakujana etc. Symptoms reflect the vitiation of ApanaVayu. Pacaka pitta is involved and contributes to theformation of Ama. Further in the Sandhi Raga, Daha andJvara, a constitutional symptoms are due to the abnormalpitta. In so far as the kapha Dosa is concerned Bodhaka,Kledaka and Slesaka Kapha are particularly vitiated.Disturbed function of the joints reflects involvement ofslesaka Kapha, and impaired digestion is accounted for bythe Kledaka Kapha, praseka, Aruci, Asyavairasya referesto vitiated Bodhaka Kapha.8) D u s ya : As evidenced by the signs and symptoms of thedisease like Aruci, Angamarda, Agnimandya, Alasya etc. itcan be inferred that the Rasa Dhatu is mainly affected inAmavata. In addition to this mamsaksaya, Balaksayaindicates the ksaya of mamsa Dhatu. Sandhi sula, Sothaand other symptoms shows the affliction of Asthi and
majja Dhatu. Among the Upadhatus Sandhi and snayu areaffected. So far as the malas are concerened purisa andmutra are affected.9) S r o t a s : In Amavata Rasavaha srotas is reckoned to becheifly involved besides the affliction of other srotases.Annavaha srotas is primarily affected and from where thepathogenesis takes root. Thirst represents theinvolvement of udakavaha srotas. Involvement of Sandhiindicates the disturbed functioning of majjavaha srotas.Abnormality in the purisavaha srotas and mutravahasrotas accounts for the vibandha and Bahumutratarespectively.1 0 ) V ya d i S v a b h a v a : The nature of disease is manifestated as Atyagika(acute), chirakari (Chronic), severe and complicated form.
Purva Roopa (Prodromal Signs and Symptoms) Purva rupa helps in diagnosing a disease to someextent as well as in prognosis and in differentialdiagnosis. If the treatment is adopted in purva rupa stageto erradicate the doshas, then the disease will never go tothe further stage. Though in Ayurvedic texts the purvarupa of Amavatahas not been clearly specified, the following symptomsmay be considered as its purvarupa48.i. Daurbalyam (weakness).ii. Hridaya Gaurava (feeling of heaviness in the chest).iii. Gatrastabdham (Stiffness of the body).i. Daurbal yam: As a consequence to mandagni and formation ofAma, deficiency of nutrient factors results in Amasaya. Asa result, the Dhatus are deprieved of nourishment. Thisterm also connotes the disturbed function of Hridaya.ii. Hridgaurava: By virtue of Guru, Manda and picchila qualities Amain the Hridaya produces a subjective feeling of heavinessin the chest and is termed as Hridgaurava. This term alsoconnotes the disturbed function of Hridaya.
iii. Gatra Stabdham: When the Ama is circulated ubiquitously in the bodyby the Vyana vayu, the former by virtue of its qualities likeGuru, Sita, Sthira, Picchila, manda etc. causes stiffnessof the body.Classification of Amavata: The disease Amavata has been classified on thebasis of Anubandha of Dosa, Severity, chronicity andmode of manifestation of the disease.A) Classification According to Anubandha of Dosa: On the basis of Anubandha of Dosa it has beenclassified into the following Varieities.I. Anubandha of one Dosa:1. Vatanuga Amavata.2. Pittanuga Amavata.3. Kaphanuga Amavata.II. Anubandha of Two Dosa:1. Vata-Pittanuga Amavata.2. Vata-Kaphanuga Amavata.3. Pitta-Kaphanuga Amavata.III. Anubandha of all Three Dosa:Tridosa Anubandha Amavata.
The above varieties of Amavata can bedifferentiated on the basis of symptoms characteristics ofthe pertaining Dosas. Severe pain is the charectaristic ofvatanuga Amavata. Redness and burning sensation aboutthe joints are the salient features of Pittanuga Amavata.Stiffness, feeling of heaviness and itching about the jointsare specific to Kaphanuga Amavata. Mixed symptoms areseen in other types of Amavata acvcording to thedominance of Dosa49.B) Classification According to the Severity of theDisease: On the basis Severity of the disease, it may beclassified into two stages.1. Samanya Amavata,2. Pravriddha Amavata. In the Samanya Amavata stage, the symptoms aremore or less general and less severe and not associatedwith Upadrava, contrary to the stage of PravriddhaAmavata.C ) C l a s s i f i c a t i o n a c c o r d i ng t o t h e C h r o n i c i t y: Once again on the basis of the chronicity of thedisease it can be classified into two stages.1. Nava Amavata.2. Jirna Amavata.
The disease may be said to Nava Amavata beforeone year of onset, while after one year of onset it may becalled as Jirna Amavata.D) Classification According to the ClinicalManifestation:Acarya Harita has classified Amavata into four types onthe basis of clinical manifestation50.1. Visthambi Amavata.2. Gulmi Amavata.3. Snehi Amavata.4. Sarvangi Amavata. The detail of each symptom is discussed under thetittle of “Rupa of Amavata”.
Rupa of Amavata The word Rupa indicate the signs and symptoms bywhich a disease is indetified – “Utpanna Vyadhi bhodakameva lingam rupam” – Vijayarakshitha’s commentary. Therupa stage or the appearance of the actual symptomscommences from Vyakthavastha or 5th stage. The rupasare the symptoms are the characteristic manifestations,which develop during the course of the disease the clearmanifestation of the prodromata itself is called as Rupa51. In a broad sense affliction of cala Sandhi, by theAma and Vata is central event in the Pathology ofAmavata. The Sandhi is formed by the junction of two ormore bony ends, backed up by snayu Bandhana andslesaka kapha. Further the Sandhi is the origin of Majjavaha srotas. From this it can be reduced that Asthi and majja areinvariably affected in Amavata. Over and above, thevitiated vata is in its Samavastha, hence the traitspathognomonic of Asthi majjagata vata and SAmavata canbe delibrated to Amavata. In addition to the cardinal articular signs andsymptoms a number of constitutional symptoms will alsomanifest in Amavata. Few of the symptoms aids indistinguishing the types of Amavata on the basis of
Anubandha of Dosa. In the advanced stage with thedeterioration of the general condition of the patient anumber of other symptoms will develop. Accordingly thesigns and symptoms of Amavata can be classified asfollows.(A) C a r d i n a l S i g n s a n d S ym p t o m s : The salient features of Amavata which arepathognomonic of affliction of the joint are reckoned to bethe cardinal articular symptoms. The presence of thesesymptoms are inevitable to arrive at a diagnosis ofAmavata. It includes the following five symptoms.1. Stabdhata (Stiffness)2. Sandhi Sotha (Swelling)3. Sasabda Sandhi (Crepitation)4. Sandhi Sula (Pain)5. Sparsa – Ashyata. (Tendor)( B ) G e n e r a l S ym p t o m s : In addition to the above cardinal signs andsymptoms in-patients of Amavata a number of otherconstitutional or general symptoms will manifest in varyingdegrees. These are considered as general symptoms. Thisincludes the following signs and symptoms.1. Angamarda.2. Jvara.3. Aruci.
4. Apaka.5. Trishna.6. Anga Sunata.7. Alasya.8. Mamsa Ksaya.9. Angagaurava.(C) Distinguishing Features of Dosa Anubandha: Few of the symptoms in Amavata specificallyindicate the Anubandha of Dosa. Such symptoms eitherlocalized or general, are catagorised in this subheading.Further it should be noted that the presence of symptomsspecific to two or three Dosas indicate the Samsarga orSannipata of the Dosas as the case may beThe symptoms are as follows:1. Vatanubandha - Tivra Sandhi Sula.2. Pittanubandha - Sandhi raga. - Daha.3. Kaphanubandha - Stimitya. - Guruta. - Kandu.( D ) S ym pt o m s o f P r a v r i d d h a A m a v a t a : As the disease progress, the symptoms will becomesevere, more number of joints will be get affected. Inaddition to this a number of other symptoms will develop,
with complications. These symptoms are described underthis heading. The symptoms include the following:1. Praseka2. Aruci.3. Asyavairasya.4. Trit.5. Cardi.6. Agni Daurbalya.7. Kuksi Sula.8. Vibandha.9. Kuksi Kathinata.10. Anaha.11. Antrakuja.12. Siroruk.13. Hridgraha.14. Brhama.15. Murcha.16. Bahu Mutrata.17. Gaurava.18. Alasya.(Utsaha hani).19. Daha.20. Nidraviparyaya.21. Grahani Dosa (Y.R.).22. Amatisara.23. Angavaikalya.24. Jadyata.25. Vataroga.Onset of Amavata: As discussed earlier the onset of Amavata can verywell be ascertained by visulization of the characteristic
feature of Sama vata condition. The quotations“Kramasah Angani Pidayet” and “Yugapat Grhanti 52Kupito Bhrisam” . Indicates both insidious and suddenonset of the disease based on the virulence of pathogenicfactors. It also indicates the perpetuity and progressivenature of the disease. Further the aggravation of thedisease by the presence of predisposing factors likecloudy weather, implies the spontaneous exacerbation andremission. Thus it stands to reason that Amavata ischaraterised by insidious or sudden onset with aworsening course as well as marked by spontaneousexacerbation and remissions.( A ) C a r d i n a l A r t i c u l a r S i g n s a n d S ym p t o m s :1. Gatrastabdhata: Inability to perform the Namana (Bending)movement at the affected joints like knee, wrist, etc.constitutes the Gatrastabdhata53 or otherwise this may betermed as stiffness of the joints. Such stiffness inAmavata patients is caused by the affliction of the joint by 54the Samavata ,2. Sandhi Sula: Severe and Contineous pain in the affected joint, attimes disturbing the sleep is the cardinal symptom ofAmavata, since it is a condition where Asthi and majja
Dhatu are chiefly affected by Vata Dosa55. The painaggravates on oil massage, during cold and cloudyweather and in the morning hours. These characteristicfeatures can show the involvement of Ama56. The severepain stimulating scorpion bite is the most characteristicfeature. Few joints may be involved in the initial stage andprogressively involvement of other joints occurs as thedisease advances. The most commonly involved joints arethe joints of the fingers, wrist, elbow, shoulder, joints ofthe feet, ankle, knee, hip, Trika and temperomandibles57.3. Sandhi Sotha: Swelling about the joint is the result of srotorodha inthe joint caused by the accumulation of Ama58. SandhiShotha means swelling of the joints. Pitta vitiated by Amacauses inflammatory changes in peshi, snayu etc. Locatedin sandhi pradesha. This further vitiates thesleshmadharakala which inturn vitiated kapha present inSandhies is exudated into the synovial cavity theaccumulated fluid kapha will not be reabsorbed into thelymphatic system and thus it causes shotha in visibleform.4. S p a r s a – A s a h ya t a : Though in Ayurvedic texts, tenderness is notseparately mentioned in Amavata, yet the term Sandhi
sula includes both subjective pain and objectivetenderness.5. Sasabda Sandhi: This symptom is mentioned by yogaratnakara, whichrefers to the joint crepitus produced during the active orpassive movement of the joint. This is indicative of theaffliction of the Sandhi by the vitiated Vata Dosa.( B ) G e n er a l S ym p t o m s o f A m a v a t a : Because of the afflication of Rasa Dhatu by thevitiated Vata and Ama in the patient; it exhibits a numberof localised and constitutional symptoms, like, aching painin the bodily parts (Angamarda), lack of desire forperforming any kind of work, even though the patient hasthe capacity to do it (Alsya), subjective feeling ofheaviness of the body (Anga Gaurava) and fever59. In spite of the above symptoms patient getsexcessive thirst, this is because of the srotorodha ofudakavaha srotas, caused by vitiated Ama. Apart from the swelling about the joint frequentlyOedema of the hands and feet (Anga Sunyata) are alsofound in Amavata patients. This is once again isconsequence of srotorodha caused by Ama in theRasavaha Srotas60.
Due to the presence of Agnimandya, even foodtaken in proper or less quantity does not get digestedproperly. Though mandagni is causative factor forproduction of Ama, in the later stages, thus generatedAma further hampers the functioning of the Agni andcreates a vicious circle. Though Mamsaksaya has notbeen described as a symptom in Amavata, since it is adisease of Asthi Majjagata Vata, Mamsaksaya is invariablyfound in Amavata patients61.( C ) D i s t i n g u i s h i n g S ym p t o ms of Dosa Anubandha:1. Sula: Severe pain in the joints is the salient feature ofVata dominant Amavata. Here it should be noted that,though pain in the joint is common in all types ofAmavata, in Vatanuga Amavata when compared to others,severe throbbing type of pain is characteristic62.2. Sandhi Raga: Redness about the joint is the characteristicfeatures of pittanuga Amavata63.3. Sandhi Daha: Burning sensation about the joint or in the bodilyparts is once again the salient feature of PittanuhgaAmavata. This is caused by the affliction of Asthi Dhatu bythe Pitta Dosa64.
4 . S t a i m i t ya : Subjective feeling as if the bodily parts are wet orcovered by a wet cloth is called as staimitya. This ispathognomonic of Kaphanuga Amavata65. It also refers tothe impaired maovement of the bodily parts66.5. Guruta: Subjective feeling of heaviness is once again is thecharacteristic feature of Kaphanuga Amavata. Though thismay be present in all varieties of Amavata, still Guruta isespecially prominent in Kaphanuga type67.6. Kandu: Once again itching sensation in the body ispathognomonic of Kaphanuga variety of Amavata68.( D ) S ym pt o m s o f P r a v r i d d h a A m a v a t a . In the advanced stage of Amavata, along with theworsening of the cardinal and general signs andsymptoms, the patient manifests a variety of symptoms.Because of the affliction of Rasa Dhatu by the vitiatedSama vata, following symptoms are produced. Since thefood is improperly digested, subsequent less production ofnutrient factors leads to the deprivation of the Dhatuposana. So the patient feels weakness and loses weight.Patient loses interest in any kind of work. His tastebecomes abnormal (Asyavairasya) or develops
tastelessness. Excessive salivation will also occur(Praseka). He feels heaviness of the body (AngaGaurava).By the affliction of Hridaya feeling of tightness of thechest will also occur69. Production of Ama in the Amasaya and thesubsequent Grahani Dosa also with abnormal upwordmovement of Vat Dosa leads to the manifestation ofnumber of Gastrointestinal symptoms like constipation(Vibandha) flatulance (Anaha). Gurgling (Antrakuja), Vomiting (Cardi) and pain inthe abdomen even may develop Kuksikathinata, AcaryaHarita adds. Amatisara is also in these symptoms70. The faulty digestion as cited earlier leads to theformation of more mala i.e. Purisa and mutra. This may bethe reason for the Bahumutrata seen in Amavata patients.The term Bahumutrata represents both excessive andfrequent micturation. When the vitiated Dosas of Amavata migrates to theSiras, it causes manifestation of many symptoms likedisturbance of sleep or insomnia (Nidranasa), loss ofsleep at night may lead to sleep in the day (NidraViparayaya), the symptoms include giddiness; transientloss of consciousness (Murcha).
In fine, stabdhata, Sandhi sula, shotha tendernessand sasabda shandhi comprise the cardinal articular signsand symptoms. The symptom sasabda Shanthi ismentioned by yogaratnakara. Angamarda, Aruci, Trisna,Alasya, Anga gaurava, Jvara, Anga Sunyata, Apaka andmamsa ksaya are the general symptoms of Amavata. Inthe stage of pravriddha Amavata. Along with theaggravation of cardinal and general symptoms a cluster ofother symptoms will also manifest. Severe pain about thejoint indicates vatanuga Amavata. Daha and Raga arepathognomonic of pittanuga Amavata and staimitya,guruta as well as kandu are manifested in the kaphanugaAmavata.Upashaya Anupasaya: Upashaya has been defined as ‘the homologatorysigns, which indicate what kind of oushadha (medicine),Anna (food), and vihara (exercise) are antagonistic to thedisease and what are agreeable to the patients system71.Anupashaya is just opposite to Upashaya Similar types of laxanans are found in manydiseases. For example, some laxanas of Amavata such assandhi shotha, sandhi shoola etc. are likely to be found inother diseases like Vatarakta, Sandhigata Vata etc. Insuch conditions where the laxanas are found similar to
that of another disease. It is difficult to diagnose thedisease and to adopt the proper line of treatment. In suchcases to avoid such difficulty Upashaya and Anupashayahas been advocated. Ruksa Sweda, langhana, Usna Kala and sayam kalaare reckoned to be the Upasaya in Amavata, while thesnigdha Sweda, Santarpana, meghodaya Kala and pratahkala are the Anupasaya in this disease. Though vata isvitiated in this disease, due to the association of AmaRuksa sweda ameliorates the signs and symptoms ofAmavata. Contrary to this, snigdha sveda beingsupporative to deleterious activity of Ama aggravates thediseased condition. Due to the presence of mandagnilanghana is benificial in Amavata, while santarpana mayfurther speed up the formation of Ama. Since cold cloudyweather and morning hours cause the body channels tonaturally remain constricted and also the sita guna atthese times enhances the deleterious action of both vataand Ama, they are considered as Anupasaya, so also, hotseason and evening hours are upasaya in Amavata.Sapeksa Nidana: (Differential Diagnosis) After the study of Upashayanupshaya, the nextimportant thing is to study the ‘Sapeksa nidana ofAmavata.
The disease mimicking Amavata are multitudinous.A variety of afflictions of the sandhi, create an illusion ofAmavata through sings and symptoms that closely tally tothat produced by Amavata. Hence in order to precise thediagnosis of Amavata. It is essential that those diseasewhich have a close bearing on the trail of Amavata in itssigns and symptoms be identified and excluded. Thefollowing diseases need special mention in this regard.1. Vatarakta2. Sandhigata Vata3. Kostaka sirsa4. Sandhika sannipata Jvara.5. Phiranga6. Sandhi bhanga The pain and swelling about the joint is thecharacteristic feature in these diseases. Apart from this,in the realm of Ayunreda many other diseases too showsymoptoms that suggest involvement of sandhi. Theseinclude – Arsa72. Atisara73 Grahani74 Antarvega Jvara75Kapha pitta Jvara76, Vatolbana sannipata Jvara77, KsayajaKasa78, Madatyaya79 Sosa80 Vatodara81 Uraksata 82 . Henceit is imperative that before a final diagnosis of Amavata ismade, all other possible alternatives are considered andexcluded. This can be achieved eihter through a close
and exhaustive investigation of all signs and symptomspertaining to the disease or through Upasaya – Anupasaya– so that the patient is saved from the agony of failedtreatment and the physician from the embarrassment.Upadrava: After the study of Sapeksha nidana, upadrava ofAmavata is taken in to consideration for our study. On perusal of ayurvedic literature, it becomesevident that there exists some ambiguity regarding theUpadrava of Amavata. Vacaspati mentioned that thesymptoms of advanced stage of Amavata are the upadravaitself. While Vijayarakista, the commentator ofmadhukosa differentiates the symptoms of advanced stageof Amavata from Upadrava. According to him Khanja,Sankoca etc. are that occur in Amavata further vacaspatiincludes the diseases expounded within the title of vatavyadhi under upadrava. It is worth nothing here that asper Harita the Anga vaikalya is a manifestation inAmavata can be considered as Upadrava of this disease83. The snayu, which bind the bony ends, are the partsof the Sandhi itself. Thus the trivial involvement of thesnayu is quite evident in Amavata especially producingcomplications in the later stages of the diseases. Apartfrom this, as cited elsewhere, the junction between the
snayu or Kandara are also cannoted by the term sandhi.Further snayu is also one of the seat of kapha dosa. Bythis it can be implied that the involvement of Snayu inAmavata is unequivocal. With regard to the abovecontention following upadravas can be considered.1. Jadyata2. Angavikalya3. Sankoca4. Granthi5. Vataroga1 . J a d yat a : This term refers to the loss of function of the limband some opinion that the term jadya implies thehardness84 Sandhi jadyata is because of sandhi slistataproduced by abnormally increased kapha in the joint85.2. Sankoca: Abnormal fixed state of any limb in flexion orinability to extend the limb is termed as sankoca86. This iscaused due to the affliction of snayu and kandara by thevitiated vata87.3 . Anga Vai kal ya: The Jadyata and sankoca leads to variety ofdeformities in the limbs, which is denoted by the termAnga Vaikalya.
4. Granthi: Caraka quotes that granthi is characteristic featureof affliction of snayu88.5. Vataroga: Vacaspati while commenting on the verses inmadhava nidana pertaning to the upadrava concluded thatthe term upadrava in the present context implies thevatarogas, vijayaraksita refer this to kanja and similarconditions. To sum up, jadyata, Anga vaikalya, sankoca,Granthi and Vataroga are rekoned to be the upadravas ofAmavata, Jadyata is because of abnormaly increasedkapha in the joint while affliction of snayu causessankoca, Granthi and anga vaikalya. The manifestationsof these upadravas indicate the poor prognosis of thedisease.Sadhya-Asadhyata: After the study of upadrava of Amavata, the sadhyasadhyatha of Amavata is dealt in brief as follows: Before undertaking the treatment of any disease,the physician should continuously scrutinize whether adisease is sadhya (Curable) or asadhya (Uncurable) andalso whether it is sukha sadhya (easily curable) or
krichrasadhya (curable with difficulty) or yapya (onlycurable as long as the treatment is given). The presence of virulent Ama, involvement oftridosa, with the dominance of vata involvement ofmadhyama Roga marga and perpetual affliction of thewhole body in degrees, illustrates the severity andlingering nature of the disease. However the variance inthe causative agent severity of the Dosic involvment aswell as affliction of dusya and difference in idiosyncraticbodily resistance for the disease contributes to thevariation in the severity of manifestation of the diseaseand there by responsible for good or poor prognosis.Accordingly in Amavata anubandha of solitary dosa, shortcourse of the disease presence of the symptoms in themilder form or affliction of fewer number of joints andabsence of upadrava are indicative of the sadhyata of thedisease. Involvement of two dosas suggests yapyata ofAmavata. Tridosic Anubandha, affliction of almost all thejoints, long courses and presence of upadravas points towords the krichra sadhyata of the disease.
AMAVATA CHIKITSA Amavata posses a formidable challenge to thephysician owing to its apparent chronicity incurability,complications and morbidity. Despite the administration ofthe best available modern drug the disease has atendency to persist, progress and cripple the patients. Inayurveda the line of treatment propunded by ancientAcaryas depend a good deal of the stage in the diseaseprocess. Cakradatta was the pioneer in describing theprinciples of treatment for this disease, which arelanghana, svedana, drugs having Tikta, Katu Rasa andDeepana action virechana, snehapana and anuvasana aswell as ksarabasti89. Bhavaprakash has added RukshaUpanaha to these thereapeutic measures90. An attempt isbeing made here to substantiate these principles on thebasis of those laid down by caraka, susruta and vagbhataetc.L a n g h a n a: It is the first measure that has been advised for themanagement of this disease. It can be justified on thebasis of Ayurvedic principles. Amavata is considered to bean amasayottha vyadhi and langhana is the first line oftreatment in such conditions91. It is also a Rasaja Vikara,
as the involvement of the Rasa is the major anomaly andaccording to caraka in such conditions langhana should beemployed92. Further langhana has been described to bethe best measure for the treatment of Aama (Y.R.). Inspite of this caraka has advocated the langhana inSamavata State, as vata is asssociated with AmaLanghana can be employed in Amavata93. It has also beendescribed that sama dosa cannot be eliminated until andunless Ama attains the pakva form, for this the langhanais the best therapy94. These factors corraborates theemployment of langhana in Amavata. The question whether samsamana or Samsodhana,both types of langhana are to be employed or whethersamsamana only is to be employed in most point. In thedescription the first two points favour employment of both,the remaining three points favour the use of samsamanalanghana only. Since Dosha can not be eliminated unlessand until the pachana is done so only upavasa orlaghubhojana type of langhana should be employed. Italso mobilizes the dosha from shakha to kostha. Langhana is contraindicated in vata, which is amajor factor in this disease, since in this condition vayu isSama and langhana is indicated in Samavata. However,
care should be taken that langhana is stopped as soon asnirama vata state is achieved. In addition langhana creates a hunger reflex inthese patients resulting in the enhanced production ofinternal corticosteroids which provide relief through thereduction of the inflammation.Svedan a : In the management of Amavata Ruksha sveda hasbeen advocated in the form of valuka pottali, Owing to thepresence of Ama. But many vaidyas employed snigdhasveda also because of the fact that in the chronic stage ofthe disease increased Ruksata takes place and thus therelief may not be remarkable, as Ruksa Sveda tends tovitiate the already vitiated vata Dosa. So it is suggestedby many renowned panchakarma specialists including R.D.lele (1964), that in the initial stage Ruksa Sveda and inthe chronic stage Snigdha Sveda should be employed.This can also be substantiated by the line of treatmentnarrated by Caraka that if vitiated Vata Dosha locates inkapha sthana, first Ruksa Sveda and Snigdha Svedashould be given & vice – versa95. The Sama and Niramastages of the disease can be readily gauged byadministrating the Ruksa Sveda and Snigdha Sveda. The
former gives relief in the Sama stage & aggravates thecondition in nirama stage & vice – versa. In case the disease process is confined to fewjoints, Sthanika Sveda can be given & if there isinvolvement of multiple joint sarvanga Sveda can begiven. Svedana helps in cleansing the body channels andthus aids in the transportation of the dosas from sakhas tothe kostha. In addition, it has been especially indicated inthe presence of stambha, Gaurava, Jadyata, Sita andShula, which constitute the predominant features ofAmavata96.T i k t a, K a t u Deepana Drug s: Through Tikta & katu Rasa drugs have described asvitiative of vata Dosa, yet these are of proven value inthis disease. This is due to the Ama pachana activity ofthese drugs, thus helping in the removal of Avarana whichis the real cause of the vitiation of vata in this disease.Deepana drugs to act through the same mechanism.These therapeutic measures also favour the transport ofDosas from sakhas to kostha.Virechan a: After the administration of langhana, svedana andTikta, Katu and deepana drug, the patient should be
subjected to virechan theraphy since the doshas renderedNirama by these therapeutic measures require eliminationfrom the body by sodhana. Now the question arises whyvirechana alone should be given and not vamana becauseusually vamana preceds virechana. If virechana is givenalone the kapha located in the amasaya may producemandagni, and its consiquences. However this rule hasbeen relaxed in the case of Udara roga, Gulma etc, thesame may also be followed in case of Amavata because ofthe following reasons:a) Production of Ama is the result of avarana ofpittasthana by the keldaka kapha, which after leaving itsnormal site settles at this place, thus hampering thedigestive activity of the pachaka pitta. Virechana helps inthis condition through two ways one it removes theavarana produced by kledaka kapha to it is the mostsuited threaphy for the sthanik dosa pitta.b) Symptoms of Amavata like Anaha, Vibandha,Antrakuja, Kuksisula etc. are indicative of pratiloma gatiof vayu. This is best conquered by virechana, whilevamana is likely to aggravate this condition.Further more, though virechana has been described to bethe best remedy for pitta dosa yet it is effective in thevitiated kapha and vata dosa also to some extent. So in
this way it appears to be the most appropriate therapeuticmeasure in this condition. The use of Eranda Taila inAmavata suggests that in this disease snigdha and notruksha virechana should be employed, since it does notproduce generalised snehana effect but by its snigdha,usna etc. Characteristics it aguments the Agni in additionto its vata anulmona action.Snehap ana: After giving the above mentioned therapies thepatient should be subjected to samana snehapana whichis justified on the basis of following points.1. The therapeutic measures employed so far are likely toproduce Rukshata in the tissues of the patient, which mayprovoke the vata dosa thus further aggravating thedisease process. This is best prevented by the oraladministration of medicated sneha.2. In addition there occurs reduction in the Bala of thepatient, which is the result of the therapeutic measuresemployed so far as well as the nature of the disease. Thisis also effectively controlled by the best administation ofsneha as the latter is described to be best balavardhakaregimen97.3. Further more, samana sneha has been stated toaugment the agni98 as it influences the digestion by
softening the food and stimulating the agni which is theprimary requirement in Amavata. This also alleviates theapprehension about the production of Ama from snehadravyas. Production of Ama may happen in case sodhanasneha is administered, as the later is likely to producekledana of the tissues and utklesa of the dosas. However,this is not the case with the samana sneha.4. Snehapana has also been prescribed in cases to asthimajjagata vata, as the involvement of these dhatus isquite evident in Amavata snehapana in this conditionseems to be quite indicated99.5. Since snehana specifies the vitiated vata due to itsinherent vata anulomana effect, it is strongly indicated inAmavata, when there is predominance only to vata dosa inits nirama state. However because of the pronenses of Amavatapatients to easily develop derangments of digestion snehais best administered medicated with deepana drugs.Basti : In Amavata both Anuvasana as well as Niruha bastihave been advocated. Anuvasana basti removes thedryness of the body caused by the Amahara treatment,alleviates vata dosa maintains the functions of Agni andnourishes the body. The niruha basti eliminates dosas
brought in to the kostha by the langhana and alliedtherapies. In addition to generalized effects, bastiproduces local beneficial effects also by removing theAnaha, Antrakuja vibandha etc. Saindhavadi taila hasbeen mentioned for Anuvasana and ksara basti forAsthapana100. Obviously many drugs and therapeutic measuresmay be employed for the management of the Ama andvata-the chief pathogenic factors. So due emphasis shouldbe places on the stage of the disease while planning thetreatment langhana, Svedana, Deepana, pachanatherapeutic measures are empoyed to accomplishAmapachana. At the same time provocation of vata shouldbe; prevented. Virechana, snehapana and Basti are mainlydirected to eliminate the dosas particularly vata. However,on the other hand normal state of Agni should bemaintained.Pathya-Apathya Just as treatment, pathya too has equal importancein the amelioration of the disease. In this regard classicaltexts emphasize that, success or failure of the treatmentdepends to a large extent on the practice of pathya orApthya.So for as Amavata is concerned, any drug or dietthat is katu. Tikta by rasa, usna and Tiksna by Guna and
having vatahara kapahara and Amapchana action isconsiderd as pathya. The list of pathya as mentioned inthe texts is given below.1. Monocotyledons: Puranasali, purna sastika sali,yava101.2. Dicotyledons: Canayusa, kalaya yusa, kulattha, 102kodrava .3. Vegetables:Nimbapatra,Punarnava,Goksura,Varuna,Sigru,Ardraka,Rasona,Karvellaka,Patola103.4. Non-Vegetables:Janghala mamsa Rasa or Lavamamsaprocessed with takra104.5. Liquids : Boiled water,Panchakola siddha Jala,Puranamadhya105.6. Cow products: Takra,Gomutra106. In the same way the drugs and diets that aremadhura and amla by Rasa, Guru, Picchila, Atisnigdha,sita and Abhisyandi, by Guna and which causeprovocation of vata kapha and formation of Ama areconsidered as Apathya in Amavata. This includes thefollowing diets.1. Dicotyledons : Masa1072. Vegetable : Upodika1083. Non-Vegetables : Anupamamsa, fish109
4. Liquids : Unclean water, curds, Tila Taila1105. Miscellaneous : Pistamaya padartha, Jaggery,unwholesome diets, Suppression of natural urges,visamasana cold water both. In to any food article that possesses katu, tiktarasa, usna, tiksna guna, and produces alleviation of vataand kapha as well as Amapachana are pathya in Amavataand contrary to this the diets which are madhura, Amla byRasa, Guru, picchila, sita by guna and that whichprovokes vata kapha Dosa or cause Abhisyandana areconsidered as Apathya in this disease.
MODERN LITERATURE REVIEWAMAVATA VIS-À-VIS RHEUMATOID ARTHRITIS The understanding of Ayurveda cannot besuperimpose with the understanding of modern medicine.But there is a trend to co-relate Ayurveda with modernmedicine. Moreover in recent years people are deviatedtowards the “Evidence based Medicine” for the rationaluse of our indiginious medical knowledges. Amavata can be co-related with Rheumatoiddiseases according to western medicine. This term Rhumarefers to “A substance that flows” & probably was derivedfrom kapha (phlegm), an ancient primary humours. TheAmerican committee for the control of Rheumatism isestablished in USA for the guidance of this disease. Thereare ten major rheumatic diseases can be included in thegroup of Rheumatoid disease. Most important diseases isSystemic connective tissue disease among them. Thisdisease humper the purpouseful motion of a indivisualswhich is depending on the effective interaction betweenjoint & neuromuscular units attached with it. The importantcomponents take part in musculoskeletal systems aremuscles, tendons, ligaments, cartilages and bones.
Definition of Rheumatoid Arthritis: Rheumatoid arthritis is a chronic, systemic,inflammatory disorder of unknown etiology that ischaracterised by its pattern of diarthroidial jointinvolvement. Its primary site of pathalogy is the synoviumof the joints. The synovial tissues become inflammed andproliferate, forming pannus. Which invades bone,cartilage, and ligament and leads to damage anddeformities111.E t i o l o g y: The cause of RA remains unknown, it has beensuggested that RA might be a manifestation of thepresence of an infectious agent in a geneticallysusceptible host112. It seems likely that there may be several initiatingfactors, which are distinct from a perpetuating factor.There is also evidence of immune overactivity:1. The presence in the serum of abnormalimmunoglobulin– rheumatoid factors – IgG and IgM.2. The infiltration of the synovial tissue byimmunologically competent cells, lymphocytes, andplasma cells, which are responsible for the localproduction of immunoglobulins including rheumatoidfactors.
3. The presence of immune antigen – antibody complexeswithin leucocytes in synovial fluid and peripheral blood.4. The finding of lowered complements levels in synovialfluid. It has been suggested that the basic mechanism inthe production of the inflammation is the combination ofrheumatoid factor and an altered immunoglobulin with theutilisation of compliments the ingestion of the resultingimmune complexes by neutrophils causes the release oflysosomal enzymes which act as mediators of thesynovitis (Welssmann, 1972).The alteration or production of immunoglobulin with whichrheumatoid factor combines is a vital step. If thealteration appears denovo. Rheumatoid arthritis can becalled an autoimmune disease. However, other etiological factors may be involved,including:1. A Genetic Influence (DR4): There is a tendency forthe disease to be aggregated in families.2. Trauma: Many patients have mentioned traumaticincidents as a precipitating cause.3 . P s yc h o l o g i c a l S t r e s s : T h e s t u d y o f i d e n t i c a l t w i n s i none of whom rheumatoid arthritis developed tends tosupport this concept113.
4. Infectious agents: Renewed interest in this subjecthas resulted in isolation of a variety of organisms fromsynovial tissue, synovial fluid & blood. These includediaphtheroid bacilli, mycoplasma and viruses.5. Vascular Changes: Alteration of the normal peripheralvascular bed, perhaps by autonomic influence, has beensuggested as the primary abnormality. This has beenimplicated to explain the striking symmetry of the arthritisin many patients.6. Neurogenic: Neuropeptides can cause inflammationreflex sympathetic areas through the spinal cord couldaccount for the contralateral distribution. Rheumatiodaffects the non-paralysed side much more severely in ahemiplegic patient114.PATHOGENESIS: Microvascular injury and increase in the number ofsynovial lining cells appear to be the earliest lesions inrheumatoid synovitis. The nature of the insult causing thisresponse is not known. Subseqently an incresed numberof synovial lining cells is seen along with perivasularinfiltration with mononuclear cells. As the processcontinues, the synovium becomes edematous andprotrudes into joint cavity as villous projections.
Light microscopic examination disclosescharacteristic constellation of features which includehyperplasia and hypertrophy of the synovial lining cells,local or segmental vascular changes, includingMicrovascular injury thrombosis and neovascularizationedema and infiltration with mononuclear cells, oftencollected into aggregates around small blood vessels. Theendothelial cells of the rheumatoid synovium have andappearance of high endothelial venules (HEV) of lymphoidorgans and have been altered by cytokine exposure tofacilitate entry of cells in to tissue. Rheumatoid synovialendothelial cells express increased amount of variousadhesion molecules involved in this process. Although thispathologic picture is typical of RA, it also can be seen in avariety of other chronic inflammatory arthritides. Themononuclear cell collections are variable in compositionand size. The predominant infiltrating cell is the Tlymphocyte CD4 T cells predominate over CD8+ T cellsand are frequently found in close proximity to HLA-DR+macrophages and dendritic cells. An increased number ofa separate population of T cells expressing the form of theT cell receptor also has been found in the synovium,although they remain a minor population there and theirrole in RA has not been delineated. The major population
of T cells in the rehumatiod synovium is composed ofCD4+ memory T cells that form the majority of cellsaggregated around postcapillary venules. Scatteredthroughout the tissue are CD8+ T cells. Both populationsexpress the early activation antigen CD69. Besides theaccumulation of T cells rheumatoid synovitis is alsocharacterized by the infiltration of large numbers ofBcells that differentiate locally in to antibody producingplasma cells. These cells produce both polyclonalimmunoglobulin and the autoantibody rheumatoid factorthat results in the local formation of immune complexes.Finally, the synovial fibroblasts in RA manifest evidencein activation in that they produce a number of enzymessuch as collagenase and cathepsins that can degradecomponents of the articular matrix. These activatedfibroblasts are particularly prominent in the lining layerand at the interface with bone and cartilage. Osteoclastsare also prominent at sites of bone erosion. The rheumatoid synoviusm is characterized by thepresence of a number of secreted products of activatedlymphocytes, macrophages and fibroblasts. The localproduction of these cytokines and chemokines appears toaccount for many of the pathologic and clinicalmanifestations of RA. These effector molecules include
those that are derived form T lymphocytes such asinterleukin (IL) 2, interferon T (IFN), and tumor, necrosisfactor α (TNF α) platelet derived growth factor insulin likegrowth factor, as well as others secreted from fibroblastsand endothelial cells like IL-1, IL-6 IL-8. The activity ofthese chemokines and cytokines appears to account formany of the features of rheumatoid synovitis including thesynovial tissue inflammation, and synovial proliferation,leads to cartilage and bone damage as well as systemicmanifestation of RA. These findings have suggested that the propagationof RA is an immunologically – mediated event, althoughthe original intiating stimulus has not been characterised.One view is that the inflammatory process in the tissue isdriven by the CD4+ T cells infiltrating the synviumevidence for this includes.1) The predominance of CD4+ T cells in the synovium2) The increase in soluble IL-2 receptors a product ofactivated T cells in blood and synovial fluid of patientswith active RA and3) Amelioration of the disease by removal of T cells bythoracic duct drainage or peripheral lymphapheresis orsuppression of their function by drugs such ascyclosporine. The chronic inflammation is the overriding of
acute inflammatory process in the synovial fluid. Theoxidative synovial fluid contains more polymorphonuclearleukocytes than mononuclear cells. A number ofmechanisms play a role in stimulating the exudation ofsynovial fluid. Locally produced immune complexes canactivate complement and generate anaphylatoxins andchemotactic factors. The precise mechanism by which bone and cartilagedestruction occurs has not been completely resolved.Although the synovial fluid contains a number of enzymespotentially able to degrade cartilage the majority ofdestruction occurs in juxtaposition to the inflammedsynovium or pannus, that spreads to cover the articularcartilage. This vascular granulation tissue is composed ofproliferating fibroblasts small blood vessels and a variablenumber of mononuclear cells and produces a large amountof degradative enzymes including collagenase andstromelysin that may facilitate tissue damage. As tissue damage occurs, additional autoantigensare revealed and the nature of the T cell responsebroadnes as additional clones of CD4+ T cells arerecruited to the inflammatory site. Finally as a result ofpersistent exposure to the inflammatory milieu thefunction of syunovial fibroblasts is altered. The important