Pama kc011 hyd


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A study on the effect of Vidangadi Churnam & Jeerakadi Tailam on Pama, D.Nageswara Rao, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, HYDERABAD

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Pama kc011 hyd

  1. 1. Introduction… 1. INTRODUCTION It is from times immemorial before the dawn of human civilization the scared science of ayurveda has taken its birth on the earth. This science or ayurveda has been divided into eight branches. (Cha. Su. 30/28) They are: 1. Kaya Chikitsa 2. Shalakya Chikitsa 3. Salya Chikitsa 4. Visha Chikitsa 5. Bhutha Vidhya 6. Kaumarbritya 7. Rasayana Chikitsa 8. Vajeekarana Chikitsa From the above branches the diseases of skin and its treatment falls in the Kayachikitsa branch. The study of skin diseases and their treatment is called as dermatology. Pama is one of the skin diseases described in Ayurveda. The signs and symptoms of pama have been described by sushrutha and other acharyas vividly. These signs and symptoms seem to coincide with ECZEMA skin disease. Though lots of progress has been done in the field of dermatology but still the humanity all over the Globe irrespective or race. Color. Caste and creed is suffering with these diseases and yet no appropriate management is discovered.So in this work an attempt is made to bring out a successful management as per Ayurvedic lines for the disease PAMA. 1created by of Dr.KSRPrasad
  2. 2. Introduction… Certain Herb mineral preparations have been chosen for the management of this disease. The drug choosen are those, having the anogonistic properties of the disease keeping in view of the dosha a dushyas. The drug Vidangadhi Churnam 3gms tid with madhu administered internally and Jeerkadhitailam applied externally for 60 days. The patya and apathya are strictly followed as per the texts. PARAMETERS OF CLINICAL TRIAL 1. While taking up the case the number of lesions and its location (Anatomical) are carefully noted and the lesion study in proper illumination under magnifying glass. A color photo- graph is taken and the clinical work is started. 2. The measurement of lesion is done before starting the work and after completing the work by the following methods A) The graphic square method b) Planimeter method 3. The subjective parameter are the symptoms as prescribed in the texts i.e kandu, pidika, srava, pardaha etc. are taken into consideration before starting the treatment and after the treatment. 4. The objective parameters are those signs seen by the naked eye as narrated in the samhitas. A colorful photograph is taken before the beginning of the treatment and another photograph after the treatment is taking and compared. To screen the patients whether they are devoid of other diseases are not. Certain simple. Routine pathological. 2created by of Dr.KSRPrasad
  3. 3. 2.1 REVIEW OF LITERATURE HISTORICAL ASPECT This branch of Medical Science reaches back to antiquity the obviously manifested skin a disease has drawn the attention of man since times immemorial. Ayurveda has dealt with this subject and has mentioned the various types of the signs and symptoms and treatments prevailing at that period which are suppose to be the oldest period. In Rig-Veda, reference of the skin disease has been given. Atharveda gives a detailed aspect of skin diseases. In the following reference of Atharvaveda the description of Kushta and Kilasa were given i.e. in 1/2/4. The kilasa disease was given synonyms in Atharvaveda; they are Dharuna Aruna and sumitra. The treatment for skin disease was also dealt in details in Atharvavea. The mentioning of drug Shyama for curing Kuhta was given in Atharvavea 1/23/24. AYURVED BRIHAT ITHIHAS: After the Vedic period the description of skin diseases has kept us its continuity up to this date. The description of pama and Kushta in sushrutha and Charaka Samhitha shows that it was well known to Dhavanthari sampradaya (Sushurtha) Athreya sampraday (Charka) which is suppose to be 1000 B.C. i.e. the period of Agnivesha. As charka has reducted the Agnivesha thanthra, the knowledge of pama and kusta existed to around about 200 B.C. The clear description of pama and kushta is Ashtanga Vaghata shows that the knowledge of Kushta (pama) was still known to that age. After them the other acharyas such as Bhava Mishra (10th Century) etc., Kept up the trend of ancient dermatelogy which is till today. The history of Dermatology or other systems of Medicine are as follows: 1. The Chinese System of Medicines falls in the period of 3000 to 2000 B.C. In this system they have give more or less accurate description of leprosy, scabies icthyasis, vitilige, eczema, aopecia, carbuncle, erysipelas and acne etc. 3created by of Dr.KSRPrasad
  4. 4. Review of Literature… 2. Egyption papyruses relating 3000 to 1000 B.C. has described eczema, leprosy, scabies, carbuncles, warts, corn etc. 3. Hipprocrates (460 to 375 B.C.) was the first attempt separarating medicine from the religion cult. He described many skin diseases and divided them into two groups according to their exogenous or endogenous casues (the theory or abnormal mixture of humours). This played a major role in dermatology for a long period. Hippocrates used terms many of which have retained their meaning to this day, Herpes, Lepa, Alopecia, Apthae, ecthyma, etc. (The word exthyma means eczema). 4. The roman writter celsus (25A.D) in his eight volume treatise “De Medicina libri octe” devoted several chapters to the description of skin diseases. 5. The Persian Scholar Abu Ali al Hysayan ibn-sina (Avicenna) who was born in 980 and lived for some time in Bukhara has described many skin diseases. In the Feudalism of Middle Ages natural sciences including dermatology suffered a period of stagnation. 6. In 1571 Mercurialis an Italian wrote the first text book of skin Diseases on this earth “ De Morbus Cuteneous “ 7. The morphological principle in the study of dermatology was give further development with a few changes in the words of British school of dermatology. The most prominent representatives of which was Robert William (1757 to 1812) and his pupil Thomas Bateman. Robert Willan introduced the term “ECZEMA” which received a wide application. He gave a clear cut description of this disease. 4created by of Dr.KSRPrasad
  5. 5. Shareera of Twak… 2.2SKIN EMBRYOLOGY Before starting the rachna aspect of the twak it is customery to deal with the embryological aspect of the Twalk. The uthapathi Krama of Homosapien starts from Shukra and artava. The shukra comprises of Soma quality and Arthava of agneya, apart from it there are qualities of other elements which helps in its developmental process. When he coitus takes place the shukra dhatus with the prerans of Vayu and Tejobjutha unites with arthava after which it gets lodged in Garbhashaya whereit starts to develop into fetus, during this process of development of Fetus the development of skin takes place as the formation of cream over the milk. This cream constitutes of 7 developmental layers. The genetic factor of development of skin is from matruja and rasaja factors. This type of description of development of skin in quite gross. Some embryological development as per the modern science can be dealt into the following way. DEVELOPMENT OF SKIN:- The three Embryological layers which form the foetus are ectoderm, endoderm and mesoderm. The soporiferous and sebaceous glands are derivatives of the ectoderm. While the dermis is formed from the somatic layer aspect of the mesodermal somites. The ectoderm at first consists by sixth week these proliferate and form to double layer a superficial periderm of flattened cells are sub adjacent stratum germinatum. The cells of the latter at first are cuboidal but become columnar. By multiplication and differentiation of these cells the different layers of epidermis are developed. The periderm is merely a temporary layer of statum. By the sixth month most of the peridum which becomes keratinized has disappear and the stratum granulosum, lucierm and corneum of the epidermis are established. The superficial cornfield cells together with the sebaceous secretion and the remnants or periderm, form a cheesy or caseous material, this is vernix caseosa, which may exercise the function of protecting the 5created by of Dr.KSRPrasad
  6. 6. Shareera of Twak… Underlying epiermis from maceration by amniotic fluid. This vernix caseosa is characteristic of the surface of the foetus during its final, months of intrauterine existence. Finally it desquamates soon after the birth. At an early but still undetermined age neural crest cells invade the developing skin and these elements differentiate into birth epithelial and connective tissue pigment cells such as melanoblasts. These assume a branching form an are hence named dandritic cells. ( In negroes foetus they develop more and turn the skin to black colour. But in less pigmente races similar cells exists in dormant from by which such individuals are fair in complextion but when stimulated by intense sunlight they are able to form melanin granules. Ectodermal area of the head and branchial region develop into occular lenses and ganglia of certain cervical nerves. This is how the epiderms and dermis develop from the ectodermal and mesodermal layers. REFERENCES 1. Sushrutha samitha. Sharirasthan 3/283 2. Sushrutha Saitha. Sharisrasthana 4/4 3. Sushurtha Saitha. Sharirasthana 3/31. Ashtanga Hridaya Sharirasthana 3 / 4 ,5,6 4. Gray Anatomy (Embryology) 6created by of Dr.KSRPrasad
  7. 7. Shareera of Twak… 2.3 ANATOMY OF SKIN (Ancient Review)Ayurveda: Sushrutha View: There are 7 Layers of skin. 1. Avabhasini 2. Lohita 3. Sweta 4. Thamra 5. Vedhini 6. Rohini 7. Mamsadhara 1. AVABHASINI:-The first is called Avabhasini, which imparts hue and brightness to the complexion with its five varieties and hence when effected it becomes the seat of sidhma th a padma Kantka, eruptions etc. It has the thickness of about 18 part of a grain (Vrihi) 2. LOHITA:-The Second is called Lohita which is as thick as sixteenth part of a grain and is affected by moles, discolourations and pigmentation. th 3. SWETHA:-The thirdis Swetha. It is about 12 part of a grain in thickness and is the seat place of Charmadhala, Ajgallika and Mashak skin diseases. 4. THAMARA:-The fouth is Thamara. It is one eighth part of a grain in thickness and is the seat of a kilasa and Kushta 7created by of Dr.KSRPrasad
  8. 8. Shareera of Twak… 5. VEDHINI:-It is the fifth layer which is about one fifth part of a grin in thickness. It is a seat of Kushta and visarpa 6. ROHINI:-The sixth is the rohini. It is as thick as the full grain in thickness. It is the seat of Galaganda, Granthi, Apachi, Abhuda, and Sleepada. 7. MAMSADHARA:-The seventh is the Mamsadhara. It is about two grains in thickness and is the seat of Bhagandhara and Arsha (Piles) and Vidhradhi. NOTE:-Regarding the dimensions described above sushrutha clarifies that these dimensions can only be found in the fleshy parts of the body and not on the bony surface. CHARKAS VIEW:- There are six layers of skin in the body. They are: 1. The outer most layer of skin is known as udakadhara (that which holds up water) 2. The Second one Asrugdhara. It holds up the blood 3. The third layer is the seat of the origin of sidhma and kilasa ( Leucoderma) 4. The fourth one is the seat of the origin of the Dadru (ring worm) and Kushta 5. The fifth one is the seat of alaji an vidradhi 6. The sixth one is that which if grossly injure causes loss of Consciousness and is the seat of origin for boils being manifested as blackish red and deep rooted on joints and are asdhya. Thus there are six layers of skin which cover entire body parts. VAGBHATA VIEW:- Vagbhata described that skin having 6 layers 1. Udhakadhara 8created by of Dr.KSRPrasad
  9. 9. Shareera of Twak… 2. Asrughdhara 3. Sidhma Kilasa Adhishtana 4. Sarva Kushta Adhistana 5. Alaji Vihradhi Adhisthana 6. Pranadhara ARUNADHATTA:- Arunadatta in his commentary on Ashttanga Hridaya Samhitha has described the following 7 Layers:- 1. Bhasini 2. Lohini 3. Swetha 4. Thamra 5. Vedhini 6. Rohini 7. Mamsadhara As Vagbhata’s treatise did not deal with it specifically so charaka and Sushrata’s priniciples are taken into consideration. 9created by of Dr.KSRPrasad
  10. 10. Shareera of Twak… The Charak and Sushrata’s View can be brought & to a common unerstanding in the following ways:- 1. Charaka view of Udhakadhara is the most superficial layers which protects the passage of fluid substance from the body forming the barrier. By the by through this layer only the five types of chaya (Krishna, shyama and gaura etc) are reflected so it is called as Avabhasini by Sushrutha. 2. Charakas view of the second layer is Raktha Dhara which is highly vascular and so Sushruta called it as Lohita. 3. In the third layer the Sidhma, and kilasa diseases occurs. The mentioning of diseases as per layers starts only in the third layer without its nomenclature as per Charak, Where as Sushrutha sidhma and padmakantaka in first layer, Tilkalka, Nyachha, Vyanga in second and third layer. Charmadela, ajgalika, Mashaka, these diseases were mentioned in swetha layer as per shushrutha. The Sushrutha included fourth layer disease such as kilasa and kushta and named it as thamra because of its colour. So the Sushrutha’s view of thir and fourth layer is being brought into Charaka’s view of third layer. 4. In the fifth layer as per Sushurutha, Kushta and Visarpa diseases occur. And as per charaka kushta and dadru diseases occur in fourth layer. So the 5th layer of Sushrutha’s view may be identical to Charaka’s view (The occurance of Kustha is in fourth layer as per Charaka, Sushruts and Vagbhata. Sushruta has mentioned Kushta in 5th layer also). 10created by of Dr.KSRPrasad
  11. 11. Shareera of Twak… CHARAKA VAGHBHATA ARUNADATTAOF SUSHRUTHA A.H.S 3/8 Udakadhara Udhakahara Bhasini Sidhma Padmakantaka Asrugdhara Asrugdhara Lohini Tilkalak, nyacha vyanga Seat of Sidma & Seat of Sidhma & Swetha (Charamadhalu, Kilasa Kilasa diseases ajagallika, Masak) Seat of Dadru & Seat of Sarva kushta Tamara Kilsa Kushta Kushta Disease disease Seat of Alaji Vidhradi Seat Alaji & Rohini Kushta Visarpa Disease Vidhradhi Pranadhara Pranadhara Mamsadhara Galaganda, Granthi, Apachi, Arbudha, Shleepada, Bhagandhara, Vidhradhi, Arsha (piles) th 5. Charaka mentioned Alaji and Vidhradhi, Sushruta mentioned diseases of 6 layer such as Galaganda, Apachi, Arbhudha and Granthi Etc. th 6. The diseases mentioned by Sushruta in 7 layer that is Bhagandhara/ Vidhradhi and th arshas (piles) are deep seated and causes the same signs and symptoms of 6 layer diseases of Charaka. Thus there views can be unified. 11created by of Dr.KSRPrasad
  12. 12. Shareera of Twak… MODERN REVIEW:- As per the modern science the skin is divided into 3 layers they are 1. Epidermis 2. Dermis 3. Hypodermis EPIDERMIS This constitutes 2 different zones of cells  Deeper Zone  Superficial Zone DEEPER ZONE: This consists of basal layer that is called as stratum basale or stratum geminatum or malphigian layer. This layer is present on the basement membrane to which they are attached by half desmosomes. Most of the miotic division is limited to this layer. So called Twak Uttapathi Kriya. The layer above this is the layer of polyhydral cells .i.e., stratum spinosum. These cells are highly complex folded surface covered with desmosomes which are assoiate with cytoplasmic tonofibrils. These cells are also called prickle cells. SUPERFICIAL ZONE:- The zone constitute of the following layers.  Stratum Corneum  Stratum Lucidem  Stratum granulosum The cells of stratum spongiosum mature and granules of keratohyalin appear in it, which is called as Stratum granulosum 12created by of Dr.KSRPrasad
  13. 13. Shareera of Twak… After this stage these granules mature a fuse with each other and form a clear layer called stratum lucidem. After this the cells become compressed into opaque squares which are now full of the horny protein keratin. These squares constitute the outer layer the Stratum Corneum. THEPIGMENTATION OF SKIN: As vivarana is one of the sign mentioned in the disease of pharma so it is better to deal with the pigmentation of skin). The final colour of the skin is due to presence of the five pigments. Melanin: Brown pigment present in stratum granulosum. Mealanoi: A similarsubstance to Mealnin is present in iffused form throughout the epidermis. Carotene: It is present in Stratum Corneum an adipose cells of dermis. Hemaglobin Oxyheamoglobin: This is present in the vasuclar supply of the skin. All the above pigments combidely for the colour of the skin. This is same as the one of the pitta i.e., it can be interpretedas Bharajaka Pittha as mentioned by Charak in Sutra that Bhrajaka gives the colour to the skin. In the disease “PAMA” pittha and Kapha are vitiated. As pittha is responsible for the normal colour of the body its vitiation naturally causes Vivarnathwam of the skin. DERMIS: This is the true dermis and constitute of two layers  Papillary  Reticular The Papillary is the superficial and is clearly demarketed from the epidermis. It has small papillary projections which pierces into the epidermis and enhances the nutrients to the 13created by of Dr.KSRPrasad
  14. 14. Shareera of Twak… Epidermis. The papillary layer consists of thin bubbles of collagen fibres and many fine elastic and argyrophil fibres. RETICULAR LAYERS: This is thicker than papillary layer. In this layer the collagen bundles are more compact and thick and intact with thick network of loops. In papillary layer there are small number of fibreblasts, histocytes, lymphocytes, most and plasma cells and peculiar pigmented cells (melanophanges). Hairs, glands, muscles, vessels, nerves and nerve endings are located in the dermis. HYPODERM: The hypoderm consists of thick bundles of Collagen and elastic fibres stretching from the reticulardermal layer to the below either to periosteum or to the muscle aponeurosis. (Among these fibres is the fat cells present, which has big drops of fat and its nucleus being pushed to the Periphery and with less cytoplasm). The Thickness of hypoderm varies from the site to site. For example it is 2mm. over the skull 5 to 10mm. thick on the back. It is absent and eyelids, nails, prepuce, scrotum, eye nose and lips. VASCULAR SUPPLY: The arteries in the skin are divided so minutely that they form minute capillaries and form anastimosis in the Dermis and Hypdermis. The epidermal cells are devoid of vasuclar supply. The nutrition to the epidermal cells is by diffusion from pappillary anastimosis. The venous drainage from the epidermis is by diffusion in the sub-pappillary plexus and then to the Hypodermis. From there it is drains back to cutaneous veins. LYMPHATIC SUPPLY: This consists of two networks. The superficial on the pappillary layers and the deep network is in the lower part of the dermis. 14created by of Dr.KSRPrasad
  15. 15. Shareera of Twak… INNERVATION OF SKIN: Skin is a sense organ apart from its various important functions. The nerve ending are of two types  Encapsulate or Corpuscles  Non-incapsulated. The kandu is one of the predominant symptoms of pharama so the anatomy of the nervous system of skin is to be dealt. The corpuscles are of many kinds they are:  Pacini Corpuscles  Meissners Corpuscles  Golgi Magini Bodies  Karuses bulbs  Rufffnis bodies. REFERENCES  Sushrutha Samhitha. Sharirasthana 4/4  Charaka Samhitha Sharirasthana7/4  Ashtanga Sangraha Sharirasthana5/29  Ashtanga Hridaya Arunadatha Commentary on Sharirasthana 3/3.  Sushrutha Samhitha Sutrasthana 21/10. Ashtanga Hridaya Sutrasthana 12/14  Gray’s Anatomy. 15created by of Dr.KSRPrasad
  16. 16. Shareera of Twak… PHYSIOLOGY OF SKIN TWAK KRIYA: PROTECTIVE BARRIER: The whole body i.e., Shadangam is covered by skin (The skin covering throughtout the body measures about 1.5 to 2 Sq.mtrs in normal adult. Its thickness may vary from few fraction of mm. to 4mm. In soles and palms. The mass of the skin is 5 % of total boy weight, and with the subcutaneous fat it is about 16 to 18 % of body weight.  Skin is resistant to all external mechanical stresses and strain such as blows, friction, and compression  Corneumprotects from drying of skin a so calle uakahara as per charaka.  Corneum protects from the effect of the electric current.  Skin surface is covered an acid (PH 5 to 6) water lipid matter which protects from chemicals and Micro-organisms. SKIN AS ORGAN OF SENSES: Charaka, sushrutha, Vagbhata has mentioned skin and seat of sense organ or Sparshanedriya. The Indriya, Dravya is Vayu and its indriyartha is sparsha (Cha. Su. 8/8, Cha.Sha. 1/30). These four types of senses, pain, heat, cold and tactile, Consists of 100 to 200 pain points. 25 tactile points, 12 to 13 cold points and 1 to 2 heat points. The sense of itch may also be considered a form of sensitivity; both exogenous and endogenous factors induce the itch sensation. The tactile sensation is perceived by two types of receptors. 1. Nerve plexuses around the hair follicles 2. Meissneris corpuscles. 16created by of Dr.KSRPrasad
  17. 17. Shareera of Twak… The heat and cold are perceived by Ruffini’s Corpuscles and Krause’s bulbs respectively. The appreciation of sensitivity in the central nervous system or the cerebral part is in the region of post central gyrus. THERMOREGULATORY FUNCTION Charak (Sutrasthana 12/11) has quote the pitta is only one which is responsible for the heat in the body which by its virtue does the good or bad to the body inits normal and vitiated condition. So the Bharajaka is one of the type of pitta which is present in the skin. Chakrapani has also stated for the above reference that Bhrajaka by virtue of its nature perceives heat and so controls its loss. The heat loss from skin is by: 1. Radiation of heat by radiant energy namely Infra Red Rays 2. Environmental heat conduction from the skin surface 3. Heat loss by Sweating (Maximum loss can be about 10 litres of sweat in 24 hours) Heat emission is regulated by reflex of Ruffini’s corpuscles and Krauses’ corpuscle and by direct stimulation of the Thermoregulatory centres, at the tuber cinerium and lateral wall of the Third ventricle in Hypotalmic region. The skin vascular reaction is controlled by sympathetic ganglion. SECRETORY AND EXCRETORY FUNTION OF SKIN: Swedha is supposed to be the mala of medas as perCharaka the seat for Swedhavaha Srotas is Medas and the root of the hairs. The body’s excretion of waste products is by sweat form with it being filtered from the blood in the sweat glands. The sebum is also excreted out through the Sebaceous glands. The composition of Sweat is 98 to 99 % water and rest is Urea, Uric acid, Ammonia, (NH4 & NH3) Creatinine, creatine (K, Cl 2, ca, salts) (Po4.SO4 Salts etc.,). 17created by of Dr.KSRPrasad
  18. 18. Shareera of Twak… METABOLIC FUNCTIONS OF SKIN: Skin colour: Bhrajaka is responsible for the colour of the Skin. The normal skin colours have been described by Charaka in Indriya stana, they are 1. Krishna (Black) 2. Shyama (Dark) 3. Syama avadata (mixture of dark and pale red) 4. Avadata (White or pale red or brown) 5. Athikrishna 6. Athigaura The Substance which contributes to the normal colour of the skin is the products of metabolism. Twak is the upadhati produced in the prasada baga of dhatuvagni paka of mamsadhatu. The five pigments that influence normal colour of skin are: 1. Melanin: Yellow to Black pigments is present in the malphigina layer of the skin. This present in the melanoblasts. 2. Melanoid: It just like Melanin but having a ifferent observant band of visible light. It may be bornfibre pigment of dark oxidation product in Keratin. 3. Carotene: Yellow orange pigment in corneum and sub-cuteneous fat. 4. Oxyheamoglobin: Red component present in highly vasuclar areas. 5. Meth Heamoglobin: Bluish purple character of skin. 18created by of Dr.KSRPrasad
  19. 19. Shareera of Twak… Absorption by skin:- The skin absorbs the various materials from outside such as abyanga, Lepa, parishaka etc. Arunadatha comments on A.H.Sut 12/14 as “It confers complexion to the skin by the paka (or conversion) of the substances used for the abyanga leps, Parishaka etc.” Skin is permeable to substances that are soluble in lipids and to substances in the gaseous state and practically impermeable to water electrolytes. Chemical agenst of small molecular dimensions pass directly though epidermis. Regarding gases exchange, skin absorbes 1/180 part of O2 as absorbed by lungs, and eliminates 1/90 to 1/65 part of CO2 eliminated by lungs. Water vapour eliminated are 800 grams daily which is 2 to 3 times of the invinsible loss of H2O from lungs in one day. The Skin takes an active part in the metabolism of H2O minerals, fats, proteins, carbohydrates, Hormones, Enzymes, Vitamins beause on the onehand it is a spacious depot and on the other hand some these substances are removed from the body with the secretion sebaceous and sweat glands. 19created by of Dr.KSRPrasad
  20. 20. REFERENCES PHYSIOLOGY  Charak Samhitha Sharirathana 7/4  Charak Samhitha Sutrasthana 8/8  Charak Samhita Sharirasthana 1/30  Charak Samhita Sutrasthana 12/11  Charak Samhitha Chikisasthana 15/18  Charak Samhitha Vimanasthana 5/8  Sushrutha samhitha Sutrasthana 21/10  Ashtanga Hirdaya Sutrasthana 12/14  Bhela Smhitha Sharirasthana 4  Charak Samhitha Indriyasthana 1/8  Charak Samhitha Chikitsasthana 15/17  Dalhana on Sushrutha Samhitha Sutrasthana 14/10  Sushrutha Sutrasthana 21/10  Ashtanga Hridaya Sutrhasthana 12/14  Skin and veneral diseases by Yu.K. SKRIPKIN  Page 45 to 53. 20created by of Dr.KSRPrasad
  21. 21. 2.4 DESCRIPTION OF PAMA NIRUKTI: The word PAMA is being derived in the following way:- (PAAMAN + MANAH+ ETHI NA-------)Kachuuh ethyamarah) (PAAMA= PAA +MANIN) (Shabda kalpa druma) This word belongs to feminine gender as per Sanskrit grammar. DEFINITION: Pama is one of the skin diseases which have been described in Ayurveda under the heading of Kushta.The most of the major skin diseases has been described in Ayurveda under the heading of Kustha. The word kustha has been described as follows. “The disease which spoils the skin and makes it look ugly is called as Kushta”. “Kushna thee thi vepuh ethi kushtam.” These skin diseases along with their signs and symptoms and treatment prevailing at that period has been described in Ayurveda by Charaka, Sushruta, Vegbhata dn other acharyas. DESCRIPTION The number of Kushtas described are 18 eighteen in number of which 11 are Kshudra Kushta’s and seven (7) are Maha kushtas. The Maha Kushta mentioned by different acharyas are 21created by of Dr.KSRPrasad
  22. 22. Sl. Shushrutha Vagbhata Kashyapa Bhava Saranga Charaka No prakasha dhara 1 Aruna Mandala + + + Mandala 2 + + + + + Udhumbara 3 + + + Jihwika Rishy jihwa RishyaJihwa 4 + + + + Kapalika Kapala 5 + + + + + Pundarika 6 + + Kakanakam Kaknaka Kakanak Kakanaka 7 Dadru + Sidhma + + Sidhma THE KSHUDHRA KUSHTAS ARE Sl Charaka Sushruta Hridaya Kashyapa Bhavaprakasha Sarangadhara No 1 Charma Sthula Charma Sthula Gaja charma Kushta Rakasa kushta Raksa 2 Eka Kushta Maha Eka + + Eka Kushta Kushta Kushta 3 Kitibha + + + + Kitibha 4 Vipadhika Visarpa Vipadika + + + 5 Alasaka Parisarpa Alasa Vishaja Alasaka Alasa 6 Shotaruka Nikushta Shotaruka + Shtarva Shataru 7 Visphota Rakasa Visphota Swetra Visphota Vishphota 8 Dadru Sidhma Sidma Dadhru + + 9 Charamadala + + + + + 10 Vicharchika + + + + + 11 Pama + + + Katchu Pama 22created by of Dr.KSRPrasad
  23. 23. Nidana… 2.5 NIDANA (ETIOLOGY) The aetological factors for pama are same as that of other Kushtas. For the purpose of better presentation they can be clasified into the 4 groups. 1. Factors related to food pattern 2. Factors related to behaviour Pattern 3. Sankramaka factors (Infection) 4. Mansika Karana They have been described by charaka, sushrutha and vagbhata: I. FACTORS RELATED TO FOOD PATTERN:  Sudden change of diet habits from santarpana to Apatarpana.  The adhyasana (Taking meals before the first meal is digested)  Eating irriatant foods without eliminating the undigested part of food.  By not following the principles of eating food as described by Acharyas.  Consuming kapaja ahara and sleeping during day time inspite of having kaphaja vikara will cause kushta (Bhela Samhita)  Continous and excesive use of Madhu (Honey) phanitha (Sugar can juice) Fish, Radish, Kakamachi, etc.  Taking incompatable foods such as fish (chilchima) with milk or fish, milk and nimba  Excessive use of Hayanka (a type of rice) yavaka shali, uddhalaka and Korahusha.  Excessive use of oils, Sweets, fats, bone marrow etc., which provokes the three doshes and vitate the dushyas (Twak, Mamsa, Rakta and Laseeka) and causes Pama. 23created by of Dr.KSRPrasad
  24. 24. Nidana…  Excessive use of pippali, kakamachi with curd and ghee, meat of deer with milk, radish with jaggery etc. II. FACTORS RELATED TO BEHAVIOURAL PATTERN: (Vihara aspect) 1. Sudden change from cold to heat a heat to old for staying in airconditioned room an sudden entry into atmosphere (may be occupational) 2. Excessive sexual act, exercieses and sudden plunges in cold water. 3. Sinfull acts in way of behaviour in this life or in the past life (Mythological view) is also said to be a causative factor. 4. Suppressing the urge for vomitting. 5. Drinking water immediated after getting fatigue. III. SANKRAMAKA FACTORS (INFECTION):- Some types of kushta are said to be of infective origin they are contagious an spreads from the patient by many ways such as: 1. Conversation with the patient of Kushta at close distances. 2. Frequent touching by coming contact. 3. Touching the infected part of the body. 4. Eating in one plate along with the patient. 5. Wearing clothes of the patient. 6. Having sexual intercourse with patient. 7. To have close contact with the patient. All these factors are possible in the spread of “Pama” disease. Except the Nishwasa. 24created by of Dr.KSRPrasad
  25. 25. Nidana… IV. MANASIKA KARNA: (BHAYYAH SHOKA) The psychological factor is also one of the factors in creating the skin disease especially a disease like pama in which itching is the one of the symptom. As the proverb goes “face is the index of mind” The skin reflects the psychological changes of a human being. It predicts the horomonal changes emotional changes etc., The itching being a psychological factor will be dealt in more detail in the description of roopa avashta of pama as per the recent advances prooving this factor. A part from it the dosh predominance in pama is pitta and kapaha as per (Ch.Chi.7/30) and as per sushruta is only Pitha. The aetiological factors which provokes the involved or predominant dosha causese the disease. The dosha involvement as per different acharyas can be tabulised as follows: Author Dosha Reference 1 Charaka Pitha Kaphaja Ch. Chi.7/30 2 Sushrutha Pittaja Su.Ni.5/16 3 Ashtanga Hridaya Kaphaja pittaja A.H.14/9 4 Sharangadhara Samhita Kaphaja Pithaja (S.S.Prva 7/89) The above study reveasl that the tridhoshas are involved as per our acharyas bu the predominant dosha Is pitha & Kapha. So the Aetiological factor for pama grossly said as those factors which causes the vitiation of pitha and kpha are to be taken into consideration. The pitha & Kapha prakopa factors in general has been described by Thrisatacharya are:- PITHA VITIATION FACTORS KAHA VITIATION FACTORS Katu foods Foods of guru Madura Amla foods Transformations of sugarcane, Juice Lavana foods Excessive sleeping Ushna foods Lack of exercise (Su. Su.21) Vidhahi Abhishyandhi foods such as platain, curds, 25created by of Dr.KSRPrasad
  26. 26. Mash etc., Teekshana foods Transformation of Thula Fasting Anup mamasa Excessove sun bathing ( Irridiation effects ) Audhaka Mamsa Excessive intercourse Vasa (fat) Thil Consuming Takra pindaka consuming Dhadhi & sure Excessive eating (A.S.Ni.1) Shiraka & Kanji Stopping the urge for vomiting Shoka & Bhaya ( Psychological Causes) Manda agni Fish & Meat Masthu Sauveerika Transfomation of alchols The period of pita prokopakala i.e. ( sharadha Ritu) Excessive consuming of alkaline foods (AH. Ni.1) Shukta Excessive intercourse while indigestion is present Certain foods such as Thilanna Amarathak, Bhallathak, Langalika, etc., The above factors are responsible for the vitiation of Pitha and kapha. Some of them can be interpreted as the factors responsible for the disease of pama. If any of the above factors of both Kapha & Pitha are consumed by the patient simultaneously then it will cause pama, as because it is a disease of pitta & kapha predominance as per (Cha. Chi. 7/34). By this the aetiological factors for pama is completed.The modern demotologists also admit that the aetiology and the pathogenesis of eczema are extremely complicated not always identical and are still unknown in many of their aspects. 26created by of Dr.KSRPrasad
  27. 27. Nidana… In various stages of study of eczema, the principal role in its aetiology and pathogenisis was attributed to the nervous system (Neurogenic theory). The endocrine glands, the allergic state of the body hereditary factors and other causes. In other words it is the effect of a complex of neuroallergic endocrine, metabolic and exogenic factors. The exogenic irritants include chemical and biological agents, bacterial allergens physical factors, drugs foodstuffs, cosmetics etc., all these are dealt in detail in the Aetiology and types of Eczema. REFERENCES  (Nidana)  Charaka Samhita Nidana Sthana 5/6.  Charak Sutra Sthana 26/80  Charaka Nidana Sthana 5/7  Sushrutha Nidana Sthana 5/8  Charaka Samhita , Chikitsa Sthana 7/30  Sushurtha Samhita Nidana Stana 5/16  Ashtanga Hridaya 14/9  Saranga dhara samhita, Poorva Kanda 7/89  Kayachikitsa by Ram Rakshak Pathak  Skin and Veneral Diseases by Yu. K. Skripkin. 27created by of Dr.KSRPrasad
  28. 28. Nidana… ECZEMA NIRUKTI: This word is derived from Greek which means “To Flow out” (Arthur Rook and Willkin son) (Greek meaning of eczema as per yu. K. Sripkin is “To ERUPT TO BOIL” DEFINITION: This disease is a universally encountered and recurrent disease characterized by pleomerphism of the Morphological lesion. This deseas can occur at any age. The important signs of the disease are multiple small groups of vesicles which rupture rapidly with the formation of serious wells. Some what resembling the surface of boiling water. Eczema is a non contagious inflammatory disease of the skin in response to endogenous or exogenous stimuli characterized by erythema, Oedima, Vesiculation, oozing, Weeping and crusting. Mircroscopically there is intra epidermal vesiculation. It is due to an antigen antibody reaction. Where the shock tissue is the epidermis. Dr. Fredrick, M. Dearborn has defined eczema as an acute, sub acute or chronic, Non-contagious inflammatory catarrhal disease of the skin, characterized primarily by a variable amount of infiltration, thickening, scaling and crusting accompanied by prounounced subjective sensations. The definition of eczema as per different authors are closely resembling as that of ‘Pama’ as per Ayurveda. HISTORY OF ECZEMA: The term “eczema has been used for many centuries (two centrueis B.C) but to designate various rapidly developing dermatoses. It was only in the first half of the 18th century that willan (1808) Bateman (1813) Rayer (1823) other authors set Eczema apart as a nostological form. 28created by of Dr.KSRPrasad
  29. 29. Nidana… AETIOLOGY & TYPES OF ECZEMA: Dr. Arter rook have classified the eczema in the following way depending on etiology and presentation.  Exogenous causes  Endogenous causes 1. Exogenous causes:  Irritant dermatitis: A response of the skin to the direct physical or chemical injury.  Allergic contact dermatitis: A response of the skin to the contact with the substances to which it is allergically sensitive. (Asethamaya Samyoga)  Infective dermatitis: A response of the skin to the contact with certain micro organisms or their products. ENDOGENOUS CAUSES: 1. Atopic dermatitis: Contitutional factors genetically dertermined are of primary importance. 2. Seborrheoc dermatitis: Constitutional factors (Svayam Prakriti) probably genetically dertermined are of primary importance. 3. Numurlar Eczeme: Constitutional factors are of primary importance but genetic pre- disposition is seldom demonstrable. 4. Pompholyx: dermatitis: It is an acute vesicular or bullous pattern of response induced by different factors. 5. Pityriasis Alba: A common pattern of superficial eczema of skin of unkown origin. 29created by of Dr.KSRPrasad
  30. 30. Nidana… A part from this there are other types of eczema depending upon age, environment and racial factors. Such as  Senile are Asteatic eczema  Eczema in children  Exudative discoid lichenoid dermatitis  Eczema of herpitiformis pattern.  Tropical Eczema  Eczema related to Malabsorption. This clearly emphasis the samprapti of pama as per ayurveda that is the formation of Ama at the level of Jataragni paka and dhatwagni paka in the form of improperly formed metabolites which are present intravelllarly and extra cellularly. Dr. Fredrick has described the aetiology into 2 types:- 1. Exogenous causes. 2. Endogenous Causes. EXOGENOUS CAUSES: 1. Chemical:- Medicinal agents such as surgical antiseptics, cosmetics, iodine, Arnica, mustard, dyestuffs, modern broad spectrum anti bacterial and antifungal ointments etc.,In Tanners, Bakers, Washer women, laboratory assistants, sheppards, butchers, dentists, surgeons, nurses, veterinarians, where the Eczema is commonly found. 2. Thermal causes: - From radiations such as sunrays, furnaces, fireman, coldwinds, X-ray technicians, radiologists, Actors etc are prone for Eczema. 30created by of Dr.KSRPrasad
  31. 31. Nidana… 3. Mechanical causes: - Persisting friction scratching, friction of drappers and napkins, gunny bag lifters, water bag lifters are prone for the ECZEMA DUE TO CONStant friction over the skin surface. Abnormalities of exercises, clothing of various synthetic clothes batching in unhygenically maintained water pools, and improper way of taking diets are considered to be the factors for causing the Eczema (These factors have been mentioned in the Nidana Aspect of pama by the ancient acharayas) ENDOGENOUS CAUSES: - The lack of compatibility of foods is one of the prominent cause for causing Eczema. The lack of proper ration in assimilation and elimination of foods lead to absorption of toxins and other poisonous substances and showing itself in the form of constipation, indigestion, renal insufficiency, which inreturn causes different types of eczematous eruptions. Almost any improper functional activity of one or more intended organs may be a causative factor, but most authorities agreed that the grout, Rheumatic or catarrhal diasthesis are the most frequent constitutional causes. Among the other predisposing causes may be diabetes mallities, Nephirits, Uteroovarian diseases, Tuberculosis, Acute fevers dentitions, Pregrancy and lactation. Apart from it, mental tension also alters the normal metabolism and there by ma cause itching and other symptoms by which it turns to Eczema. Ultimately we can say that pama disease aetiology is numerous and all of them play the role in creating the disease. HISTOPATHOLOGY The Histopathology features of Eczema reflect a dynamic sequence of changes. The connecting link between the causes of Eczema and its pathology, anatomy is namely always trophoneurotic in character, causing a catarrhal inflammation on the skin very similar to the catarrhal of mucous membrane. In general it may be said as that the blood vessels are silated there is a cellular exudation of the tissues with round cells infiltration in the papillary layer of the corium. In the popular form the changes takes place around the folliclses, especially the hair follicles, and the 31created by of Dr.KSRPrasad
  32. 32. Nidana… Rete cells become separated fluid exudation and swell up. In the vesicular form there is a further liquefaction of the cells the contents of which unite the small accumulation beneath the corneus layer, while a pastule is formed by the contents of the liquefied cells. The rete mucosum is expressed when the horny layer is cost off without vesiculation as occurs in Eczema rubrum, cell infiltration extents almost to become markedly hypertrophied. The above histopathogenesis can be expressed systematically in the following way. EPIDERMAL CHANGES: The essential feature is spongiodis an intercellular epidermal oedema that leads to stretching and rupture of intercellular attachments, with the formation of “Premordial” vesicles. These commonly occur in discrete foci and in the mid- epidermal region (so the layer of involvement of the disease pama as per acharyas may be thought as swetha, thamara VEDHINI). On the palms and soles the vesicles do not rupture easily but becomes large by coalescence. The variable infiltration of epidermis by lymphocytes, accelerated epidermis leads to Acanthosia but if the spangiosis is intense, disintegration of supra papillary epidermis may form the clefts exposing underlying dermis. In the subacute stage Spongiosis diminishes the increasing acanthosis is associated with the formation of a parakeratotic horny layer. Acanthosis means proliferation of prickle cell layer of the epidermis without the distruction of intercellular fibrils and often with the downward projection of interpapillary process, this often contains layers of dried up serum and pyknotic nuclei of inflammatory cells. Later the rete ridges become elongated and broadened. Then the hyperkerotosis replaces pure keratosis. DERMAL CHANGES: The first change is vascular dilatation. As the vessels become tortous, infiltration of lymphocytes mostly occurs and in acute Eczema the polymorphs and oesinophils are also seen.The trama of superficial rubbing or scratching may cause superficial erosion, heamorrhage 32created by of Dr.KSRPrasad
  33. 33. Nidana… Or sub- epidermal fibrinoid changes. So these changes may be called as neurodermatitic reactions.The patogenesis of Eczema as per the occurrence of the stages can be described in the following ways:- ACUTE STAGE: - This histological picture is dominated by spongiosis vesicle formation. 1. The intercellular oedema may be diffuse but more commonly occurs in descrete foci and all most intense in mid epidermal region. 2. Loosening and disruption of local Malphicion Cells. 3. Further occumulation of fluid at that spot causes the vesicle formation. SUB-ACUTE STAGE:- 1. Spongiosis and vesicilation diminishes give rise to acanthosis increases 2. A para Keratatotic statum cornium forms. 3. The Rete pegs become more elongated and give the appearance of Linchenification. CHRONIC STAGE:- 1. Hyper Kerotosis co-exist with the para kerotosis. 2. Spongiosis and vesiculation gives rise to acanthosis. 3. Now the cells no longer invade epidermis dermal changes become more prominent. RECOVERY STAGE:- In uncompleted Eczema, these changes gradually regress to normal. Infection or rubbing or scratching obviously modifies this process. The presence of primordial vesicle and of parakeratosis are crucial for the diagnosis and are always present at some stage or the other in all lesions that are reffered to “ECZEMA”. All the 33created by of Dr.KSRPrasad
  34. 34. Nidana… changes mentioned except for the premodial vesicle may be found in the burns and or simple traumatic lesions of the skin. The differention between the psoriasis and eczema is by finding of micro abscesses. PATHOGENESIS OF SYMPTOMS (ITCHING) Itching is one of the prominent symptoms in pama. So to deal with its pathology is necessary. Itching cannot be assessed other than by patient himself. There are no convenent units of Itch. So neat measurements of Itching can not be made and the subjects. Variation in moods and placebe respenses cloud even further, already hazy picture. Any way the study of kandu in the modern side has advanced to a greater extent. DEFINITION: A noxious stimulus of low intensity perhaps operating over a long period and effecting the outer most skin layer, will be interpreted as itching, while a more penetrating or intense stimulus will cause pain. So that is the reason why the pain overlaps the itching sensation. THE PHYSIOLOGY OF ITCHING: The work of Shelley and Arthur (1957) effectively disposed of the idea of specialized itch receptors, and it is now agreed that itch spots on the skin have no strict anatomical counter part, being related to a greater assessability or a lower threshold of the fine free nerve ending in the area,. Cauna (1977) has reported a characteristic change in proportion of these free nerve endings deried from no myelinated fibres in areas of itchy skin. He noted the accumulation of an extra cytoplasmic material, probably glycogen, between the axon terminals and the Schwann sheath. As per Ayurveda the kandu is sign of Kapha prakopa. So as per the above physiology the accunumulation of glycogen material in the extra cytoplasmic region i.e., between the axon terminals and the Schwann sheath is in the support of Ayurvedic principle, because in the glycogen is the material having th Kaphaja properties and it is the source of energy for the body which is the lakshana of the kapha. 34created by of Dr.KSRPrasad
  35. 35. Nidana… PHYSIOLOGY OF PARIDAHA (BURNING SENSATION): The central pathways leading to pain perception have been studied in much greater details than those converned with itching ans as they seem to be shared, current theories about the pain have been examined to see if they fit itch else. The gate control theory of pain perception (Melzack and wall 1985) still dominates the subject. Impulse concerned with pain pass laong large myelisnated C fibres and also along non-myelinated fibres. The pain mediated by large myelinated finbres is localized and pricking C fibres requires stronger stimulation and the pain produced has a diffuse burning character. That is the reason why the Acharyas has described the Paridhana lakshana afte the kandu i.e., by the kandu the local scratching increases and the local nerves i.e., the C-fibres get stronger stimulation and pain stimuli produced has the diffuse burning character which in other words paridaha. Carlsson at al 1975 has reported that Electrical transcutnaeous nerve stimulation has reduced the itching to a larges extent. The well known phenomenon of refered pain has its counterpart in mitemfindungen (referred pain). Evana (1976) reported that about one person infive is conscious that scratching an itchy area may produce the sensation of itching elsewhere. These referred itch sensation are well localized, ipsilateral and can be repeatedly provoked. Each person seems to have his own pattern of itch referral. The mechanism is unknown but Evans feels that it may involve the thalamus where the agreement of sensory regions appears particularly favrouable for these types of referral. THE PHARMACOLOGY OF ITCHING: - The histamines in the blood induce itching. However this theory has been reduced in stature that the proteolytic enzyme can cause itching without releasing hitomine as the final mediater. In the pathogenisis of the pama, it has been dealt that the increasing dathwagnigata ama causes the eruption over the skin and it is also the cause of production of the symptoms such as kandu etc. 35created by of Dr.KSRPrasad
  36. 36. Nidana… This theory is made stronger according to the recent advance in the pathogenesis of the itching. Some of the vaso active compounds may cause itching by liberating histamines. For example prostaglandins. These are a class of biologically active poly unsaturated fatty acids known to be present in the most animal tissues. They have been recovered from several types of skin diseases in man. Most notably from contact eczema (PAMA) and Ultra violet induced erythema. (Graves et al 1971, Greaves and sundergaard 1970). It is also found on expermetal grounds the prostaglandin and Histamines have get the interaction which can be explained as follows:- The found that the prostaglandin which caused no itching on scarified skin, increased sensitivity to the itching caused by histamine, suggesting that the itching in the inflammed skin could be result of pharmacological synergism in which locally systhesised prostaglandin sensitized the nerve endings to the pruritic effects of histamine ( Greaves and Mc Donald- Gibson 1973). The above pharmacology in which prostaglandin is essential component and is a poly unsaturated fatty acid is similar to the Dhatwgnigate ama which provokes the Kandu, and there is specific dhatwagnigata ama which provokes the kandu that is the cause that the particular prostaglandin provokes itching or a particular prostaglandin potentiates the local doshas to vitiate the dhatu or the in other words the local nerve endings. The human skin has got certain enzyme i.e. Histamin-N-Methyle transferase which neutralizes the histamines to inactive metabolite methyle histamine. So that it will not cause the itching. This enzyme can be taken as local pitha which when gets vitiated it can not do its function thus the histamine will have its effect on the local nerves and causes the itching. So in disease PAMA the both the doshas are involved get vitiated.That is the kapha in the form of Histamine, Prostaglandin etc., and pitha in the form of Histamine- N- Methyle transferase. (Francis Greaves Yammamate 1977) 36created by of Dr.KSRPrasad
  37. 37. Nidana… The itching can also be produced from the proteolytic enzymes without necessarily releasing histamines. This proteclytic enzymen may be from the damaged cells. The other proteclytic enzymes are, Chymase, Chymotrypsin. Most cells can also release granule associated enzymes including chymase and a tryptic like kallik krein, which can release bradykinin from kininugen. All these may produce itching. INTERNAL DISEASES AND ITCHING: Itching can be associated with underlying systemic skin diseases, can listed no less then 45 systemic causes of itching. CHOLESTASIS: The bile acids and salts have long been thought to be the causes of itching in the obstructive liver diseases. In complete colestasis and the rate of Chenodeoxycholate (dihydroxy bile salts) to cholated (Trihydroxy bile salts ) is known to increase and it seems likely that changes in proportion of dihydroxy to trihydroxy salts may be more important as a cause of itching then the total bile salts concentration. This also fits well with the relief given by the cholestyramine which has been shown to wind hydroxy salts preferentially (Johns and Bates 1970) RENAL FAILURE: The itching is present in the case of chronic renal failure may be because of increased Blood Urea or the Nitrogenous products in the blood (Cawley 1975). This may be interpreted as the deposition of Mal Bhagga in the dhatus causing the Kandu. CNS DISEASES: Itching is present in the multiple sclerosis and Brain tumours and also in Herpes Zoster (Riddell 1974). 37created by of Dr.KSRPrasad
  38. 38. Nidana… OTHER DISEASES: The other diseases in which itching are present is Hyperthyrodism. Myelomatosis, lymphoid neoplasm and myelopro liferative disorders The other problem is the iron deffeiciency itching (7.4% of women with Iron deficiency has complained of itching. To avoid these problem of itching other diseases in the patients in this work, Precaution where taken to screen out the patients. PSYCHOLOGICAL FACTOR: The study of different authors show that the itching increases in patients having the high mental stress. REFERENCES  (Eczema)  Skin and Veneral diseases by Yu. K.Skripika  A text book of Medicine by A.F.Golwala  A text book of Dermatology by Arthur Rook & Wilkinson  Milne’s Dermatology  Recent Advances in Dermatology.  4 , 5 & 6 series. th th th 38created by of Dr.KSRPrasad
  39. 39. Poorva Roopa… 2.6 POORVAROOPA Purva roopa of pama has not been described in Ayurvedic texts separately. The poorva roopa for all the kustas i.e., skin disorders has been described commonly. They are as follows: (Su.Ni.5/4 Cha. Chi. 7/11 to 12). Bhavaprakasha 54/12 & 13 Madyama Kanda) S.No Premonitory Symptoms of Charaka Sushuruta Kashyapa Bhavaprakasha Kusta Samhita Samhita Samhita 1 Aswedhanam + + + + (Anhidrosis) 2 Athi Swedhanam + + + + (Hyperhydrosis) 3 Parushyam + + - + 4 Ati slakshana + - + + (Over Smoothness) 5 Vivarnyam + - + + (Discolouration) 6 Kandu + + - + (Itching Sensation) 7 Nisthoda + - - + 39created by of Dr.KSRPrasad
  40. 40. 8 Supthatha (Numbness) + - - + 9 Loma harsh( Harripilation ) + + + + 10 Kharatwa (Hardness) + - + + 11 Gourawa (Heavyness) + - + - 12 Svyathu( Swelling) + - + + 13 Ruksha( Dryness) + + - + 14 Pipasa( Thirsty) - - + + 15 Saraga( Redness) - - + + 16 Dourbhalya( Weakness) + - + + 17 Pidaka( Papule) - - + + 18 Daha( Burning sensation) + - - + Out of the above mentioned premonitory symptoms for all Kustas, only few of them has been observed in pama disease in my clinical work. They are Kandu, Nistoda, Parushyam, Aswedha, Khartwa, Rukshatwa, Daha, Vivarnyam, Sookshma, Pidaka etc. 40created by of Dr.KSRPrasad
  41. 41. Roopa… 2.7 ROOPA OF PAMA After exhibiting the poorva roopa avashtha the pama starts exhibiting roopa avastha. The Lakshna’s of pama are: CHARAKA: He has described the doshic predominance in the pama as pitha & Kaphaja. (Ch.Chi7). A-part from it the lakshanas as described by charaka are swetha, Aruna, Shyava Varna pidika with excessive itching is called as pama. SUSHRUTHA: He vividly described the lakshanas of pama they oozing, itching, burning sensation and has small vesicles. (Su.Ni.5/147) VAGBHATA: In Ashtanga sangraha separate signs & symptoms have not been mentioned, only the signs and symptoms as per doshic profile in kushtha has been mentioned and treatment aspect has been dealt in details. MADHAVA NIDANAM: (Ma.Ni. 49/21) Madhava kar has also clearly narrated the lakshanas of pama they are small or minute external vesicles with oozing and burning and itching. BHAVA PRAKASHA Bhava Mishra has mentioned the lakshanas as of pama having small innumerable vesicles with oozing, burning itching over the skin (54/29 Madhyama kanda) SHARANGADHARA SAMHITA: The specific lakshana for pama was not described but only the treatment aspect was dealt in it. 41created by of Dr.KSRPrasad
  42. 42. Roopa… KASHYAPA SAMHITA: Kashyapa has vividly described the signs and symptoms of pama. They are kandu thodha, srava and small vesicles are present. The lakshanas that are exhibited as per doshas in general in all kushtas also require a mention because this maneavour facilities in choosing the lakshanas of pama as per the disease. These Laskshanas can be better presented in tabularform: VATA LAKSHANA PITHA LAKSHANA KAPHA LAKSHANA 1 Rookshaya Daha Swetha Varna 2 Shosha Raga Shythya tha 3 Thodha Parisrava Kandu 4 Shitha Paka Sthyryatha 5 Sankocha Vishra gandha Gowrava 6 Katinatha Kledha Snighdhata 7 Ayama Anga Pathaha Kledatha 8 Kharathva Krimi Upthpathi 9 Romaharsha 10 Shyawa Aruna varna (Ref. Ch. Chi. 7/34 to 36): 42created by of Dr.KSRPrasad
  43. 43. Roopa… As per my observation the clinical work of pama majority of cases of pitha and kapha lakshanas are only exhibited. After exhibiting the most of the above lakshanas there will be change of colour of normal skin. The normal colour aspect of the body also requires a mentioning. Ayurveda describes that the skin exhibits they chaya and prabha. The difference between chaya & Prabha are the chaya superceeds the Varna, but prabha can be seen from far of distances, such as Manni and Mukta (Ch.In. 7/9 & 16) CHAYA: Depending on Mahabhutas the chayas are five types 1. Akasha : Neelavarna (Blue) Bright colour 2. Vayu : Shayama Varna (Grey & Red) Rough Dull 3. Agni : (Red) not clear, too bright. 4. Jala : Clear just like vydurya 5. Pruthvi : Stationary, strong, shyama and swetha (Black & White) PRABHA: This is of Tijo pradhana this is of seven types 1. RAKTA (Red) 6. Pandu (Pale Yellow) 2. Peetha (Yellow) 7. Krishna (Black) 3. Shyava (Greyish) 4. Swetha (White) 5. Haritha (Green) 43created by of Dr.KSRPrasad
  44. 44. Roopa… The above hues have been seen vitiated and dosha predominant mahabhutas exhibit their hues such as charka said in pama the pidikas are of shava aruna Varna which is of vata dosha. Apart from it the long standing pama causes the partivachaya i.e., stationary, strong, shyama and swetha etc., this is clearly depicted in the colour photographs which are inforporated in this work. SIGNS AND SYSMPTOMS ECZEMA: They are similar to that of pama it has numerous small grouped vescicles over the skin with itching followed by oozing and burning. The detailed aspect has been dealt in the eczema chapter separately. REFERENCES (POORVA ROOPA & ROOPA) 1. Sushrutha samhita, Nidana sthana 5/4 2. Charaka Samhita, Chikitsa Sthana 7/11 to 12 3. Bhava Prakasha Madyana Kanda 54/12& 13 4. Charaka Samhita, Chikitsa stana 7. 5. Shushrutha samhit, nidana stana 5/14 6. Madhava nidhana 49/21 7. Bhava Prakasha 54/29 (Madhyama Kanda) 8. Sharangadhara samhita 9. Kashyapa samhita 10. Charaka samhita, Indriya stana 7/9 to 16 11. A text book of skin diseases by roxiburg. 44created by of Dr.KSRPrasad
  45. 45. Classification… 2.8 TYPES OF ECZEMA Dr. Fredrick has described four elementary varieties of Eczema:- 1. Erythematous 2. Papular 3. Vesicular 4. Pustular These lesions constitute the peculiar type which may remain distinctive at late or predominant thoughout the course of the disease. Though the secondary forms such as Eczema rubrum, Eczema squamosum and Eczema fissum may develp. Thus technical division of a disease which constitutes between 20 to 30 % of all skin disease and is met with at all ages sexes all countries all seasons in all conditions of life. If necessary for the convenience of description but it is well again to emphasize that even in the mixed types one lesion usually predominates. 1. Eczema Erythematosum: This occurs in infancy and oldage, usually on face and palms toes and genetali. The patches may spread or remain isolated. There may be rough surface, scales or fishures or a general weeping of the surface may appear whether vesicles may appear or not. If scales are present it is called Eczema exfoliativum. If the eruption remains in small patches well defined it is called Eczema circumscriptum. If an opposing surfaces as in between the genital folds it is calld as Eczema intertrigo. 2. Eczema Vesiculousm: - This is the most typical catarrhal inflammation of the skin. It may occur on any place of the body ordinarily the eruption is preceeded by sensations of itching and burning followed by diffused local erythema u pon which within a short time a closely aggregated pin point to pin head sized vesicles appear. These may enlarge and coalesce or repture causing serious secretions. 45created by of Dr.KSRPrasad
  46. 46. Classification… These vesiculations occur mostly in night times. Scratching or rubbing naturally increases the weeping so typically or moist Eczema. If not scratched these exists a yellowish brown crust followed by scales (Eczema squamosum) this may persists for a time or a severe form may ensure. 3. ECZEMA PAPULOSUM:- Pin headed size rounded or acuminated bright or dull red, discrete or closely aggregated papules commonly situated on the flexour surface of extremities or other parts but never on scalp. This may turn into the squamous Eczmea. 4. ECZEMA PUSTULOSUM: This begins as above one but in the place of paules only pustules occur. This always present with mixed future of both the vesicles and pustules. ECZEMA RUBRUM: - This is a complication or aggregation of the above types. It presents in redness, and swelling, infiltration exudation, bleeding and consequent crusting are pronounced. The name Eczema madidans has been give to that aggregated form of red raw and weeping Eczema in which the moisture constantly oozing from the surface with pronounced burning and itching. ECZEMA SQUAMOUSUM: - Scaling and infiltration are the pronounced future of the development from the chronic erythematous or popular type. ECZEMA TYLOTICUM: - The palms and feet skin become enourmously thickened the horny appearance will lead one to think of kerotosis plantaris or Palmaris. In any type of Eczema in which there is much induration or in a location where there is a natural crease, there may be separation of the surface leading to the condition known as Eczema fissum. The other types are Eczema sclerousm (Degree of Scleroderrma) Eczema Verruscousm. (Watery excrescences) Eczema papillomatosum. 46created by of Dr.KSRPrasad
  47. 47. Classification… The types Eczema differ as per anatomical area also. Dr. Skripkin in his book’ skin and veneral diseases’ has described the following types of Eczema:- I. True Eczema (Idiopathic): a) Prurigionous Eczema b) Dyshidrotic Eczema. II. Microbical Eczema (Sankramaka pama): a) Numular Eczema b) Varicose Eczema c) Sycosiform Eczema. III. Seborrhoeic Eczema:- IV.Infantile Eczema: (Occuring in infants only):- 47created by of Dr.KSRPrasad
  48. 48. Samprapthi… 2.9 SAMPRAPTHI OF PAMA The separate samprapthi was not described for pama. But genralised samprapthi for all kushtas has been described which will be considered here:- They are: AS PER CHARAKA (Ch.Chi. 7/9 & 10) The aetiological factors vitiate the tridoshas. They inturn vitiates the Twacha, Rakta, Mamsa, Lakseeka and causes the 18 types of kushta among which pama is one of them. Thus in pama all the tridoshas are vititated and apart from it Twacha, Rakta, Mamsa and Laseeka are also vitiated. ASHTANGA HRIDAYA:- The different aeiological factors provoke the Tridoshas which goes obliquely and traverses the vessels from here it vitiates the Twacha, Laseeka, Rakta and Mamsa and shakes off and comes out through Twacha in the form of various skin disorders i.e., Kushta or pama etc (A.H.Ni. 14/123) SUSHRUTHA SAMHITA: Sushrutha says that due to the provacative factors the excess of vayu takes the pita & Kapha traverses obliquely through vessels and spreads in Bhahya roga marga i.e., Twacha, Rakta ,Mamsa and laseeka. After which the sites where the vitiated dosha springs out there if causes the rash and the other clinical features of the particular skin disease. After seeing views of different acharyas and modern dermotologists view the samprapthi of pama can be thought in the following way. 48created by of Dr.KSRPrasad
  49. 49. Samprapthi… The vitation of the dosha’s occur due to the various causes mentioned in the Nidana Chapter, This vitiated doshas forms the Ama i.e., dhatwagni ghata Ama. (Improperly formed metabolites) (Intra Cellular substances) as per the K.C.Dwarakanath in his book digestion and metabolism. This Ama goes in thiryaka gathi means (passes of the different cellular barriers abnormally) and traverses the channels (means flows through the natural channels) and vitiate the Twaka, Laseeka, Rakta, Mamsa (Spoils this definite dhatu tissues while passing through it) and then it comes over the skin surface in the form of eruptions. Charaka has mentioned in suthra sthana 28 chapter that pama is caused by Ama in Rakta or as a Sa Aama rakta pradoshaja vyadhi( Ch. Su. 28) This same type of pathogenesis is being in corporated in modern lines also. The famous dermotologists Sir Arthu cook and D.S. Willkinson in his book “The text book of Dermotology’ has described the cause for eczema as Mal absorption. The same Mal absorption is the cause for the formation of Ama of intra cellular improperly formed Metabolites (Dhatwagni gata Ama) DIFFERNETIAL DIAGNOSIS Pama has to be differentiated from the following types of Kushta:  EKA KUSHTA: In this there is no sweating the lesion has extensive scales resembling the scales of the fish. (Ichthyosis. Exfoliation, dermatitis, scabies crustosa) (Cha... Chi. 7/11, Su. Ni. 15/7 & 14 A.H.Ni.14/20 Cha. Chi. 7/19).  CHARAMAKUSHTA: The skin is thick like the elephants skin Xerodermia pigmentosa,Keratosis, folliculoaris, Sclerodermatitis, Seborrhea- Keratosis, Hypostatic, Sclerosis, Scleroderma, Hyperkerratotic exzema and eryseplous chronicum. (Ch. Chi. 7/19, A.H.Ni. 14/20)  KITIBHA KUSHTA: (Cha. Chi 7/20, Su. Ni. 5/18)  This is dark in colour rough to touch and a hard scar if formed. (Psoriasis, Psoriasis diffuse, pityriosis, versicolo, occupational consmonic melanosite) 49created by of Dr.KSRPrasad
  50. 50. Samprapthi…  VIPADHIKA KUSHTA: In this there is dermatitis of hands and feet clear cut features are not available. There controversy in it (Characters like fissures in the hands and feet pain etc) (Su/Hi 15/25 Cha. Chi. 7/2 to 6)  ALASKA KUSHTA: This is full of itching and red papules. Lichen planes, Pityriasis, rosen dermatitis, herpitiformis. (Cha. Chi. 7/21. A.h.Ni. 14/22).  DADRU: Itching redness and pimples. It is circular in shape and elevated.  CHARMADHALA: Red itching eruptions painful, warmness, pricking and burning sensation (Excoriation, Pustular erispalas).  VISPHOTA: White blackish red papules thin skin (Impetigo Herpes Simplex, Pemphigard Erysepalas)  SHATARUKA: It is red dark, burning pain and has many fissures. It is also deep rooted, attended with discharge and infected by organisms and generally afflicts the joints.  VICHARICHIKA: - Dark itching eruptions with profuse discharge dry and painful fissures on hand and feet. So the above Lakshanas has to be born in mind in differentiating the pama disease. It is described as a skin disease, having multiple small vesicles with itching, oozing and burning. 50created by of Dr.KSRPrasad
  51. 51. Chikitsa… 2.10 CHIKITSA To Study the treatment of Kushtha Systemically, it is necessary to look at three principles of the treatment which are described by Charaka i.e. Samshodhana, Samasamana and Nidana Parivarjana Seperately. SAMSHODHANA: The therapy expels out the morbid Doshas from the body is known as Shodhana (A.H.14/5). Medicines given after Shodhana are more effective. All Acharyas have emphasized on Shodhana terapy in the management of Kushtha due to some basic things related Kushtha Roga which are:A person having Kushtha Roga is called `Bahu Doshi` because of vitiation of Dosha in greater extent (Ch. Chi. 7/41). Kushtha is considered as a Tridoshaja Vyadhi (Ch.Chi.7/31) and in Kushtha, Doshas aer `Tiryaggami` (Ch. Su. 25/40). By nature, Kushtha is difficult to cure disease, so it is called `Dushchikitsya`. But by the application of Shodhana therapy, cure of the disease becomes easier due to removal of the root cause, hence Shodhana has great importance. According to Charaka, general line of treatment according to predominance of vitiated Dosha. Vatottareshu Sarpihi vamanam Sleshmotthareshu Kushteshu Pittothareshu Mokshoraktasya Verechana Chaagre [Ch.Chi. 7/39] That means, in Vata dominance Ghritapana, in Kapha dominance Vamana and in pitta dominace Virechana and Raktamokshana are to be carried out.In excessive morbidity of the Doshas Acharya susruta says repeated Shodhana should be performed at regular intervals. Pakshath Pakshath Chardananya abhyu peya Masanmasath Sramsanam Chaapi Deyam Sravyam Raktam vatsare hi dhviralpam nasyam dadyacha triratratri ratrath [Su.Chi.9/43] It says the patient has to undergo the following treatments: 51created by of Dr.KSRPrasad
  52. 52. Chikitsa… Vamana once in 15 days, Verechana once in a month, Raktamokshana once in 6 months and Nasya once in 3 days Sushruta has advised to carry out ‘Ubhayato Samsodhana’ even at the Purvarupa condition of Kushtha. Sushrutha also advised Samsodhana in the treatment of Rasagata, Mamsagata and Medogata Kushtha (Su. Chi. 9/6) SHAMANA CHIKITSA: Shamana therapy is also an important part of the treatment of Kushtha. After completing the Shodhana Karma, Shamana Chikitsa is indicated to subside the remaining Doshas. Shamana Chikitsa is very useful in those patients who are unable to undergo or contraindicated for Samshodana. Charaka has advised Shamana therapy with Tikta and Kashaya dravyas after administration of proper Shodhana (Ch. Chi. 7/58). Charaka has also indicated several other drugs & formulation of Shamana therapy in 7th chapter of Chikitsa Sthana. EXTERNAL APPLICATION: Kushtha, being exhibited through the skin, external application are also advocated. For the external application drug should be applied after elimination of the Doshas from the body by Shodhana karma and Raktamokshana. Various forms of local application are prescribed like Udvartana, Pralepa, Parisheka, Abhyanga, etc. Kshara Karma and Agada Karma are also prescribed in special condition of Kushtha. In short, it may be said that the treatment of Kushtha may divided into three parts i.e. treatment according to the predominance of Doshas, internal & external purification. Keeping in mind the above thing, the treatment of “PAMA” was selected. NIDANASYA PARIVARJANAM: It means to avoid etiological factors. Nidana Parivarjana stops the further progression of the disease, by restricting vitiation of Doshas. Main etiological factors of Kushtha are Mithya Ahara- Vihara & Viruddha Ahara so they should be avoided. 52created by of Dr.KSRPrasad
  53. 53. Acharya Charaka has defined ‘Pathya’ as they are the wholesome drugs and regimen which don’t not adversely affect the body and mind. Those which adversely affect them are considered to be Apathya (Ch. Su. 25/45,46). 53created by of Dr.KSRPrasad
  54. 54. Pathyapathya… 2.11 PATHYAPATHYA Dietic and physical recommendations for the disease are known as Pathya. Acharya Lolimbaraja says in “Vaidhya Jivan”. A person follows the Pathya, the treatment is not needful but if a person not follows the pathya the treatment is not needful to cure the Disease. Acharya Charaka described wholesome diet is prime cause for the growth and development of the body, on the contrary unwholesome diet cause several diseases. (Ch.Su. 25/31) Acharya Charaka also classified Hita and Ahita ahara definition. Indirectly he says Hita Ahara means pathya ahra and Ahita ahara means Apthya ahara. In short apathaya means etiological factor of the disease and avoided during and after treatment and Pathya is supportive factor for cure the disease (Ch. Su. 25/33) There is no any direct description regarding to PathyaPathya of Ekakustha but the pahtyapatha of Kustha should be considered as pathyapathya of Ekakustha. The description of Pathyapathya can be categorized as follows: PathyaPathya Pathya Apathya Ahara Vihara Ahara Vihara 54created by of Dr.KSRPrasad
  55. 55. Pathyapathya… Charak has described a list of pathyapathya in chapter of kustha chikitsa. Following diet should avoid in case of Ekakustha. Avoid the following item in single or in combination with each other. Pickles, Jam and Sauce Laddu, Ghee, Sweets, Cake, Chocolate, Bread Milk and its derivatives like Curd, Buttermilk, cheese, paneer etc. Recent mellowing grains like Wheat, Polished rice, Bajara, Berely. Black gram, Pigeon – peas, Lentil Guava, pear, Banana, Pineapple, Mango, Cherry, Pomegranate, Orange, Sweet lime etc. Fish, Pig, Deer, Rhinoceros, Bullock Chicken, Mutton, Pigeon, Peacock etc Honey, Jaggery, Phanita Sesame and Casteroil Radish PATHYA: Guna : Laghu, Hita Suka dhanya : Godhuma, Yava, Shali Simbi dhanya : Mudga, Ahara, Masura Shaka : Tikta shaka Mamsa : Jangala 55created by of Dr.KSRPrasad