Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta, ANIL KUMAR BACHA, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG
ACKNOWLEDGEMENT I express my deep sense of gratitude to my respectedguide Prof. Dr. Varadacharyulu Vangeepuram M.D (Ayu) Head of Departmentof Kayachikitsa, D. G. M Ayurvedic medical college and Post GraduateStudies and Research Center, Gadag. He has been very kind to guide me inthe preparation of thesis and for whose extraordinary efforts, tremendousencouragement and most valuable thoughts provoking advice made me tocomplete this work. I am also grateful to my respected co-guide Dr.Shashidhar.H.Doddamani M.D (Ayu.) lecturer in Kayachikitsa, Post GraduateStudies and Research Center, D.G.M Ayurvedic medical college, Gadag, forpatiently going through the draft of thesis and correcting with preciousremarks which have been very useful. I am thankful to Dr. G. B. Patil principal, D. G. MAyurvedic medical college and Post Graduate Studies and Research Center,Gadag, providing all necessary facilities for this research work. I wish to convey thanks to my teacher Dr. Siva RamaPrasad Kethamaka, M.D (Ayu.), Reader in Kayachikitsa, Post GraduateStudies and Research Center, D. G. M Ayurvedic medical college, Gadag. Forbeing kind and affectionate through his valuable suggestions and advises asand when approach. It gives me pleasure to expresses my gratitude to Dr. A.K. Panda M.D (Ayu) lecturer in Kayachikitsa, Post Graduate Studies andResearch Center, D.G.M Ayurvedic medical college, Gadag, for kind co-operation during my study.
I acknowledge the valuable help given to me by Dr.Raghavendra. V. Shettar, M.D (Ayu.) lecturer in Kayachikitsa, Post GraduateStudies and Research Center, D.G.M Ayurvedic medical college, Gadag, fortheir guidance and encouragement during my Post Graduate Study. I am ever grateful to Dr. S. A. Patil for their constant co-operation. I wish to convey thanks to all U.G lecturers of D. G. MAyurvedic medical college, for their help and suggestions during my PostGraduate Study. I sincerely thank my beloved classmates Dr. B. M.Mulkipatil, Dr. V. N. Kulkarni, Dr. Sitaram Prasad and Dr. G. S. Hiremath, fortheir deep co-operation and involvement in the P.G Study. I am also thankful to all my post graduate colleagues Dr.C. V. Rajashekar, Dr. Shyal kumar, Dr. R. D. Suresh, Dr. S. K. Tiwari, Dr. J. I.Hiremath, Dr. I. V. Kotturshetty, Dr. A. S. Patil, Dr. S. S. Hiremath, Dr. G. S.Hadimani, Dr. Srinivas Reddy, Dr. Yasmin A. P, Dr. Santmangesh, Dr. B. G.Swamy, Dr. Shankergouda Sankadal, Dr. Shyju. O, Dr. Chanbassappa.Hanmanthgouda, Dr.Vanitha, and Dr. U. V. Purad for their co-operation andhelp. I wish to convey my thanks to beloved Dr. Chandrakant.M. Halli, for their encouragement and help throughout my career. I wish to convey my thanks to beloved Librarian Sri. V. M.Mundinmani and S. B.Sureban for supplying me essential references in thestudy. I am thankful to Sri. B. S. Tippangouda; Lab. Technician also extendedhis co-operation in Investigations.
I wish to thank the Physicians, House surgeons, Hospitalstaff, Nurses and Non- teaching staffs for their timely assistance in completionof this work. I thanks to Mr. P. M. NandaKumar for his help in thestatistical evaluate. Let me express my thanks to all patients, those are onthe trial for their consent for enrolling in this clinical study and obedience toadvises. I am highly indebted to my beloved parents, Sri.Pandharinath Bacha and Smt. Chandrakala Bacha, Sisters Smt. Sunita, Smt.Rajani and beloved Brother Mr. Chandrashekar Bacha and all other familymembers for their love and affection rendered throughout my career. I am ever thankful to Mr. Vinay kumar Katta and Mr.Bheemgopal Shanbhogar for their constant moral support, encouragementand help throughout my career. I am thankful to Wise Computers Gadag, in bringing outthe computer print of my thesis in such an elegant way. I express my thanks to all the persons who have helpedme directly and indirectly with apologies for my inability to identify themindividually. Lastly I pay my deep homage and tribute to myGrandparents Smt. and Sri Sambayya Bacha for their love and affectionsrendered throughout my career. ANIL KUMAR BACHA.
List of PhotographsPhotograph – 1 Structure of the SkinPhotograph – 2 TilaPhotograph – 3 TriphalaPhotograph – 4 TrikatuPhotograph – 5 BhallatakaPhotograph – 6 SitaPhotograph – 7 MadhuPhotograph – 8 GhritaPhotograph – 9 KushtaPhotograph – 10 SarshapaPhotograph – 11 Moolakabeeja
Photograph – 12 PriyanguPhotograph – 13 HaridraPhotograph – 14 NagakesharaPhotograph – 15 Before TreatmentPhotograph – 16 After TreatmentPhotograph – 17 Before TreatmentPhotograph – 18 After Treatment
List of GraphsGraph number –1 Sex incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –2 Age incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –3 Occupation incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –4 Marital Status incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –5 Religion incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –6 Chronicity incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”
Graph number –7 Family history incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –8 Food habits incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –9 Treated and fresh cases incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –10 Socio-economic status incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –11 Prakruti incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –12 Signs incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”
Graph number –13 Symptoms incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –14 Sthana incidence in “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Graph number –15 Result of the “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”
List of ChartsChart number – 1 Demographic Data of “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Chart number – 2 Laboratory Investigation of “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Chart number – 3 Assessment of “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”Chart number – 4 Statistical assessment for the “Evaluation of the effect of Saptasamayoga (Internal) and Kushtadilepa (External) in Sidhma Kushta”
INTRODUCTION Ayurveda is an ancient Indian medical science reminded by LordBrahma. The main aim of this Ayurvedic medical science is to protect thehuman beings from various diseases following by rules and regulations ofswasthavritta and to have disease free human beings to have a healthysociety. Perfection cannot be achieved if only one science is studied. Disease is nothing but, life under altered conditions. These alteredconditions in fact manifest themselves through the agency of doshas, dhatusand mala in the body. Ayurveda, the science of life aims at the prevention of health. This isthe gift of almighty, prevention and curing of diseases. In day today practice aclinician is confronted with various skin conditions, which are complicated totreat as well as to cure, and they require prolonged line of treatment. The present day unwholesome food habits are influencing deficienciesof vital nutrients and leads to disorders. The skin is the largest organ of thebody invisible. Skin is the one of the contributory factors towards the beauty ofthe body, and it also it acts as principle organ of attraction. Seasonalvariations, intake of unwholesome food and infections leads to many skindisorders. In contemporary medicine a separate branch known asdermatology has been dealt. It is a part of general medicine. Diseases of theskin are a common occurrence. Our ancient Acharyas also vividly dealt theskin disorders under Kushta roga. Among the various chronic diseases that have been pesteringhumanity- women and men was an alike, skin disease having a uniqueposition. Irrespective of times and climes, such diseases spread all over the
universe, due to various reasons in undeveloped countries. Constant use ofplastics, rubber, paints, perfumes and beautifying articles of inferior quality,consumption of improper or incompatible food materials, influx of civilization,pollution of water, air and sound and usage of certain particular items ofmodern medicines are some of the important factors that accelerate the attackof skin diseases. Due to economic backwardness, the masses in undevelopedand under-developed regions in the world could not either have sufficientnutritious items of food or lead hygienic lives individually as well ascollectively. Above all these, they take food materials, which vitiate thetridosha and consequently are victimized by various kinds of diseases. The food habits of the people accustomed to food having katu, amlaand lavana rasa and consumption of incompatible items of food like milk andfish are responsible for the high rate of skin disease. Dermatology is an essential part of general medicine since the skin isnot, by any means, foreign to body, which it covers. Diseases of the skin are acommon occurrence. There are not many statistics to prove the exactfrequency of skin diseases in this country. However according to studyconducted at the skin clinic of the school of Tropical medicine, Calcutta in theyear1977, it was observed, that around 4% people were affected by theSidhma i.e., Pityriasis Versicolor, which is fungal infestation namelyMalassezia Furfur. Ayurveda considered Kushta as an important disease and hascategorized it as a “MAHAROGA”. Though curative and preventive measuresare in full swing and though under the auspices of the W.H.O. and theCentral and State Governments, several measures are being pursued for
warding off Kushta if carefully scrutinized the grim reality would be revealedthat all steps already taken and are still in progress are quite insufficient forimmunizing this dreaded disease. In the circumstance along with Ayurvedicscientists and physicians, practitioners of Unani, Siddha and other alliedsystems of treatment should also raise equal to the occasion and work wholeheartedly and with a dedicated spirit for eradicating this dreaded disease formthe world permanently. The Sidhma is most uncared disease among the people as well asphysician, even though it causes itching, burning, pricking pain, scaling,soreness, etc., which patient experiences silently i.e., Sidhma patient is asilent sufferer. In addition to the physical discomfort, it inflicts great injury onthe patients mind. Especially the subject if happens to be fair sex, as it masksthe beauty of the individual. Even though beauty is skin deep, yet its significance in modern world isgreater. The vast turnover of beauty aid products is it is a clear pointer todisfact. Therefore Sidhma requires special attention in view of the above. As such a careful selection of natural remedies like Tila, Triphala,Trikatu, Bhallataka, Sita, Madhu and Ghrita internally and Kushta,Moolakabeeja, Sarshapa, Haridra, Priyangu, and Nagakeshara externally areselected keeping in view of the tenderness of the twak. Fortunately aformulation named as Saptasamayoga was found in Chakradutta,Kushtachikitsadhyaya, for internal intake in Kushtas and same has beentaken for the present clinical study along with the external application i.e.,Lepa, Kushtadilepam, a skin preparation from Chakradutta, a popular treatyand Ayurvedic therapeutics. This combination of Anthahparimarjana and
Bahihparimarjana proved to be a safest in treating Sidhma and other alliedconditions of fungal origin, for which unfortunately there is no propermedication in the modern medicine. The results and other observations madeduring the study are mentioned in the clinical study section. One of the important aspects of the study is that, it is 100% safe, sinceno irritation or caustic agents were used in the preparation. Moreover, timetested beauty promoting agents like Tila, Bhallataka, Triphala, Trikatu, Ghrita,etc., not only helps in pathological clearance, but also acted asRaktashodhaka. “Raktam Jeevamiti” i.e., rakta itself is life. So once rakta ispurified by the raktashodhakas naturally it boosts up the beauty.
REVIEW OF LITERATURE The Ayurveda is the oldest system of medicine and philosophy inworld. All the diseases and treatment aspects concerned to the medicine areavailable from ancient time to the present era in different manners; historicalaspects play an important role in determining various diseases and theirtreatment. The prevalence of “Twak rogas” is described, since Vedic period, manysuch references regarding skin diseases are clearly mentioned in Vedas. The description of Sidhma Kushta is found in the context of kushta inBrihatrayee and Laghu trayee. Symptomatology of Sidhma Kushta describedin the classics has lot of variation causing spectisicium among the disciplesfollowing the Ayurvedic principles. As Sidhma Kushta explained under thecontext of kushta, the historical review of the kushta becomes necessarily tobe dealt along with Sidhma Kushta.Rigveda: In this period lord Indra was said to be a great physician who treatedpersons called Aphala, Ghosha and Shyava who had kushta and cured themgiving normal health1.Atharvanaveda: In this Veda various drugs references are available for Twak rogas,Viz, Kilasa, Dulitha, and Sidhma etc. were treated with Nakthaamala, Krishna,and etc2. Harina sringa (horn of a Deer) possessing the property ofTwakrogahara3. Changala Koshta is said to be having kushta roga haraproperty and also many drugs are indicated in Twak vikaras
In Atharvanaveda description about skin and its physiological conditionwere explained among the saptadhatu vitiated rakta is responsible for thetwak vikaras. The disease Sidhma Kushta is mentioned under the twakvikaras and its treatment.Yajurveda: In 10th Shuktha of Shukla Yajurveda, we find a quotation about Twakrogas and number of kushta roga and their list of drugs are also available4.Garuda Purana: In various chapters of Garuda purana description about Twak disordersexplained Viz, Kushta, Sidhma Kushta, etc. description about the SidhmaKushta and its management also being explained in period of Garuda Purana.Panini (700 B.C): In Asthaadhaya of Panini grammatically literature about the diseasesare explained. Diseases like Atisara, Arshas, and Kushta major diseases havebeen explained the diseases caused by Anuvamshika doshaja vyadies arebeing explained and Mahakushta consider under that category referenceabout the Pama, Sidhma and other types of kushta are also narrated.Kaushika Sutra: The references of kushta and its treatment is mentioned in Kaushikasutra (this was made on mantra samhita), like chanting mantras,Aushadhayukthajala (Medicated Water), external application with the pastemade up of drug like Bhringaraja, Haridra, Indravarunya & Neelikapushpa forthe diseases like kushta are explained.
Thithariya Brahamana and Vajaineeya Samhitha: The terms of Sidhma or Sidhmala a variety of Twakroga are seen inVajaineeya samhita5 and Thithariya Brahamana6 also.Skanda Purana: The disease Sidhma that is also a variety of Twakroga is mentioned inSkanda. The Lakshana of this are Aruna, Sweta and Shyava, associated withPidakas, Rajoyukta, and kandu, particularly observed during summer due toexcessive sweating etc7.Mahabharata: The references of Twakrogas are available in Mahabharata also. TheShyantanu’s elder brother of Devaki was the victim of Twakrogas thatprevented him in becoming the king8.Samhita Kala: Since Vedic period, the description of Twak rogas and their treatmentwas available, which later on continued in the Ayurvedic texts. The descriptionof Twakrogas according to Atreya sampradaya and Dhanvantari sampradayais an ample of proof in existence of these diseases.Charaka Samhitha (400-500B.C): Charaka samhitha has been narrated as best among chikitsa we finddetailed explanation of kushta rogaadhyaya along with its utpatti. Kushtaroganidana is explained in nidana 5th chapter and chikitsasthana 7th chapterenumarating Sidhma Kushta under Maharoga. Charak samhita hasmentioned its lakshanas separately and samanya chikitsa sutra also.
Sushruta Samhitha (800-700B.C): In Sushruta samhita also elaborative description of kushta roga hasbeen presented in nidanasthana 5th chapter and chikitsasthana 9and10thchapter respectively. Kushta dhatugatathwa has been mentioned in Sushrutasamhita only. Sushruta explained Sidhma Kushta under Kshudra Kushta.Ashtanga Hridaya (500A.D): In Ashtanga Hridaya, Vagbhata has given explanation about kushtaroga in the 14th chapter of nidanasthana and treatment is explained underchikitsasthana 19th chapter. Vagbhata also explained Sidhma Kushta underKshudra Kushta only.Madhava Nidana (800A.D): In Madhavanidana 49th chapter detailed explaination about Sidhmakushta in the context of Mahakushta along with dhatugatatwa and sadhyaasadhyata.Bhavaprakasha: In Bhavaprakasha madhyamakanda 54th chapter complete informationof kushta is given, in the same chapter Sidhma kushta is explained inMahakushta.Sharangadhara: In Sharangadhara Samhita explained about the Sidhma Kushta inpoorvakanda of Kushtarogaganana in 7th chapter.Bhela Samhita (800-700B.C): In this samhita, 5th and 6th chapter of nidana and chikitsasthana kushtaroga has been explained.
Yogaratnakara: In Yogaratnakara uttaradha information of kushta is given, in the samechapter nidana, chikitsa and sadhyaasadhyatwa of Sidhma Kushta isexplained. Yogaratnakara has explained Sidhma Kushta under Mahakushtaas like Charaka explained.Kashyapa Samhita: In Kashyapa Samhita detailed explanation about Sidhma kushta underkushta chikitsa adhyaya.Bhaishajyaratnavali: In Bhaishajyaratnavali 54th chapter many kushtarogaharayogas areexplained in treatment aspect.Chakradatta: In Chakradatta 50th chapter, the kushtaroga detailed treatmentschedule is given Sidhma Kushta is also explained in this chapter.Vangasena: Vangasena also explained about Sidhma Kushta in Kushtaadhikarachapter. Rasaratna Samuchaya: In 3rd chapter while explaining Gandhakagunas, he mentioned that it isuseful in kushtavyadhies and other skin diseases like Sidhma, Dadru, Visarpa,also.
Rasatarangini: In Gandhakaprakarna, Gandhakataila is indicated in Mahakustha andother skin diseases9. It is interesting to note here that Kubera was suffering from kusthasince he was not using Takra in his regimens. Majority of classical textbooks of Ayurveda including Brihatrayeediscussed kushta in detail as Mahagada.
NIRUKTIDerivation: “KUSHNAATI ROGAM! KUSH + HANI ITITHANI”10 In the term of kushta, the word “Kush” is added to HANI to form, whichgives a meaning i.e., gives an ugly look to the body.Kushta: “Kushta” the word is derived from the root “Kush” which means thatwhich comes out the inner part to outer part.“KUSHNATI AKSAHITA NIRASTU VET NIRAKOSHITH”NIRAKOKASHAT CHUKOSH NISHKARSHA CHEVRIHAYATAPARICHEDAH MADHYASTITASYA VASTUNOBAHIRNIHSAARANASCHA”11 The word “Kushta” is derived from dhatu “Kush” meaning the morbidfactors mainly rakta is drawn towards the region of twak so as to causeKushta.Paribhasha of Kushta (Definition):“SHARIRAM KUSHNATI TASMATAT KUSHTAM ITHYUCCHYATA”12 According to Arunadatta kushta is defined as that which causesdisfigurement to the body.SIDHMA KUSHTA NIRUKTI: “SIDHYATHI AASU BHESHAJENA ITI SIDHMA”13The word Sidhma has been defined as variety of Kushta and Superficialpathological lesion that can be treated rapidly. ‘SIDHMA’ is a variety of Kushtaroga according to all the authors of theBrithatrayee and Laghutrayee. However Charaka Archarya described it is adisease purely related to the superficial skin and classified under Mahakushta
and other Acharyas like Sushruta and Vagbhata, brought it underKshudrakushta. Eventhough the classification differs the symptometology of SIDHMA ismore or less same. The great Aacharya Charaka has explained the symptomof SIDHMA as follows. SIDHMA is a type of Kushta, the sign’s and symptoms are Ruksha,Shukla, and Raktavarna in colour. In the periphery it is fissured and thin incenter; it is smooth, white and red shade. It appears in large number andthere is less pain, itching, burning sensetion, puya, lasika, srava i.e. pus andserous discharge. Its causation and ulceration are sluggish and less of germinfestation. It appears like flower of ALABU14. According to Acharya Sushruta explained the “SIDHMA” a pathologicalstate frequently occurring in the summer with severe itching, whitish in colourand naturally disappears in winter season, generally the disease occur abovethe NABHI, i.e URDHWAKAYA15. According to Vagbhata the Sidhma Kushta appears to be externallydry, internally it is moist in nature and while scratching scales like dust will beseen. It is smooth on touch, which is very light and it looks like“Daugdhikapushpa” with the colour of whitish brown16. According to Bhavaprakasha Sidhma Kushta laxanas like skin colour,which is white, copper colour, followed by the scales and appears likeALABUKUSUMOPAMAM. This variety of symptometology appears in Sidhma.Lesions are mainly seen over VAKSHASTHALA. It is also develop on theother parts of the body17.
Madhavakara, Yogaratnakara, Vangasena also explained the sign’sand symptoms like as Acharya Charaka18. Acharya Bhela emphasized the sign’s and symptoms of the SidhmaKushta in 5th chapter of Kushta Nidana & 6th Chapter of Kushta Chikitsaadhyaya19. Acharya Kashyapa also explained Sidhma Kushta in the chikitsasthana of 6th chapter20.
DESCRIPTION ACCORDING TO MODERN SCIENCEPITYRIASIS VERSICOLORDefinition: It is an opportunistic infection caused by pityrosporum orbiculare (syn.Malassezia furfur) that affects mainly the stratum corneum in the form of scalyhypo or hyperpigmented macules and rarely papules. This variation in colourgives the name versicolor.Aetiopathogenesis: The yeast llike organism malassezia to distinguish it from themicrosporum species of dermatophytes. Malassezia furfurand pityrosporumorbiculare have beeen found to be the same organism by immunologic andultrastructural studies. Pityrosporum orbiculare is a dimorphic lipophilic organism that grows invitro only with the addition of medium chain fatty acids (C12-C24). Theorganism is culturable from normal as well as lesional skin and can be amember of the normal skin flora. Under favourable conditions such as warmhumid environment, diabetes, corticosteriod therapy, immunosuppression orand inherited predisposition, this saprophytic yeast converts to the pathogenicmycelial phase and presents as clinical disease.Immunology: The host-parasite interaction has two major components, viz.colonization of the host by the parasite and response of the host to thiscolonization. In tinea virsocolor, the host response to fungal colonization isminimal and there is seldom any inflammatioin. Immunological data, however,is insufficient and variable. Elevated specific antibody titres are seen in
patients and also in age-matched normal controls. A defect in lymphokineproduction by patients with chronec tinea versicolor has been demonstrated.Complement activation via the alternative pathway has been demonstrated invitro with pityrosporum orbiculare but the significance of this finding remainsunclear.Clinicals Features: The trunk, proximal extremities and the neck are affected and lesscommonly the abdomen, back and face. The scalp and genitalia are rarelyinvolved. The inverse type of tinea versicolor is usually seen in the axillae.The characteristic scale of tinea versicolor is described as dust like orfurfuraceous. It can be seen by lightly scraping the fingernail over the involvedarea (the fingernail sign are Coup d’ongle sign). Pityrosporum orbiculare mayalso colonize follicular structures and hence a high rate of recurrence is seen. It is characterized by hyper or hypopigmented tiny scaly lesionsbecoming larger by coalescence. The hypopigmentation is due to smaller andfewer melanosomes in melanocytes and irregularly dispersed melanosomeswhich are markedly decreased in number within the keratinocyte.Histochemical studies with dopa reaction reveal a normal number ofmelanocytes. Dopa reaction shows an identical picture both in affected andunaffected skin. The hypopigmentation may be due to UVL – screening effect of theskins, blockage of transfer of melanosomes from melanocytes tokeratinocytes, and inhibition of tyrosine activity by azelaic acid formed byfungal enzyme acting upon unsaturated fatty acids in the skin.
Hyperpigmented lesions of pityriasis versicolor are particularly found inpigmented individuals. The pigmented is due to an increase in themelanosome size and a change in its epidermal distribution from theaggregated to the non- aggregated form. The fungus is also a low infectivityand it is unusually for the disorder to be transmitted to another person21. On dark skin, they often appear as hypopigmented areas, while on lightskin, they are slightly hyperpigmented. In some darkly pigmented individuals,they may only appear as scaling patches22.
SHAREERA All the authours like, Charaka, Sushruta, and Vagbhata says thekushta is one of the skin diseases.Derivation of Twacha: The word Twacha is derived from the root “Twacha- Samvarnane”means, which covers. It can be defined as the body substance that covers theinternal tissues like rakta, mamsa, medas and other dhatus. Modern medicalscience defines skin is the out protective covering of the body consisting ofcorium and the epidermis.Synonyms of Twacha: Twak Charma Raktadhara Asrgdhara Sparshanendriya etc.Embrological development of Twacha: The development of twacha follows the fertilization of streebeeja andpumbeeja and entry of the Atma into it. After joining the chetana dhatu twachastarts to develop during the fourth month of the garba. The different layer oftwacha is formed and all tridoshas and particularly Pittadosha cause thisformation. The formation of twacha and its layers are identical to the formation oflayers of Santanika on the surface of the boiled milk. The Santanika becomesthicker and thicker, as creamy layer multiply. Similarly the layers formed in thedevelopment stage of the embryo and form the twak23.
Dhatu Parinama: The term dhatu is derived from Sanskrit root word, which meansdharana to support and poshana i.e., to nourish. It means that which supports,those are Rasa, Rakta, Mamsa, Medha, Ashti, Majja, and Shukra are calledas dhatu These sapta dhatus are promotes the growth of shareera. They areconstantly formed, destroyed and reformed from poshaka dravya. Dhatu alsoare of two kinds those are, 1) Sthayee 2) Asthayee. The Asthayee dhatu, which is nourishes the former dhatu i.e., poshya dhatus. Jatharagni and Bhutagnipaka activate the qualities potentially presentin Aharadravyas in the final stage of digestive process. In pittashaya theaharadravya are being utilized in dhatupaka. All these events including theabsorption of sarabhaga take place in the amashaya. Dhatwagni refers to the agni (pitta) concerned with the pakas ofaharadravyas; these dhatwagnies mediate further metabolic transformation ofthe nutrient substances before they are made available to the sapta dhatusthrough their specific srotases for being assimilated by them. Dhatwagnipaka is stated to have two aspects: 1. Prasada paka 2. Kitta paka, the end products of prasada paka are utilized for the nourishment of dhatus and formation of upadhatus, whereas that of the
Kittapaka provides the materials for the formation of excretion such as Sweda,Mootra, and Pureesha etc. Rasa is purviewed to dhatu through distinctchannels. These srotases carry nutrient materials specific to each dhatu24.Upadhatu25: As per Charaka and Vagbhata the upadhatus are 7 in numbers they are, 1. Sthanya 2. Arthava 3. Sira 4. Khandara 5. Vasa 6. Twak 7. Snayu. These are produced in prasada paka from dhatus. Upadhatus are formed as the byproducts of dhatwagni vyapara. Poshakadhatus are utilized for the formation of Sthiradhatus. The kitta bhaga is utilizedfor the contribution of such structures as Hairs, Nails, Sweat and Excretion ofthe Eyes, Ears etc., or they will come out from the body that is Mootra,Pureesha and Sweda. These are utilized in the production of supportingstructure in the body. Dhatu Upadhatu Rasadhatu Sthanya and Arthava Raktadhatu Sira and Khandara Mamsadhatu Vasa and Twacha Medadhatu Snayu Twacha is the upadhatu of mamsadhatu in addition to the Vasa26.
So twacha can be considered as a maternal element. Ashtanga Hridayaexplained formation of twak is in the sixth month of gestation27.Rachana of Twacha: According to “Sushruta” twacha is composed of 7 layers and six layersby Charaka and Vagabhata Acharyas. Sushruta described the thickness ofeach layer taking “One Vrihi” as standard for total skin, where as Charakadoes not mention the thickness of layers. The above Acharyas have described the diseases that manifestation ineach layer. But they have difference of opinion about the layer in which theSidhma occurs.Kriya of Twacha: 1. Bhrajaka pitta sthana28 2. Sparshanendriya sthana 3. Sthana for Swedagranthi29 4. Absorption area of Abhyanga, Lepa, Parisheka etc30. In Sidhma the cardinal symptoms are accepted as hypopigmentation. Thus the study regarding the factors responsible for Varna as per Ayurveda is essential.Production of colour during embryonic stage: Tejobhuta is the main factor in the formation of skin colour and amongthe doshas, Pitta is said to be responsible for the normal as well as abnormalcolour of the skin. The colour of the Shukra dhatu and its Panchamahabhautikapredominance, the food habits of Mother, Desha and Kala are the factorsinfluencing the Varna of an individual in the embryonic stage.
Sushruta further says during transformation of Shukra and Shonita togarbha, the predominance of each panchamahabhutas are determine thecolour of the garbha as mentioned below, Tejas + AP - > Gaura Varna Tejas + Prithvi -> Krishna Varna Tejas + Akasha - > Krishan shyama Tejas + AP + Akasha - > Shyama Charaka describes prakruta varnas are four in number those are,Krishna, Krishnashyama, Shyamaavadata and Avadata31. Acharaya Charaka and Vagbhata differs regarding the Shyama varna which isarises out of the combination of all the panchamahabhutas32. Beside this Atikrishna and Atigourava are among the Ashtaninditasmentioned in charaka sutrasthana33.Chaya and Prabha: The factors, which are having, close relation to the skin colour. Chayamakes the Varna, while Prabha improves the brightness of the Varna. Chayacan be appreciated from close vision, while Prabha is visible from distance34. Tejobhuta is the basic of all types Prabha. The Prabha is classified intoseven viz., Rakta, Peeta, Sita, Shyava, Harita, Pandu and Asita35. Varna is normal in permanent from birth to death; Chaya may alter dueto arishta (Asanna mrityu laxana) while Prabha changes according to thetemporary state of health.
Chaya nirupana (Panchabhuta sambandha) 36 No. Type Lakshanas 1 Nabhasi Nirmala, Neelavarna, Snehayukata, Saprabha 2 Vayavi Ruksha, Syavavarna, Hatahprabha 3 Agneya Vishudharakta, Deeptabha, Darshanapriya 4 Apya Shudha, Vaidurya Vimala, Susnigdha 5 Parthiva Sthira, Snigdha, Ghana, Shyama, SwetaTWACHA VIVECHANA Twacha is the largest organ of the body and is considered as one ofthe sapta dravya responsible for the manifestation of kushta. The descriptionof rachana and kriya of twacha becomes important, according to Charaka andVagbhata, twacha is divided into six layers, and where as Sushruta Acharya’sdescription of twacha includes seven layers. Twacha is considered asMatrujabhava and Upadhatu of mamsadhatu, it is also considered as one ofthe jnanendriya, Vayu and Akasha are the Indriya dravya as present intwacha, sparsha is indriyartha, sparshajnana is indriya buddi, among all thedosha twak is the seat of brajaka pitta. During the process of shukra andshonita and after the formation of garbha, twak and all other dhatu begin toform, just as the cream of milk being formed during boiling of milk. The thickness of twacha is not uniform all over the body and variesdepending upon the functions and performance.
COMPARATIVE AND CO-ORDINATIVE TABLE OF ANCIENT AND MODERN LAYERS OF SKINNo. Sushruta Charaka Vagbhata Thickness in Vrihi Modern Name1 Avabhasini Udakadhara Udakadhara 1 / 18th Stratum Corneum2 Lohita Ashrgdhara Ashrgdhara 1 / 16th Stratum Lucidum3 Sweta - - 1 / 12th Stratum Granulosum4 Tamra - - 1 / 8th Stratum Malphigi5 Vedini - - 1 / 5th Papillary layer6 Rohini - - 01 Pecticular layer7 Mamsadhara - - 02 Subcutaneous layer I) LAYER OF TWACHA: AVABHASINI Sushrutacharaya names the first or outer most layer of twacha as Avabhasini. Charakaacharya and Vagbhataacharya are named as Udakadhaara. The thickness of this layer is said to be 1/18th vrihi pramana, Chaya and Varna of individual depend on this layer, in vikrutavasta of this layer, Sidhma, Padmakantaka manifest in this twacha. The name udakadhara indicates that this layer regulates the fluid and maintains the fluid balance. This layer is correlated to horny layer of epidermis, which also called as stratum cornieum. II) LAYER OF TWACHA: LOHITA This layer is next to the outer most layers and is named as Lohita by Sushrutacharya and Asrgdhara by Charaka and Vagbhata. The thickness of this layer is said to be 1/16th of vrihi pramana. The diseases, which occur in
this layer, are Tilakalaka, Nechya, and vyanga. This layer is correlated tostratum lucidium.III) LAYER OF TWACHA: SWETA Charaka and Vagbhata have not given any name for this layer. Sidhmaand Kilasa diseases are said to occur in this layer, where as Sushrutacharayanaming it as Sweta has said that it measures 1/12thvrihi pramana inthickness. The diseases, which occur in this layer according to Sushruta, areCharmadala. Ajagallika and Mashaka. This layer is compared to stratumgranulosum of epidermis.IV) LAYER OF TWACHA: TAMRA Sushrutacharya has named this layer as Tamra. Where as Charakaand Vagbhatacharya have not given any name. According to Sushruta thethickness of this layer is said to be 1/8th vrihi pramana and it is said to be theadhisthana of Kilasa kushta. Charakacharya says that Dadru kushta occurs inthis layer but Vagbhatacharya says that all types of kushta are produced inthis layer. As the adhisthana of Sidhma kushta is not mentioned by any acharyaand considering Vagbhata’s opinion that fourth layer of twacha is theadhistana of various types of kushta. This layer is correlated to stratummalphigium.V) LAYER OF TWACHA: VEDINI Kushta and Visarpa are said to occur in this layer, designated as vedinitwacha by Sushrutacharaya and said to be 1/5thvrihi pramana. Alaji and
Vidradhi are said to occur in this layer for which Charaka and Vagbhata giveno name. This layer is compared to papillary layer of dermis.VI) LAYER OF TWACHA: ROHINI Granthi, Apachi, Arbuda, Sleepada, Galaganda are said to occur in thislayer, termed as Rohini and thickness of which is said to be 1 vrihi pramanaby Sushruta. Vagbhata as termed it as pranadhara. Charaka has not givenany name for this layer. Both these Acharya have not listed any specificdiseases that occur in this layer, but say that trauma to this layer leads tomoorcha. This layer is correlated to reticular layer of dermis.VII) LAYER OF TWACHA: MAMSADHARA Sushrutacharya is the only author who has described the 7th layer oftwacha as Mamsadhara, measuring about 2vrihi pramana. Bhaghandara,Vidradhi and Arshas are said to occur in this layer. This is compared tocutaneous tissues and muscles.IMPORTANT FUNCTION OF SKIN:1 The most important function of skin is to maintain an effective barrier for theloss of water, electrolytes and macromolecules, which are the function ofUdhakadhara twacha.2 It avoids the external injuries, physical, chemical and microbiologicalsubstances into the internal involvement of the body, which is function ofbahya srotas.3 Skin is a prime sense organ for touch, temperature pain and itch, which arethe functions of Twagendriya.
4 Skin plays the most important role in the regulation of body temperature,through sweating and cutaneous vasoconstriction and vasodilation. Which arefunctions of Bhrajaka pitta.5 The flexibility, elasticity and roughness of skin allow motions and provideshape and form of the body.6 The skin surface has antibacterial and antifungal properties.7 Changes in its vascular bed affect the regulation of blood pressure.8 Skin is a secretory organ by virtue of its apocrine sweat and sebaceousglands.9 Skin produces keratinized structures such as hair, nails and Stratumcornieum, which are the functions of the Rohini twacha.10 Skin is a reservoir of electrolytes, water, vitamins, fats, carbohydrates,proteins and other materials, which are the functions of Udakadhara andPranadhara twacha.11 Processes in the skin (melanin function, vasodilation and keratanization)play an important role in detecting the colours of the individuals. This is thefunction of Avabhasini twacha.12 The skin functions in a limited way as an excretory organ.13 Vitamin D is produced in the skin.14. Finally the appearance of skin is valuable to the physician as a mirror orindicator of internal processesRAKTA VIVECHANA: Rakta is one among the kushta karaka sapta dravya. While describingrakta pradoshaja vyadhies, Charaka mentions kushta as one among them. Healso mentions some specific varieties of kushta like Sidhma, Dadru,
Charmadala, and Switra etc. but has not mentioned Sidhma kushta being avariety of kushta can be considered as a rakta pradoshaja vyadhi. Rakta is common morbid factor in all varieties of the kushta along withtwak, mamsa and laseeka39. While mentioning raktajakrimi, it has beenmentioned to produce kushta. Vagbhata expresses the same opinion in thechapter on kushta. It is very important to note here that rakta plays animportant role in the vitiation and maintenance of most of the diseases40.MAMSA VIVECHANA: Mamsa is also one among the sapta dravya which cause kushta,twacha is the sarabhaga of mamsadhatu, meda pushti and mala pushti arethe functions of mamsa dhatu. When mamsa dhatu is involved inpathogenesis, the skin disorders can also manifest Sidhma kushta.LASEEKA VIVECHANA: It is a kind of udakamsha and is included among the sapta dravyaresulting in kushta. It is the mala of rasadhatu and stays in twak41. Laseeka isa piccha bhaga of udaka. According to Dalhana, it is Dravya exudation fromswinna mamsa by pitta42.Twacha varna and Bhrajaka pitta: Bhrajakapitta is stated to be located in the skin and to impart to thisstructure its characteristic colour and luster. It has also been stated that itgoverns the normal and abnormal temperature of the body. Acharya Charaka has not described this pitta as a separate entity buthe has included the functions attributed to it among those of pitta in general.He has stated that the production of normal and abnormal temperature of thebody, as well as the normal and abnormal colour of the skin is due to pitta43.
Chakrapanidatta in his commentary on the above has stated that theregulation or otherwise of the body heat and variations in the colour of thebody are the functions of Bhrajakapitta, which is located in the skin. Sushruta,Bhela and Vaghbahta have on the other hand, made separate and mentionthis pitta, including the functions ascribed to it. Bhrajakapitta, which is located in the skin, is spoken as Bhrajakagni asmuch as it enables the digestion of substances used for “Abhyanaga”,“Parisheka”, “Avagaha”, “Lepana” etc. it eradicates the glow of one’s naturalcomplexion. Commenting on above Dalhana observes by Twacha isunderstood the Bahyatwacha known as Avabhasini, by Abhyanga etc., ismeant the dravyas employed for the kriya and karma etc. According to Bhela, Bhrajakapitta is that which is responsible formanifestation of the specific characteristic of body, it emphasizes itsimportance, creates different prabhas (hues) of the head, hands, feet, sides,back, abdomen, thighs, face, nails, eyes and hair. It also brightens them. “Vaghbhata” mentioned Bhrajakapitta is located in the skin. It is socalled because it imparts luster to the skin and makes it radiate.“Arunadatta” commenting on Ashtanga Hridaya, he mentions Bhrajakapittabecause it performs deepana and pachana of substances used for abhyanga,lepa, parisheka etc44. Twak is one of the seats of jyanendriya, it is made up of two mainbhoutika components, they are Akasha and Vayu are the indriya dravya ofsparsha is indriyaartha and sparsha is indriyabuddhi45.
ANATOMY AND PHYSIOLOGY OF SKIN ACCORDING TO MODERN SCIENCE Derivation: The epidermis and its appendages are developed from the ectoderm; the corium or true skin is of mesodermal origin. About the fifth week of foetal development the epidermis consist of two layers of cells, the deeper one corresponding to the ratemucosum. The subcutaneous fat appears about the fifth month, and the papillae of the true skin about the sixth month. A considerable desquamation of epidermis takes place during foetal life, and this desquamated epidermis mixed with sebaceous secretion constitutes the vernix caseosa The nails are formed at the third month and begin to protect from epidermis by the sixth month. The hairs appear between the third and fourth month in the form of solid, down growths of the deeper layer of the epidermis. The central cells of the solid down growth undergo alteration to form the hair, while the peripheral cells are retained to form the living cells of the hair follicle. About the fifth month of the foetal life hairs appear first on the head and then on the other parts, they drop after birth and give place to permanent hairs. The cellular structure of the sudoriferous and sebaceous glands is formed from the ectoderm where as the connective tissues and blood vessels are derived from the mesoderm. All the sweat glands are fully formed at birth; they begin to develop as early as the fourth month. Anatomy of the skin: - Skin acts as a protective covering for the body minimizing loss of water from the body tissues. Various sensory nerve endings on the skin help to
protect the body from injury by invoking appropriate response to nexionsstimuli. The skin also plays an important role in temperature regulation46. The skin or intugement is an anatomical and physiologically specializedboundary lamine, which is of major importance in the life of an individual. Itforms the entire external surface and is continuous with the mucosal surfacesof the respiratory, in alimentary and urogenital tracts at their respectiveorifices, where the modified skin of the muco-cutaneous junctions occurs. Italso lines the external auditory meatus, covers the lateral aspect of thetympanic membrane and is continuous with the conjunctiva at the margin ofthe eyelids and with the lining of the lacrimal candiculi at the lacrimal puncta. The skin is adapted to serve many different roles, since it is majorinterface between the body and its environment. The skin is a major sensorysurface, containing the receptive fields of a variety of somatic sensory nerveendings. It is capable of limited absorption and excretion, and provides asurface for the conversion of precursor compounds into vitamin D by theaction of ultraviolet light, it posses at its surface good frictional properties,enhancing locomotion and manipulation by its texture and physical structure. Skin also provides a major pathway for social communication, by virtueof vascular responses associated with signaling of emotional states andmuscular response of expression, creating a complex sign language and bythe equally subtle possibilities of tactile communication47. The skin is not only a covering of the body tissues and organs but alsobeing composed of epithelial, mesenchymal, glandular and neuromuscularelements, is part of the corporate system. It helps in the maintenance of thewastes of body metabolism, besides having its own active cellular activity. In
this process it is exposed to and influenced by both endogenous andexogenous factors. It is the inter action of the skin with external influencessuch as the climate, physical, chemical and biological agents and socio-culture and economic factors in relation to skin disease. All living organisms are sustained by vital and basic life supportprocesses such as air, water and proper nutrition. They also possess agenetic code and memory of the living cells by which they guided for theirlongevity and adaptability to the environment. In the process of survival of thefittest, man realized the need to now the influence of natural forces and theenvironment on his health. He began to alter and modify his environment tosuit his basic needs of existence of and life style48.Structure and functions of the skin: The skin is a complex organ of the body consisting of cellular epidermisand an underlying dermis of connective tissue, subcutaneous fat lies beneaththe dermis. The skin is dynamic organ knowledge of its structure, physiology,chemistry and functions is essential to understand the pathology of skindisorders and also an essential prerequisite to understand the nature of thedisease and to plan proper treatment. The skin varies in thickness from less then 1mm on the eyelid to upto4mm over the back. The epidermis varies in thickness from 0.04mm oneyelids to 1.6mm on the palms. The thickest skin is of course, the skin overthe palm and soles. The epidermis has 4 types of cells, viz. keratinocytes(which constitute 70% of total epidermal cells), melanocytes, langerhans cellsand mercer cells. The dermis predominantly contains undifferentiated
connective tissues are blood and lymph vesselss, nerves, muscles,sebaceous, eccrine and apocrine glands, and hair follicles. The dermis is 15-40 times thicker than the epidermis. The skin covers the exterior of the body and is continuous with themucous membranes lining the body orifices. The skin over the palms andsoles is called glabrous (smooth) skin, whereas the skin over the rest of thebody is hair bearing. The structure of the skin varies at different sites of thebody. These anatomical variations must be known to accurately interpretclinical and histopathological variations49.Structure: Two main layers 1) Epidermis 2) DermisEpidermis: It is the most superficial layer and is composed of stratifiedsquamous type of epithelium. The epidermis is derived from the ectoderm. Itis keratinizing stratified squamous epithelium from which arise the cutaneousappendage, i.e., pilose baceous follicles, nails and apocrine and eccrineglands. Epidermal keratinocytes are transformed from undifferentiated basalcells to fully differentiated, fully keratinized cells. The dividing basal cells giverise to a progeny of cells, which migrate upwards until they die and are castaway. The cellular epidermis can be divided into four layers or stratadepending on the state of differentiation at each layer. From below upwardthey are basal, spinous, granular and corneal layers. These cellular layers ofskin should be considered as successive stages of maturation of germsinative
keratinocytes into fully cornified keratinocytes. From outside inward stratifiedepithelium may be divided into 5 layers50.A) Stratum corneum: It is most superficially placed. The cells arekeratinised. The cell outlines are indistinct and the nuclei are absent. Thislayer is thickest at the sole and the palm and thinnest at the lip, hairs, loops,nails, feathers, scales etc, are special outgrowth of this layer.B) Stratum lucidum: This is a thin more or less transparent layer 3-5 cellsdeep placed below the stratum corneum. The cell outlines are indistinct andthe nuclei are absent. The cell contains droplets of ‘eleidin’, which is precursorof keratin.C) Stratum Granulosum: It is situated below the stratum lucidum andconsists of 3-5 layers of flattened polyhedral cells filled with keratohyalingranules, which take a deep stain with haematoxylin.D) Stratum basale: stratum basale consists of a single layer of columnarcells. Their cytoplasm contains tonofibrils. Which pass towards the basementmembrane uniting them to the dermis. It is in thin layer and stratum spinosumthat new cells are produced to replace the cells constantly being worn awayfrom the surface process, which is stimulated by the removal of the superficiallayers.E) Stratum spinosum: It consists of several layers of irregularly shaped cells,which tend to become more flattened as the stratum granulosum isapproached. These cells are readily separated by shrinkage except whereadhesion plaques or desmosomes attaches them to each other hence theyhave a spiny appearance in many histological preparations51.
Dermis: The dermis or corium supports the epidermis and is composed of thefibrous connective tissue components, collagen and elastic fibres in intimateassociation with the ground substance. It is very thick in the palms and soles of the feet, thicker on theposterior than on the anterior aspect of the body and on the lateral than on themedial sides of the limbs. It is exceeding thin and delicate in the eyelids,scrotum and penis52.MICROSCOPIC STRUTURE OF THE DERMIS The dermis consists of the two layers viz. 1) The upper papillary dermis. 2) The lower reticular dermis. The papillary dermis is bounded superiorly by the epidermis, laterallyby the epidermal ridges and inferiorly by the superficial vascular plexus andreticular dermis. The reticular dermis lies between the papillary dermis and thesubcutaneous fat. While account for the clevage lines, the highly irregularpapillary dermis accounts for the complex arrangement of whorls, loops, andarches. The dermis gives support to the epidermal appendages, bloodvessels and nerves, and also has cellular components like mast cells,fibroblasts and macrophages and a muscle component in the form of arrectorpili53.
Appendages:Hairs: Hairs or pili are growth of the epidermis variously distributed over thebody. Their primary function is protection. Although the protection is limited,hairs on the head guard the scalp from injury and sun’s rays. It alsodecreases heat loss, eyebrows and the eyelashes protect the eyes fromforeign particles. Hair in the nostrils protects against inhaling insects andforeign particles. Hairs serve a similar protective function in the external earcanal. Touch receptors associated with hair follicles are activated whenever ahair is even slightly moved. Normally hair loss is an adult scalp is about 70-100 hairs per day. Both the rate of growth and the replacement cycle may bealtering by illness, diet, high fever, surgery, bloodloss or severe emotionalstress. Rapid weight-loss diets that severely restrict calories or proteinsincrease hair loss. An increase in the rate of shedding can also occur for 3-4months after childbirth.Nails: Nails are plates of tightly packed hand-keratinized cells of theepidermis. The cell from a clear, solid covering over the dorsal surfaces of theterminal portions of the fingers and toes. The average growth in the length ofthe fingernails is about 1mm (0.04in.) per week. The growth rate is somewhatslower in the nails. Nails growth is faster in the summer and on most-usedhand. Functionally, nails help us grasp and manipulate small objects invarious ways and provide protection against trauma to the ends of the digitsand allow us to scratch various parts of the body.
Sweat glands: 3-4 million sweat glands empty their secretions onto the skin surface.They are divided into two principal types,1) Eccrine2) Apocrine, based on their structure, location and the type of secretion. Eccrine sweat glands are much more common than apocrine sweatglands. They are distrisbuted throughout the skin except for the margins of thelips, nailbeds of the fingers and toes, glans penis, glans clitoris, labia minoraand eardrum. Eccrine sweat glands are most numerous in the skin of thepalms and the soles; their density can be as high as 450sq.cm. in the palms.The secretory portion of eccrine sweat glands is frequently located in thesubcutaneous layer, and the excretory duct extents outward through thedermis and epidermis. It ends as a pore at the surface of the epidermis. Apocrine sweatglands are found mainly in the axilla (armpit), pubic region and areolae of thebreasts. The Secretion portion of the apocrine sweat glands is located in thedermis and the excretory duct opens into hair follicles. Apocrine sweat glandsbegin to function at puberty and produce a more viscous secretion thaneccrine sweat glands. They are stimulated during emotional stresses andsexual excitement and the secretions are commonly known as a “cold sweat”. Sweat is the fluid produced by sweat glands. Most comes from eccrinesweat glands because they are so much more numerous. Sweat is a mixtureof water, ions (mostly Na+ and Cl-), urea, uric acid, amino acids, ammonia,glucose, lactic acid, and ascorbic acid. Its principal function is to help regulate
the body temperature by providing a cooling mechanism. Sweat alsoeliminates a small amount of wastes from the body.Sebaceous glands: Sebaceous glands are connected to hair follicles. The secretingportions of the glands lie in the dermis and open into the necks of hair folliclesor directly onto a skin surface (lips, glans penis, labia minora and tarsalglands of the eyelids). Absents in palms and soles, sebaceous glands vary insize and shape in other regions of the body. They are small in most areas ofthe trunk and limbs, but large in skin of the breast, face, neck and upperchest. Sebaceous glands secrete an oily substance called sebum, which is amixture of fats, cholesterol, proteins and inorganic salts. Sebum helps keephair from drying and becoming brittle, prevents excessive evaporation ofwater from the skin, keeps the skin soft and pliable and inhibits the growth ofcertain bacteria. When sebaceous glands of the face become enlargedbecause of accumulated sebum, blackheads develop. The colour of theblackheads is due to melanin and oxidized oil, not dirt. Since sebum isnutritive to certain bacteria, pimples or boils often result54.Skin colour: Three pigments contribute to skin colour: Melanin, Carotene, andHaemoglobin. Of these, only melanin is made in the skin. Melanin, a polymermade of tyrosine amino acids, ranges in colour from yellow to reddish-brownto black. Its synthesis depends on an enzyme in melanocytes called tyrosineand, as noted earlier, it passes from melanocytes to the basal keratinocytes.Racial differences in skin colouring reflect the relative kind and amount of
melanin made. Melanocytes of black-and brown skinned people producemuch more and darker melanin than those of fair-skinned individuals, andtheir keratinocytes retain it longer. Freckles and pigmented moles are localaccumulations of melanin. Melanocytes are stimulated to greater activity whenwe expose our skin to sunlight. Prolonged sun exposure causes a substantialmelanin buildup, which helps protect DNA of viable skin cells from UVradiation. Indeed, the initial signal for speeding up synthesis seems to be anincreased rate of repair of photodamaged DNA. In all but the darkest people,this response causes visible darkening of the skin. Despite melanin’s protective effects, excessive sun exposureeventually damages the skin.Carotene: It is a yellow to orange pigment found in certain plant productssuch as carrots. It tends to accumulate in the stratum corneum and in fattytissue of the hypodermis. Its colour is most obvious in the palms and soles,where as stratum corneum is thickest and most intense when large amountsof carotene-rich foods are eaten. However the yellowish tinge of the skin ofsome Asian peoples is due to variations in melanin not to carotene. The pinkish hue of fair skin reflects the crimson colour ofoxygenated haemoglobin in the red blood cells circulating through the dermalcapillaries. Since caucasion skin contains only small amount of melanin, theepidermis is nearly transparent and allows haemoglobin’s colour to showthrough. When haemoglobin is poorly oxygenated, both the blood and theskin of light-skinned people appear blue. This condition is called cyanosis. In
dark skinned individuals, the skin does not appear cyanotic because of themasking effects of melanin, but cyanosis is apparent in their mucousmembranes and nail beds55.Functions of Skin: Skin serves several function those are,1) Protection: The skin covers the body and provides a physical better thatprotects underlying tissues from physical abrasion, bacterial invasion anddehydration and ultraviolet radiation. Hair and nails also have protectivefunction.2) Sensation: The skin contains abundant nerve endings and receptors thatdetect stimuli related to temperature, touch, pressure and pain.3) Excretion: Besides removing heat and some water from the body, sweatalso is the vehicle for loss of a small quantity of ions and several organiccompounds.4) Immunity: Certain cells of the epidermis are important components of theimmune system, which fends off foreign invaders.5) Blood reservoir: The dermis houses extensive networks of blood vesselsthat carry 8-10% of the total blood flow in a resting adult. In moderateexercise, skin blood flow may increase, which helps dissipate heat from thebody. During strenuous exercise, however, skin blood vessels constrictsomewhat, which allows more of the blood to circulate through contractingmuscles.6) Synthesis of vitamin D: It begins with activation of a precursor moleculein the skin by ultraviolet rays in sunlight. Enzymes in the liver and kidneysthen modify the molecule; finally providing calcitrial contributes to the
homeostasis of body fluids by aiding absorption of calcium in foods from thedigestive tract into the blood. Thus vitamin D is a hormone, since it isproduced in one location in the body transported by the blood and then exertsits effect in another considered an endocrine organ.7) Regulation of body temperature: In response to high environmentaltemperature or strenuous exercise, the evapouration of sweat from the skinsurface helps lower an elevated body temperature to normal. In response tolow environmental temperature, production of sweat is decreased, whichhelps conserve heat. Change in the flow of blood to the skin also helpsregulate body temperature56.
CLASSIFICATION OF KUSHTA Different Acharya have mentioned different classification of kushta,Sidhma Kushta is mentioned in Mahakushta according to Charaka andKshudrakushta according to Sushruta and Vagbhata. The same type of causative factors produces all the varieties of kushta,depending upon the permutation and combination of the various fractions ofdosha and their locations in the body. In the name and treatment of the various types of kushta, there isvariation in the nature of colour, pain, and specific manifestations. Accordingto one classification they are of 7types and according to another classificationthere are eighteen types. According to some, kushta is of innumerablevarieties57. However a compiled list of Kushta varieties is given here. CLASSIFICATION OF MAHAKUSHTAName of the disease Cha. Su. A.Hr. M.N. B.S. B.P. Ka.S. Kapala + + + + + + + Audumbara + + + + + + + Mandala + _ + + + + + Aruna _ + _ _ _ _ _ Rushyajihwa + + + + + + + Dadru _ + + _ _ _ _ Kakanaka + + + + + + + Sidhma + _ _ + + + + Pundarika + + + + + + +
NIDANA Specific nidana of Sidhma kushta are not described in Ayurvedicclassics, as Sidhma kushta is one among the 18 types of kushta, some of thenidanas mentioned in the context of kushta holds good for Sidhma kushtaalso. “Sidhma Kushta” is a variety of “Kshudra Kushta” according toSushruta and Vagbhata Acharya. There is no specific nidana factor forSidhma kushta. As such the causative factors attributed to kushtas are to betaken as causative factors for Sidhma kushta also. However Acharya Charaka has included “Sidhma Kushta” underMahakushta and causative factors are the same for the both types of kushtas,as such there is no controversy about nidanic factors. The nidanas mentioned for the causation of kushta can be broadlyclassified and studied under the following five headings. 1) Aaharaja 2) Viharaja 3) Daivapacharaja 4) Chikitsa sambandhi 5) Sankramika
NIDANA DUSHTIViruddhahara Pitta and RaktadushtiAjeerna, Adhyashana AmlotpattiMatsya KaphadoshavriddhiDugdhati sevana Kaphavriddhi, Rasa and MedovriddhiAmlati sevana Kapha and Pittavriddhi, RaktadushtiGuru ahara Kapha and MedovriddhiDadhi sevana Kaphavriddhi, Medovriddhi and RasadushtiSneha Vatavriddhi, KledakarakaLakucha and Kakamachi Sleshmavriddhi, Kledakaraka, Rakta and PittaMatsya with Payasa Pitta, Raktadushti, KledakarakaAhitashana Kaphavriddhi and KledakarakaDrava, Snigdhahara Kaphakaraka and KledakarakaUddalaka, Kusumba Kaphakaraka, Medovriddhi and KledakarakaNavanna, Yavaka, Kulatta Kaphakaraka, Medovriddhi and KledakarakaLavana, Hayanaka, Atasi Raktakopaka, Kledakaraka and PittakarakaMoolaka, Satatamadhu sevana VatavardhakaTilapishta, Guda Kapha and Pittakaraka, RaktadushtiChilichima with milk Pitta and Rakta dushtiMadyamla, Dravya with Milk Pitta and Rakta dushti, KledakarakaGuda with milk Pitta and Rakta dushti, KledakarakaMatsya, Nimba with milk Pitta and Rakta dushti, KledakarakaMamsa with Madhu KaphapittavardhakaPapodaka Pitta and RaktadushtiPippali, Haritashakha, Vatakaphavardhaka and Raktautkleshakara.Vidagdha ahara sevanaGuda with Moolaka Krimiutpatti, TridoshakopakaHaviprashana Kaphakaraka and Kledakaraka
ROLE OF VIHARAJA NIDANA IN KUSHTA NIDANA DUSHTIChardinigraha Kushta, Visarpa, Kandu utpattiVegavarodha Vatakaphavriddhi and KushtakarakaSheetambusevana after atapa Ashrugdhara sroto dushti, Kledakarakasevana, Divaswapna kaphautkleshakarakushta, Kota, Pidaka, and kandu utpatti.Mithya vihara Tridoshavriddhi, KushtakarakaVyayama, Atisantapa, Bhuktopasevana Rasadidhatukshaya, Vataprakopaka and Kushtakaraka.Shrama bhayartana Sheetambu Rasadidhatukshaya, Vatavriddhi, Kushtasevana utpattiRatrijagarana, Ajeernepi, Vyayama Vatavriddhi, Amlotpatti, Kushtadiroga utpattiSneha peetasya vantasya, vyayamam Vatavriddhi, Kledakaraka, Raktadushti KushtakarakaVyavaya after vidahi ahara sevana Tridoshavriddhi, Rasa and RaktadushtiGramya Dharma Sevana Pitta, Raktadushti
AHARA SAMBHANDHI NIDANAi) Rasa sambhandhi: Excessive and regular intake of food articles, which havepredominance of amla and lavana rasa act in two ways, firstly, they causedosha dushti and secondly, they cause Rakta dushti. The resultant kushta is acombined effect of both. This is evident from the statement of Charaka Acharya stated thatexcessive intake of amla rasa causes kapha vilayana and pitta vriddhi. Healso indicates that it causes rakta dushti. Thus the excessive intake of amlarasa acts as ubhaya hetu; the same is true with lavana rasa also.Viruddhahara sambhandhi: According to Acharya Charaka, viruddha ahara influences on theequilibrium states of dosha, dushya, mala, and srotas, these may becomeresponsible factors for the manifestation of the diseases. In the same context he has mentioned that along with many diseases,which are caused due to viruddha ahara, kushta roga is also one amongthem. Among hetus mentioned in the list of ahara a few are capable to vitiaterakta directly and other vitiates only dosha59. Intake of chilichima or all varieties of matsya with milk directly vitiaterakta. Because both ksheera and matsya will have the qualities of madhurarasa, madhura vipaka and abhishyandhi, but they are opposite to their Veeryai.e., milk has got sheeta Veerya and matsya has got unsnap Veerya, by thisquality (guna) they directly vitiate rakta and cause morbidity in it. BothKsheera and Matsya combinedly cause obstruction in channels due to their
abhishyandhi quality hence this hetu may be considered as vyadhi hetu.Since they are directly vitiates rakta and cause shithilatha in it, which in turnleads to kushta.Vishesha nidana: The other hetu such as intake of food mostly containing Hayanaka,Moolaka, Kakamachi, etc. are only competent enough in producingaggravation of dosha. But as an exception the eaten Kakamachi directly maycause kushta by vitiating rakta since Acharya Charaka considers it asviruddha. Hetu listed under ahara and koshtasthithi; generally impair the processof digestion. This ultimately leads to excessive production of ama dosha.II) Viharaja nidana60: The causative factors, which are enlisted in the ahara and viharajanyacategory, affect the process of digestion. Ultimately utpatti of ama leads toaggravation of doshas. Among the nidanic factors categorized under viharajanya nidanas,shareerika vegadharana plays an important role. In them chardi vegadharanaacts as a vyadhi hetu. Where as the suppression of the other Vegas serve asdosha hetu. Chardi manifests when kapha and pitta move upwards with the help ofudana and vyana vayu. By suppressing this urge kapha and pitta get settled.The aggravated kapha and pitta cause kushta by the exposure of theindividual to excessive physical activities (Vyayamadi).
III) Daivapaacharaja61 The exact role of some of the nidanas mentioned such as Papakarma,Gohatya, etc. in the causation of kushta is difficult to understand and analyse.However these can be taken as vyadhi hetu or vishesha hetus of kushta.Gandhadhar commentator of Charaka also supports this view. Vagbhataconsiders these nidana as Adrushtakarmaja vyadhihetu.IV) Chikitsa sambandhi nidana: The hetu listed under chikitsa sambandhi are usually vyadhihetus.Panchakarma mityapachara is considered as a nidana for kushta inBrihatrayee. The vyapath of shodhana is a cause for kushta. That too, ayogaof vamana and virechana is a stronger cause for kushta than atiyoga of theseprocedures. The panchakarma procedures are adopted to eliminate the aggravateddoshas, but improper application of panchakarma measures will causeadverse effects. By the ayoga of vamana and virechana, doshas that aresupposed to be eliminated from the body will not be completely eliminated.There will be residual doshas in the body, which again get localized oraccumulated in shakhadi margas, ultimately leading to the manifestation ofkushta by causing shithilatha in the dhatus. If snehakarma is continued evenafter samyak sneha it causes sneha vyapath. Then it leads to shithilatha andklinnatha of dhatus. This excessive sneha leads to kotha and causes kushta. Similarly the continuation of brimhana therapy even after the exhibitionof samyak brimhana lakshana causes increase of kapha dosha and rasadidhatu with their kledatvadi vruddhi resulting in the shithilatha, which ultimatelyleads to manifestation of disease kushta.
V) Sankramika nidana62: Sushrutacharya is an only author who has mentioned the categorynature of kushta, even though he has not mentioned these in the context ofexplaining the causative factors of kushta. All the modes of communicating acontagious and infectious disease such as inhalation, physical contacts,including sexual contacts, contamination of food etc. have been mentioned. The diseases manifesting, due to sankramika hetu can be termed asbhootabhishangaja, here bhoota refers to krimi. In krimi prakarana while explaining about the raktajakrimi has been toldwhile clearly justifies the role of krimi in kushta.
SAMPRAPTHI OF SIDHMA KUSHTA All the classical textbooks of Ayurveda have elaborated one commonsamprapthi for kushta. Even though kushta is classified into Mahakushta andKshudrakushta, any author has not emphasized the separate samprapthi ofthese two types, not even the samprapthi of individual variety of kushta also.Naturally a separate samprapthi for Sidhma kushta is not available in any ofthe Brihatrayee or in the works of later authors. The common samprapthi of kushta according different authors is asfollows. According to Charaka Acharya, the vitiated sapta dravyas areconsidered as sannikrishta karanas for kushta. The vitiated doshas vitiatetwacha, mamsa, rakta, and lasika and the combination of these sapta dravyasleads to the disease process. The morbid sapta dravyas will be localized inbetween twak and mamsa and may produce different varieties of lesions atdifferent sites over the skin. They are named differently based on the site andnature of the lesions63. According to Vagbhata, by the said nidanas the doshas get vitiatedthen spread to tiryak siras. They vitiate twacha, lasika, and ashrg. Thisproduces shithilikarana and vaivarnya of bahya twacha. The disease kushtamanifests wherever the morbid doshas get lodged64. Madhavakara description of kushta samprapthi is similar to that ofCharaka Samhita, however there are some manifestations. The morbidtridoshas vitiate twacha, rakta, mamsa, and ambu. These sapta dravyas areconsidered as sannikrishta karanas, which are responsible for producing
seven Mahakushtas and eleven kshudrakushtas. He has used the term ambuin the place of lasika among the sapta dravyas65. Bhavaprakasha and Yogaratnakara have followed the descriptions ofCharaka Acharya66. The samprapthi described in Bhela Samhitha focuses on the vitiation ofthe vata dosha. The state of mandagni gives rise to the provocation of vata.The provocated vata vitiates the other doshas in their sanchayavastha.Depending on the rutus, the tridoshas get lodged in rakta and vitiates rudhirafollowed by mamsa. The combination of tridoshas along with rakta, mamsagives rise to 18 types of kushtas depending on the etiological factors67. The description of kushta samprapthi available in Harita Samhitha issimilar to the Charaka samhitha with special emphasis on lasika as amamsatwakantara udakadhatu. The samprapthi described in Sushrutha Samhitha is as follows, thevata aggravated by the nidanas in combination with the aggravated pitta andkapha enter into the siras, which are transversely spread over the surface ofthe body. Thus the enraged vayu deposits the pitta and kapha on the skinthrough the medium of their channels and spreads them over the surface ofthe body. The areas of the skin in which the morbid doshas are depositedbecause marked with mandalas or skin patches (Mandalani pradurbhavanthi).The doshas thus lodged in the skin continue to aggravate and having beenneglected at the out seat tend to enter into the deeper tissues and furthervitiates the dhatus68. After going through the samanya samprapthi of kushta according todifferent authors, the samprapthi described by Sushrutacharya seems to be
elaborate and accurate denoting samprapthi of both Mahakushta andKshudrakushta. But Kshudrakushta samprapthi is to be limited to the stage ofMandalani pradurbhavanthi. The further stage of pathogenesis described bySushruthacharya has to be restricted to Mahakushta. Among sapta dravyas of kushta mentioned for the causation of kushta,the tridoshas viz. vata, pitta, kapha, and two dushyas namely rasa and raktaseems to play an important role in the manifestation of “Sidhma Kushta”. Therole of mamsa and lasika seems to be less. Among the tridoshas Charaka has stressed the role of vata and kaphaby classifying “Sidhma Kushta” under the heading of vatasleshmatmakakushtas on the other hand Sushruta has stressed the role of kapha in thepathogenesis Sidhma Kushta. However these two opinions need not be taken as contradictory toeach other, because all these doshas take part in pathogenesis at differentstages of the manifestation of the disorders. Classical textbooks of Ayurveda mentioned kushta as a Janmabalapravruta vyadhi, “Sidhma Kushta” being one among them. In the geneticallypredisposed persons the intake of pitta and kapha karaka nidanas results inthe vitiation of kleda initiating the process of pathogenesis. Both Mahakushtaand Kshudrakushta are sankleda pradana vyadhies. The nidanas vitiate pitta and kapha dosha and cause the shithilatha ofbahya twacha. These doshas cause marghavarodha of vata dosha in turnleading to vata vriddhi. This vitiated vata carries the vitiated pitta, kapha, andlasika into tiryak siras and lodge them in the udakadhara, raktadhara, andmamsadhara twacha. Among with tridoshas kleda plays an important role in
the pathogenesis of any variety of pitta including “Sidhma Kushta”. Both pittaand kapha being dravadhatus are considered as kledakaraka sannikrishtakaranas. The Siddhanta explained in the classics suggest that usually ifinitially the vitiation of kapha in predominant with the predominance of sneha,sheeta and picchila gunas, then the vitiation of kleda occurs. On the otherhand if initially the vitiation of pitta is predominant with predominance of itsgunas i.e. sneha dravya then also kleda gets accumulated. The accumulation of kleda results in the srotorodha and leads vatavriddhi. Because of the combined effect of vata vriddhi and srotorodha, therasadhatu does not properly enter the srotas. Twacha being entirelydependent on rasa for its manifestation becomes heena satwa resulting inshaithilya of twacha. There will be abhava of snigdha guna of rasa in thetwacha resulting in further vata vriddhi. Twacha becomes shyava Varnabecause of vata vriddhi. At the same time due to ushna guna of pitta,dravamsha of kleda escapes through sweda. Due to the loss of thisdravamsha, the kleda that remains in the twacha will be ghanibhuta kleda. In“Sidhma Kushta”, this affects the twacha and parushata, kharaparushata.
SAMPRAPTHI GHATAKA As told earlier samprapthi is nothing but series of changes, which takesplace inside the body, from the day of consumption of nidana to vyaktavasta.Here it becomes very essential to know all the factors involved directly orindirectly in the manifestation of Sidhma Kushta. In Charaka it is mentioned as samprapthi vighatana meva chikitsai.e., to say, “Systemic breaking of samprapthi is chikitsa”. This shows that theproper knowledge of all the samprapthi ghataka is very important. There areabout 12ghataka. This plays role in the manifestation of “Sidhma Kushta”.They are dealt as follows, 1) Dosha : - Vata, Pitta, and Kapha 2) Dushya : - Rasa, Rakta, Mamsa, and Lasika 3) Agni : - Jataragni 4) Ama : - Jataragni janya ama 5) Srotas : - Rasa, Rakta, and udakawaha srotas 6) Srotodushti prakara : - Sanga 7) Udhbhavasthana : - Amashaya and Pakwashaya 8) Sancharasthana : - Rasayanee 9) Adhisthana : - Twacha 10) Vyakta sthana : - Sarvadehika (Twacha) 11) Rogamarga : - Bahya 12) Rogavastha : - Chirakari
VISHESHA SAMAPRAPTHI IN SIDHMA KUSHTA An attempt is made to understand Sidhma Kushta according thevarieties of samprapthi as follows, 1) Sankya samprapthi: -Sidhma Kushta is one in number. 2) Pradhanya samprapthi: -According to Charaka and Vagbhata Sidhma is VataKaphaja and according to Sushruta Sidhma is Kapha doshaja. 3) Vidhi samprapthi: -Sidhma is adibala pravruta vyadhi. 4) Vikalpa samprapthi: -The vikalpa samprapthi of Sidhma Kushta is as follows,Dosha Gunataha Vridhis Karmataha Vridhi Dravyataha VridhiVata Rukshata, Parushata Vedana RajogrishtamPitta Ushna Guna Daha -Kapha Snigdha, Picchila Kandu, Sweta Varana Srava 5) Bala samprapthi: Sidhma is Dwidoshaja Pradhana according toCharaka and Vagbhata and Ekadoshaja according to Sushruta andEkamargaja. 6) Kala samprapthi: Sidhma gets flared up due to the exposure inGreeshma rutu.1) DOSHA: Kushta is caused due to the involvement of all the tridosha. Among thistridosha, Vata and Kapha play major role. The predominance of tridosha individually is understood by theirfactors. In Sidhma vatadhikya features are seen such as ruksha, parusha and
vedana. Feature like daha are suggestive to pitta dosha predominance.Features like kandu, picchila and sweta varna are suggestive of kapha doshapredominance. According to Charaka and Vagbhata Sidhma Kushta is Vataand Kapha dosha pradhana and according Sushruta Kapha dosha pradhanavyadhi.Vata dosha: Among tridosha vata and kapha dosha plays major role and isresponsible for carrying, pitta dosha to other parts of the body. Charaka hasmentioned very clearly that the seat of vyana vata is sarva shareera.Transportation of rasadi dhatu is done by vyana vata only. Because ofvitiation of vata dosha, snigdhata of twacha is deranged there by vrikruti in thetwacha is seen this shows the involvement of vata dosha.Pitta dosha: The involvement of pitta dosha is ascertained by the presence offeatures like vaivarnata, daha etc, twacha vaivarnata is indicative of brajakapitta dushti. The vitiation of brajaka pitta vitiates the prakruta karma of twacha.Because of nidana sevana, pachaka pitta is deranged this inturn vitiates otheragni, because pachaka pitta present in amashaya nourishes the other pitta.Ranjaka pitta does the ranjana karma. All the nidana of kushta are raktaprakopaka, there is close relation between rakta and ranjaka pitta andtherefore whenever rakta dushti takes place ranjaka pitta dushti also takesplace. The above said description indicates the involvement of trividha pitta.Kapha dosha:
According to Charaka and Vagbhata, kapha dosha plays a major role in the manifestation of Sidhma Kushta. The snigdhata is because of kapha dosha, which is vitiated due to nidana sevana; this is probably due to vitiation of kledaka kapha. 2) DUSHYA: Charaka has mentioned dushti of saptadravya in the manifestation ofkushta roga. Among this saptadravya twak, rakta, mamsa and lasika are the4dushya. Among these four dushyas twak and lasika are predominantlyaffected and these features concerned are sarvadehika in nature. After twak,rakta, mamsa and ambu dushti takes place. The nidana of kushta vitiate bodilydosha especially vata and kapha dosha, this vitiates rakta and producesSidhma.3) AGNI: In Ayurvedic classics it is mentioned as rogaha sarvepe mandagni i.e.,almost all the diseases are cause due to mandagni only. In kushta agni plays role. Jataragni gets vitiated due to nidana sevana. Normaly dhatwagni are nourished by jataragni. The vitiated jataragni, vitiate dhatwagni. As jataragni mandyata is present in kushta, dhatwagni mandata is also produced. 4) AMA: Normalcy of jataragni is mandatory for normal health. Any variation tojataragni can give rise to diseases. As due to nidana sevana jataragni is vitiatedand jataragni janya ama is produced. If jataragni is vitiated, dhatwagni also getsvitiated and dhatwagni janya ama is produced. 5) SROTAS: