Evaluation of the Efficacy of Takradhara in Kitibhakushta (Psoriasis) By Chandramouleeswaran P. Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. (PANCHAKARMA) In PANCHAKARMA Under the guidance of Dr. G. Purushothamacharyulu, M.D. (Ayu) And co-guidance of Dr. Shashidhar.H. Doddamani, M.D. (Ayu) Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2006.
Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled“Evaluation of the Efficacy of Takradhara in Kitibhakushta(Psoriasis)” is a bonafide and genuine research work carried outby me under the guidance of Dr. G. Purushothamacharyulu, M.D.(Ayu) , Professor and H.O.D, Post-graduate department ofPanchakarma and co-guidance of Dr. Shashidhar. H. Doddamani,M.D.(Ayu) , Assistant Professor, Post graduate department ofPanchakarma.Date:Place: Chandramouleeswaran P.
CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “Evaluationof the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a bonafideresearch work done by Chandramouleeswaran P. in partial fulfillment ofthe require ment for the degree of Ayurveda Vachaspathi. M.D.(Panchakarma).Date:Place: Dr. G. Purushothamacharyulu, M.D. (Ayu). Professor & H.O.D Post graduate department of Panchakarma.
ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “Evaluation ofthe Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is a bonafideresearch work done by Chandramouleeswaran P. under the guidance ofDr.G. Purushothamacharyulu, M.D. (Ayu), Professor and H.O.D, Postgradu-ate department of Panchakarma and co-guidance of Dr. Shashidhar.H.Doddamani, M.D. (Ayu), Assistant Professor, Post graduate department ofPanchakarma.Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Panchakarma.
CERTIFICATE BY THE CO- GUIDE This is to certify that the dissertation entitled “Evalua-tion of the Efficacy of Takradhara in Kitibhakushta (Psoriasis)” is abonafide research work done by Chadramouleeswaran P. in partial ful-fillment of the requirement for the degree of Ayurveda Vachaspathi.M.D. (Panchakarma).Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).Place: Assistant Professor, Post graduate Department of Panchakarma.
I Acknowledgement “Many hands make light work”. I take this opportunity to mention mydeep gratitude to several personalities who have helped me in the successful completionof this work. I express my obligation to my honorable Guide Dr. G.Purushothamacharyulu M.D. (Ayu), H.O.D., P.G. Department of Panchakarma,P.G.S&R, D.G.M.A.M.C, Gadag for his critical suggestions and expert guidance for thecompletion of this work. I am extremely grateful and obliged to my co-guide Dr. Shashidhar.H.Doddamani, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag for his guidance andencouragement at every step of this work. I express my deep gratitude to Dr .G.B Patil, Principal, D.G.M.A.M.C,Gadag, for his encouragement as well as providing all necessary facilities for thisresearch work. I express my sincere gratitude to Dr. P. Shivaramudu M.D (Ayu),Assistant Professor and Dr. Santhosh. N.Belavadi MD (Ayu), Dr. M.D. Samudri,Lecturers for their sincere advices and assistance. I express my sincere gratitude to Dr. V. Varadacharyulu M.D (Ayu),Dr.M.C.Patil M.D (Ayu), Dr. Mulgund M.D (Ayu), Dr. K. S. R. Prasad M.D (Ayu), Dr.Dilip Kumar M.D (Ayu), Dr. R.V. Shetter M.D (Ayu), Dr. Kuber Sankh M.D (Ayu),Dr.G.Danappagowda M.D (Ayu) Dr. Jagadish Mitti M.D (Ayu) Dr. Nidagundi M.D(Ayu) and other PG staff for their constant encouragement. I also express my sincere gratitude to Dr.B.G.Swamy, Dr.U.V.Purad,Dr.K.S.Paraddi, Dr.G.Yargeri, Dr.S.H.Radder and other undergraduate teachers for theirsupport in the clinical work. I thank to Shri. Hadapad (Statistician) Shri. Nandakumar(Statistician), Shri. V.M. Mundinamani (Librarian), Shri. B.S. Tippanagoudar (labtechnician), Shri. Basavaraj (X-Ray technician) and other hospital and office staff fortheir kind support in my study.
II I express my sincere thanks to my colleagues and friends Dr. UdaykumarA.A.N., Dr. Ratnakumar K., Dr. Ashwinidev, Dr. Krishnkumar K., Dr. Sreena, Dr.Soumya, Dr. Devanathan, Dr. Subin V., Dr.Satheesh. R.Warrier, Dr. Febin .K. Anto,Dr.Renjith.P.Gopinath, Dr. Prassannakumar L., Dr.Shajil.N, Dr. Shyju Ollakode, Dr.Gavi Patil., Dr.Santhosh.L.Y, Dr.Varsha.S.Kulkarni, Dr. Anjaykannan, Dr. KrishnkumarK.M., Dr. Jayaraj Basarigidad, Dr. Kendadamath, Dr.V.M.Hugar, Dr. Shaila.B, Dr.Suresh Hakkandi, Dr.Manjunath Akki, Dr. L. R.Biradar, Dr.Vijay Hiremath, Dr. Sajjan,Dr. Bhingi, Dr. Sunita, Dr. Veena Dr. venkareddy, Dr. Kalamath B.L., Dr. Pradeep, Dr.Basavaraj Ganti., Dr. Anitha., Dr. Shibaprasad, Dr. H.S. Madhushri., Dr. DevendrappaBudi., Dr. Payyappagoudar., Dr. Ashok., Dr. Sharanu., Dr. Anand Doddamani., Dr.Kumbar., Miss Meena B. and other post graduate scholars for their support. I pay my respect to my philosopher and uncle Late Dr. Srinivasan LI.M.who had been a source of inspiration for me and prime cause for taking this nobleprofession. I would like to mention the support and inspiration provided by Dr. S.N.Suresh., Dr. Krishnkutty Nair and also acknowledge the support and inspiration providedby my teachers Dr. Ramadass., Dr. S. Swaminathan., Dr. Vasudev Reddy., Dr.Saikumar., Shri. Venugopal. I also thank Shri. Habib I. Khatib and family for the supportand encouragement provided during my stay at Gadag. I acknowledge my patients for their wholehearted consent to participate inthis clinical trial. I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. I also express my wholehearted thanks to my family members Mr. & Mrs.Balasubramnyam and Mr. & Mrs. Ganesan, Shivaramkrishnan, Kartikeyan, Soundaryaand Ravikumar. Finally I dedicate this work to my respected parents Shri. ParameswaranK., Sreemati Subbulakshmi P. and my brother Er. Jayaraman P. who are the primereasons for all my success.Date : Signature of the scholarPlace : Gadag. (Dr.Chandramouleeswaran P.)
IV Abstract The study “Evolution of the efficacy of Takradhara in Kitibha Kushta(Psoriasis)” is focused on an important technique Takradhara and a commonpsychosomatic disorder Kitibha kushta (Psoriasis). The objectives of this study are – 1. To evaluate the efficacy of Takradhara inKitihba kushta (Psoriasis), 2. To evaluate the efficacy of Aragwadi gana kashayaTakradhara in Kitibha kushta (Psoriasis). The aim of the study was to find out the psychosomatic effect of AragwadadiGana kashaya Takradhara in Kitibha kushta (Psoriasis). The study design selected for thepresent study was an observational study, After treatment out of 30 patients 8 patients (26.66%) got complete remissionform the symptoms, 4 patients (13.33%) showed marked improvement, 7 patients(25.90%) got moderate improvement and 5 patients (16.66%) showed mild improvement.No response was found in 6 patients (20%). Among all the parameters Itching andScaling showed high significant in all the parts. Other parameters like Erythema andThickness were not significant in body and legs (As by using paired t test). Triggering factors like Bhaya, Krodha Chettodvega and Shoka were also studiedand they showed high significant response.(As by using paired t test) Kitibha kushta is a form of kshudra kushta. Based on the similarities of symptomsand other description available in the medical literature many of the Ayurvedicresearchers who have worked on skin disorders have equated it to Psoriasis. Psoriasis ismore stress sensitive than other Skin disorders.Aragwadadi gana kashaya Takradhara,which was selected for the study showed that it is having the role in reducing vitiatedmanasika as well as shareerika doshas.
V TABLE OF CONTENTSChapters Page No.1. Introduction 1-32. Objectives 4-73. Review of literature 8-904. Methodology 91-1075. Results 108-1376. Discussion 138-1627. Conclusion 163-1648. Summary 1659. Bibliography10. Annexure
VI List of TablesTable Showing the Page No. No. 01. Layers of skin according to Charaka 17 02. Layer of the skin according to Sushruta 17 03. Correlation between the Ayurvedic & Modern skin layers 18 04. Relation between skin and hormones 26 05. Difference between Maha Kushta and Ksudra kushtas 47 06. Classification of Kushta according to different Acharyas 47 07. Relation between doshas and kushtas 48 08. Symptoms according to dosha predominant 49 09. Aharaja Nidana of Kitibha kushta 49 10. Viharaja Nidana of Kitibha 50 11. Daivapacharaja Nidana of Kitibha 51 12. Poorvaroopas mentioned by different acharyas 60 13. Lakshanas of Kitibha Kushta 61 14. Comparison between the kitibha kushta lakshana and psoriasis 66 15. Differential diagnosis of Kitibha kushta 67 16. Pharmacodynamics of drugs of Aragwadadi Gana 91 17. Pharmacodynamics of Drugs Used For Moorchana of 93 Tilataila 18. Chemical composition of the drugs used in Tilataila 95 moorchhana 19. Showing the Pharmacaodynamics of drugs of Gandharva Hastadi 96 Kashaya 20. Drugs used for preparing of Medicated Milk 97 21. Qualities of Takra 97 22. Method to assess PASI score 104 23. Distribution of patients by Age 108 24. Distribution of patients by Sex 109 25. Distribution of patients by Occupation 109 26. Distribution of patients by Economical status 109 27. Distribution of patients by Religion 110 28. Distribution of patients by Marital status 110 29. Distribution of patients by Dietary habits 110 30. Distribution of patients by Addiction 111 31. Distribution of patients by Agni 111 32. Distribution of patients by Koshta 111 33. Distribution of patients by Nidra 112 34. Distribution of patients by Deha prakriti 112 35. Distribution of patients by Satmya 112 36. Distribution of patients by Sara 113 37. Distribution of patients by Samhana 113 38. Distribution of patients by Satwa 113
VII39. Distribution of patients by Ahara shakti 11440. Distribution of patients by Vyayama shakti 11441. Distribution of patients by Onset 11442. Distribution of patients by Dominant rasa 11543. Distribution of patients by Nidana 11544. Distribution of patients by Viruddha ahara 11645. Distribution of patients by Mithya ahara 11646. Distribution of patients by Mithya vihara 11747. Distribution of patients by Manasika Nidana 11748. Distribution of patients by Family history 11849. Distribution of patients by Chronicity 11850. Distribution of patients by Medication 11951. Distribution of patients by Aggravating season 11952. Distribution of patients by Types of Psoriasis 11953. Distribution of patients by Chief complaints 12054. Distribution of patients by Associated complaints 12055. Distribution of patients by Confirmation test 12156. Distribution of patients by Precipitating factor 12157. Distribution of patients by Psoriasis with different site of 121 involvement58. Distribution of patients by Particular site involvement 12259. Overall response to the treatment 12260. Distribution of patients with different severity scorings in Head 12361. Distribution of patients with Itching Head 12362. Distribution of patients with scaling Head 12463. Distribution of patients with Erythema Head 12464. Distribution of patients with Thickness Head 12565. Distribution of patients with Area Head 12566. Distribution of patients with different coverage area in Head 12667. Distribution of patients with Head total PASI score 12668. Distribution of patients with different severity scorings in Arms 12769. Distribution of patients with Itching Arms 12770. Distribution of patients with Erythema Arms 12771. Distribution of patients with scaling Arms 12872. Distribution of patients with Thickness Arms 12873. Distribution of patients with Area Arms 12974. Distribution of patients with different coverage area in Arms 12975. Distribution of patients with Arms total PASI score 13076. Distribution of patients with different severity scorings in Body 13077. Distribution of patients with Itching Body 13178. Distribution of patients with Erythema Body 13179. Distribution of patients with scaling Body 13280. Distribution of patients with Thickness Body 13281. Distribution of patients with Area Body 13382. Distribution of patients with different coverage area in Body 133
VIII83. Distribution of patients with Body total PASI score 13384. Distribution of patients with different severity scorings in Legs 13485. Distribution of patients with Itching Legs 13486. Distribution of patients with Erythema Legs 13587. Distribution of patients with scaling Legs 13588. Distribution of patients with Thickness Legs 13689. Distribution of patients with Area Legs 13690. Distribution of patients with different coverage area in Legs 13791. Distribution of patients with Legs total PASI score 13792. Total PASI scoring for all 30 patients 13893. After treatment statistical results of PASI score of different areas 13994. After treatment statistical results of PASI score of different 139 symptoms of head95. After treatment statistical results of PASI score of different 140 symptoms of arms96. After treatment statistical results of PASI score of different 140 symptoms of body97. After treatment statistical results of PASI score of different 141 symptoms of legs98. After treatment statistical results of PASI score of total PASI for 141 all parts99. Statistical results of manasika bhavas 141
IX List of Graphs01. Graph No. 01. Showing the distribution of patients by Age groups.02. Graph No. 02. Showing the distribution of patients by Deha prakriti.03. Graph No. 03. Showing the distribution of patients by Onset.04. Graph No. 04. Showing the distribution of patients by Samanya Nidana.05. Graph No. 05. Showing the distribution of patients by Manasika Nidana.06. Graph No. 06. Showing the distribution of patients by Family history.07. Graph No. 07. Showing the distribution of patients by Chronicity.08. Graph No. 08. Showing the distribution of patients by Aggravating factor.09. Graph No. 09. Showing the distribution of patients by Type of Psoriasis.10. Graph No. 10. Showing the distribution of patients by Chief complaints.11. Graph No. 11. Showing the distribution of patients by Associated complaints12. Graph No. 12. Showing the distribution of patients by Confirmation test.13. Graph No. 13. Showing the distribution of patients by Sites of involvement.14. Graph No. 14. Showing the Overall response to the treatment. List of flow charts1. Samprapti of Kushta according to Charaka 552. Samprapti of Kushta according to Sushruta 553. Samprapti of Kushta according to Vagbhata 564. Samprapti of Kushta according to Bhela 565. Samprapti of Kitibha Kushta 57 List of Figure01. Figure No. 01. Showing Histology of skin.02. Figure No. 02. Showing histological changes in skin of Psoriasis. List of Photographs01. Photo No. 01. Showing the medicaments used for Takradhara.02. Photo No. 02. Showing the procedure of Takradhara and the effect of therapy before and after treatment.
INTRODUCTION Ayurveda the eternal science took birth with world itself and is not liable to changeat any time or in any part of the world. Aim of Ayurveda is to promote health and curediseases. Ayurveda has designed a variety of treatment modalities among whichPanchakarma is the most superior. Panchakarma mitigates the root causes of the diseasesand promotes health. Man, the gifted creature of God is running behind everything today. Nobodywants to spend sufficient time on required day-to-day activities. Due to the fast movinglife style all the daily activities of the man turned up side down and gave to two types ofdisorders viz. Somatic and Psychosomatic. The main discussion of this thesis, Kitibhakushta (Psoriasis) is a disorder of psychosomatic in nurture, which arises due to the faultylife style. Position of anything that made of silver is identified as a sign of wealth. But notthe silvery scales, which is the cardinal symptom of Psoriasis. This obnoxious illnessthough not contagious, isolates the patient from their family and society or else thepatient himself hesitates to move with his family and society fearing dejection. The history of psychosomatic problem is as old as the history of humancivilization. Till today somatogenic and psychogenic solution are put forward althoughboth are extremists. In our classics Manas and Shareera are regarded as separate entitiesbut not in the sense of separation, because an organism is a complex combination ofAtma, Manas, and Shareera i.e. soul, mind and body. So Ayurvedic approach to a diseaseis definitely psychosomatic in nature. For example – Kushta is due to disrrespective givento Gurus, Bramahanas, doing Papakarmas, etc. So our Acharyas has given more emphasisto the integrated aspect of mind and body. 1 Introduction
Kitibha kushta of Ayurveda closely resembles the clinical symptoms of Psoriasis.As per the of disease nature, this is a chronic recurrent dermatosis. The primary lesion isan epidermal papule. The Psoriatic papule is pink in colour of various intensities. Thefresh lesions are brighter and older ones are darker. The papules are flat and have roughsurface covered with silver white microlamellar scales, which scrap off easily. At first thepapules have a regular round, countour and a diameter of 1-2 mm each. Later they spreadperipherally after attaining size with an intensive itching sensation of the skin. If weconsider the above symptoms they closely resembles the symptoms of Kitibha kushta.And also the researchers those who worked on skin disorders have correlated Kitibhakushta with Psoriasis. So the present study entitled “The Evaluation of The Efficacy ofTakra Dhara in Kitibha Kushta (Psoriasis)” was undertaken. The main aim of the study is to focus the psychosomatic treatment for Psoriasis. Itis more stress sensitive than other skin disorders since anxiety and tension aggravate thecondition. As stated before Shareera and Manas go hand-in-hand in causing the disease,hence a humble attempt is made to pacify vitiated Manasika and Shareerika bhavas. Ayurveda considers Kushta as an important disease and categorized it as a“MAHAROGA”. Though curative and preventive measures are in full swing and underthe guidance of W.H.O., the central and state governments and voluntary organizations,several measures are being persuaded for warding of Kushta. The grim reality would beto reveal all steps already taken and still in progress or quite insufficient for immunizingof this dreaded disease. In this circumstances along with Ayurvedic physicians andscientists, practitioners of Unani, Siddha, and other allied systems should also raise equalto the occasion and work whole heartedly and dedicated spirit for eradicating this dreadeddisease from the world permanently. 2 Introduction
Science is a gradual evolution; it is not a sudden invention. Ayurveda as a scienceis not an exception for it. The imperishable fundamentals of Ayurveda, which were laiddown by great sages of the olden days, are still applicable because of scientific andeternal background. Such fundamentals must be subjected to scientific research not onlyto prove its certainty but also to add something new to the existing knowledge. Bykeeping this in mind the present study was undertaken. 3 Introduction
NEED FOR THE STUDY Takradhara is one among the Keraleeya chikitsa krama. It is said to be the best fordhatu shaithilya and all kinds of doshakopa. It is the process in which the medicatedbuttermilk is poured in a continuous stream on the head especially on the forehead in thespecific manner. Procedure of any kind of Dhara has been mentioned in our classics. But indifferent contexts the word Parisheka has been mentioned which is equated to dhara.Vagbhata considered Seka as one of the type of Moordhini taila. Bhavaprakasha in hisnetra roga chikitsa adhikara mentioned Seka for the eyes, which means a sukshma dhara. Kitibha kushta is a form of Kshudra kushta. Based on the similarities ofsymptoms and other description available in the medical literature, many of theAyurvedic researchers and authors of recent past who have worked on skin disordershave equated to Psoriasis. However the correlation of Kitibha kushta to Psoriasis ordetailed description of Psoriasis is not the subject of the study. Psoriasis affects 1-3% of the world population. It occurs with almost equalfrequency in males and females, however a high prevalence in males (24%) to females(0.8%) is noted in earlier studies. Contemporary systems of medicine has paid a lot ofattention to counter this dreadful disease. The modalities of the management of Psoriasisare only palliative and recurrence oriented. The external applications and the internalmedications provide only a temporary relief to the patient and also most of the drugs usedfor the remission of this disorder are known for their side effects. In the above situation Ayurveda has got the answer for the treatment of such skindiseases. Among the various treatment modalities, which are good for various skinailments, Takradhara plays pivotal role and is stated best for both Shareerika andManasika doshas, as stress and tension aggravate the Psoriasis. 4
PREVIOUS WORK DONE ON KITIBHA KUSHTA (PSORIASIS)Trivendrum : - 01. Dr. Patil 1980. Worked on the effect of Snehapana in Kushta (W.S.R.T. Psoriasis). 02. Jayarama 1988. Studied classical management of Kushta (W.S.R.T. Psoriasis). 03. Dr. Mohan 1984. Studied the role of Takradhara in the Management of Kitibha Kushta (Psoriasis).Jamanagar : - 01. Dr. Makwana 1979. Worked on Efficacy of Arogyavardhini and Gandhaka Rasayana internally, Gandhaka Malahara externally Kitibha (Psoriasis). 02. Dr. Sabu 1988. Worked on Comparative Efficacy of Raktamokshana and Brihat Manjishtadi Kashaya with Talasindhoor in Kitibha (Psoriasis)Ahamedabad : - 01. Dr. Kale 1993. Worked on Comparative Efficacy of Virechana and Shamana with Panchatikta Ghrita Guggulu and Chandamaruta Sindhoora externally in Kitibha (Psoriasis).B.H.U. : - 01. Dr. Tangoria 1989. Studied the Management of Kitibha (Psoriasis) by an indigenous drug Stree Kutaja. 02. Dr. Anken 1991. Studied Concept of Kitibha in Ayurveda and Modern medicine and its Treatment with Stree Kutaja – A further study. 5
Banglore : - 01. Dr. Rajeshwari 1986. Studied Jalokavacharana in Kitibha Kushta (Psoriasis). 02. Dr. Jayashree 1986. Studied Efficacy of Panchakarma in the Management of Kitibha kushta (Psoriasis). 03. Dr. Rekha 1995. Studied The effect of Vamana and Virechana on Psoriasis. Takradhara is a simple technique; ingredients are easily available and economicaland is also indicated in dhatu shaithilya and doshakopa, which is normally seen inKushta. Considering the utility of Seka and Takra in different Kushtas the expandedversion will be studied as Takradhara. 6
OBJECTIVES OF THE STUDY 01. To Evaluate the efficacy of Takradhara in Kitibha kushta (Psoriasis) 02. To Evaluate the efficacy of Aragvadadi gana kashaya Takradhara in Kitibha kushta (Psoriasis). 7
HISTORICAL REVIEWKARMA It is essential to know any Panchakarma procedures or any KeraleeyaChikitsakrama, which are available in Vedas. As they are the prime sources of ancientwisdom, from the research point of view one must search for such and possibleevidences. Such search of Vedas for reference regarding Panchakarma, Keraleeyachikitsakrama, Seka or Dhara in particular was not fruitful. But, if we go through ourSamhita granthas carefully, we can find ample references for Seka. Among all theSamhita granthas Charaka Samhita (1000 B.C.)1 was the first to describe Seka indifferent diseases. Acharya Bhela2, Kashyapa3, Sushruta Samhita4, Vagbhat5, had considered seka asthe type of moordhini taila. The latter texts such as Bhavaprakasha6, Yoga Ratnakara7,Chakradutta8 have also mentioned about Seka. Even though the therapeutic utility ofSeka in various disorders has been mentioned in our classics the utility of Takraseka orTakradhara has not been explained. Reference for the Takra is available from the Vedicperiod to Samhita kala. Takra is said to be Amruta9 and it is even difficult for Indra10 toget it. Different forms of takra and its kalpanas11 are also mentioned in classics. Textbooks on Ayurveda originated form Kerala such as Dharakalpam12,Keraleeya chikitsakramam13, Chikitsa Sangraham14, Ayurvedic treatments of Kerala15had described Takradhara as an effective technique for all kinds of doshakopa16 anddhatu shaithilyata17, which is normally seen in Kushta. 8
VYADHI01. Vedic Period18 Vedas are considered as the oldest and the first available literature of the world.The history of Indian medicine starts with Vedas, so the history of Twak rogas beginsfrom vedic period. Many references regarding kushta are found in Vedas. A. Rigveda18a – In Rigveda there is no complete description of kushta. But somedescription indicates that kushta was prevalent in that period also. The Charmaroga of Aapala was cured by the Lord Indra. Ghosa was suffering form Kushta roga. She was disliked by her husband becauseof her ugly looks due to kushta roga. By administration of proper medication she gotcured and ultimately accepted by her husband. B. Yajurveda18b – Shukla Yajurveda mentioned various medicines having kushtanashahara properties. C. Atharvana Veda18c – In Atharvana veda, the various sites for disease havebeen described and amongst them skin has been described as one of the chief site of thedisease. The names of the various diseases have been illustrated where by kushta hasbeen described as Kshatriya roga. There is description of some herbs like Rama, Neeli,Asaru, Shyama, etc. for the treatment of kushta. Shringa i.e. Horn of deer possessing aproperty of twak rogahara has been mentioned.02. Purana Kala A. Mahabharata18d – It is mentioned that the person suffering from twak doshais not fit to be a king. This reference highlights that at that time people suffering formkushta were looked down by the society. 9
B. Agni Purana18e – Kushtahara medicines are mentioned under the heading ofNanarogahara aushadhani. C. Garuda Purana18f – In various chapters of Garuda purana description aboutTwak roga has been explained viz. Kushta, Sidhma kushta, etc. D. Panini18g – In Ashtadhyaya of Panini grammatical literature about the diseaseis explained. The diseases like Atisara, Arsha, Kushta have been explained and also thediseases caused by Anuvamshika doshas and vyadhis are also been explained. E. Kaushika Sutra18h – The reference of Kushta and its treatment is mentionedin Kaushika Sutra like chanting Mantras, external application of paste made up of drugslike Bhringaraj, Haridra, Indravaruni, Neelika pushpa, etc.03. Samhita kala19 A. Charaka Samhita – Charaka described in detail for the first time, a long rangeof skin diseases with their etiology, pathogenesis and specific classification under theheading of Kushta. Charaka has described eighteen types of kushta. Seven types ofkushtas have been described under the category of Mahakushta in Nidanasthana19a. InChikitsasthana19b eighteen types of Kushta have been classified under seven Mahakushtaand eleven Kshudra kushta. Apart from these; description of kushta is available in the following chapters – 01. Kushta is described as samanya hetu of Nija shotha19c. 02. Kushta is considered as a Santarpanajanya vyadhi19d. 03. It is included as one of the disease caused by the rakta19e. 04. Use of stamabana dravyas in the initial stage of Raktapitta, Raktarsha, and Amatisara leads to kushta. 10
05. Kushta is noted in Lekhana yogya and Pracchana yogya vyadhis19f. 06. Agni karma is contraindicated in kushtaja vrana19g. B. Sushruta Samhita – Acharya Sushruta, for the first time clearly described theAnuvamshika (Hereditary) and Krimija (Infectious), nidanas as a causative factors forkushta20. Kushta has been included in Aupasargika roga which may spread from oneperson to other21. He also explained dhatugatatwa and uttarottara dhatu pravesha ofkushta roga22. The number of kushta rogas described by Sushruta is the same as that ofCharaka, but Dadru has been mentioned under Mahakushta and Siddhma under kshudrakushta. Sushruta describes the chikitsa in two chapters i.e. Kushta chikitsa andMahakushta chikitsa. Guggulu, Shilajatu, Shweta bakuchi, etc and rasayana drugs arealso mentioned. C. Ashtanga Hridaya – Vagbhata has followed Sushruta regarding classificationof Mahakushta and Kshudrakushta23. But Kitibha kushta has been mentioned underkshudrakushta with some lakshanas as described by Charaka24. D. Bhela Samhita25 – Bhela Samhita has described kushta roga in both nidanaand chikitsasthana. He has mentioned that polluted water is the main etiological factor ofkushta. E. Kashyapa Samhita26 – Kashyapa samhita has described eighteen types ofkushtas as Charaka except the Shwitra, Vishaja kushta and Sthul ruksha kushta, Insteadof Charma kushta, Alasaka and Visphotaka. Kahsyapa has given the classification ofkushta on the basis of sadhyasadhyata. Thereby nine kushtas are described as Sadhyawhile others as Asadhya. 11
04. Sangraha Kala A. Madhava Nadana27 – Madhava has described Nidana panchaka of kushtaaccording to Charaka and Vagbhata. While dhatugatatwa, sadhyasadhyata andSankramakata (contagious) have been described according to Sushruta. B. Sharangadhara Samhita28 – Classification of kushta has been described inPoorvakhanda. He describes Tamra which is the fourth layer of skin is the site for alltypes of kushtas. C. Vangasena29 – Vangasena has mentioned seven types of special causes ofkushta i.e. Taila, Kulatha, Valmika linga roga, Mahisha dugdha, Mahisha dadhi andVruntaka. D. Bhavaprakasha30 – Bhavaprakasha has described a detail description ofkushta roga. He has followed Charaka for classification and nomenclature of kushta. Thedhatugatatwa and sahdyasadhyata are compiled form Sushruta. F. Yogaratnakara31 – Yogaratnakara describes kushta according to the earlierclassics, contagious aspect of kushta is also described by him. G. Rasaratna Samucchya32 – In third chapter, while explaining Gandhaka gunashe mentioned that it is useful in kushta. H. Rasatarangini33 – In Gandhaka prakara, Gandhaka taila is indicated isMahakushta and other skin diseases. 12
VYUTPATTI & PARIBHASHA The word Takradhara is comprised of two words viz. Takra and Dhara. Takra34 – This word is derived form Tak + Rak pratyaya. It is napumsakalinga,if ¼th of water is added to it then is called as Takra. Dhara35 – Means, Dharabhir Nivruttam | It is napumsakalingam, Dhara which ischaracterized by streams – means the fall of liquid substance in a stream.Vyutpatti of Kushta (Derivation of Kushta) The word kushta is derived form the root “Kush” which means that which comesout from inner part to outer part36. In the term kushta the word “Kush” is added to “Hani” to form kushta, whichgives a meaning that it gives an ugly look to the body37a. The word kushta is derived form the dhatu “Kush” meaning; the morbid factormainly rakta is drawn towards the region of twak so as to cause kushta37b.Paribhasha (Definition of Kushta) According to Arundutta, kushta is defined as that which causes disfigurement tothe body38.Nirukti & Paribhasha of Kitibha kushta The term Kitibha is constituted by the combination of “Kiti” and “Bha”. The wordKiti refers to variety of insects, which is black in colour, stays in kesha pradesha or inhair39. The word “Kiti” is also termed as “Akuna” by Hemadri. This indicates that it iseither a louse or some other insect, which is similar to louse. 13 Vyutpatti & Paribhasha
The word “Bha” refers to the resemblance or similarity. So the term Kitibha,which is constituted by suffixing “Bha” to “Kiti”, suggests something, which resembleslouse. The similarity is mentioned only in colour (Krishna), as it resembles, the colour oflouse but not referred to its shape or size. So the definition of Kitibha is “A pathological skin condition where the colour ofskin is black like Kiti i.e. Louse. Sushruta has also given one more meaning to Kitibha; itis an upadrava caused as a result of the bite of the poisonous variety of insect40. Etimology of Psoriasis – The word “Psoriasis” is derived from the Greek work“Psora” which means “itch” or “scale”.Definitions of Psoriasis Psoriasis is defined as a skin disorder, which have been classified and discussedunder various headings. Keratinization disorder is one group, in which there will behyperkeratinization of the basal cells of epidermis. Kitibha kushta is which skin becomeshard or horny, as like psoriasis in contemporary context. Psoriasis is one among thekearatinization disorders of the skin, which also involves either genetic or immunologicalderangements. According to various authors the psychosomatic disorder, psoriasis is defined andcharacteristic features are established as under – 01. Psoriasis is characterized by the development of erythmatous, well defined,dry, scaly papules and plaques of sizes ranging from a pin head to larger lesions(Pavitram K 1994.). 14 Vyutpatti & Paribhasha
A common genetically determined disease of the skin consisting of well definedpink or dull red lesions surrounded by the characteristic silvery scale. (Baker Harvey &Wilkinson. D. S. 1986.) A chronic disease characterized by sharply defined patches of erythema coveredby silvery scales (Kirbua John D. 1986.)It is a common chronic and non-infectious skin disease characterized by well-defined,slightly raised, dry erythematous macules with silvery scales and typical extensordistribution. (Bhela P. N. 1987.) 15 Vyutpatti & Paribhasha
RACHANA SHAREERA OF TWAK Beauty is an important part of human experience. Beauty without perfect blemishless skin is incomplete. Clean skin suggests absence of acquired or inherited healthdisorders. Hence, people spend much time and money to restore skin to a more normal oryouthful appearance.Ayurvedic View In Ayurveda, the word “Twacha” or “Charma” is used for skin41. Twacha isderived from “Twacha Samvarne” dhatu means – the covering of body. It can be definedas body substance that covers the internal tissues like Rakta, Mamsa, Medas, and otherdhatus.Synonyms of Twacha Twak, Charma, Sparshanendriya, etc.Formation of the skin Sushruta described the process of formation of twacha in the developing foetus.He says that after formation of the ovum twacha develops just like a cream on the surfaceof the milk42. In the uterus during the course of development of garbha differentiation ofthe layers of the skin takes place and is produced by all three doshas particularly by pittadosha. Twacha develops consecutively in seven layers by the synchronized peculiaraction of dosha. Vagbhata described the formation of twacha due to paka of rakta dhatu by itsdhatwagni in the foetus. After paka, it dries up to form twacha just like the deposition ofthe cream over the surface of the boiled milk43. 16 Shareera
Layers of the Twacha A. There are differences of opinion regarding the layers of skin. Charaka hasdescribed six layers of the skin. Out of these six he has given names to the first andsecond layer. The rest four layers have been described in terms of the disease44.Table No. 01. Showing layers of skin according to Charaka. No. Layer Disease 01. Udakadhara - 02. Raktadhara - 03. Triteeya Sidhma, Kilasa 04. Chaturtha Dadru, Kushta 05. Panchama Alaji, Vidradi. 06. Shashta Arhsa, Bhagandhara B. Sushruta has described seven layers of the skin along with the specific names.He has also mentioned the thickness of each layer along with the disease, which are proneto that layer45.Table No. 02. Showing the layer of the skin according to Sushruta.No. Name Thickness Disease01. Avabhasini 1/18th of Vrihi (0.05-0.06 mm) Sidhma, Padmakantaka02. Lohita 1/16th of Vrihi (0.06-0.07mm) Tilakalaka, Nyachya, Vyanga03. Shweta 1/12th of Vrihi (0.08-0.9 mm) Charmadala, Mashaka, Ajagallika.04. Tamra 1/8th of Vrihi (0.12-0.50 mm) Kilasa, Kushta.05. Vedini 1/5th of Vrihi (0.2-0.3mm) Kushta, Visarpa06. Rohini 1 Vrihi (1-1.1mm) Shleepada, Arbuda, Granthi, Apachi, Galaganda07. Mamasadhara 2 Vrihi (2-2.1 mm) Arsha, Bhagandara, Vidrudhi 17 Shareera
C. Vagbhata has described seven layer of skin without naming them.Commentators Arunadutta and Hemadri named them according to Sushruta46. D. Sharangadhara has also mentioned seven layers of the skin along with theprobable onset of disease. The names of the six layers of the skin are same as Sushrutabut seventh layer is named as Sthula, which is the site of Vidradhi47. Dr. Ghanekar, the commentator of Sushruta shareerasthana has correlated thelayers of the skin with the latest modern anatomy.Table No. 03. Showing the correlation between the Ayurvedic & Modern skin layers.No. Ayurvedic Terminology Modern Terminology Types of Skin01. Avabhasini Stratum corneum Epidermis02. Lohita Stratum lucidum Epidermis03. Shweta Stratum granulosum Epidermis04. Tamra Malpighian layer Epidermis05. Vedini Papillary layer Dermis06. Rohini Reticular layer Dermis07. Mamsadhara Subcutaneous tissue & Muscular layer DermisKriya Shareera of twak The Kriya Shareera of the twaka can be understood by knowing its relation withthe dosha, dhatu, mala which are the basic structural and functional units of the body.01. Twak & Tridosha – Twacha is said to be one of the sites of Vata and Pitta dosha48. A. Twacha & Vata Dosha – Charakacharya has described Twacha as a sparshanendriya adhishthana. Sparsha i.e. touch sense is the subject of sparshanendriya which is performed by Vata dosha49. 18 Shareera
B. Twacha & Pitta dosha – Bhrajaka pitta, which is located in the skin is responsible for the luster of the skin. It is also called as Bhrajakagni. Charaka did not specified about the types of pitta, but he has said that theproduction of normal and abnormal temperature as well as the normal and abnormalcolour of the skin is due to the pitta dosha. Commenting on this Chakrapani says bodyheat regulation and variation in the colour of the body are the functions of the bhrajakapitta50. Sushruta describes it as a bhrajakagni and it enables the digestion and utilizationof substances used through Abhyanga, Pariseka, Alepa, Avagaha, etc. It indicates theglow of one’s natural complexion51. According to Bhela bhrajaka pitta is that which is responsible for themanifestation of the specific characteristics of the body. It emphasizes its importance increating different prabhas (Hues) of the head, hand, feet, sides, back, abdomen, thighs,face, nails, eyes and hair. It also brightens them52. Vagbhata mentioned bhrajaka pitta is situated in the skin. It is so called because itimparts lusture to the skin and makes it radiate. Arundutta says it is so called because itperforms deepana-pachana of substances used for abhyanaga, lepa, pariseka, etc. C. Twacha & Kapha dosha – The Snigdhata, Shlakshnata, Mriduta, Sheetata, Prasannata are the attributes to the presence of kapha dosha in the skin. Ropana karma i.e. self healing process is also one of the function of kapha dosha.02. Twacha & Saptadhatu – A. Rasa dhatu – In Several places twacha has been used as synonym of rasa dhatu like Twaka sara purusha, etc. Sushruta mentioned that in early stages Kushta is situated only in Twacha. Dalhanan commented on that and says it as Twachashrita i.e. Rasashrita kushta53. 19 Shareera
B. According to Chakrapani, Udakadhara which is the first layer of skin maintains water content of the body. Rasadhatu is jalamahabhoota pradhana in its panchabhautika constitution. This declairs the relation between rasadhatu and twacha. C. Twacha and raktadhatu – Sushruta has described varnaprasadana as one of the functions of raktadhatu i.e. it imparts the colour to skin. Raktadhatu is also responsible for the proper conduction of tactile sensation of the skin54. D. Twak and Mamsa dhatu – Twacha is an upadhatu of Mamsa dhatu. Development and nourishment of twacha is depending on the dhatupakavastha of Mamsa dhatu55.03. Twacha and Trimala – Mala, Mutra and Sweda are the three main malas are theoutcome of sarakitta vibhajana process during dhatwagni viparyaya. The kitta part isexcreted out from the body. The sweda is the mala of Medo dhatu, which is excreted outfrom the swedavahi strotas of twacha. Sweda maintains luster and humidity of the skin56. According to our science nails and hairs are the mala of asthi dhatu and twachagatsneha is the mala of Majja dhatu57. Kustha involve morbidity of seven dravyas. They are Tridosa and four Dhatus(Rasa, Rakta, Mamsa and Lasika). So from above description one can easily understandthe importance of these units. The Vikrti of these seven essentials leads to the occurrenceof many skin diseases i.e. Occurrence of many Kustha Rogas. 20 Shareera
Modern View – Anatomy of Skin58 Skin is one of the largest organ in the body in surface area and weight. In adultsthe skin covers an area of about two square meters and weights 4.5-5 kgs. It ranges inthickness from 0.5-4.0 mm. depending on location. From all the body’s organs none ismore easily inspected or more exposed to infection, disease and injury than the skinbecause of its visibility. Skin reflects our emotions some aspects of normal physiologicalprocess, which are held in our body. All the constituents are derived from ectoderm or mesoderm. 01. The epithelium structure i.e. epidermis pilosebaceous / apocrine units, eccrine sweat units and nail units are ectodermal derivations. 02. Melanocytes, nerves and specialized sensory receptors arise from the neuro- ectoderm. 03. The other elements in the skin i.e. Langer Han’s cells, macrophages, mast cells, fibroblasts, blood vessels, lymph vessels, muscles and lipocytes originate from mesoderm.Microanatomy of Skin Structurally the skin consists of two principal parts – A. The superficial thinner portion, which is composed, of epithelial tissue is called epidermis. B. The epidermis is attached to the deeper thicker connective tissue called dermis. C. Deep to the dermis there is a subcutaneous layer, which is called superficial fascia or hypodermis, which consists areolar and adipose tissue. 21 Shareera
Epidermis The epidermis is defined as squamous epithelium, which is about 0.1 greater up to0.8-1.4 mm on the palm and sole. Its prime function is to act as a protective barrier. Keratinocyte is the main cell of this layer, which produces a protein keratin. Thefour layers of the epidermis represent the stages of maturation of keratin by keratinocytes. 01. Basal layer – Stratum basale. 02. Prickle cell layer – Stratum spinosum. 03. Granular layer – Stratum granulosum. 04. Stratum lucidum 05. Horny layer – Stratum corneum. Stratum Basale – The basal cell layer of the epidermis is comprised mostly ofkeratinocytes which are either dividing or non dividing. The cells contains keratin,tonofibrins are secured to basement membrane by hemidesmosomes. Melanocytes makeup 05-10% of the basal cell population. These cells synthesis melanin and transfer it viadenritic process to neighboring keratinocytes. Melanocytes are most numerous on theface and other exposed sites and are of neural crust origin. Merkel cells are also found abit in frequently in the basal cell layer. These cells are closely associated with terminalfilaments of cutaneous nerve and seem to have a role in sensation. Their cytoplasmcontains neruopeptid granules as well as neurofilaments and keratin. Stratum spinosum – Daughter basal cells migrates upwards to form these layer ofpolyhedral cells, which are interconnected by dermosomes. Keratin tonofibrils form asupportive mesh in the cytoplasm of these cells. Langer Hans cells are mostly found inthis layer. 22 Shareera
Stratum granulosum – Cells become flattened and loose their nuclei in thegranular cell layer. Keratohyalin granules are seen in the cytoplasm together withmembrane coating granules, which expel their lipid contents into the intercellular space. Stratum lucidum – Normally only thick skin of the palms and the soles has thislayer. It consists of 3-5 rows of clear flat dead cells that contains droplet of anintermediate substance that is formed from keratohyalin and is eventually transformed tokeratin. Stratum corneum – The end result of keratinocytes maturation can be found in thehorny layer which is comprised of sheets of overlapping polyhedral cornified cells withno nuclei (corneocytes). The layer is several cells thick on the palms and the soles butless thick else where. The corneocyte cells envelop is broadened and the cytoplasm isreplaced by keratin tonofiriles in a matrix formed from the keratohyalin granules cellswhich are struck together by a lipid glue which is partly derived from membrane coatinggranules.Dermis The dermis is derived as a tough supportive connective tissue matrix containingspecialized structures found immediately below and intimately connected with epidermis.It varies in thickness being thin 0.6 mm on the eyelids and thicker more than 3 mm onpalm and soles. The dermis chiefly consists of white fibrous tissue, elastic fibers and non-stripedmuscles and contains blood vessels, nerves, hair, sweat gland, sebaceous glands andnerve corpuscles. The outer portion of dermis is about 1/5th of the thickness of the totallayer is named as papillary region. The deeper portion of the dermis is called as reticularregion. It consists of dense irregular connective tissues containing interlacing bundles ofcollagen and coarse elastic fibers. 23 Shareera
The reticular region is attached with underlying organs such as bone and musclesby the subcutaneous layer also called as hypodermis or superficial fascia.PHYSIOLOGY OF SKIN59 The skin is metabolically active organ with vital functions including theprotection and maintaining homeostasis of the body.Functions of the skin 01. Regulation of the body temperature. 02. Protection 03. Immunity 04. Sensation 05. Excretion 06. Blood reservoir 07. Synthesis of vitamin DKeratin Maturation The differentiation of basal cells into dead but functionally important coenocytesis a unique feature of the skin. The horny layer is important in preventing all types ofagents from entering the skin including microorganisms, water and a particular matter.The epidermis also prevents the body fluids from getting out. Epidermal cells undergo the following sequence during keratinocyte maturation. 01. Undifferentiated cells in the basal layer immediately above divide continuously. Half of these cells remain in place and half progress upwards and differentiate. 24 Shareera
02. In the prickle cell layer cells change from being columnar to polygonal. Differentiating keratinocytes synthesize keratin, which aggregate to form tonofilaments. The desmosomes connecting keratinocytes are condensation of ton filaments. Desmosomes distributes structural stresses throughout the epidermis and maintain a distance of 20 mm between advancement cells. 03. In the granular layer enzymes induce degradation of nuclei and organelles. Keratinohyalin granules mature the keratin and provide an amorphous protein matrix for the tonofilaments. Membrane coating granules attach to the cell membrane and release an impervious lipid containing cement which contributes to cell adhesion and to the horney layer. 04. In the horney layer the dead flattened corneocytes have developed thickened cell envelops encasing a matrix of keratin tonofibils. The disulfide bonds of the keratin provide strength to the stratum corneum but the layer is also flexible and can absorb up to 3 times its own weight in water however if it dries out i.e. water content falls below 10% pliability falls. 05. The corneocytes are eventually shed from the skin surface. Rate of Keratin maturation – Kinetic studies show that on an average thedividing basal cells replicate every 200-400 hours and the resultant differentiating cellstake about 14 days to reach the stratum corneum and a further 14 days to be shed. Thecell turnover time is considerably shortened in keratinization disorders, such as psoriasis. Biochemistry of the skin – The important molecules synthesized by the skin are(a) keratin, (b) melanin (c) collagen and (d) glycosaminoglycans. Hormones and the skin – the skin is the site of production of one hormone (vit.d) but it is often a target organ for other hormones and is frequently affected in endocrinediseases. 25 Shareera
Table No. 04. Showing the relation between skin and hormones.No. Hormone Site of Production Effects01. In dermis from precursor Important for the absorption of Vit – D through the action of UV Ca-. and for calcification. radiation02. - Receptors on several cells in both epidermis and dermis - Produce vasoconstriction Corticosteroids Adrenal cortex - Reduce mitosis by basal cells. - Generate anti-inflammatory effects on leukocytes. - Inhibit phospholipase A03. - Receptors on hair follicles and Androgens Adrenal cortex and gonads sebaceous glands. - Stimulate terminal hair growth and increase output of sebum04. MSH & ACTH Pituitary glands - Stimulate melanogenesis05. Estrogens Adrenal cortex and ovaries - Stimulate melanogenesis06. - Receptors found on keratinocytes, hair follicles, and Epidermal Skin sebaceous glands and sweat duct growth factor cells. - Stimulates differentiation after Calcium metabolism.07. Cytokines and Effects on immune functions, eicosanoids Cell membrane inflammatory and cell proliferation. 26 Shareera
Immunology of Skin :60 The skin is an important immunological organ and normally contains nearly allthe elements of cellular immunity with the exception of B-Cells. Much of the originalresearch into immunology was done under the skin as a model. The immunologicalcomponent of skin can be separated into. 1. Structures 2. Cells 3. Functional systems 4. Immunogenetics. Structure – The epidermal barrier is an important example of innate immunitysince most microorganisms that have contact with the skin don’t penetrate it. Equally thegenerous blood and lymphatic supplies to the dermis are important channels throughwhich immune cells can pass to or from their sites of action. Cells – Langerhans Cells : The langerhans cells of the epidermis are theoutermost sentinels of the cellular immune system. They are dendritic, bone - marrowderived cells characterized ultra structurally by a unique cytoplasmic organelle known asthe “Birbeck granule”. Langerhans cells play an important role in antigen presentation.Dendritic cells are also seen in the dermis these lack the birbeck granule but their othercharacter suggests that they too can present antigen. T-Lymphocyte : T-Lymphocytes are now believed to circulate through normalskin where they are thought to mature. Different types of T-Cells are recognized. i.e. 1. Helper - Facilitate immune reaction 2. Delayed hypersensitivity - Specially sensitized. 3. Cytotoxic suppressor - Regulate other lymphocytes. 27 Shareera
Surface receptors detectable by the use of monoclonal antibodies on tissuesections help to categorize the subgroups. Helper T- Cells often show the CD-4 receptorsand suppressor T- Cells shows the CD-9. B-lymphocytes are not found in normal skin butare seen in some diseases. Mast cell : These are normal residents of the dermis as are macrophages, bothmay be recruited to the site during inflammatory reactions. Keratinocyte : It has recently been recognized to have an immunologicalfunction. They can produce pro-inflammatory cytokines (specially interteukin-1) and canexpress on their surface immune reactive molecules such as MHC Class II antigens e.g.HLA – DR and Inter cellular Adhesion molecules ( ICAM-I)Functional Systems 01. Skin associated lymphoid tissue : The skin with its atternt blood supplylymphatic drainage, regional lymph nodes, circulating lymphocytes and resident immunecells can be viewed as forming a regulatory immunological unit. 02. Cytokines are soluble molecules that mediate actions between cells. they areproduced by t-lymphoctyes and sometimes by other skin cells including langerhans cells,keratinocytes, fibroblasts, endothelial cells and macrophages. Eicosanoids are nonspecificinflammatory mediators (e.g. Prostaglandis, Thromboxanes and Leukotrienes) and are producedfrom Arachidonic acid by most cells, macrophages and keratinocytes. 03. Adhesion Molecules : The Adhesion molecules particularly ICAM-1 are cellsurface molecules found on lymphocytes and some times on endothelial cells andkeratinocytes. By interacting with leukocyte functional antigens they help to bind t-cells andincrease cell trafficking to the area. 28 Shareera
04. Immunogenetics : The tissue type antigens of an individual are found in theMajor Histocompatibility Complex (MHC) located in man on the HLA gene cluster onchromosome 6. The MHC Class-II antigens of which the commonest is HLA-DR areexpressed on B-lymphocytes, Langerhans cells, sometimes T-cells, Marophages,Epithelical cells and Keratinocytes. They are vital for immunological recognition but alsoare involved in transplant rejection. In addition the appearance of specific HLA genes is associated, with an increaselikelihood of certain diseases, some of which are Autoimmune in nature. 29 Shareera
DHARAKARMA61a Shira seka is one of the many special types of treatments widely practiced inKerala for diseases of head. In classical medical literature one meets with the causalreferences for this as well, but details are not available from any of them. Shiraseka otherwise called as Dhara is the process in which medicated oil, milk orbuttermilk, is poured in a continuous stream on the head especially on the forehead in aspecific manner. Dhara is a method of the Kerala special treatment evolved from the genius of themedical tradition there. Many such distinctive and excellent forms of treatments notpracticed in other parts of India, are conducted by the Kerala physicians. Dhara is oneamongst them and the most important. Although there are many physicians conductingthis treatment, only a few manage it with a thorough understanding of its principles. Toconduct a dhara in a proper manner order is very difficult and expensive too. To manageit properly without any omission or mishaps, the physician should be well studied andexperienced. Besides, to select the suitable cases for dhara, he must have gooddiscretionary ability. To speak the truth, dhara is good for all diseases. Changing the liquid as per thedosha condition with necessary alteration in its process is useful to alleviate any dosha.For instance, oils medicated with appropriate medicines in vata, ghee prepared with pittahealing medicines in pitta and mere oils in kapha can be used. For a healthy man,Yamaka (mixture of oil and ghee) is preferred as per tradition. According to anotherversion, the suitable liquid medium for vata is unctuous liquids (as oils, ghee, etc.) forpitta milk and for kapha buttermilk. Sometimes in pitta diseases as per the conditions, 30 Takradhara
dhara with tender coconut water, or breast milk or cold water is performed. Similarly forkapha, dhara with some decoctions and in vata with Dhanyamla (a vinegar prepared withcereals, citrus fruits, etc.) is also conducted. This can be carried on with other liquids alsoas per our discretion looking into the details of the doshas, diseases and their seats. There are varieties of dhara. They are mainly grouped as Moordhanya (on thehead), Sarvanga (all over the body) and Pradeshika (local). The most important of these isMoordhyanya. It is employed in diseases like insanity, diseases of the head and eyes,chronic cold, sinusitis (peenasa), diseases of the ear, mouth, Vata diseases, etc. thesecond is Sarvanga dhara. It is to be done in Sarvanga vata (Vata affecting the wholebody), Sarvangeena shopha (anasarca, swelling all over the body), etc. Pradeshika orlocal in cases of rheumatoid arthritis, swelling, ascitis, abscesses, wounds, etc.MOORDHANYA DHARA There are many varieties of Moordhnidhara. The following are the importantamong them. a. Takra dhara b. Ksheera dhara c. Stanya dhara d. Sneha dhara Not only for Moordhanya dharas but for all dharas many arrangements are to bemade ready earlier. The following are the important once.DHARAPATI OR DRONI The first requirement is the proper droni. To make a proper dharapati, manyorderly steps are to be followed. The first one is the selection of the suitable wood. Manytrees as Deodar, Pine, Punnaga (Calophyllum inophyllum) Mango tree and others arespecially recommended for this. 31 Takradhara
The ideal wood universally accepted by physicians is Nuxvomica. But the woodof jack and Asana (Madras Kino wood) are also good. An average Dharapatti must be 55to 80 cm in breadth and 2.5 to 3 meters in length. On the head side the part that comesunder the neck of the patient when lying, is elevated. Behind it there is a pit to whichliquid flows when dhara is conducted. There is a hole to the pit to allow the liquid to flowout, so that the flow of the liquid to the part of the Droni where the body rests isprevented. The part of the droni where the head rests should be low by 9 to 12 cm. Thereshould be an outlet on the foot side also to allow the fluid to go out. Besides, there shouldbe handles on all the four corners 12 to 24 cm long. It is to help carry the patientsconveniently from each of the four extremes to keep the droni up from the floor. Theheight of the support is to be 24 to 36 cm. The droni for Sarvanga dhara is to have itsborders higher than other ones. Here the heights of the supports also are to be altered. Onthe head side they should be higher and on the foot side lower.DHARACHATTI (The vessel for Dhara) Amongst the apparatus required for a dhara, one very essential is the dhara vessel.It is to be made with the utmost care. It can be made with metals like Gold, Silver, etc.but some liquids used for dhara may not agree with some metal containers. So thesevessels are usually made of clay, which is best and congenial to, all alike. This vesselshould contain at least 5.5 liters of liquid and so formed that the liquid is drawn to thebottom from all sides evenly. Otherwise, when the vessel is moved to and fro, the liquidmay overflow and the steady downward flow is hindered. There is no need foremphasizing that the vessel should be made of pure clay, well baked and made durable.The edges of the vessel is to be thick a turned outwards, so that it is easy to tie a rope 32 Takradhara
around it for hanging. A hole is bored in the very center of this vessel. The circumferenceof this hole should be large enough to allow the insertion of the finger of the patient oranybody else. A wick of thread is pushed down through this hole along which the liquidis allowed to flow down. This wick should be of well spun thread soft and even. This is tobe tied (in the form of a ring) in the middle of a strong stick, about 12 cm in length. Thestick is then placed inside the vessel and the wick is let down through the hole. To place acoconut shell, bored in the center between the stick and the hole, is a practice amongphysicians. A coconut shell with regular slope is selected avoiding soft spots and is madesmooth. The edge of this shell is serrated. The shell is placed mouth downwards at thevery center of the vessel. The stick is fixed above the shell and the wick of the thread isallowed to pass down through the holes of the shell and the vessel. The benefits of thisdevice are that, when the vessel, is moved to and fro, the range of movements of the rollis controlled. If the stick is placed just inside the vessel above the hole with no coconutshell between them. The whole thread hanging down swings uncontrollably. Since thereis space between the teeth of the coconut shell, there is no chance of any hindrance to theflow of the liquid. Along with this, another trick is also done. Between the shell and thevessel round piece of plantain leaf (made out by heating) is put. This leaf is bored hereand there at various spots. This helps regulates the speed and girth of the flow, in itsabsence, there is probability of forceful rush of the liquid down when refilling the vesselrepeatedly. Fall of the liquid on the head, sometimes feebly, may create troubles. Theedge of the vessel is to be wound with strong ropes and made ready for suspending fromabove. 33 Takradhara
DHARADRAVAM (The liquid for Dhara) How to prepare the liquid for Dhara is our next concern. This is the mostimportant item in dhara. Dharas are named after the liquids employed for them. Theeffect of a dhara mainly depends upon the quality of the fluid selected. So we have toseparately deal with the liquids commonly used and with the differences in naming theirvarieties etc. Whatever be the fluid for the dhara on the head, its quantity is to be not lessthan 1800 ml or more than 3600 ml. Usually an average of 2700 ml is taken. Dhara, themost important among them in vague is Takradhara. This is not simply with rawbuttermilk as the name suggests. Dhara simply with raw buttermilk is very rare. Usuallythe buttermilk is mixed with the decoction of Amalaka (Emblica myrobalans) or someother liquids. The preparation of this buttermilk also has to be managed with special care.The tubers of Musta (Cyprus rotundus) for which outer skin removed, are taken in theratio of 30 gms/450ml of buttermilk, tied in bundle and put in milk with four times ofwater. Remove the water completely by boiling. The milk must be pure. When boiling asteady and mild fire is to be maintained. Too much blazing or drying must be avoided. Ifthe water is not removed completely, it may be the cause of many troubles. Duringboiling, the milk is to be stirred repeatedly. Even after removing the milk from the stove,the lading is continued until it cools down. The ferment is put only when the milk issufficiently cooled. On the first day, ordinary buttermilk without any water is used as aferment, since the medicated buttermilk prepared on the above lines is not available then.After adding the ferment it should be kept closed in a safe place and on the next daymorning the butter is removed by churning well. The bundle of the medicines put in themilk earlier is squeezed well and removed when the boiling process is over. But some 34 Takradhara
told that the best time for its removal is only when the curd is churned. The quantity ofmilk required for next day’s dhara fluid and also for preparing the ferment is to becollected and boiled. Besides Musta, other medicinal herbs like Chandana (Sandal wood),Usheera (Vettiver), Madhuyashti (Liquuorice) and Hribera (Coleus vettiveroides) are alsoput in the milk while boiling. Such choice is left to the direction of the physician.Whatever may be the number of medicines, the total quantity should not exceed the ratioof 30 grams for 450 ml. Generally for all diseases, Musta enough for the intendedbenefits.ATTENDANTS The attender is the next important requirement for dhara. There must be at leastthree of them. They are to be well trained, experienced in having worked together co-operatively, attentive, with love and attachment towards the patients so that he also likesand feels confidence in their care and interest towards him.THE PHYSICIAN In all treatments, the main part belongs to the physician. Dhara can never be donewithout him. The patient may have undergone many dhara treatments earlier, theattendants may be well experienced and clever, still to start a dhara in the absence of aphysician is completely wrong. The physician, who is well versed in the medical scienceand one with good experience in treatment, must have a thorough knowledge of thenature of the patient. He must be intelligent and wise so that no mistakes are committedand if anything goes wrong, he is able to rectify it immediately. Attention should be paidby him not only when dhara is being done, but also in gathering the equipments and inthe daily routine of the patient. 35 Takradhara
Although not so important as the above, there are other minor things also to beprepared earlier. A bed sheet, pillow, a roll of cloth to tie around the head, pieces of cloth,a bath towel, a vessel to collect the dhara liquid. Coming out form the droni, two suitablereceptacles to receive liquid and pour it again into the dhara vessel, two or three smallcups made of leaves, two or three small seats for the physician and attendants, a lampwith oil and wick, a time keeper, oil for the head and kuzhampu or Trivritasneha for thebody, herbal shampoo, water boiled with Amalaka for washing the head, powder of greengram or hours gram for removing the oil on the body, another fresh bath towel for dryingthe head, the medicine to be taken immediately after bath, the food at the proper time,places selectively arranged for undergoing dhara, lying and sitting all these are to be setready before the dhara. Some of these that are to be specially attended to are pointed outbelow – Bed sheet – Must be pleasing to the patient, soft and clean, but not too warm. Pillow – This is a temporary pillow prepared with soft cloth folded repeatedly. Ifis finally covered by a plantain leaf made soft by heating. This leaf cover preventswetting and since it extended to the top of the droni, from where it is let out. The length,height and thickness of the pillow are adjusted for the comfortable resting of the headduring dhara. Carelessness in this may cause many troubles. Pillows can be made of verysoft leather or oilcloth. This pillow is to be used only at the time of Dhara. At other timesthe ordinary pillow is enough for use. Varti (Roll of cloth) – This is prepared by wrapping old soft cloth. This is tiedaround the head to prevent the liquid form coming down. It is to be as thick as the thumb 36 Takradhara
of the patient and long enough to be wound around the head and tied at a side. It is betterto wet the parts of the cloth that goes round the head in the dhara liquid earlier. Oil for the head – Medicated oil for the head is to be selected to suit thetemperature of the patient and the symptoms of the disease. It should be kept safe formcold. The quantity for immediate use is taken in another pot or cup. Take care to this cupwell before use. If wet, it may cause troubles. Generally Bhringamalaki tailam,Manjishtadi tailam, Asanavilwadi tailam, Triphaladi tailam, Chadanadi tailam (Big),Tungadhrumadi tailam and Balaguduchyadi tailam are taken for this purpose. Kuzumpu for the body – These also are to be mediciated as those for the head.Usually pinda tailam, Dhanwantaram tialam, Sudhabala, Ksheerabala, Prabhanajanavimardhana, Lakshadi and Balashwagandhadi are applied warm on the body. The amalaka water – This has to be made ready, boiled and cooled the previousday. The mentioned preparation is the same as for the Paneeyas of the Ayurvedicformulary. 10 grams of Amalaki (Emblica myrobalan) seedless are put in 1800 ml ofwater (Prastha) boiled and reduced to half. Reducing only ¼ th part and leaving ¾ th foruse, is also accepted. The total quantity of Amalaka water, should not be less than sixprastha (10800 ml). For those with excess of pitta, vettiver or clearing nut (Kataka) andfor those suffering form cold, pepper leaves itself, for those with vata troubles the leavesof bala (Sida cardifolia) and for those with excess of kapha, Haritaki, are also addedwhen for preparing Amalaka water as per the tradition of the physician. Hot water – This is water was boiled with herbs healing vata such as the leaves ofcastor plant or leaves of jack tree, etc. This is not to be too hot. It has to be adjusted tosuit the temperature of the patient. 37 Takradhara
The power for rubbing on the crown – Rasnadi power is the one commonly used.But for those with an excess of Pitta, Kachoradi power is better. Manjishtadi also isrecommended. Amalaka and pepper are roasted and powdered and made use of. The medicine to be taken in – Generally, in all treatment of dhara, Pizhichil,Navarkizhi, etc. Gandharvahastadi kashayam is the accepted medicine is to be taken inthe morning. It’s both laxative and digestive. But sometimes in pitta predominancy, thism ay prove unfavorable. In such conditions, for proper evacuation of the bowelsdecoction of grapes and haritaki is better. This can be used in all treatments as per theneed. Drakshadi kashayam, Mridweeki kashayam, Dhanwantarm kashaya also can beprescribed as per the condition of the patient. Here, the physician has to use hisdiscretion, observing the doshas, the tissues involved, etc.PROCEDURE OF TREATMENT Karkatakam (July-August), Tulam (October-November) and Kumbham(February-March) are considered as the best time for this treatment. In these monthswhen the climatic conditions are favorable, free form excess of wind, mist cold, rain etc.,on an auspicious day, in the morning hours, the treatment is generally started. In aspacious room protected form wind and other excesses, the Dhara droni which has beenset up, already well washed and dried on the previous day itself, is now brought in andagain wiped with a cloth and placed with its head towards the east. The head part is to bea bit raised and leg part lowered. If the supports of the Droni are not suited for thisposition, the height is to be adjusted by placing adequate pieces of wood etc., under theDroni. The droni is to be firmly fixed. It is to be remembered that the purpose of raisingthe head portion of the droni is to have space enough to place the receptacles (small 38 Takradhara
droni) for receiving Dhara liquid flowing form the Droni and also for the convenienthandling of the Dahra vessel by the physician seated on a stool. The Dhara vessel shouldbe suspended exactly above the head of the patient lying in the Droni. How to set up theDhara vessel in this way is already explained. The wick of thread hanging from the vesselshould be so adjusted as to be just 5 cm (two fingers) (according to ayurvedic treatmentof Kerala four finger) space form above the forehead of the patient, lying supine in theDroni. Then spread the sheet in the Droni and set the pillow on its position. Thereceptacle, the cups for refilling and seats are all to be placed in their respective positions.Now make sure whether the oil for the head and Dhara liquid, the bath towel and othernecessary equipments are all ready and then light the lamp already placed on the south,the head side. The wicks of the lamp should be laid prominently to the west and then tothe east. Seeing that everything is ready and in order, the physician can now allow thepatient to enter. The patient in his turn should be ready by this time after having attendedto the calls of nature and cleaning the mouth, teeth, etc. When the physician calls him, heshould wash his feet once again, enter the treatment room and then stand facing the eastbefore the lamp. He is to submit offerings to his own deities or as directed by thephysician and having performed auspicious rituals, offer Dakshina to the physician alsoaccording to his mite. Then with the permission of the physician, he seats himself in thedroni facing the east. The physician now stands at the right side of the patient facing the east. Thenpaying homage mentally to his teacher and the God and taking oil on his palm he appliesit on the crown of the patient. This is repeated thrice. Then the patient himself can apply 39 Takradhara
the oil. But not too much as to trickle down. If the patient has long hair, it has to beparted and tied in the back. The next step is to tie the Varti around the head just above theears, eyebrows. It is not to be too tight or loose. If too tight, the blood supply may behindered, if too loose, it allows the Dhara liquid to pass through it to the inside of theDroni and to the body. The knot should be only on the side of the head. If it is on theback, it creates difficulties to lie with the head placed in order. If it is on the forehead, ithinders Dhara. Now the patient is to lie in a supine position in the Droni. Then inspect theposition of the pillow, the thread hanging down form the vessel, its height and thicknessare all found to be in order, the liquid is poured into the dhara vessel. When pouring,draw back the vessel form the upper part of the head with one hand, and firmly close thehole at the bottom of the vessel with the other hand. So it is clear that another personpours the fluid. Pouring is to be done very slowly to prevent scattering and spraying.After the whole liquid is poured, the finger at the whole is loosened very slowly andgradually and the liquid is let down along the wick. If the wick is too thick, some threadis drawn out form it. If not which enough press the hole tightly to stop the flow and thenadd more thread to the wick. When the wick is wet and the liquid starts to flow along it,its edges are to be cut even, with scissors, even if they have been cut earlier. After theseprecautions, the vessel is brought forward above the forehead and moved to and fro, i.e.left and right slowly. As per traditions, the movements of the wick to the left and right, need no bemore than 5 cm form the center of the forehead, the middle of the eyebrows. But therecould not be any objection to make some alterations so as to allow the liquid to spread allover the head in the beginning. Massaging the scalp under the hair with the free palm of 40 Takradhara
the physician or the attender, first in the beginning and then at intervals is advised toprevent delay in wetting the whole head with the liquid. Even if the liquid falls correctlyon the head, it is the duty of the physician to make sure that it is also flowing out throughthe proper channel. If it is not followed properly, it may be either because of the hole ofthe droni is blocked or the diverted liquid flows to the part of the droni where the bodylies. Whatever may be the reason; it has to be corrected immediately. So the physicianwho handles the suspended dhara vessel, should be vigilant and pay concentratedattention. If he fails in fall in this and doesn’t hold the vessel firmly, the scattered liquidmay fall in the eyes or nose of the patient, or fail to fall properly on the head, orsometimes when refilling the vessels, may collide with each other, break and createavoidable difficulties. So the physician, should be vigilant with a firm hold on the ropeand vessel, so that in case of collision or the breaking of the tie of the rope, the danger ofthere falling down is always prevented. The attendants also should be equally careful.The receptacles should be placed exactly where the liquid comes out. When onereceptacle is full, it is immediately replaced. The full vessel is removed carefully andslowly without spilling and again poured inside the dhara vessel with no chance ofclashes. This goes on continuously. It is always better to take the receiving vessel beforeit is full and empty it, unto the dhara vessel. Paying attention to the filling and emptyingof the vessel, one can has to adjust the speed of the refilling. The fall of the dhara liquid from too high, or too low level is both harmful. It isthe same if it is too fast, or too slow. Both increase or decrease in the thickness of flow isnot good. As per tradition, if the wick through which the liquid flows is two fingers (5cm) above the forehead, circumference of the hole is the size of the little finger of the 41 Takradhara
patient and if the dhara liquid is neither too thick nor too thin everything is satisfactory.But in these matters, it will be better to consider the comfort of the patient also. For somepeople, the fall form 5 cm height may be intolerable for others too low a position may bedisagreeable. Some patients like a thick flow, while others a thinner one. Thesedifferences in reaction may be due to the difference in temperaments. Sometimes it mayalso be due to the difference in doshas. For instance, in Pitta a low fall, but with morethickness is beneficial. A patient with Kapha temperaments may like the fall form ahigher position. He also appreciates a speedy flow. Different liquids also can create this change in reactions. We have to observeclosely and judge accurately. A fall from a higher position causes headache, fever,burning sensation, etc. Too low a fall not only fails to alleviate the disease, but alsosometimes, even aggravates the condition. A speedy flow provokes vata and createsheadache, swoon, etc. If too slow, kapha is increased and heaviness of the head is felt.The disturbance created by using too thick a fall is the same as due to increase in heightand slow flow. Too thin a fall fails to give any good results. On the contrary, it causes,cold. One has to closely observe and understand these changes. Various other aspects likeviscidity are to be considered carefully. Thus, until the scheduled time is over, all have to do their work earnestly andcarefully and the patient is to lie still. He is not to turn on his sides, but lie supine. Suchnecessities as urination, etc It should not arise during this time if it is unavoidable itshould be done in lying position without any movement of the head. Sneezing, coughing,etc in this position also create troubles. In urgency, the physician is to be informed so thathe can draw back the dhara vessel from the forehead and hold it aside until it is over. He 42 Takradhara
must be very careful to avoid any interruption in the flow by drawing back the vessel toomuch. When refilling also, the best thing is to draw the vessel a little to the back and stopthe movement to avoid the troubles. If somewhat the dhara liquids happens to drop in theeyes or the face, immediately wipe it well. It is for this purpose that storage of old clothesis suggested. One hour dhara on the first day is the usual practice in all common disease. Thenthe duration is increased by five minutes each day, so that on seventh day it is one and ahalf hour (3¾ Nazhikas). On the eight day also, the same time is taken as on seventh.From the ninth day onwards, a reduction of five minutes is done so that on the fourteenthday it is again one hour as on the starting day. This order is for a fourteen-day course. If itis a twenty-one days course, the order of increasing the time is the same as given beforeuntil the seventh day i.e. reaching to one and a half hour on the seventh day. But from theseventh to fifteenth day, the same duration is kept. From sixteenth day, a reduction of fiveminutes per day is effected, so that it is one hour again on the twenty-first day. Usuallythe time for the course of dhara. Is either fourteen or twenty one day. But there is noobjection in extending or reducing the duration as per the condition of the patient. Suchdiscretion is the responsibility of the physician. Well-considered decisions are alwayswelcome. But prolongation of the dhara time to more than one and a half hours isunnecessary, inconvenient and objected to by the shastras. In unavoidable circumstances,competent physicians resort to extensions of the number of days. There is also a versionthat the maximum time allowed is only three Nazhikas (75 minutes). The minimum timeallowed is one Nazhika or 25 minutes. The physician has to choose the time limitconsidering all factors like the nature of the disease, doshas and the tolerance of thepatient. 43 Takradhara
DUTIES AFTER DHARA At least five minutes before the compilation of Dhara all attendants should beparticularly vigilant. Everything for the next step, like bath towel, etc are to be keptready. Refilling the Dhara vessel is to be stopped some seconds earlier before the exactstopping time. At the exact moment, stop Dhara by drawing the vessel back. Then wipethe head with the towel. This is not to be done by the patient himself to avoid anyshaking. After wiping well, same oil applied himself earlier is again smeared. Then hemay take bath as usual. But Amalaka water for some people for the head and warm waterfor the body are indispensable. But for some people warm water may not be agreeable.For them cold water for the body may not be harmful. To remove the oil from the body,pasted greengram, horsegram etc. and the head, shampoos of leaves like Vellila(Mussaenda frondosa) which are neither too cold not too hot in potency are used. Formen of pitta temperament, the residue of the Amalaka water prepared as a paste can bemade use of. After bath wipe the head without delay. It has to be done carefully so that nomoisture is retained. After wiping well with a wet towel again wipe with a dry one also.After wiping, part the hair and rub medicated powder. As said earlier it is Rasnadi power,which is usually taken for this. This prevents cold better. Powers like Kachoradi also canbe used as per the disease. After bath, enter the room slowly, and then facing the east takein the prescribed medicine. Then lie down for a while on the left. Care should be taken toarrange the bed earlier. But, this rest is only for a while, from a minimum of five minutesto a maximum of thirty minutes only. Then take food with the prescribed restrictions. 44 Takradhara
RESTRICTIONS DURING DHARA Chilies, tamarind, newly harvested paddy, fish, seasum, black gram, pumpkin,brinjal, onion, drumstick, asafetida are harmful. Natural urges should not be stopped. Daysleep, exposure to mist, sun, dust, wind, and rain are being avoided. Walking long timetraveling in jerky vehicles, prolonged standing and sitting are harmful.Effects of Takradhara 61b This Dhara treatment cures premature graying of the hairs, fatigue, infirmity andemaciation, headache, lack of vitality, pricking pains of the palm and sole, diabetes, lackof proper functioning of the limb, joints, pain in the chest, heart diseases, disgust forfood, indigestion, dyspepsia and diseases of the eyes, nose throat and ears. This Dharaalso alleviates the derangement of the three doshas and improves the power of all sensoryorgans. 45 Takradhara