Ayurveda Research Work

A COMPARATIVE STUDY ON JANU BASTI AND JANU PICHU WITH MURIVENNA IN JANU SANDHI GATA VATA.

By

Dr. PRASANTH. D.B.A.M.S

Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences,Karnataka,Bangalore

In partial fulfilment

of the requirements for the degree of

AYURVEDA VACHASPATHI DOCTOR OF MEDICINE (AYU)

In

PANCHAKARMA

Under the guidance of

Guide: Co -Guide:

Dr. K. N. RAJASHEKAR M.D.(Ayu) Dr. PRASANNA AITHAL M.D.(Ayu)

DEPARTMENT OF POST GRADUATE STUDIES IN PANCHA KARMA

ALVAS AYURVEDA MEDICAL COLLEGE & HOSPITAL MOODBIDRI 574227.

2009-2010

ALVAS AYURVEDA MEDICAL COLLEGE DEPARTMENT OF POST GRADUATE STUDIES IN

PANCHAKARMA MOODBIDRI, KARNATAKA

I here by declare that this dissertation entitled A COMPARATIVE STUDY ON JANU BASTI AND JANU PICHU WITH MURIVENNA IN JANU SANDHI

GATA VATA. is a bonafide and genuine research work carried out by me,

under the guidance of Dr.K.N.RAJASHEKAR M.D.(Ayu) and Dr. PRASANNA

AITHALM.D.(Ayu) ,Department of Post Graduate Studies in Panchakarma,

Alvas Ayurveda Medical College, Moodbidri.

Date :

Place : Moodbidri

Dr. PRASANTH. D

III Year M.D. (Ayu)

Dept. of P.G. Studies in

Panchakarma, Alvas Ayurveda Medical College

Moodbidri 574227.

Declaration


PANCHAKARMA MOODBIDRI, KARNATAKA.

This is to certify that the dissertation entitled A COMPARATIVE

STUDY ON JANU BASTI AND JANU PICHU WITH MURIVENNA IN

JANU SANDHIGATAVATA submitted by Dr. PRASANTH. D, in partial fulfillment for the degree of Ayurveda Vachaspathi (M.D.) in Panchakarma, of

Rajiv Gandhi University of Health Sciences, Bangalore, is a record of research

work done by him during the period of his study in this institute, under our

guidance and supervision and the dissertation has not previously formed the

basis to the award of any degree, diploma, fellowship or other similar titles.

We recommend this dissertation for the above degree to the University for

the Approval.

Co-Guide: Guide:

Dr. PRASANNA AITHAL M.D.(Ayu) Dr. K. N. RAJASHEKAR M.D.(Ayu) Asst Professor, Dept. of P.G Studies Asst Professor, Dept. of P.G Studies in Panchakarma, in Panchakarma, Alvas Ayurveda Medical college Alvas Ayurveda Medical college Moodbidri 574227 Moodbidri - 574227

Date:

Place: Moodbidri

Certificate



This is to certify that the dissertation entitled A COMPARATIVE STUDY ON

JANU BASTI AND JANU PICHU WITH MURIVENNA IN JANU

SANDHIGATAVATA is a bonafide research work done by Dr.PRASANTH. D

under the guidance of Dr. K. N. RAJASHEKAR M.D.(Ayu) and Dr. PRASANNA

AITHALM.D.(Ayu) in partial fulfilment of the requirement for the award of the

degree in Ayurveda Vachaspathi (M.D.) in Panchakarma, of Rajiv Gandhi

University of Health Sciences, Bangalore, Karnataka.

Date:

Place: Moodbidri

H.O.D.

Dept. of P.G Studies in

Panchakarma,

Alvas Ayurveda Medical College

Moodbidri 574227


Certificate


This is to certify that the dissertation entitled A COMPARATIVE STUDY ON

JANU BASTI AND JANU PICHU WITH MURIVENNA ON JANU

SANDHIGATAVATA is a bonafide research work done by Dr.PRASANTH. D

under the guidance of Dr. K. N. RAJASHEKAR M.D.(Ayu) and Dr. PRASANNA

AITHALM.D.(Ayu) , Department of Post Graduate Studies in Panchakarma, Alvas

Ayurveda Medical College, Moodbidri.

PRINCIPAL,

Alvas Ayurveda Medical College.

Moodbidri 574227,

Dakshina Kanada. (Dist)

Karnataka

Date :

Place : Moodbidri

Endorsement

COPYRIGHT

I here by declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation in print or electronic format for academic/research purpose.

Date:

Place: Moodbidri

Rajiv Gandhi University of Health Sciences, Karnataka

Dr. PRASANTH. D III Year M.D. (Ayu)

Dept. of P.G. Studies in Panchakarma Alvas Ayurveda Medical College

Moodbidri 574227

ABSTRACT

4

ABSTRACT

Janu Sandhigata Vata is one among the most common Vta Vydhi. This

disease affects the joints with its signs and symptoms like pain, swelling, and

restriction of joint movements. Commonly this Sandhigatavata is presented in

Janusandhi, which is one among the most important weight bearing joint in body and

also considered as a Marma.

Osteoarthritis is most common form of arthritis characterized mainly by pain,

bony swelling and functional restriction of the joint. This condition too, is commonly

presented in knee joint. Due to its similarities in signs and symptoms it can be very

much correlated to Janusandhigatavata. Studies reveal there is a steady rise in

prevalence of OA from age 30 such that by 65, 80% of people have radiographic

evidence of OA, though only 25-30% are symptomatic. Its a slowly progressing

degenerative disorder. Potent analgesics and anti-inflammatory drugs are available in the market, which run the risk of producing side effects like gastric erosion, hepatic

and nephro toxicity etc. Even surgery statistically reveals to have a failure rate of 10%

in knee replacements. Its a limitation in contemporary science to provide a

comprehensive effective management. So research works in Ayurveda has evident

scope in this condition.

According to Ayurveda Snehana, Svedana, Dahana and Upanaha are the prime

modalities of treatment in the management of Sandhigatavata, which are mostly

aimed at Bramhana. Janubasti and Janupichu are the procedures basically evolved

from Shirobasti and Shiropichu, which are mentioned among Moordhini Tailas3b,6 are

also having Bramhana action where Sneha is allowed to stay for a stipulated duration

in the affected joint.

Murivenna commonly used Anubhuta yoga in Kerala, listed in Kerala

Ayurveda pharmacopeia is useful in Sandhi Bhagna has Vedanasthapaka and

shothagna effect. Murivenna is also considered as one of the best yoga in

Marmabhighata too. Murivenna in the form of Janubasti or Janupichu in managing

Janusandhigatavata vata was not studied before.

Therefore this study is intended to compare the effect of Janubasti and

Janupichu done with Murivenna in the management of Janusandhigatavata.

A COMPARITIVE STUDY ON JANU BASTI AND JANU PICHU WITH MURIVENNA IN JANU SANDHIGATAVATA.

ABSTRACT

5

Objectives:

1. Evaluation of effect of Janu Basti with Murivenna on Janusandhigatavata.

2. Evaluation of effect of Janu Pichu with Murivenna on Janusandhigatavata.

3. To compare and ascertain the effect of Janu Basti and Janu Pichu with Murivenna.

Methods:

It is a single blind clinical study with pre-test and post-test design. A special proforma was prepared with all the points of history taking, physical examination and

investigations.

The study was carried out in 30 Patients of Janu Sandhi Gata Vata with who

were divided equally into two groups. In group A, Patients were administered Janu

Basti with Murivenna for 45 minutes, for 7 consecutive days.In group B, patients

were administered Janu pichu with Murivenna for 45 minutes for 7 consecutive days.

Data was collected from the patient on the 1st day before treatment, 8th day

after procedure and on 14th and 22nd day of the study period. Placebo was given internally during the study period in the form of rice flour capsule 1 Bid. Interpretation and Results:

Assessment inside a group was statistically done using paired t test and student t test was utilized for comparative assessment in between groups.

The test of significance showed that both the procedures had significant improvement statistically in all the signs and symptoms except for Gait in

group B.

On comparison between the groups except for pain and gait none of the symptoms showed statistically significant changes.

Conclusion:

On the overall glance over the study showed that among the 30 patients of

Janu Sandhigatavata 2 (06.6 %) got 100 % relief, 03 (10 %) got more than 90 %

relief, 22 (73.4 %) got moderate relief between 60 % and 90 % & 3(10%) got partially

improved results.


ABSTRACT

6

On comparative assessment between groups, In Group A, 2 patients (13.4 %) got 100

% relief & 3 patients (20 %) got more than 90 % relief while in Group B, no patients

got more than 90 % or 100% relief. 9 patients (60 %) of Group A, got relief in

between 60-90 % and whereas 13 ( 87%) patients of Group B got relief in between

60-90 %.

Analysis of the results showed that Janu Basti with Murivenna provided a better relief

in the signs and symptoms of JanuSandhigatavata mainly in pain, stiffness, gait,

tenderness, swelling, crepitus and range of movements compared with Janu Pichu

done by the same.

Key words:

JanuSandhigatavata, Janu Basti, Janu pichu, Murivenna.


ACKNOWLEDGEMENT

As always I have known, Gratitude is the best attitude. First of all I would like to

remember almighty for making me reach what I am today; in spite of all odds what I had

been made to pass through in life. I strongly believe in the silent prayers and invisible

presence of my Mother and the constant inspiration of my Father, I am always grateful

to them. I can never forget the inspiration and love that my Sister has showered on me,

making me responsible without which my life would have been meaningless. Nothing on

earth can replace a mother, but I cant forget the immense support and inspiration that

my Step Mother has provided constantly right from the day she chose to be one among

us.

It is my privilege to thank my guide, Dr. K.N.RAJASEKHAR, who kept constant belief

in me and guided me throughout in all my activities, observing me closely, helping me

whenever in need. I cant forget the help, constant support, strong belief and intelligent

ideas rendered by my co guide, Dr. S.G. PRASANNA AITHAL. It is a blessing to be

under Dr. ZENICA DSOUZA, my H.O.D who stood as an inspiration and a constant

motivation in all my activities including this, and a simple expression of gratitude doesnt

feel worthy enough for all her blessings.

It would be really ungrateful if I dont mention the constant support and timely help

provided by Dr. VASANT PATIL, Dr. C. V.RAJASHEKAR, Dr. P.K. MOHANLAL,

Dr. VIKRAM and all staff members of my college throughout my post graduation life. If I

have saved anything in my life, all I can count upon are my friends, I can never forget the

confidence and help they have rendered me throughout. I would specially like to mention

the help rendered by MR. SIDDHARTH, Dr. SHARATH, Dr. ANUPRABHA, Dr.

SREERAJ, Dr. ARUN KUMAR, Dr. ANANTH RAM, Dr. NATRAJ, Dr. SANDEEP,

Dr. SUSHA, Dr. NATASHA, Dr. SMITHA, Dr. JESSICA and Dr. RAIBY without

whom this work would have never been in this form.

I owe my sincere regards and boundless gratitude to Dr.M.Mohan Alva, Chairman,

Alvas Education Foundation, Moodbidri, for giving me an opportunity to do my post

graduate studies in this prestigious institution. I render my immense and heartfelt thanks

to Dean of P.G faculty, Alvas Education Foundation, Moodbidri, and Principal, Alvas

Education Foundation, Moodbidri, for their constant help, and support in completing

this work.

Also I would never forget the constant sparks and endless support provided by my dear

friends & departmental colleagues Dr. CHANNABASAPPA, Dr. PARVATHY and

Dr. PRIYA for the trust that they have entitled in me, without whose help this work would

have never been complete as of any other activity of mine.

I can never forget all my gurus who have taught me the greatness of this vast ocean of life

AYURVEDA in front of which Im still a child who is mesmerized by its intense beauty

and depth, waiting to feel another wave from shore. Without your blessings Im

incomplete.

Last, not least, Also I would take this opportunity to thank all my seniors, juniors,

Panchakarma therapists, the library staff the printing and graphics department for

their immense cooperation during the work

If I have left anyone, I would like to thank all who have directly or indirectly helped me in

the successful completion of this work.

Dr.PRASANTH.D

Sl. No CONTENTS Page No

Abbreviations i - ii

List of Table iii - iv

List of Graph & Pictures v

Introduction 1 - 3

I Conceptual Study 4 - 21

Historical Review 4 - 7

Janu Sandhi Review 8 - 11

Anatomy of Knee Joint 12 - 14

Twak Review 15 16

Anatomy of Skin 17 - 20

Janu Basti Review 21 - 24

Janu Pichu Review 25 - 28

II Disease Review 30 - 57

Janu Sandhigata Vata 30 - 35

Nidana 35 - 39

Poorvarupa 40

Rupa 40 - 42

Samprapti & Samprapti Ghataka 42 - 46

Upashaya & Anupashaya 47

Sapeksha Nidana 48 - 49

Sadhyaasadhyata 49 - 50

Chikitsa 51 - 55

Pathya Apathya & Shamana Aushadhi 56 - 57

III Drug Review 58 - 74

IV Clinical Study 75 - 110

V Discussion 111 - 125

VI Summary & Conclusion 126 - 129

References & Bibliography 130 - 138

Annexure I - XV

i

ABBREVIATIONS

1) A.H : Astanga Hridaya

2) A.S : Astanga Sangraha

3) A.T. : After Treatment

4) Bel.sa : Bela Samhita 5) Bh.Pr : Bhava Prakasha

6) B.R : Bhaishajya Ratnavali

7) B.T. : Before Treatment

8) C.D : Chakra Datta

9) Cha.S : Charaka Samhita

10) Comm. : Commentary 11) Ckr : Chakrapani.

12) D.G : Dravya Guna Vijnana

13) DL : Dalhana

14) D.P.P.M : Davidsons Priciples And Practice Of Medicine

15) H.P.I.M: Harrisons Principle of Internal Medicine

16) I.P.D. : In Patient Department

17) K.S : Kashyapa Samhita

18) M.N : Madhava Nidana

19) Madhu : Madhukosha

20) O.P.D: Out Patient Department

21) S.D : Standard Deviation 22) S.E : Standard Error 23) S.K.D : Shabda Kalpa Druma

24) S.S : Susrutha Samhita

25) Saha.Y: Sahasra Yogam

26) Sha.S : Sharangadhara Samhita

27) Vag : Vagbhata

ii

28) Vang : Vangasena

29) Yo.Ra : Yogaratnakara

30) Yrs. : Years

31) + : Present

32) - : Not Present

33) % : Percentage

ABBREVIATIONS OF STHANAS OF SAMHITA

1) Chi : Chikitsa Sthana

2) I : Indriya Sthana

3) Ka : Kalpa Sthana

4) Ma.Kha: Madhyama Khanda

5) Ni : Nidana Sthana

6) Po.Kha : Poorva Khanda

7) Sha : Shareera Sthana

8) Si : Siddhi Sthana

9) Su : Sutra Sthana.

10) Utt : Uttara Khanda

iii

List of tables

Sl No Name of tables Page No.

1 Aharaja Nidana of Vata Vyadhi. 37 2 Viharaja Nidana of Vata Vyadhi. 38 3 Manasika Nidana of Vata Vyadhi. 39 4 Anya Karana for Vata Vyadhi. 39 5 Rupa of Sandhivata mentioned in various classics. 42 6 Sapeksha Nidana of Janu Sandhivata 48 7 Different Chikitsa procedures indicated for Janu Sandhivata 51 8 Ingredients of Murivenna 72 9 Rasa Panchaka of the drugs used in the preparation of Murivenna 74 10 Distribution of 30 patients according to different age group 81 11 Sex wise distribution of 30 patients 82 12 Distribution of 30 patients according to occupation 82 13 Distribution of 30 patients according to religion 83 14 Distribution of 30 patients according to socio- economic status 84 15 Distribution of 30 patients according to marital Status 85 16 Distribution of 30 patients according to habitat 85 17 Distribution of 30 patients according to educational status 86 18 Distribution of 30 patients according to Prakruti 87 19 Distribution of 30 patients according to Saara 88 20 Distribution of 30 patients according to their Satwa 89 21 Distribution of 30 patients according to Samhanana 89 22 Distribution of 30 patients according to Saatmya 90 23 Distribution of the 30 patients according to dietary Habits 91 24 Distribution of 30 patients according to addictions / Vyasana 91 25 Distribution of 30 patients according to Aahara- Abhyavaharana

Shakti 92

26 Distribution of 30 patients according to Aahara-Jarana shakti 93 27 Distribution of 30 patients according to Agni 93 28 Koshtha wise Distribution of 30 Patients of Janu Sandhivata 94 29 Distribution of 30 patients according to their nature of

work/Vihara 95

30 Distribution of patients according to Vyaayama Shakti 96 31 Distribution of patients according to their Nidra Sheela 96 32 Nidana (Ahara) wise Distribution of 30 Patients of Janu

Sandhivata 97

33 Nidana (Vihara) wise Distribution of 30 Patients of Janu 1Sandhivata

98

34 Nidana (Manasika) wise Distribution of 30 Patients of Janu Sandhivata

99

iv

35 Chronicity wise Distribution of 30 Patients of Janu Sandhivata 100 36 Effect of Janu Basti with Murivenna in signs and symptoms of

15 patients of Group A AT. 101

37 Effect of Janu Basti with Murivenna in signs and symptoms of 15 patients of Group A 14th day.

102

38 Effect of Janu Basti with Murivenna in signs and symptoms of 15 patients of Group A 22nd day.

102

39 Effect of Janu Pichu with Murivenna in signs and symptoms of 15 patients of Group B AT.

103

40 Effect of Janu Pichu with Murivenna in signs and symptoms of 15 patients of Group B 14th day.

104

41 Effect of Janu Pichu with Murivenna in signs and symptoms of 15 patients of Group B 22nd day.

104

42 Comparative effect of procedures in signs and symptoms of patients in group A & group B.

105

43 Comparative effect of procedures in percentage relief after treatment.

106

44 Comparative effect of procedures in percentage relief on 7th, 14th and 22nd day.

107

45 Overall effect of the treatment. 109 46 Comparative effect of the treatment. 110

v

List of Graphs

Sl no: Name of graphs Pg. no

1 Distribution of 30 patients according to different age group 81 2 Distribution of sex of 30 patients 82 3 Distribution of 30 patients according to occupation 83 4 Distribution of 30 patients according to religion 83 5 Distribution of 30 patients according to socio- economic status 84 6 Distribution of 30 patients according to marital Status 85 7 Distribution of 30 patients according to Habitat 86 8 Distribution of 30 patients according to educational status 86 9 Distribution of patients according to Prakruti 87 10 Distribution of patients according to Saara 88 11 Distribution of patients according to their Satwa 89 12 Distribution of 30 patients according to the Samhanana 90 13 Distribution of 30 patients according to their Saatmya 90 14 Distribution of 30 patients according to their dietary Habits 91 15 Distribution of 30 patients according to addictions / Vyasana 92 16 Distribution of 30 patients according to Aahara- Abhyavaharana

Shakti 92

17 Distribution of 30 patients according to Aahara-Jarana shakti 93 18 Distribution of 30 patients according to Agni 94 19 Koshtha wise Distribution of 30 Patients of Janu Sandhigatavata 94 20 Distribution of patients according to their nature of work / Vihara 95 21 Distribution of patients according to Vyaayama Shakti 96 22 Distribution of patients according to their Nidra Sheela 97 23 Distribution of patients according to their Nidana (Ahara) 98 24 Nidana (Vihara) wise Distribution of 30 Patients of Janu

Sandhigatavata 99

25 Nidana (Manasika) wise Distribution of 30 Patients of Janu Sandhigatavata

99

26 Chronicity wise Distribution of 30 Patients of Janu Sandhigatavata 10027 Comparative effect of procedures on signs and symptoms

expressed in percentage , after treatment 106

28 Comparative effect of procedures in percentage relief on 7th, 14th and22nd day.

108

29 Overall effect of the treatment 10930 Comparative effect of the treatment 11031 Structure of Knee Joint 14 32 Structure of Skin 20 33 Illustrations of procedures 29

INTRODUCTION

1

INTRODUCTION

Vata, which is prime among the Tridoshas, is the major factor responsible for all

activities and manifestations of disease in the body. In Vriddhavastha, all Dhatus

undergo Kshaya, thus leading to Vata Prakopa. This makes the individual prone to

many diseases, among which Sandhivata stands at the top of the list. When this

deranged Vata lodges in Sandhi, it is characterized by pain, swelling, and restriction

of joint movements. Commonly, this Sandhigata vata manifests in Janusandhi, which

is one among the most important weight bearing joints in body. It is also considered

as a Marma.

Osteoarthritis is the most common form of arthritis characterized mainly by pain,

bony swelling and functional restriction of the joint. It commonly presents unilaterally

in the knee joint, which is the most important weight bearing joint in the body.

Osteoarthritis of the knee joint is the most common joint disorder seen in elderly

people. Due to similarities in signs and symptoms, it can be very much correlated to

Janu sandhigata vata.

Osteoarthritis is the most common articular disorder that begins asymptomatically in

the 2nd and 3rd decades and is extremely common by age 60. Studies reveal there is a

steady rise in prevalence of OA from age 30 such that by 65, 80% of people have

radiographic evidence of OA, though only 25-30% are symptomatic. It is a slowly

progressing degenerative disorder. Due to the increased prevalence of this disorder it

has become a major problem and burden for society, as it indirectly reduces the

working potency resulting in dependency. It limits everyday activities such as

walking, dressing, bathing etc., thus making individual partially or even fully

handicapped. Joint pain and soreness, especially with movement, pain after overuse

or after long periods of inactivity, joint swelling and joint fluid accumulation are the

features of osteoarthritis.

Potent analgesics and anti-inflammatory drugs are available in the market, which run

the risk of producing side effects like gastric erosion, hepatic and nephro toxicity, etc.

Even surgery has a statistical failure rate of 10% in knee replacements. One of the


INTRODUCTION

2

current limitations of contemporary science is the lack comprehensive and effective

management. Research work in Ayurveda has a large scope in this condition.

Charaka was the first person who separately described the disease named Sandhigata

Anila, but he has not included it among the 80 types of Nanatmaja Vyadhi1. Sushruta

and Vagbhata also gave importance to Sandhivata and included in the chapter of Vata

Vyadhi2, 3. When Vata involves Janu Sandhi, it is named Janu Sandhigatavata.

According to Ayurveda, Snehana, Svedana, Dahana and Upanaha are the prime

modalities of treatment in the management of Sandhigata vata. These are mostly

aimed at Bramhana. Sushruta has mentioned the treatment for Sandhigatavata as

Snehana, Svedana, Upanaha, Agnikarma, Bandhana and Unmardana4. Vagbhata

explained that Sneha should be used according to Yukti for Bhakshana, Basti, Nasya,

Abhyanga, Gandusha, Murdhni Taila, Karna Poorana and Akshi Tarpana5. Janu Basti

is one of the modalities of treatment commonly adopted in the management of Janu

Sandhi Gata Vata. Research has shown that Janu Basti with Taila gives encouraging

results in relieving the signs and symptoms of Janu Sandhi Vata.

Janubasti and Janupichu are the procedures that have basically evolved from

Shirobasti and Shiropichu, which are mentioned among Moordhini Tailas. These also

have Bramhana action due to the Sneha which is allowed to remain over the affected

joint for a stipulated duration.

Murivenna6 is a commonly used Anubhuta yoga in Kerala, and is listed in the Kerala

Ayurveda pharmacopeia. It is useful in Sandhi Bhagna due to its Vedanasthapaka and

shothagna effect. Most of the ingredients in Murivenna have Katu Rasa, Theekshna

Guna, Ushna Veerya and Katu Vipaka. Murivenna is also considered as one of the

best yogas in Marmabhighata. But Murivennas role in Janubasti or Janupichu for

management of Janusandhigatavata vata has not yet been studied. Currently, the Janu

basti procedure is given more importance and is widely practiced, even though in both

treatments the principle of management is very similar. The main goal is to allow the

sneha to stay in the affected joint for a stipulated period of time. Moreover the cost

effectiveness of Janu pichu is much less in comparison to Janu Basti and the

procedure is also much simpler.


INTRODUCTION

3

Considering all of these facts, an observational study was conducted to compare the

effectiveness of Janubasti versus Janupichu using Murivenna in the management of

Janusandhigatavata.

This is a comparative study which was carried out for 22 days along with follow up

assessment. Patients were selected on the basis of clinical assessment depending on

signs and symptoms fulfilling specific diagnostic criteria. 30 patients were randomly

selected and arranged into two groups of 15 patients each.

Janu Basti Group Janu Basti with Murivenna for 45 mins Janu Pichu Group Janu Pichu with Murivenna for 45 mins

Clinical trials, case study, adopted treatments for each group and methods with

subjective and objective parameters, objectives, results, discussion and conclusion are

dealt with at the end of this thesis.


HISTORICAL REVIEW 4

HISTORICAL REVIEW

Everything we do in the past, its history. No one can reject the fact that history is the

most important among all disciplines. To know any subject, we are supposed to learn

history and use it for our benefit and prosperity. History gives us the today, by

which we can utilize all the things we have to make our lives easier and more

comfortable. Man always struggled with the present for creating a better tomorrow.

Here, a glimpse is given to the historical sight of Ayurveda science, chiefly on

Sandhivata and Swedana Chikitsa and it is presented as follows.

The knowledge of the origin of a disease is very essential. To obtain the historical

background of a disease we have to search deep into the Vedic literature. Vedas are

considered to be the oldest literature available and the root of Ayurveda. Its a known

fact that it is difficult to specify the source period of Ayurveda. Therefore it is not

possible to fix an exact date of origin for Ayurveda. History of Indian medicine is

usually studied under the heading of Pre-Vedic period, Vedic period, Samhita Kala,

Sangraha Kala, Nighantu Kala, and Adhunika Kala (Modern period).

PRE-VEDIC PERIOD:

References of Sandhigata Vata are not available in the Pre-Vedic period.

VEDIC PERIOD:

Vedas are the primary source of all the knowledge and are really the treasures

produced as a result of ancient Indian culture. They are the first written

documentation of Indian civilization. One can see the basic roots of each and every

subject in Vedas. Ayurveda is considered as the Upaveda of Atharva Veda. This

treatise describes many Roga, many Aushadha and many other connected factors.

Regarding Sandhigata Vata, we do get the references of body parts and the

possibilities of joint disorders in Rig Veda and Atharva Veda. It is mentioned that

Sandhi Vikriti is caused by Shleshma Vikriti.


HISTORICAL REVIEW 5

In Atharva Veda, two references are available about Sandhi Roga, one deals with the

disease situated in Sandhi and other is related with Sandhi Vishlesha [Ath.2/33/6;

6/14/1]. Also some references in Atharva Veda show the importance given for Vata

[Ath.8/2/3; 2/10/3], its Bhedha [Ath.10/2/3] and disorders of Vata [Ath.9/8/20]. Two

Dravya, Pippli and Vishanka, are considered as Vata Roganashaka [Ath.6/109/3;

6/44/3].

In Vedas even though there are no detailed and vast explanations about Swedana one

can see the mentioning about the same. Descriptions about Atapa Sweda are available

in Atharva Veda during the explanation of Swedana. It is given that this Swedana is

effective in pacifying the bodily disorders. In Rig-Veda, sun is considered as the

source of energy and it also states that sun bath has the curative property on Kamala

and Hridroga.

SAMHITA KAALA:

This is the period where we find realistic references of various diseases along with the

Nidana Panchaka. Specific signs, symptoms and treatment are not mentioned for Janu

Sandhigata Vata but in general, the Nidana Panchaka of Sandhigata Vata can be

considered for Janu Sandhigata Vata. Many authors described this disease in their

treatise during this period.

Charaka Samhita:

This Samhita, written by Acharya Agnivesha and re-edited by Acharya Charaka, has

mentioned the disease Sandhigata Anila in the chapter of Vata Vyadhi Chikitsa. Here

he has not mentioned any treatment for the Sandhivata7. He has also explained 13

types of Sa Agni Swedana and 10 types of Niragni Swedana8, 9.

Sushruta Samhita:

This treatise, written by Acharya Sushruta, has mentioned about the disease

Sandhigata Vata in Nidana Sthana and Chikitsa Sthana. A separate Chikitsa has been

mentioned for Sandhigata Vata in this Samhita. He has also added one more symptom

Hanti Sandhi in the Lakshanas of Sandhivata10, 11. There are 4 types of Swedana

which are explained by Acharya Sushruta12.


HISTORICAL REVIEW 6

Bhela Samhita:

Acharya Bhela has not clearly mentioned about this disease. However, under the topic

of Asthimajjagata Vata Vyadhi, a description of Sandhi Vichyuti is available13 in his

Samhita.

Harita Samhita:

Acharya Harita has mentioned in his Samhita about the management of Sandhigata

Vata, but the diagnostic aspect of this disease is not mentioned in detail (H. S. 3/20).

SANGRAHA KALA:

This is the period where many authors started compiling the various existing Samhitas

and started making their own treatise. Along with the compilation of the previous

works they contributed their own knowledge and made the learning process easier for

the later ones.

Ashtanga Sangraha & Ashtanga Hridaya:

These books, written by Vriddha Vagbhata & Vagbhata respectively, have mentioned

the disease Sandhigata Vata in their treatise. Lakshanas are similar to those which are

mentioned by Acharya Sushruta14, 15, 16&17.

Madhava Nidana:

Acharya Madhavakara, in his samhita Madhava Nidana, has mentioned an additional

symptom, Atopa in the symptomatology of Sandhigata Vata18. The remaining

lakshanas are the same as in Sushruta Samhitha.

Bhava Prakasha:

Bhavamishra explained the Lakshanas and treatment of Sandhigata Vata in

Madhyama Khanda Vatavyadhyadhikara19 in his treatise Bhava Prakasha.

Yogaratnakara:

In this book the Lakshana and the Chikitsa of Sandhigata Vata are explained in the

Vata Vyadhi Adhikara20.


HISTORICAL REVIEW 7

A glimpse on these references reveals that the later authors after Acharya Charaka &

Sushruta followed their footsteps and made minimal addition to the subject. There are

not many changes in the views of different authors who have written about

Sandhigata Vata. It also shows the importance of disease in their period as it is

mentioned by most of the authors.


JANU SANDHI REVEW

8

JANU SANDHI REVIEW

The knowledge of the physiology and structures related to a particular organ as well

as its surrounding structures is very important before studying the pathology of any

disease related to that region. Hence the anatomy and physiology of the Janu Sandhi

should be understood properly. In Janu Sandhigatavata, the Vata lodges in Janu

Sandhi. In Ayurvedic classics the details regarding the anatomy and physiology of

Sandhi are scattered in various parts. So here an humble attempt is made to gather the

references related to Sandhi.

In general, Sandhi means the union of two or more structures of body. But in this

context, the word Sandhi is limited to Asthi Sandhi only.

The place where there is union of Asthi is called Sandhi40.

In Ayurveda, Sandhis are mainly classified into two types41

1) Sthira Sandhi

2) Cala Sandhi (Chestavanta)

Again Sandhi is classified into following eight types based on shape42:

1) Kora 5) Tunnasevani

2) Ulookala 6) Vayasa tunda

3) Samudga 7) Mandala

4) Pratara 8) Shankhavarta

In modern anatomy, joints are classified as: 43

1. Fibrous or fixed joints (Synarthroses)

2. Cartilaginous or slightly movable joints (Amphiarthroses).

3. Synovial or freely movable joints (Diarthroses).

The Asthi Sandhi located at the region of Janu is called Janu Sandhi. It can be

classified under the group of Chestavanta and Kora Sandhi according to its features.


JANU SANDHI REVEW

9

They are two in number (one in each Shakha). The structures that constitute the

Sandhi are mentioned below:

1. Asthi

2. Snayu and Kandara

3. Sleshmadhara Kala

4. Sleshma (Shleshaka Kapha)

5. Peshi

6. Sira and Dhamani

Asthi:

Asthi is the basic constituent of any Sandhi. Its main function is Dharana of Sharira.

Vata takes Ashraya in Asthi and it has Ashraya Ashrayi Bhava Sambandha i.e., when

the Ashrita gets Vriddhi, the Ashrayi also goes on Vriddhi and vice- versa. In

Sandhivata, the Prakupita Vata results in Asthi Kshaya44,45.

Vata can be considered under 5 different names based on its Sthana and Karma. Out

of these, there is no direct reference regarding the Vata residing in the Sandhi. The

Vyana Vata is said to be Kritsna Deha Charah46 i.e. it moves all over the body, but

based on its function of Gati or movement, we may consider Sandhi, as one of its

sites. In Tantrantara, a specific reference is available stating Sandhi as one of the sites

of Vyana Vata. Also, the functions such as Aakunchana, Prasarana, etc. which are

attributed to Vyana Vata, are possible through Sandhi. Further, the primary aim of the

Sandhi is to provide movements to the body organs therefore Vata must have one of

its seats of action in Sandhi. In addition, while dealing with Vata Vikara, Gati Hanana

has been explained as one of the outcome47. Hence, Vyana Vata can be considered as

the one deranged in the disease Sandhivata.

Snayu and Kandara:

Snayu is a structure which binds Asthi, Mamsa and Meda. Out of 900 Snayu, 10

Snayus are present in Janu Sandhi. These are responsible for bearing of body weight.

Sushruta has explained this by giving a simile of boat. As a boat made of planks and

wood tightened together by means of large number of bindings can float on the water


JANU SANDHI REVEW

10

and is capable of carrying loads of passengers, in the same way, the human body is

tightened at the Sandhi by large number of Snayu and is able to bear weight48.

Kandara is a type of Snayu that is Vritta or cylindrical in shape. Its functions include

Prasarana and Aakunchana of the joint49.

Shleshmadhara Kala

Kala is a structure located in between Dhatus and Ashaya that contains Kleda which is

described as Dhatu Rasa Vishesha by Acharya Vagbhata. It is the fourth Kala, which

is situated in Sarva Sandhi. This helps in lubrication of joints 50. Just as a wheel

moves well by lubricating the axle, joints also function properly if supported with

Kapha. Synovial membrane has similar functions.

Sleshma or Shleshaka Kapha

Sleshma, which is present in the Sandhi, is termed as Shleshaka Kapha 51. It facilitates

free movement of the Sandhi and provides lubrication to the Sandhi. The function of

Shleshmadhara Kala and Sleshma are similar. So, we may consider that Sleshma is

the one that is present in Shleshmadhara Kala, and that it does Kleda of Sandhi.

Peshi

Peshi is the fleshy mass which covers the different structures of the body such as Sira

Snayu, and Asthi, and it provides strength to those structures and to the Sandhi. In

Janu sandhi they are five in number. They are strong structures that help to maintain

alignment of the joint 52.

Sanghata

Sanghata, or assemblage of bones, is fourteen. One is situated in Janu Sandhi53.

Sira and Dhamani

The Kaphavaha Siras carry Prakrita Kapha, maintain the Sandhi, ensure its Sthirata

and increase its Bala. One of the functions of Vatavaha Siras is Cheshta, such as


JANU SANDHI REVEW

11

Prasarana and Akunchana. The Raktavaha Siras does Dhatu Purana, brings about

Sthirata and does Poshana. Asthi is one among the Dhatus and hence these functions

are applicable for Asthi Dhatu Poshana also54,55,56.

The Sparshavaha Dhamanis are spread in the upward direction and these have the

function of carrying the Sparsha Jnana 57. The Sparsha may be Sukhakara or

Dukhakara.


ANATOMY OF KNEE JOINT

12

KNEE JOINT

The knee joint is a type of Synovial joint. In Synovial joints, the articulating osseous

surfaces are not in continuity although the bones involved are linked. Synovial joints

evolve from fibrous and cartilaginous joints by subsequent developments. They are

made up of a combination of unique structures including the fibrous capsule, articular

surfaces, Synovial membrane, Synovial fluid, ligaments, muscles, etc.

The knee joint is one of the largest joints of the human body. Despite its single cavity

in man, it is convenient to describe it as two chondylar joints between the Femur and

Tibia, and a sellar joint between the Patella and Femur.

Articular surface

Articular surfaces are most dissimilar. The Tibial surface is slightly hollow centrally

and flattened peripherally wherein a meniscus rests. Laterally, the Tibial surface is

circular and smaller, while medially the Tibial surface is oval with a longer antero-

posterior axis.

The lateral and medial femoral chondyles in front have a faint groove. This groove

demarks the femoral patellar and chondylar surfaces. Lateral Femoral surfaces are

almost circular and medial, while the femoral surface is larger and oval. The Patellas

articular surface is adapted to the femoral surfaces.

Fibrous capsule

The fibrous capsule has parallel but interlacing bundles of white collagen fibers. It is

complex, partly deficient and partly augmented by expansions from adjacent tendons.

It forms a cuff with its ends attached continuously around the articular ends of the

tibia and Femur.

Synovial Membrane

Derived from embryonic mesenchyme, the Synovial membrane lines the fibrous

capsule and covers exposed osseous surfaces, intra-capsular ligaments and tendons. It

is absent from intra-articular discs or menisci and ceases at the margins of articular

cartilages.



13

Synovial Intima: It is also called as lamina propria synovialis or Synovial lining layer.

It consists of pleomorphic synoviocytes embedded in a granular, amorphous, fiber

free inter-cellular matrix. It helps in removal of debris and synthesis of components of

Synovial fluid.

Synovial fluid

It occupies the Synovial joints, bursae and tendon sheaths. It is clear, pale, yellow,

viscous, and slightly alkaline. Most probably the protein lubricin (rather than

hyaluroic acid) is the lubricating factor, which is amplified the secondary lubricating

activity of hyaluroic acid. It provides a liquid environment with small range of pH,

nutrition for articular cartilage, discs, menisci, lubrication and reduction of erosion.

Menisci

They are the fibrocartilagenous disc-shaped crescents which deepen the articular

surfaces of the chondyles of the tibia and also partially divide the joint cavity into

upper and lower compartments. They possess two ends, two borders and two surfaces,

and act as shock absorbers. By lubricating the joint cavity, they give rise to

proprioceptive impulse58.

OTHER STRUCTERS:

Ligaments

The capsules and ligaments of Synovial joints unite the bones, help to direct bone

movement and prevent excessive and undesirable motion. Thus, with more ligaments,

the joint becomes stronger. In the knee joint, the tibial collateral ligament, fibular

collateral ligament, oblique popliteal ligament, arcuate popliteal ligament,

ligamentum patellae, cruciate ligament etc. help to maintain stability.

Muscle Tone

The muscle tendons that cross the joints are the most important stabilizing factor. The

amount of stability is due to the tone of the respective muscles. In the knee, muscle

tone is extremely important for reinforcing joints. The thigh muscles are especially

helpful.



14

Bursae

These are apertures in fibrous capsule through which Synovial membranes protrude.

They are numerous; as many as 13 burses have been described.

Blood Supply

5 Genicular branches of the popliteal artery The descending genicular branch of the femoral artery The descending branch of the lateral circumflex femoral artery 2 recurrent branches of the anterior tibial artery The circumflex fibular branch of the post-tibial artery

Nerve Supply

Femoral nerve Sciatic nerve - through the genicular branches of the tibial and Common Peroneal nerve Obturator nerve - through its posterior division59.

Picture No. 31: Structure of Knee Joint


TWAK REVIEW

15

TWAK

Janu Basti & Janu Pichu are the procedures which are done over the Twak. Janu

Sandhi is covered by Twak externally. Absorption of the Aushadhi is carried out only

through the media of Twak and hence it is very important to study Twak Shareera

when we deal with these Bahi Parimarjana Chikistas.

In view of Ayurveda:

Twak is a Sthana of Sparshanendriya. Twacha and Charma are synonymous words

which are commonly used to indicate the skin in all Ayurvedic classics. Twak is one

of the Indriya Adhishtanas which completely covers Meda, Shonita and all other

Dhatus of the body, and it spreads all over the body. It is considered as the seat of

Sparshanendriya, as well as one of the main seats of Vata. Bhrajaka Pitta is also

situated in Twak60,61.

Formation of Twak:

According to Charaka, Twak is the Upadhatu of Mamsa and is considered to be

formed from Mamsa. According to Sushruta, at the time of fertilization, Shukra,

Shonita and Atma unite for the formation of Garbha. Its growth is rapid and it is

nourished by Tridoshas. The seven folds, or layers of Twak, are formed at that time

and are deposited on this rapidly transforming product in the same manner as the

layers of cream are formed and precipitated on the surface of boiling milk 62.

According to Vagbhata, Twak is formed by the Paka of Rakta Dhatu by its Dhatvagni.

After the Paka of Rakta, it becomes dry in the form of Twak, similar to the deposition

of cream on the surface of the boiling milk. Thus, Twak is also called as Rakta

Santanika 63.

Layers of Skin (Twak):

There are some different opinions regarding the number of the layers of the skin

(Twak) among the ancient Acharyas.


TWAK REVIEW

16

Acharya Charaka has mentioned six layers of skin, but only the first two layers are

named while the remaining four are counted as those producing diseases 64.

1. Udakadhara

2. Ashrukadhara

3. Tritiya

4. Chaturtha

5. Panchami

6. Shashti

Acharya Sushruta has mentioned seven layers of skin along with their specific names,

thickness and probability in origin of specific diseases 65.

1. Avabhasini

2. Lohita

3. Shweta

4. Tamra

5. Vedini

6. Rohini

7. Mamsadhara

Acharya Vagbhata has also described seven layers of skin, but the names are not

mentioned. Commenting on Vagbhata, Arundatta and Hemadri have named them

according to the nomenclature given by Sushruta 66.

Sharangadhara has also mentioned seven layers of skin along with the probable onset

of disease. The names of the first six layers are the same as Sushruta, but the 7th layer

is called Sthula67.


ANATOMY OF SKIN

17

ANATOMY OF SKIN

According to modern science: 68

Skin is one of the largest organs of the body in surface area and weight. In adults, the

skin covers an area of approximately 2 square meters and weighs between 4.5 to 5 kg.

It ranges in thickness from 0.5 to 4.0 mm, depending on the location.

ANATOMY:

The skin consists of two principal parts. The outer thinner portion, called the

epidermis, is composed of epithelium. It is attached to the inner, thicker, connective

tissue part called the dermis. The dermis is a subcutaneous layer known as the

superficial fascia or hypodermis, which consists of Areolar and Adipose Tissue. This

subcutaneous layer, in turn, attaches to underlying tissues and organs.

EPIDERMIS:

The epidermis is composed of Stratified Squamous Epithelium and contains four

principal types of cells called: (i) Keratinocytes, (ii) Melanocytes, (iii) Langerhans

cells, and (iv) Marked cells. Four or five distinct layers of cells form the epidermis. In

most regions of the body, the epidermis is about 0.1 mm thick and has four layers.

Where exposure to friction is greatest, as in the palms and soles, the epidermis is

thicker (1 to 2 mm) and has five layers. Constant exposure of thin or thick skin to

friction or pressure stimulates formation of a callus, an abnormal thickening of the

epidermis.

The names of the five layers, from the deepest to the most superficial layer are as

follows:

Stratum basal or germinativum: It forms the lowest layer, consists of a single row

of columnar cells and is capable of continuous cellular division. As these cells

multiply, they push up towards the surface and become part of the upper layers. The

stratum basal also contains tactile (Merkel) discs that are sensitive to touch.


ANATOMY OF SKIN

18

Stratum spinosum or Malpighi layer: This prickle cell layer lies upon the basal

layer and has 8 to 10 rows of polyhedral cells that fit closely together. This layer

involves most of the pathological conditions of the skin.

Stratum granulosum: It consists of about three to five rows of flattened cells that

develop darkly staining granules of a substance called Keratohyalin. This compound

is the precursor of keratin. Keratin forms a barrier that protects deeper layers from

injury and microbial invasion and makes the skin waterproof.

Stratum Lucidum: Normally, only the thick skin of the palms and soles has this

layer. It consists of three to five rows of clear, flat, dead cells that contain droplets of

an intermediate substance that is formed from keratohyalin and is eventually

transformed to Keratin.

Stratum Corneum: This layer consists of 25 to 30 rows of flat, dead cells completely

filled with keratin. These cells are continuously shed and replaced by cells from

deeper strata. The Stratum corneum serves as an effective barrier against light and

heat waves, bacteria, and many chemicals.

DERMIS:

The dermis chiefly consists of white fibrous tissue, elastic fibers and non-stripped

muscles, and it contains blood vessels, nerves, hair, sweat glands, sebaceous glands

and nerve corpuscles. The outer portion of the dermis, about one fifth of the thickness

of the total layer, is called the papillary region. The deeper portion of the dermis is

called the reticular region. It consists of dense irregular connective tissue containing

interlacing bundles of collagen and coarse elastic fibers. The reticular region is

attached with underlying organs, such as bone and muscle, by the subcutaneous layer,

and it is also called the hypodermis or superficial fascia.

Keratinization:

In the process of Keratinization, cells newly formed in the basal layers undergo a

developmental process as they are pushed to the surface. As the cells relocate, they

accumulate keratin, and simultaneously the cytoplasm, nucleus, and other organ cells

disappear and the cells die. Eventually, the keratinized cells slough off and are


ANATOMY OF SKIN

19

replaced by underlying cells which in turn become keratinized. The whole process by

which a cell forms in the basal layer, rises to the surface, becomes keratinized and

sloughs off takes two to four weeks.

Pigmentation of the skin:

Three pigments, namely melanin, carotene and hemoglobin, give skin a wide variety

of colors. Melanin is located mostly in the epidermis; carotene is mostly in the

stratum Corneum and dermis; and hemoglobin is in red blood cells within capillaries

in the dermis.

Blood supply of skin:

There are two horizontal and parallel systems of plexuses which maintain vascular

supply the skin. These plexuses or networks of blood vessels exist between the dermis

and the subcutaneous tissue. Their exact position can never be accurately described.

Each arteriole supplies an area of skin, while the corresponding plexus drains the

same area.

Nerve supply:

The nerve supply of the skin is very complicated, with the pathways of mediation of

sensation through the various nerves being very much under debate. The varied

sensations arising from the skin are derived from a diverse population of cutaneous

nerve endings or receptors. Thus tactile, temperature and pain sensations are each

sub-served by different groups of receptors.

FUNCTIONS OF SKIN68

The skin is a metabolically active organ with vital functions including protection and

homeostasis of the body.

Regulation of body temperature: Skin regulates the evaporation of sweat and

converts any elevation of body temperature into a lower temperature or to normal.

Changes in the flow of blood to the skin also help the regulation of body temperature.


ANATOMY OF SKIN

20

Protection: The skin is considered under the Integumentary system. It provides a

physical barrier that protects the underlying tissues from physical abrasion, bacterial

invasion, and dehydration and UV radiation.

Sensation: The skin contains abundant nerve endings and receptors that detect stimuli

related to temperature, touch, pressure and pain.

Immunity: Sweat of the epidermal cells is one of the important components of the

skin immune system, which wards off foreign invaders.

Excretion: Sweat is the vehicle for loss of a small quantity of ions and several

organic compounds, along with removal of heat and some part of water.

Blood reservoir: The dermis houses extensive networks of blood vessels that carry 8

10% of the total blood flow in a resting adult. In moderate exercise this flow

increase, which helps to dissipate the heat from the body. During exercise, the skins

blood vessels can also constrict to allow more blood to circulate through contracting

muscles.

Picture No 32: Structure of Skin.


JANU BASTI REVIEW

21

JANU BASTI

Janu basti comprises of two words: Janu meaning the Janu Sandhi, and Basti the

derivative term of urinary bladder whose main function is to withhold. None of our

classics have explanations about Janu Basti as such. It is a procedure that has evolved

from Shiro Basti. Vagbhata has explained four types of application of Sneha over the

head, included in the classification of Murdhni Taila, which includes Shiro-

Abhyanga, Shiro-Seka, Shiro-Picu and Shiro-Basti21.

Shiro Basti is the procedure in which the Sneha is retained over the scalp with help of

Masha Pishti and a Charma Patta (leather sheet) for a specified period of time22.

Observing the results of Shiro Basti, the later physicians developed a similar

procedure over Janu and named it Janu Basti. In this way, Janu Basti evolved from the

Shiro Basti procedure. Today, the same is performed over the Kati and Greeva

regions and named respectively as Kati Basti & Greeva Basti.

Derivation

The term "Janu-Basti" consists of the following two words:

1) Janu 2) Basti

Janu

Vyutpatti - Jan - Junn

Nirukti - Uru Jangayormadya Bhaga (Shabda Stoma Mahanidhi)

Janu-Sandhi i.e., the knee joint

In general 'Janu' means - the junction between Uru and Jangha.

Basti

Vas is formed by the Tich Pratyaya.

It belongs to masculine gender.

The word Vas means to reside, to abide, to produce effect of aromatic

drugs.


JANU BASTI REVIEW

22

Meanings related to organ:

Nabheradhobhage Mutradhare Sthane

- Organ that lies below the umbilicus (Nabhi).

Bastih- Basteh Avrinoti Mootram

- Organ in which the urine is collected and retained for some specific period of

time.

Meanings related to Karma:

The treatment which is administered using a Basti is called as Basti. Here the urinary

bladder of animals is used to inject the drugs into the rectum23, 24.

The word 'Basti' is used here with the meaning to reside or to retain. In 'Janu-

Basti' the medicine is made to dwell or be retained over the Janu-Sandhi for a

prescribed time.

Bahir-Parimarjana Chikitsa

Chikista can be classified as Anta-Parimarjana, Bahi-Parimarjana and Shastra-

Pranidhana on the basis of route of administration. Janu-Basti may be included under

Bahir-Parimarjana type of treatment25.

Sandhigata Vata is one among the Vata Vyadhi. The symptoms and treatment of

Sandhigata Vata is explained in the classics. The principle line of management is

Snehana, Svedana, Upanaha and Agnikarma26. Among these, Snehana and Svedana

are Samprapti Vighatana Chikitsa.

Janu-Basti is one such procedure that can provide both Svedana and Snehana effect.

Procedure of Janu-Basti

The procedure of Janu-Basti can be performed in the following three stages:

1. Poorva karma

2. Pradhana karma

3. Paschat karma


JANU BASTI REVIEW

23

Each of the Steps is explained as follows:

1. Poorva Karma

This includes preparatory measures like preparation of patient, preparation of

medicine and collection of materials required for the smooth execution of the

procedure. It can be conducted under following considerations.

a) Atura Pariksha

The patient is examined in relation to Dashavidha Pariksha and by applying

Pratyaksha, Anumana and Aptopadesha siddhantas to assess Vyadhi, Bala and Deha

Bala27. Then, the affected knee joint is examined properly and the region of maximum

tenderness is noted. It is also examined for scars & wounds.

b) Sambhara Sangraha

It includes a metal ring, Masha Pishti, Aushadha Dravya (Vasa), spoon, bowl, vessel,

water, gas stove and table.

c) Atura Siddhata

Patient is asked to lie in supine position or to sit erect and extend the lower limbs on

the table, whichever is more comfortable. The affected knee is exposed properly.

Limbs are supported properly so that they are placed horizontally and comfortably.

2. Pradhana Karma: This includes -

a) Basti Yantra Dharana

First, Masha pishti is prepared by adding sufficient quantity of water to the flour of

Black gram. Then, with the use of metal ring and Masha pisti a pit of about 2 Angula

height is constructed over the Janu-Sandhi. The concavity of pit (Basti Yantra) should

be well sealed to prevent the leakage of the medicine retained in the cavity.

b) Aushadhi Dharana

The bowl containing medicine (Vasa) is heated indirectly by keeping over hot water.

Then, the gently heated Luke warm Vasa is poured slowly and carefully on the Janu-

Sandhi along the side of the Basti-Yantra.


JANU BASTI REVIEW

24

The heat of the medicine should be sufficient enough to be tolerated by the patient.

The level of the medicine should be two Angula above the highest point inside the

cavity.

c) Maintenance of constant temperature of medicine (40-450C)

The medicine in the pit is replaced with heated medicine every 5 minutes so that a

constant temperature is maintained throughout the procedure.

d) Removal of Dravya and Basti Yantra

After the specified time, i.e. 45 minutes, the Murivenna is removed from the Basti

Yantra and then the Basti Yantra is removed.

e) Samyak Lakshana

The Samyak Lakshanas of Janu-Basti are not described in our classics. Even though

Janu-Basti is a modification of Shiro-Basti, those Samyak Lakshanas cannot be

interpreted for Janu-Basti. Therefore, the Ayoga, Atiyoga and Samyakyoga bahya

Lakshanas of Swedana & Snehana that are mentioned in the classics can be

considered as the Lakshanas of Janu-Basti28, 29. Among Samyak Sveda Lakshanas,

Sheetoparama, Stambhanigraha, Gauravanigraha and Vyadhihani can be considered

for assessment. In case of Samyak Snigdha Lakshanas, Snigdha Gatratva and Mrudu

Gatratva can be taken for assessment.

f) Time

In case of Vataja disorders, the Dravya should be retained for Ten thousand Matra

Kala30. Hence, the procedure is performed for 45 min every day.

3. Pashchat Karma

After removing the Dravya and Basti Yantra, Mridu Abhyanga is done over the Janu-

Sandhi for about 5 min.

Duration - This treatment is done for 7 days.


JANU PICHU REVIEW

25

JANUPICHU

Janu Pichu comprises of two words Janu meaning the Janu Sandhi and Pichu that

literally means cloth whose function is to withhold the oil in the affected area. None

of our classics have explanations about Janu Pichu as such. It has too evolved from

the concept of Moordhini Taila. The various process by which oil is applied over the head is termed Murdhni taila. Shiro pichu among the Moordhini tailas serves as the

base for Janu Pichu.

Shiro Pichu is the procedure, in which the Sneha is retained over the scalp with help

of plotha or a cloth for a specified period of time30. Observing the results of Shiro

Pichu the later physicians developed a similar procedure over Janu and named it as

Janu Pichu. In this way Janu Pichu procedure is evolved from Shiro Pichu procedure.

Now a days same is performed over various regions of body and named accordingly.

Derivation

The term "Janu-Pichu" consists of following two words:

1) Janu 2) Pichu

Janu

Vyutpatti - Jan - Junn

Nirukti - Uru Jangayormadya Bhaga (Shabda Stoma Mahanidhi)

Janu-Sandhi i.e., the knee joint

In general 'Janu' means - the junction between Uru and Jangha.

Pichu Pichu plotha sa cha taile tulapatalam nishichya shirasi deya ithi pichusamjna (Sa.S.Dipika) Pichu plotha tulavastradi tailakthadharanam . (Sa.S Gudharthadipika) Pichu literally means cloth, it is a process of placing a piece of cotton cloth, immersed in oil, over the affected area.


JANU PICHU REVIEW

26

Indications In the context of Shirashoola Pichu is advocated. It is clearly stated that in Vataja

shirashoola, if the condition is severe the procedure of Pichu is opted rather than

Abyanga19. In Dantapatanaka after its management, Pichu can be performed

continuously using Vatasani taila20. Pichu with Vatasani taila or Dhanvantara taila is

indicated in Manyastambha21. In children when the nasal passage is blocked with

Kapha, Shiropichu is beneficial when done with Sigrupatra rasa and Eranda taila or

with the juice of Sahadevi with Trikatu and breast milk22. Pichu is extensively used in

the context of Pinasa, in Arogyakalpadruma, Pichu for two yama with Manjishtadi

yamaka is indicated in Pittajapinasa, Mustadi yamaka in Kaphajapinasa, Talisapatradi

yamaka in Dushtapinasa. Pichu is also indicated in the state of unconsciousness in

sannipatajwara23.

Procedure of Janu-Pichu

The procedure of Janu-Pichu can be performed in the following three stages:

1. Poorva karma

2. Pradhana karma

3. Paschat karma

Poorva Karma

This includes preparatory measures like preparation of patient, preparation of

medicine and collection of materials required for the smooth conduction of the

procedure. It can be conducted under following considerations.

a) Atura Pariksha

The patient is examined in relation to Dashavidha Pariksha and by applying

Pratyaksha, Anumana and Aptopadesha siddhantas to assess Vyadhi Bala and Deha

Bala35. Then, the affected knee joint is examined properly and the maximum tender

region is noted. It is also examined for scars & wounds.


JANU PICHU REVIEW

27

b) Sambhara Sangraha

It includes the collection of necessary items required for the stable conduction of the

procedure. 2 cotton pads (4*1 inch) , Aushadha Dravya (Murivenna), bowl, vessel,

water, gas stove and table.

c) Atura Siddhata

Patient is asked to lie in supine position or to sit erect by extending lower limbs on the

table, whichever comfortable. The affected knee is exposed properly. Limbs are

supported properly so that they are placed horizontally and comfortably.

2. Pradhana Karma: This includes

a) Janu Pichu Dharana

The bowl containing medicine (Murivenna) is heated indirectly by keeping over a

coloumn of hotwater. Then in the gently heated Luke warm Murivenna, pichu is

dipped slowly and carefully. This is placed along the Janu-Sandhi analyzing the

tolerability of the patient .The heat of the medicine should be sufficient enough to be

tolerated by the patient..At the area of maximum tenderness Pichu is placed and

retained until the temperature of the oil reduces.

b) Maintenance of constant temperature of medicine (40-450C)

The medicine in the initial Pichu is replaced with the heated oil by another Pichu of

same size every 5 minutes. In the mean time the oil from the initial Pichu is drained &

kept for heating and this process is alternatively continued so that a constant

temperature is maintained throughout the procedure.

c) Removal of Dravya and Basti Yantra

After the specified time i.e. 45 minutes the Murivenna is removed along with the

pichu.


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d) Samyak Lakshana

As the Samyak Lakshanas of Janu-Pichu are not described in our classics, Samyak

Lakshanas of Shiro-Pichu cannot be interpreted even though Janu-Pichu is

modification of it. Therefore, the Ayoga, Atiyoga and Samyakyoga bahya Lakshanas

of Swedana & snehana mentioned in the classics can be taken for Samyak Lakshana

of Janu-Pichu36,37. Among Samyak Sveda Lakshana Sheetoparama, Stambhanigraha,

Gauravanigraha and Vyadhihani can be considered for assessment. In case of Samyak

Snigdha Lakshanas Snigdha Gatratva and Mrudu Gatratva can be taken for

assessment.

e) Duration

In case of Vataja disorders the Dravya should be retained for ten thousand Matra

Kala38. Hence the procedure is performed for 45 min for 7 days.

3. Pashchat Karma

After removing the Pichu along with oil Mridu Abhyanga is done over the Janu-

Sandhi for about 5 min.

Duration - This treatment is done for 7 days.


29

ILLUSTRATIONS

MURIVENNA

11

Prerequisite

JANU JANU

Picture No 33: Illustrations of Procedures.

DISEASE REVIEW

30

JANU SANDHIGATA VATA

The disease 'Janu-SandhiGata-Vata' is to be understood from 3 terminologies i.e.,

Janu, Sandhi and Gata Vata. Etymology, definition and specific interpretation of these

terms i.e., Janu, Sandhi and GataVata are as follows.

Janu

Vyutpatti - Jan - Junn Nirukti - Uru Janghayor Madhya Bhaga

(Shabda Stoma Mahanidhi)

- Janu Sandhi i.e., the knee joint

Paribhasha - Janu - Napumsakalinga In general 'Janu' is the junction that lies between Uru and Jangha.

Sandhi

Vyutpatti - Sam + Dha + Kihi (Shabda Kalpa Druma), (Shabda Stoma Mahanidhi)

Nirukti - Sandhirnamsa Samyogaha (Shabda Kalpa Druma)

Asthidwaya Samyoga Sthana

(Shabda Stoma Mahanidhi)

Sandhirnama Asthnam Anyonya Sangam Asthnani

(Brihatsharira 1part, 6th chap)

Junction, connection, combination, and union which contain a conjugation, transition

from one to another 69.


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Paribhasha

Sandhi Pullinga, Sandhanamiti Yuga Sandhini - Yugashabde Deha Sandhini

Marmashabde Cha Drishtavyaha. (Shabda Kalpa Druma)

Generally, Sandhi means the junction between two structures. In Ayurveda Shareera,

Sandhi is a technical word indicating that, it is the place where two or more bones join

or articulate together and the joint formed may be fixed type or with less or freely

movable.

Acharya Sushruta told that, in the body there are innumerable junction between Peshi,

Sanyu, Sira, Asthi, etc. but the description given here is only for Asthi Sandhi 70.

Dalhana also supports Sushrutas view that 'Sandhi' means Asthyashrita Sandhi 71.

In Parishadya Shabdartha Shareera it is described that the meaning of Sandhi is union

or meeting place, but in Shareera the word Sandhi is mostly used for Asthi-Sandhi

[bony articulations].

By viewing all these we can say that the word Sandhi denotes only Asthi Sandhi.

Vata

Vyutpatti - Va - Gati Gandhanayoho Va - Gati Sevanayoho

Va + Kta

(Shabda Kalpa Druma)

The term Vata is derived by the application of Kta or Krt Pratyaya to the verb root

Va which means Gati Gandhanayoh.


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32

Nirukti - Sparsha Matra Vishesha Gunake Bhutabheda Pavane - Dehasya Dhatubheda Cha

(Shabda Sthoma Mahanidhi)

The term Gati is having meanings like Prapti, Jnana (Panini) and the meaning of

Gandhana is like Utsaha, Prakashana, Soocana, (Shabdasthoma) Gandhana, Prerana

(Siddhanta Kaumudi).

Considering the different meanings of Gati and Gandhana, if it is understood that the

term Vata act as a receptor as well as stimulator. Hence it can be understood that Vata

is a biological force, which governs and stimulates all the activities in the body.

Concept of Gatatva

Sandhivata is also named as Sandhi Gata Vata. Different theories have been quoted to explain

the Samprapti of various diseases. Gatatva is one such complex phenomenon mentioned in all

Ayurvedic classics. Gatatva of Dhatu, Upadhatu, Ashaya, Avayava and Indriya etc. have been

described in classics 72.

Synonyms of Gatatva:

Gata / Gatam Sthite / sthitam Avasthite Ashrite / Samashritam Prapte Sthe / Stha etc.


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33

By the above meanings and synonyms, it can be stated that the word has two

implications. One suggests the movement (Subjected to Gati of Vayu) and the other

related with occupation of site (subjected to Adhishtana).

Hence Gatatva of Vata implies an undesirable movement of Vata and its unwanted

occupation at certain sites.

SANDHIVATA & SANDHI GATA VATA

By the use of both terminologies Sandhivata and Sandhigatavata in the context of

same disease doubt arises, whether two are synonyms of the same disease? A

screening of the available Ayurvedic literature reveals that the disease entity

Sandhigata Vata is found in all the major treatises, even than a disease entity by the

name of Sandhivata is nowhere to be found. However, in Bhavaprakasha, under the

chapter of Vatavyadhi, in the context of Phalashruti of the treatment of

Sandhigatavata, the term Sandhivata has been used as analogous to Sandhigatavata. It

implies that both Sandhigatavata and Sandhivata are synonyms of the same disease

entity 73.

SANDHIGATA VATA

Disease Sandhivata is described initially by Acharya Charaka as Sandhigata Anila

with symptoms of Shotha which on palpation feels as bag filled with air and Shula on

Prasarana and Aakunchana (pain on flexion and extension of the joints) 74. Sushruta

also mentioned Shoola and Shotha in this disease leading to the diminution (Hanti) of

the movement at joint involved 75. Another disease Vata Kantaka is mentioned by

Sushruta which occurs due to the vitiated Vata by involving Khuda Sandhi.

According to Dalhana and Gayadasa, Khadu means Padajangha Sandhi i.e. ankle 76.


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34

Another view has been quoted according to which Khadu may be taken as Parshani

(calcaneum). Madhava has not explained Shotha but mentioned Atopa as a symptoms

of Sandhigata Vata 77, which may also be taken equivalent to air filled bag. He has

added one more symptom i.e. Hanti Sandhi (restricted flexion and extension). Thus,

the disease Sandhigata Vata can be defined as a joint disease with symptom of Shula,

which aggravates by movement, along with Shotha & complete restricted movements

at later stages. This disease is comparable with Osteoarthritis, a degenerative joint

disease, the symptoms of which are same as Sandhigata Vata and usually occurs after

the age of 40 years.

RELATION BETWEEN VATA AND SANDHI

There is a relation between the Dosha and Dushya because of their Bhautika

constitution, which has been well narrated in Ashtanga Hridaya while describing the

properties, actions and importance of Tridosha. This is also called as Ashaya Ashrayai

Bhava i.e. inter-relation between Dosha and Dushya. Vata is located in Asthi, Pitta in

Sveda and Rakta and Kapha in Rasa, Mamsa, Meda, Majja and Shukra. It is because

of this relation that the drugs or dietetic regimens which augment one particular

Dosha also have the effect on its dependant Dhatu. By augmentation of the Dosha,

there would be similar effect on their respective Dhatu. But, on contrary to this

augmentation of Vata (Ashrayi), due to its properties will lead to decrease (Kshaya) in

the Asthi (Ashraya) and vice versa. In the similar way it is related with Kapha.

Kshaya of Kapha will cause increase in the quantum of Vata and vice versa 78,79.


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35

SYNONYMS80,81

Different authors named this disease according their own views, but most of them are

out of views. The probable synonyms of Sandhivata used in the different context or

considered equivalent to Sandhivata by the commentators are as follows.

Sandhigata Anila

Sandhigata Vata

Khudavata

Gulphavata - Synonyms meant only for Gulpha Sandhigatavata

NIDANA

In Ayurveda, Nidana is a broad term deals with etiology as well as diagnosis of a

disease and it disturbs whole physiological system of Shareera. For prevention and

cure Nidana plays an important role so it is considered as prime among Nidana

Panchaka.

Nidana are classified basically into Samanya nidana & Vishesha Nidana. Samanya

Nidana is common for all Vatayadhis, whereas Visesha Nidana is specific cause for

specific disease. No specific Nidanas are mentioned for Sandhigata Vata in our

classical samhitas. are responsible for Sandhigata Vata reflects as Nidana.

However factors which vitiate the Vata Dosa can be considered as Nidana explained

under the context of Vata Vyadhi in different Samhitas 82--87 and Asthivaha Srotodusti

Karana and Majjavaha Srotodusti Karana88 may be taken as Nidana of Janu

Sandhivata.


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36

They can be classified under the concepts of:

Sannikrushta Hetu Viprakrushta Hetu

Under Sannikrushta Hetu the following Nidanas can be considered:

Ati Vyayama:

Ati Vyayama includes excessive physical works, running, jogging, walking etc. If

these are done excessively then it affects the structure of the Sandhi. The joint

stability is affected by the over exertion and leads to Janu Sandhigata Vata.

Bharaharana:

Janu Sandhi is the main weight bearing joint in the body. Carrying heavy and

excessive loads creates more pressure and exertion over the Janu which leads to

destruction of the joint.

Abhighata:

As Sandhi is formed by different Asthi, Peshi and Snayu, injury to any of these

structures can cause harm to the stability of the Sandhi. Abhighata can cause

structural deformity of the joint and hence it is also a main Nidana for Sandhigata

Vata.

Atisamkshobha:

It is a Nidana for Asthivaha Sroto Dushti. Since Asthivaha Srotas is involved in

Sandhigata Vata this can be considered as Nidana for the same. Violent activities like

Atyadhva, Plavana, Langhana, Balavat Vigraha, Pradhavana etc. will have its effect


DISEASE REVIEW

37

on joint. As told earlier knee is the weight-bearing joint, the violent exercises or

activities will alter the structural integrity of the joint.

Marmabhighata:

Marma is a vital part which includes Asthi, Mamsa, Sira, Snayu and Sandhi. Janu is

included under Vaikalyakara Marma and according to the concept of Marmabhighata,

it is definitely a Nidana for Sandhigata Vata.

Under Viprakrushta Hetu the following Nidanas Can be considered

Table 1: Aharaja Nidana of Vata Vyadhi

Rasa Janya

Charaka

Sushruta

Vagbhata

Madhava

Nidana

Yoga

Ratnakara

Bhava

Prakasha

Kashaya - + + - - +

Katu - + + - - +

Tikta - + + - - +

Guna Janya

Rooksha + + + + + +

Laghu + + - + + +

Sheeta + + - + + -

Dravya Janya

Vallura - + - - - -

Varaka - + - - - -

Shuskha Shaka - + - - - -


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Uddalaka + - - - -

Neevara - + - - - -

Mudga - + - - - -

Masura - + - - - -

Harenu - + - - - -

Kalaya - + - - - -

Nishpava - + - - - -

Table 2: Viharaja Nidana of Vata Vyadhi

Ati Vyayama + + + + + -

Langhana + + - + + -

Plavana + + - + + -

Atyadhwa + - - + + -

Pradhavana - + - - - -

Pratarana - + - - - -

Atyuchabhashana - - + - - -

Balavadvigraha - + - - - -

Abhighata + + - + + +

Marmaghata + - - + + -

Bharaharana - + - - - -

Dukhashayya + - - + + +

Dukhasana + - - - - -

Gaja,Ushtra,Ashva

Sheegrhayana

+

+ - + + -


DISEASE REVIEW

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Prapeedana - + - - - -

Ati Adhyayana - + - - - -

Ati vyavaya + + + + + +

Atijagarana + + + + + +

Vegadharana + + + + + +

Vishamopachara + - - + + -

Shrama - - - - - +

Upavasa + + + + + +

Puravata sevana - - - - - +

Divaswapna + + + + + -

Table - 3 : Manasika Nidana of Vata Vyadhi

Cinta + - + + + +

Shoka + - + + + +

Krodha + - - - - -

Bhaya + - - - - +

Table - 4 : Anya Karana for Vata Vyadhi

Ati

Raktasravana

+

- - + + -

Ati

Doshasravana

+

- - + + +

Dhatukshaya + - - + + +

Rogatikarshana + - - + + +


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POORVARUPA

No specific Poorvarupa of Janu Sandhigata Vata is available in any of the classics.

Purva Rupa is manifested due to Dosa Dusya samurchana. It takes place at fourth

stage (Sthansamsraya) of kriyakala. In the Vata Vyadhi Chikitsa Adhyaya of Charaka

Samhita the Poorvarupa of Vata Vyadhi is mentioned as Avyakta Lakshana89. The

mild manifested or un-manifested features of the actual disease can be considered as

Poorvarupa of Vata Vyadhi. Janu Sandhigata Vata being a Vata Vyadhi, clinical

features in milder form can be considered as Poorvarupa of Janu Sandhigata Vata.

RUPA

The Rupa of Sandhivata mentioned in different Samhitas are 90--96

Vata Purna Dhruti Sparsha (Sandhi Shotha):

Shotha is explained by most of the authors. The feeling of air filled bag when the

Sandhi is palpated is the nature of Shotha or Shotha in Sandhigata Vata. This

Lakshana is explained by Acharya Charaka and Acharya Vagbhata.

Vedana:

Vedana or Shula is explained by all the authors. Acharya Charaka and Vagbhata

specify the presence of Vedana during Prasarana and Akunchana of the body parts.


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41

Sandhi Hanti (Stabdhata):

This Lakshana is explained by Sushruta firstly and followed by later authors of

Madhava Nidana, Bhava Prakasha and Yogaratnakara. While commenting on word

Hanti Dalhana and Gayadasa explained it as Akunchanaprasaranayoh Abhavah and

Prasaranakuncanayoh Asamarthah respectively97. With this we can infer that the word

Hanti refers to inability to move the joints. Mudhukoshakara opines that word Hanti

refers to Sandhi Vishlesha or Stambha Adi Vikara98.

Atopa

Madhavakara explained this symptom in his treatise. While commenting on the word

Atopa in another context, Madhukoshakara quotes the opinion of Gayadasa and

Kartika stating -

Atopaha Chalachalanamiti Gayadasaha, Gudaguda Shabdamiti Kartikah.

Also Bhavamishra says Atopo Gudagudashabdaha 99.

Considering the above references we can say that Atopa in this context is the sound

produced by the movement of joints i.e., Crepitus.


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42

Table - 5 : Rupa of Sandhigata Vata mentioned in various classics

SAMPRAPTI

This is a series of pathological process happening in body during the production of a

Vyadhi from Nidana sevana to Roga pradurbhava 100. A proper understanding of

Samprapti is important for the treatment, since Chikitsa explained in the Ayurvedic

text is nothing but Samprapti Vighatana 101.

The series of pathological events from the onset of Dosha Dushya Dushti till the

appearance of Vyadhi comprise various stages. Samprapti is the one which explain

this series of events. It explains the total pathogenesis of the disease.

As Janu Sandhigata Vata is not explained as a separate disease with Nidana Panchaka

in the classics, so the Samanya Samprapti of Vata Vyadhi can be adopted as

Samprapti of Sandhivata or Janu Sandhigata Vata.

SYMPTOMS C.S. Su.S. A.H. A.S. M.N. B.P. Y.R.

Sandhi Vedana + + + + + + +

Sandhi Shotha (Vata Purna dhruti Sparsha)

+ + + + - + +

Sandhi Hanti

(Stabdhata) - + - - + - -

Atopa - - - - + - -


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Intake of Vatakara Ahara Vihara does the vitiation of Vata. This vitiated Vata lodges

in Rikta Srotas i.e. Srotas in where Shunyata of Snehadi Guna is present. Vata after

settling in Rikta Srotas produce disease related to that particular Srotas 102.

While explaning the Samprapti of Vata Vyadhi Acharya Vagbhata tells that

Dhatukshaya aggravates Vata and the same is also responsible to produce Riktata of

Srotas. Thus the vitiated Vata travels through out the body and settles in the Rikta

Srotas and further vitiates the Srotas leading to the manifestation of Vata Vyadhi 103.

Explanation of Srotoriktata due to the Nidana Sevana can be given as follows; the

chief properties of Parthiva Dravya are Guru, Sthula, Sthira, Gandha Guna in excess.

These are the properties, which are necessary for Sthairya and Upacaya of the body.

Excessive intake of Dravyas having Laghu, Ruksha, Sukshma, Khara properties lead

to Guru and Sneha Guna Abhava due to their opposite quality. Thus it leads to

Dhatukshaya in the body. Akasha is the Mahabhuta that produces Sushirata and

Laghuta in the body. Vayu Mahabhuta fills up this Sushirata. So due to Dhatukshaya

Akasha Mahabhuta increases in the b

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