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→Vidhi Vimarsha
=== ''Vidhi Vimarsha'' ===
=== ''Vidhi Vimarsha'' ===
==== Importance of ''vata dosha'' in overall health and disease ====
This text highlights the grandness of ''vata'' as a humor. ''Vata'' is equated to ''ayu''. Life is sustained by ''vayu'' only. Even though ''ayu'' is previously defined as conglomeration of ''sharira'' (physical body), ''indriya'' (sensorium), ''satva'' (mind) and ''atma'' (soul), <ref> Ibid 1/42 </ref> here it is mentioned equivalent to ''vayu''. The sense organs, mind and soul in physical body are manifested through the functions of ''vayu'' only. The strength of the individual is also provided by ''vayu''. These two usages of ''ayu'' and ''bala'' are later explained as, ''prana'' is life and ''udana'' is strength. (verse 3)
''Vata'' performs all its activity for a healthy long life subject to status of its three functions. They are ''akupita''(not increased, decreased or vitiated), ''sthanastha'' (located in its own place) and ''avyahatagati''(nothing is interfering with its movement or ''gati'').
==== Nature of ''vata'' ====
''Pitta'' and ''kapha'' are relatively compact and in corporeal form. On the contrary ''vata'' is incorporeal (''avayavasamghātarahita''). It can be termed as rarified in nature. The ''vata'' is ''anavasthita'' (unstable) too. These two properties are due to its composition formed by ''akasha'' and ''vayu'' predominantly<ref> Vagbhata Vridha, Astangasamgraham with Sasilekha Commentary Sutrasthāna20/2; Sreekumari Amma (eds.) 1st ed. Trivandrum: Publication Division; Ayurveda College, 2000.</ref> which are incorporeal (''amurta''). ''Chalatva'' (mobility) and ''apratighata'' (unobstructability) are characteristics of ''vayu'' and ''akasha'' perceptible by the tactile sense organ<ref> Agnivesha, ''Charaka Samhita'' with Ayurveda Dipika commentary Shareerasthana; 1/29-30; Dr.Gangasahay pandey (eds.) 6th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 2000 </ref>. The biological ''vata'' (which is present in the living being) is self originated (''svayambhu''), subtle (''sukshma'') and all pervasive (''sarvagata''). It is invisible (''avyakta'') but its activities are patent or manifest (''vyaktakarma'').<ref>Sushruta. Sushrutasamhita with Nibandhasamgraha Commentary, Nidanasthānam 1/5; Vd. Yadavji Trikamji Ācharya (eds),Reprint, Choukhamba Krishnadas Academy, 2004 </ref>
Anavasthita (unstable) is due to chala property of ''vata''. This continuous moving nature of ''vata'' is explained with other terminologies also like ''sheeghravata''<ref>Agnivesha, Carakasamhita wtih Ayurveda Dipika commentry Vimanasthāna; 8/98; Dr.Gangasahay pandey (eds.) 6th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 2000.</ref> (swift movement), ''ashukari'' (instantaneous action), ''muhushchari'' (rhythmic movement).<ref>Sushruta. Sushrutasamhita with Nibandhasamgraha Commentary, Nidanasthānam 1/9; Vd. Yadavji Trikmji Ācharya (eds),Reprint, Choukhamba Krishnadas Academy, 2004</ref>. It abounds in the fundamental quality of ''raja'' (the principle of cohesion and action). The predominance of ''raja'' is responsible for the instability of ''vata''. The quality of ''chalatva'' is directional in nature, which is explained by the term ''gati''. ''Vata'' convenes all bodily activities by this important feature.
Owing to its incorporeal nature and instability ''vata'' is ''anasadhya'' (inaccessible) also. The inaccessibility is characterized in regard to its functional and physical attributes but more relevant regarding the therapeutic aspect. Above explained cardinal features make ''vata achintya veerya'' (inconceivable prowess) and ''doshanam neta'' (propeller of all functional elements in the body).<ref>Ibid 1/8 </ref>
==== Properties of ''vata'' ====
In chapter vātakalākalīya (Cha.Su.12), questions have been raised about exciting and alleviating factors regarding qualities of vāta. Rūkṣa(dry), laghu(light ), shītā(cool), dāruna (dreadful), khara (rough) and vishada (clean) have been explained as qualities of vāta. Repeated use of substances with these qualities and actions of such similar qualities causes aggravation and excitation of vāta and is alleviated by use of substances possessing contrary qualities. This brings out the phenomenon of two mutually interrelated and inseparable of sharira vāyu viz. (1) that, the sharira vāyu is a biophysical force and (2) that it is closely associated with material substances which form part of the structure of the body for example, functions of nervous system. It is a chemical reaction sequence which occurs during the course of life. This chemical reaction –sequence, can be accelerated (excited) or inhibited by substances with similar properties (dravya sāmānya), qualities (guna sāmānya) and actions (karma sāmānya) and inhibited by substances with opposite properties. In other words, it may be concluded that the bio – physical force – the sharira vāyu – is closely linked with some material structural factors. These can be influenced by diet and medicine on the basis of similar increase and opposite decrease. .
Sodium, Potassium, Calcium, Chloride, ions are continuously moving around [Brownian movement] which is the result of its ionic state [swabhāva / swayambhu guna]. The ionic inflow and outflow within the cell causes depolarization and repolarization or in other words impulse is generated. Hyper or hypo state of these ions is the cause for disease condition which may present in the form of seizures, palpitations, muscle cramps, lethargy, altered sensorium, coma and death.
Therefore, the biological energy produced by this ionic movement is the cause for sharira vāyu and as per modern science too their concentration depends on āhara and vihara.
The continuous, controlled movement of the ions is responsible for cell activity which together at the level of cells contributes to tissue activity which together contributes to the organ, system and in turn whole body. (verse 4)
Types of vata dosha: In Vedic literature, as a medical system, the important five types of vāta are explained with their locations and functions. The word ‘tantrayate’ is used to explain the functional quality of vāta and sharira (physical body) is yantra for functioning of tantra. The vāta dōsha on basis of its functions is classified into five types. They reside in the sharira at the level of sharira parmānu (cell) and also at gross level. Five types of vāta work together in a synchronized manner for the normal functioning of the sharira (vāyu tantrayantra dhara). (verse 5-11)
General etiological factors and basic pathogenesis of vāta disorders:
The etiological factors can be divided into two:
a) which cause direct vāta vitiation and
b) which cause indirect vāta vitiation.
Daysleep (divāswapna) do not directly lead to vitiation of vata. However, it leads to formation of ama and cause vāta vitiation indirectly by obstructing vāta. Vegasandharana (suppression of natural urges) and marmābhighata (trauma to vital organs) etc. are examples of direct vitiation. The pathogenesis is also bi-fold. The initial pathology is aggravation of vāta and diminution of dhātus and vice versa. One augments the other. This ultimately causes emptiness in channels and rarity in tissues which gives more space for movements of vāta. The second pathology is by increase in dhātus leading to excessive filling in channels to cause their clogging and blocking vāta. (verse 15-19)
Premonitory signs and symptoms:
Clinical manifestations may not be apparent because of vague manifestation of symptoms (Avyaktaṁ lakṣaṇam). This occurs in two situations, either the pathogenesis is extremely slow or it is abrupt. In the initial case, it is unable to appreciate the prodromal symptoms and presenting complaints separately. If it is an abrupt pathology the clinical presentation immediately follows the prodromal symptoms without appreciable gap. (verse 19-20)
Clinical features:The clinical presentations vary according to the specificity of hetu (cause) and sthāna (location). The treatment options also vary accordingly. For example if vāta prakopa takes place due to rūkṣa vriddhi in pakvāśaya it may lead to habitual constipation in which snigdha, ushṇā and tikshna aushadha like mishraka snēha may be a good treatment option. If the same vāta gets vitiated in āmāshaya due to snigdha vriddhi, it leads to gastro-esophageal reflux disease (GERD), rūkṣa uṣṇā and tikshna like gomūtra bhavita shaddharana is the ideal treatment option. Anuvasana is the ideal therapy in vata vitiated in pakwashaya, whereas vamana is the best therapy in vata vitiated in amashaya. (verse 20-24)
Three modes of pathogenesis of vata diseases:
The three characteristics of vāta vitiation viz. svātantra dushti (vitiation due to independent specific causes), gata vāta (increased movement of vata) and āvarana (obstruction to movement of vata). imply three possible modes of pathogenesis in vāta diseases. These can be further analysed as follows; due to the following three important properties of vāta, it is regarded entirely different from other dōsha5.
1. Asamghāta (Incorporeal)
2. Anavasthita (Unstable)
3. Anāsādhya (Inaccessible)
Pathogenesis of various conditions:
All the verses explain a specific type of samprapti (pathogenesis) like Kōṣṭhagata vāta (vata affecting alimentaty tract), āmāshayagata vāta (vata affecting stomach.) etc. They are not to be considered as a single disease. These specific diseases may lead to many disease presentations in which the treatment strategies can be generalized. Any dosha may occupy any particular site or area and lead to diseases. This type of pathology of vitiated vāta is called as gatavāta. Normally in all gatavāta, the affected dushya(vitiated body components) will be kshina (depleted) and affected srotas will be rikta (empty). The concept of gatavāta can be further explored physiologically. Dhātu are classified into two types’ asthāyi (temporary) dhātu and sthāyi (permanent) dhātu. Asthāyi dhātu are the ones which are dravaswarupa (liquid state) and undergoing conversion (parinām āpadyamānanām) and they are being vikshepita (circulated) from their mulasthān (origin) throughout the sharir (abhivahan) for the purpose of poshana (nourishment) of the sthāyi dhātu. This parinaman (conversion) and abhivahan prakriya(transportation) takes place in mārga (channel) which are known as srotas; hence mārga is one of the synonym used for srotas alongwith sirā (vein), dhamani (artery), rasāyani (capillary), rasavāhini (channels carrying nutrient fluid), nādi (nerve), panthāna (pathway), sharir chhidra (perforated channel), samvrita-asamvritāni (covered or uncovered), sthāna (site), āshaya (organ), niketa (habitat), sharirdhātu avakāsha (hollow space in body tissues).
Prakupita(vitiated) dosha have the capacity to further vitiate both sthānastha dhātu (fixed tissue element) as well as margagata (circulating tissue elements) sharir dhātu. When prakupita vāta vitiates the dhātu, it is called as gatavāta. In this condition, vitiated vata affects the specific site due to specific etiological factors. While designing treatment protocol, in this context specific etiological factors for each and every gata vāta related diseases must be observed to clarify why vitiated vāta goes to specific part of the body or to specific dhātu to develop kosthagata vāta, raktagata vāta etc.. In this condition, dhātu is dushya (getting vitiated).
Koshthagata vata: Vāta getting vitiated in the kōṣṭha (elimentary tract) is explained as koshthagata vata.
Gudagata vata: It can also be explained that gudagata vāta and pakvāśayagata vāta are different clinical entities. In gudagata vāta, obstruction of stool, urine and flatus is observed, whereas in pakvāśayagata vāta there ispainful defecation, micturition with āntrakujan (gurgling sound), ātopa (distension) and ānāha (constipation). Ashma sarkara (urolith) is exclusively present in gudagata vāta with pain and atrophy in calf muscles, thighs, sacram, feet and back. This can be compared with lumbo-sacral plexopathy. It may be understood as in case of pakvāśaya gatavāta, proximal part of large intestine alongwith ascending, transverse and descending colon is involved; whereas in gudagata vāta, involvement of sigmoid colon, rectum, anus and their nerve supply.
Amashayagata vata: This is a typical presentation of vata leaving its own site and vitiating other site. Here the local dosha is considered important because it is more virulent than the external dosha coming from other sites. The clinical entities originating from āmashaya (stomach) are caused due to vitiated vāta entering into āmashaya. It increases emptiness of stomach leading to indigestion or āma pradōṣaja vikāra like visuchika (diarrhea) etc.
Indriyagata vata: Indriyagata vāta is applicable to any sense organ. Indriya vadha may be interpreted as complete, partial or minimal loss of sensation. ‘Shrotra’(ears) has specific importance among other indriya, in which inherent dosha of shrotra is vāta itself. So vāta prakopa in shrotra is more impacting. It is worthy to remember the notion in vātakalākaleeya that vāta is ‘sarvendriyānām udyojakā’ (motivating factors for all sense organs).
Twakgata vata: Tvak (skin) is referred as somatic organ even though it is a sensory organ. Supti (numbness) and tōda (pricking sensation) are not symptoms specific to tvakindriya. Here tvak represents ‘rasa dhātu’. Rasa does not have cellular pattern and hence not included in shakha. The tvak is derivative of rasa and is included in shakha. Tvakindriya gatavāta should be understood under indriyagatavāta.
Siragata vata:
When vāta afflicts sirā (blood vessel) it may broaden or narrow the sirā. Widening may lead to śōpha and narrowing may lead to shosha or vice versa as per the site of affliction. Two different conditions of vascular diseases i.e. aneurysym (mahat) and atherosclerosis / venous thrombosis (tanu) are examples.
Sandhigata vata (osteoarthritis): There is depletion of periarticular and articular tissue by vitiated vata in sandhigata vata/osteoarthritis, empty spaces are occupied by vata which is felt as crepitus on palpation. Vata also causes hypertrophic tissue in the form of osteophytes and causes painful flexion and extension movements. This is the characteristic feature of swelling in sandhigata vata.
Ardita: Ardita is a disease of episodic origin. It may lead to facial paralysis or hemiplegia or both. In other classics ardita is explained as facial paralysis only. (verse 38-42)
Antarayama (Emprosthotonous) and bahirayama(ophisthotonous): These diseases are tetany like conditions in which the body is sharply bent forward and backward respectively. (verse 43-48)
Hanugraha: It is a lock jaw like condition that may be persistent or intermittent or recurrent due to vitiation of vata affecting the mandibular joint. (verse 49)
Dandaka:
Daṇḍaka is a condition in which the muscles are hypertonic but without convulsions. When it further manifests as tonic clonic convulsions it is referred as daṇḍa akshepaka.This condition is caused due to vitiation of vata simultaneously in muscle groups. (verse 51)
Episodic nature of various vata disorders: The disorders mentioned from ardita onwards are vegavān (episodic). All vegavān disorders have two phases, vega and vegāntara. Vegāntara is the symptom free period and is considered as right time for medication. (verse 52)
Pakshaghata: Three diseases namely pakṣāghāta(hemiplegia), ekāngarōga (monoplegia) and sarvāngarōga (quadriplegia) are explained. In pakṣāghāta no painful symptoms are explained. Sirā and snāyu are considered as dushya in ekāngarōga and sarvāngarōga. Sirā is the upadhātu of rakta and snāyu is the upadhātu of meda, therefore meda and rakta have vital role in pathogenesis of these diseases. (verse 53-55)
Gridhrasi: Gr̥dhrasī is a snāyugata (affecting tendon) rōga. The word gr̥dhrasī is derived from ghridhra, which means vulture, the typical gait of the disease is highlighted by the name. The patient’s gait is changed like a vulture due to affected tendons by vitiated vata.
Khalli is the term given to severe painful twisting conditions of tendons. (verse 56-57)
Nomenclature of diseases: All the vāta disorders cannot be named or explained. They should be understood on the basis of site of affliction as well as nomenclature. (verse 58)
Diagnosis of dhatukshaya (degenerative pathology) and avarana (obstructive pathology) induced vitiation of vata: Vata can be vitiated due to dhātukṣaya and margāvarana types of pathogenesis. Dhātukṣaya leads to depletion of tissues and more space for vāta to move. This leads to gatavāta phenomenon. Avarana of vāta can be caused by other dosha or dhātu. So the differences between āvarana and gatavāta should be understood.
The word, avarana means obstruction or resistance or friction to the normal gati of vāta. Hence when its normal movement is hampered or vitiated, it becomes Āvr̥ta and leads to different disorders. The gatatva and āvr̥tatva are entirely different phenomenom. Here an attempt is being made to differentiate the both physio-pathologies. [16]
1. In Āvarana, generally the vitiation of vāta is passive. When vitiated dosha or any other thing obstructs the pathway of vāta, āvarana happens. Normal state of vāta gets vitiated as āvarana progresses. The substance which obstructs the pathway of vāta is called as ‘āvaraka’ and the dosha (vāta in general or its components) affected by āvarana is called as āvariya or āvr̥ta. Normally the āvarana is caused by the etiological factors for the vitiation of āvaraka. Etiological factors for the vitiation of vāta (sva nidāna) will be absent.
In case of gatavāta the vitiation of vāta will be active. Here its own etiological factors are operating in the vitiation of vāta in the pathogenesis and the vitiated vāta adopts specific pathway and abnormally localizes at particular sites.
2. In the process of āvarana ‘chala’ property of vāta is diminished due to obstruction. Other properties are not involved in the process of obstruction. But in case of gatatva the vitiation of vāta takes place by involvement of other properties like rūkṣa, laghu, khara, vishada etc along with chala.
3. In āvarana the ‘gati’ of vāta is obstructed partially or fully. Once gets obstructed the vāta may simply get lodged there (baddha mārga, mārgarodha), try to nullify the obstruction, may get covered by the obstructing substance (āvr̥ta), adopt an opposite direction (pratiloma) or alter the direction (viloma). The different terminologies have been used to denote āvarana in different contexts according to the nature of āvarana and the state of vāta and mārga (passage). In case of gatatva the gati of vitiated vāta aggrevated and starts moving abnormally leading to localization at particular sites.
4. Āvarana is caused by purnata (filling) of other dosha in the srotas/mārga (passage) of vāta. In gatatva the srotas or sites of occupation of vāta are rikta (unfilled or spacious) and the aggrevated vāta fills the srotas/site.
5. In āvarana of vāta, swakarma vriddhi (exaggerated activities) of āvaraka (covering dosha) is manifested. The āvr̥ta (i.e. vāta) will show swakarma hāni (diminished activity). This is the general feature of āvarana. Here the excessively increased strong āvaraka suppresses the normal action of āvr̥ta (i.e. vāta). Therefore, when the obstruction is complete it may lead to the prakopa of vāta resulting in the presentation of vāta vitiated symptoms as well as its disorders14.
In case of gatatva the symptomatology will be predominantly of vāta vitiation and pain is a common and chief complaint in all the conditions of gatatva.
6. Obstruction or covering of vata is possible by body components like dosha (pitta and kapha),tissues,food, excretory products or mutual affliction of vata types. Gatatva of vāta (affection) is happening in empty spaces or hollow cavities of tissues, their elements, organs and other body parts. In avarana, the body component is in increased state causing fullness in respected channels, while in gatatva pathology, the body components are in depleted state casusing emptiness in the respected channels. Dhātugata vāta will be presented with decreased quality of tissues associated with signs of vitiated vāta. Obviously, exceptions are possible according to the complexities of process of āvarana or gatatva.
7. In case of āvarana of vāta, the āvaraka is important for treatment since vitiation of vāta is passive. When āvarana is removed vitiated vāta gets pacified. But in cases of gatatva the vitiated vāta has to be treated first along with correction of adhisthāna.
8. Diagnosis of āvarana is made with the help of upashaya–anupashaya (pacifying and aggravating factors) method. Diagnosis of gatatva is made according to the rupa (symptomatology).
9. Complications of āvarana are explained in case of improper diagnosis and delayed treatment like hr̥drōga, vidradhi, kamala etc. No known complication occur in gatatva.
10. Āvarana of vāta may cause depletion of nutrition to dhātu (dhātugata sāma) leading to successive diminition of rasādi dhātu (rasādimsca upasosayet).15 No such reference is available in case of gatatva.
The above discussed points are briefly enlisted in the table below.
Āvr̥ta (obstructed)vāta Gata (excess movement)vāta
1. Vitiation of vāta is passive 1. Vitiation of vāta is active
2. Normally svanidana (specific causes for vitiation) of vāta are not responsible 2. Vitiation of vāta by svanidana
3. Only chala property of vāta is involved and it is diminished in the phenomenon 3. Other properties of vāta are also involved and the chala property aggravated in the phenomenon
4. Gati of vāta is obstructed 4. Gati of vāta is aggravated5.
5. Purnata (fullness) in srotas/ mārga 6. Riktata (emptiness) in srotas
6. Vāta shows svakarma hani (decreased function) 7. Vāta shows svakarma vriddhi (increased function)
7. Dhātu are in vriddha (increased) or sāma 8. Dhātu daurbalya (decrease) present
8. Āvarana possible with other dosha/anna/mala/individual components of vāta 9. Not possible
9. Āvarana by avayava(body part) or āshaya (organ) not possible 10. Gatatva in āshaya and avayava explained.
10. Āvaraka gets importance in treatment 11. Vāta gets importance in treatment
11. Diagnosis made with upasaya anupashaya (hit and trial) 12. Diagnosis with rupa
12. Complications of āvarana possible 13. None
13. Successive diminuation of rasadi dhātu possible 14. None.
As āvarana proceeds it may end up in dhātukṣaya as the āvr̥ta will block rasadhātu which give nourishment. This is commonly observed. This is possible in many other disorders also. The best example is rajayakshma.
Prognosis: Exclusive vata disorders are serious and have poor prognosis. The symptoms / diseases explained manifest when vitiated vāta affects vital parts. The therapeutic approaches should be cautious and extra efforts are essential for a better recovery. As the disease becomes chronic the curability rate drastically declines. The physical strength of the patient is also very important in determining prognosis. (verse 72-74)
General principles of management: The general line of management of Vātavyādhi applies to absolute vāta vitiation only. If there is any association or obstruction of other dosha in Vātavyādhi, the treatment will be different. Kevalam term indicates pathology of vitiation of exclusive vata. Nirupastambha is condition without any association of other dosha. This pathology shall be primarily treated with oleation therapy.
As in exclusive vātaja disease the major gunavriddhi is rūkṣa which leads to riktatā in srotas and dhātu and more avakāsha (space) for vāta; Snēhana is essential and ideal. Various methods for snēhana are employed depending on avastha (stage), sthāna (site) and bala (strength) of the diseases and as well as patient.
Following snēhana, swedana is also mandatory. Here the ushṇā guna (hot property) operates to control śītā (cold). Repeated snēhana and swedana imparts high grade of flexibility.
Snēha is a good medium to control vāta as well as vāta-pitta. Generally, this line of treatment can be counted as a part of brimhana. (verse 75-83)
Repeated snēhana and swedana therapies can control vāta well. However, samshodhana (purification) therapies are executed to remove the residual dosha. As shodhana has a definite chance for causation of vāta prakopa, the approach should be cautious, so mridu samshodana (mild purification) is done. Snēha virēchana is done by tilwaka ghrita or erand taila etc. Eraṇḍataila is very effective in treating vāta prakopa due to udāvarta. If virēchana is not possible, anulomana diet should be adviced. If the patient is extremely weak niruha is better option. Even after shodhana; recurrent application of snēhana and swedana are essential.(verse 83-88)
Management of vata at different sites:
Treatment of disorders of vāta, when located in different sites, habitat (sthāna) is more important in comparison to the invaded (āgantu) dosha e.g in kōṣṭhagata vāta, kōṣṭha is given preference in treatment, and so kshara is used which helps in digestion (pāchana). But when vāta is located in pakvāśaya or guda which is vātasthāna, udāvartahara treatment is selected, which includes vāta anulomana, basti, varti etc. In āmashayagata vāta, shodhana in the form of vamana is done.
Hridya anna (favourite food) is typically indicated in tvakgata vāta because, rūkṣatā in tvak is a result of rasakṣaya caused by overworrying.17
Bahya snēhana in the form of abhyanga or dharā etc are very effective in asthi and majjāgata vāta. Ābhyantara snēhana replenishes meda dhātu and subsequently asthi and meda. It is worthy to note the utility of tikta ghrita in asthikṣaya.
In śukrakṣaya (depletion of shukra), harshana (pleasure) and vrishya annapāna (aphorodisiac diet) is very useful. 18
Management of ardita (facial palsy):
The line of treatment of ardita aims at mastishkya (brain), therefore, nasya is indicated. Nasya is explained to be the direct entrance to the cranial vault. Nasya may be shodhana, shamāna or brimhana as the case may be. But there is opinion that since the word nāvana (..) is used, it means snaihika nasya. Mūrdhni taila is absolutely meant for treatment in head region and is of four types viz. abhyanga ( head massage), seka (pouring liquid on head), pichu ( therapeutic unctuous swab on head) and shirobasti. Tarpana (nourishment therapy ) is akshitarpana ( nourishing eyes) and shrotratarpana (nourishing ears). Nadisweda is very specific in ardita and ksheeradhooma (medicated fumes of milk). Poultice prepared from flesh of marshy animals is used for brimhana in atrophy of muscles. Vamana is indicated in ardita, when it is associated with śōpha and raktamokshana is indicated when associated with dāha (burning) and raga (redness).
In Pakṣāghāta, swedana, fomentation mixed with unctuous material and virechana or purgation therapy with unctuous substance is indicated. Virechana is the line of treatment in pakṣāghāta and outweighs basti which is said to be ideal for vātakopa. Pakṣāghāta may be understood as a concealed urdhwaga raktapitta (bleeding from upper orifices of body) in which the only and effective choice is adho-shodhana (purgation). Gr̥dhrasī is a tendon and ligament disorder and shastra, kshara, agnikarma are the main line of treatment. Therefore sirāvyadha (blood letting) and dāhakarma (cauterization) is advised. Basti is also a good choice since pakvāśayagata vāta leads to kateegraha and gr̥dhrasī.
Agnikarma and sirāvyadha are the two line of treatment which are useful in acute phase to relieve the pain in gr̥dhrasī and also in khalli. Agnikarma relieves muscle spasm thereby reducing pain whereas, sirāvyadha may be helpful by reducing the blood stasis. Improved circulation removes cytokines and other inflammatory factors thereby reducing pain. (99-103)
Agni karma : Agnikarma is a para surgical procedure in which a metallic thin pointed rod called shalaka is heated. Then the hot shalaka is touched to specific points of pain for relieving. It is commonly used as efficient pain reducing therapy in musculoskeletal disorders.
Importance of site of affliction in treatment:
The specificity of treatment depends on the site of affliction and the associated morbid tissues. For example masthishkya is very specific for ardita, pakṣāghāta, indriyagatavāta etc. Even though vamana is kaphahara, it is exclusively indicated in āmashayagata vāta taking into account of site of affliction. (verse 104)
Brimhana treatment of vata vitiation: The treatment of exclusive vāta vitiation (without involvement of other dosha) is brimhana. If associated dosha is present, they shall be treated first. (verse 105)
Balā is excellent for lone vitiated vāta. The head of goat is indicated on the basis of the principle ‘sāmānyam vridhikārānam’(like increases like). These also explain the awareness of utilization of brain of goat in degenerative brain lesions. Lavana relieves stambha (stiffness) and samghata (conglomeration). Upanāha is also prepared with such well fomented flesh and added with different oils, salts etc. Such upanāha are brimhana. (verse 106-108)
Avagaha (immersion) sweda:
Avagāha is typically indicated in apāna vāigunya (defects due to apana vata vitiation), it is a type of drava sweda (liquid fomentation). Nādisweda is also an excellent option for all types of vātarōga. Poultices (upanāha) of different types provide self generated heat to cause swedana. It is by virtue of various dhanya (cereals) and kinwa (yeast) available in it. (verse 109-118)
Different formulations:
Different medicated ghrita,taila, vasā, majjā and mahā snēha ( combination of all four sneha) are indicated for various conditions in the form of oral ingestion, inhalation, enema and external application etc. Mahā snēha is guru (heavy to digest) and ultimately indicated in disorders like convulsions, tremor etc. (verse 119-136)
Pinyaka taila is a preparation in which rūkṣa guna is imparted to taila and is highly useful in kapha associated Vātavyādhi. (verse 136-137)
Importance of oil in treatment of vata: By virtue of vyavāyi guna (pervading/diffusive), it reaches the different interior parts of the body without any metabolic changes. By processing taila can adopt any type of qualitative changes. The drugs are potentiated by repeated processing in its own media. Drugs like ksheerbalā (101 āvartita), dhanwatharam (21 āvartita) etc. are worth mentioning here. This approach of samskāra makes snēha as sukshma snēha (with better bio-availability and penetration) .(verse 181-182)
Management of avrita vata:
In pittāvr̥ta vāta, hot and cold should be applied alternately. Jīvanīya sarpi is also very brimhana. Brimhana is the ideal pacifying line of treatment for vāta and vātapitta.
In kaphāvr̥ta vāta, rūkṣa is given importance. In association of kapha along with pitta in vātarōga, pitta should be given importance in management. It is because of the fact that pitta makes the disease process as ‘ashukāri’(instantaneous).
In Kaphāvr̥ta vāta; tīkṣṇā sweda, niruha and vamana which reduces kapha is indicated followed by virechana intended for vāta anulomana and also useful for kapha.
Jirna/purāna sarpi (old ghee) which has kaphaghna quality has to be used; tila and sarṣapa which are kapha vātaghna are to be used. Warm drinks of yava, jāṇgala mānsa rasa which gives strength to the patient without increasing kapha are to be administered. (verse 183-188)
Kshara basti (gomūtrayukta basti) in case of kapha-vāta and ksheera basti in pitta-vāta is recommended. Raktāvr̥ta vāta is similar to uttāna-vātarakta and treatment is accordingly same. Rakta āvr̥ta vāta is one of the phases of vātarakta. Thus raktamokshan and basti cikitsā which is useful in vātarakta is also helpful in rakta āvr̥ta vāta.
Prameha samprapti mentioned in Sutrasthān 17th chapter explains kapha, pitta, meda and mānsa which when increased causes āvarana of vāta. Therefore, pramehagna cikitsā is helpful in meda āvr̥ta vāta and also in mansāvr̥ta vāta. Hence in mansāvr̥ta vāta the pipilika iva sanchar (tingling sensation) reduces, if prameha is treated. Similarly, in obesity, medasāvr̥ta vāta (vata obstructed by excess meda) (Ca.Su. 21/5) and meda and mānsa ativridhi [Ca.Su.21/9] is observed. These conditions are best treated on the principles of management of prameha, sthaulya associated with vitiated vata. Therapeutic emesis to expel out the intoxicated food in stomach is advised in condition of annavrita vata ( vata obstructed by food). Pāchana and deepan helps in digestion and also pacifies vāta.
Hot foementation reduces urethral pressure. A study done by Shafik A. showed that sitting in warm water helps in micturition which seems to be initiated by reflex internal urethral sphincter relaxation. A thermo sphincter reflex is likely to be involved.
Uttara basti effect is similar to catheterization. Further depending on the medicines used for uttara basti, tridōṣa shamāna can be done.
The lines of treatment of raktagatavāta and raktvritavāta as well as śukragatavāta and shukrāvr̥ta vāta are one and the same irrespective difference in samprapti as gatavāta or āvr̥ta vāta. It is because of the fact that rakta and śukra are mobile and comparatively pervaded all over the body like vāta so gatavāta and āvr̥ta vāta are mutually complimentary here.
Finally, the treatment strategies of anyasthānagata(in other sites) vāta are explained. The importance is given to sthānastha dosha (in own sites).(189-199)
Movements of vata and concept of anyonyavarana:As discussed earlier avyāhatagati (free movement) is a cardinal feature of vāta to perform normally. In āvarana certain obstacles like dosha, dhātu or anna etc which are immobile, occupy the pathway of mobile vāta. It is not mandatory that such immobile articles only cause obstruction to vāta. If the individual sub types of vāta are considered prāna, udāna, vyāna, samāna and apāna are mobile and has some specific direction for their gati. For example, prāna has movement from murdha (head) to downwards. Udāna has movement from uras(chest) to upwards. Vyāna moves upward downward and sidewards like rasa. Samāna moves around jatharāgni. Apāna move downwards from pakvāśaya. This can be further analysed as follows. Udāna possess upward movement. Likewise ‘apāna’ has downward direction. Vyāna vāyu moves in horizontal direction (vyāpanat vyāna uccyate) along with upward and downward directions as rasa samvahana (circulation) is concerned.[19]Samāna is also having such qualities to equally distribute the nutrients through out the body. Prāna has multi directional gati. So, the movements of individual subtypes of vāta are directional in nature. When these meet in opposite direction it makes anyonyāvarana. For example prāna and udāna meet opposite and interfere with mutual normal movements leads to difficulty in inspiration as well as expiration which is comparatively irreversible. This concept is called anyonyāvarana. It is of 20 types taking into account of 5 diiferent types making 4 particular combinations. Anyonyāvarana are comparatively difficult situations. (verses 199-206)
Anyonyāvarana is characterised by Svakarma hani or vriddhi (either increase or decrease in functions) which depends on the nature and site of anyonyāvarana (mutual covering). For example prānaāvr̥ta udāna may lead to difficulty in respiration, followed with cardiac symptoms, aphasia or dysarthria and some times upper respiratory symptoms. This presentation is comparatively acute in onset and. Here the functions of udāna are masked by prāna. But in udānaāvr̥ta prāna the symptoms are loss of motor power, immunity and complexion leading to death. Here the functions of prāna are seriously hampered. This symptom may be acute or chronic in nature. When apāna got āvarana by udāna the normal peristalsis is hampared and anulomana is the line of treatment. In apāna āvarana to udāna increased bowel motility can be seen grāhi is the line of treatment which should be adopted here.
Rehabilitation of vata: Prakr̥tisthāpanam means re-establishment in its own pathway (sva mārgaga)/ or in its own place (sva sthāna gamayed enam). Therefore for udāna vāyu, vamana etc. treatment should be administered to regulate the normal functional status of udāna vāyu. Apāna has adhogati, therefore anulomana chikitsā should be done, thereby regularizing the urdhva apāna bhava of Apāna vāyu. Shamāna should be line of treatment for samāna vāyu. Empowering digestive power should be done. Samāna being sited near agni, proper digestion and absorption of essential elements will be observed. Proper electrolyte balance will be maintained, thereby maintaining the pH of body fluids. As discussed previously vyāna has all the three gati i.e. urdhva, adho and madhya gati. Here the general line of treatment of anyonyāvarana is discussed. (verse 219-221)
Importance of udana and prana vata:
Among various āvarana, the involvement of udāna and prāna are very important. As explained in the introductory comments, prāna is life and udāna is strength. These are very vital issues as far as āvarana is concerned. Improper management or avoidance of treatments may lead to permanant disabilities in Āvarana. (verse 231-236)
Complications of āvarana:
This includes hr̥drōga, vidradhi, plīhā, gulma, a'tīsāra. Hr̥drōga is a common complication of ill treated āvarana of prāna and udāna. Vidradhi and plīhā are caused by wrongly managed āvarana of vyāna. Gulma and atīsāra are common complications of āvarana of samāna and apāna.
Srotoshodana is an important line of management in Āvarana. It ensures unobstructed movement of vāta. All abhishyandi(..) food causes srotorōdha (obstruction of channels). Yāpana Basti is ideal for all age group and safe to severe clinical presentations. It protects all marma points. As it is neither lekhana (..), nor brimhana, it is useful for managing vāta as well as āvaraka kapha or pitta. Guggulu rasāyana and shilajatu rasāyana is ideal for many clinical conditions of āvarana.
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