a clinical comparative study to evaluate the efficacy …

I

RAJIV GANDHIUNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

“A CLINICAL COMPARATIVE STUDY TO EVALUATE

THE EFFICACY OF MRUDU VIRECHANA AND

SHAMANA CHIKITSA IN THE MANAGEMENT OF

AMLAPITTA”

The Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

In partial fulfillment of requirements for the award of the degree of

DOCTOR OF MEDICINE (AYURVEDA)

In the speciality of

KAYA CHIKITSA

By

Dr.ASHISH KUMAR DUBEY B.A.M.S.

Guide

Dr.ARCHANA.C.P.M.D. (Ayu) Reader

Department of Post Graduate Studies in Kaya Chikitsa,

Ayurvedic Medical College &P.G. Centre, Davangere

Co-guide

Dr. GNANESWARA. L.M. M.D.(Ayu) Reader

Department of Panchakarma,

Ayurvedic Medical College &P.G. Centre, Davangere

DEPARTMENT OF POST GRADUATE STUDIES IN

KAYA CHIKITSA

AYURVEDIC MEDICAL COLLEGE AND P.G. CENTRE

DAVANGERE-577006

2012-2013

II

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A CLINICAL

COMPARATIVE STUDY TO EVALUATE THE EFFICACY OF MRUDU

VIRECHANA AND SHAMANA CHIKITSA IN THE MANAGEMENT OF

AMLAPITTA” is a bonafide and genuine research work carried out by me under the

guidance of Dr .Archana.C.P. M.D. (Kayachikitsa) Guide & Reader, Dept. of P.G.

Studies in Kayachikitsa, Ayurvedic Medical College & P.G. Center, Davangere.

Date:

Place: Dr. ASHISH KUMAR DUBEY

III


CERTIFICATE BY THE GUIDE

This to certify that this dissertation entitled “A CLINICAL



AMLAPITTA” is a bonafide and genuine research work done by Dr. ASHISH

KUMAR DUBEYIn partial fulfillment of the requirement for the degree of

Doctor of Medicine (Ayurveda) in the specialty of Kayachikitsa under my direct

guidance.

Dr.Archana.C.P.. M.D. (Ay).

Guide & Reader

P.G. Department of Kayachikitsa

Date: AyurvedicMedicalCollege&

P.G.Center,

Place: Davangere.

IV


CERTIFICATE BY THE CO-GUIDE

This to certify that this dissertation entitled “A CLINICAL



AMLAAPITTA ” is a bonafide and genuine research work done by Dr.

ASHISH KUMAR DUBEY in partial fulfillment of the requirement for the

degree of Doctor of Medicine (Ayurveda) in the specialty of Kaya Chikitsa

under my supervision.

Dr.GNANESWARA L.M ,M.D. (Ay).

Co-Guide & Reader,

Department of Panchakarma

Date: AyurvedicMedicalCollege&

P.G.Center,

Place: Davangere Davangere.

V


ENDORSEMENT BY THE HOD, PRINCIPAL/

HEAD OF THE INSTITUTE

This to certify that this dissertation entitled “ A CLINICAL



AMLAPITTA” is a bonafide and genuine research work done by Dr. ASHISH

KUMAR DUBEYunder the guidance of Dr.Archana.C.P..M.D. (Ayu), H.O.D.&

Reader, Post Graduation Dept. of Kayachikitsa, Ayurvedic Medical College & P.G.

Center, Davangere.

Dr. Jayanthi.C.M.D. (Ayu) Dr.S.Dayananda ,M.D. (Ayu)

H.O.D. & Reader. Principal & Professor,

PG. Dept. of Kayachikitsa, PG. Dept. of Kayachikitsa,

Ayurvedic Medical College & Ayurvedic Medical College &

P.G. Center, P.G. Center,

Davangere. Davangere.

Date: Date:

Place: Place:

VI

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

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

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

Date :

Place : Dr. ASHISH KUMAR DUBEY

VII

ACKNOWLEGEMENT

While penning the acknowledgement of the present work, I remember the

moments when I needed someone desperately to come upon for the help. It was the

GODDESS SARASVATI who always transformed strengths in me tout-class every

that nasty things.

I prostrate to the feet of Goddess Sarasvati for standing behind me in every

hurdle of life. It’s beyond the reach of any language to express the pure, warm, sweet

and bright flame of gratefulness to my loving parents Shri. Ramnaresh Dubey and

Smt. Shudha Dubey and my sister Puja and my brothr Punit, Naveen, Abhishek

and my bhabi Priyank Dubey whose love, support and encouragement were the

initiating sources in each and every step of my life.

I express my deepest sense of gratitutde with all humbleness

toDr.Dayananda.SPrincipal andDr.Bharthi .D.A. Incharge Principal of Ayurvedic

Medical college and P.G.Centre.Davan gere.

I owe an irredeemable debt of gratitude to affectionate, intelligent, enthusiastic

and helpful guide Reader. DrArchana.C.P ., who guided each and every aspect of

this study.

Heartiest thanks to respected Dr. Gnaneswara L.M, my co-guide for his

most valuable suggestions and pruning which has shaped this work to a great extent.

I express my deepest sense of gratitutde with all humbleness to Dr.Jayanthi.C

, HOD and Professor P.G. Department of Kayachikitsa, A.M.C and P.G. Centre.

At this juncture I heartily thanks to Dr.Muktha M.H, Dr. Pradeep J.M,

Dr.Rudresh.,Dr.SriHarsha,Dr.Manthesh.,Dr.HarshaMurthyof Kayachikitsa

Department as well as Dr. Bharathi D.A, Dr. Usha Rani.S,Dr.Srikanththe teachers

of this institute for enriching me with their unconfined knowledge during my Post

Graduation.

I am very much thankful to Our College Founders and Management Members

of Ashwini Educational Association, Dr.M.N.Hiremath, Dr.Suresh.V. Ambedkar,

Dr.G.B.Ravindranath, Dr.N.R.SankarNarayan, Dr.K.G.Chandrappa and for

giving me an Opportunity to study in this college.

VIII

I also express my gratitude to Dr. Raaju.U.Rfor his kind guidance and

encouragement throughout the work.

I would like to express a lot of thanks to my beloved friends Dr. Manoj,

Dr.Vinay, Dr. Mumtaj, Dr Shyama, Dr. Sandeep, Dr. Sandesh, Dr.Parvaty, Dr.

Dipti,Dr.veresh for their support and helful nature in my studies.

I am thankful to my department seniors. Dr. Rekha, Dr. Lohit, Dr. Lokesh,

Dr. Mukesh, for their timely help.

I also thankful to Dr.Sangam for helping me in doing statistical work

I also thank Mr. G.P. Sanjeev Kumar of M/s Gundal Computer Center for

the meticulous computerized laser typing and styling of this dissertation work.

I also pay thanks to all those kind people who delivered their support directly

and indirectly to accomplish the work. At last, I seek pardon and apologize for any

errors which might be remained in the work.

Date :

Place : Dr. ASHISH KUMAR DUBEY

IX

ABBREVIATIONS

A. H. - Ashtanga Hridaya

A. S. - Ashtanga Sangraha

B.P. – Bhavaprakasha

B.R. – Bhaishajya Ratnavali

Bh. - Bhela Samhita

Ch. - Charaka Samhita

Chakra. - Chakrapani

Chi. - Chikitsasthana

Dal. - Dalhana

GN - Gadnigraha

Ha. Sam. - Harita Samhita

Ka. - Kashyapa Samhita

M. N. - Madhava Nidana

Ni. - Nidanasthana

Pu. - Purva Khanda

Sha. - Sharangadhara

Si. - Siddhisthana

Su. - Sushruta Samhita

Su. - Sutrasthana

Ut. – Uttartantra

V.S.-Vanga Sena

Vi. - Vimanasthana

Y. R. - Yogaratnakara

X

ABSTRACT

Objectives : To review the literature on Amlapitta to asses the effect of Yasti

madhu churna with Sootashekara vati. To asses the effect of Sootashekara vati.To

intercompare the results of both groups.

Methods : Cases presenting with classical signs and symptoms of amlapitta

were selected. They are randomly allocated in two groups in groupA Yastimadhu

churna with Sootashekara vati and in groupB Sootashekara vatiwas given. The signs

and symptoms of Amlapitta like Aruchi, Avipak, Utklesh, Amloudgar,

Hridahakanthdaha were assessed before, during and after the completion of treatment

Analysis of the overall effects in Group A indicate that 40% of patients

showed major improvement of the illness, 35% of patients showed moderate

improvement where as other 20% of patient showed minor improvement. And 5% of

patients Not improved.

Similarly analysis of the overall effect in the Group B indicate that 30% of

patient showed major improvement of the illness, 35% of patient showed moderate

improvement, where as, 25% of patients showed minor improvement, and 10 % of

patients showed Not improved .

Conclusion : Group A cases showed better improvement out of 40 cases as compared

to Group B.

Key Words - Amlapitta , Mrudu Virechana , Shamana chikitsa , Yastimadhu

Churna , Sootashekara rasa vati.

XI

TABLE OF CONTENTS

Sl.

No. Chapter Name Page No.

1. INTRODUCTION 1-2

2. OBJECTIVES 3

3. REVIEW OF LITERATURE 4-56

4. METHODOLOGY 57- 62

5. OBSERVATION & RESULTS 63 -95

6. DISCUSSION 96 -105

7. CONCLUSION 106

8. SUMMARY 107 -108

9. LIST OF REFERENCES 109-112

10. BIBLIOGRAPHY 113 -114

11. ANNEXURES 115 -122

XII

LIST OF TABLES

Sl.

No. Title

Page

No.

1. The Classical Nidana of Amlapitta 11 -12

2. Showing Roopa of Amlapitta 19 -27

3. Ingredients of Yastimadhu churna 53

4. Ingredients of sootasekar vati 54 -55

5. Distribution of patients according to age group 64

6 Distribution of patients with respect to Sex 65

7 Distribution of patients according to religion 66

8. Distribution of patients according to Education 67

9. Distribution of patients according to Socio – Economic Status 68

10. Distribution of patients according to their Maritial status 69

11. Distribution of patients according to their nature of work 70

12. Distribution of patients according to Manasika Sthithi 71

13. Distribution of patients according to vyasana 72

14. Distribution of patients according to type of Prakruti 73

15. Distribution of patients according to Sara 74

16. Distribution of patients according to Samhanana 75

17. Distribution of patients according to Satva 76

18. Distribution of patients according to Satmya 77

19. Distribution of patients according to Kostha 78

20. Distribution of patients according to Vyayama Shakti 79

21. Distribution of patients according to occupation 80

22. Distribution of patients intake of predominant rasa 82

23. Distribution of patient intake of water 82

XIII

24. Distribution of patients of duration of symptoms 83

25. Didtribution of patients of most of onset of Amlapitta 83

26. Distribution of patients based on Relieving factor 84

27. Showing the effect on Aruchi in group A 84

28. Showing the effect on Aruchi in Group B 85

30. Showing the effect on Avipak in group A 86

31. Showing the effect on Avipak in Group B 86

32. Showing the effect on Utklesh in group A 87

33. Showing the effect on Utklesh in Group B 87

34. Showing the effect on Amloudgar in group A 88

35. Showing the effect on Amloudgar in Group B 88

36. Showing the effect on Hridkanthdaha in group A 89

37. Showing the effect on Hridkanthdaha in Group B 89

38. Comparision of effect of treatment on Aruchi in two groups 90

39. Comparision of effect of treatment on Avipak in two groups 91

40. Comparision of effect of treatment on Utklesh in two groups 92

41. Comparision of effect of treatment on Amloudgar in two groups 93

42. Comparision of effect of treatment on Hridkanthdaha in two groups 94

43. Overall Assessment of each therapy. 95

XIV

LIST OF FIGURES

Sl.

No. Title

Page

No.

1. Schematic representation of Samprapti of Amlapitta 29

2. Showing Yastimadhu Churna 56

3. Showing Sootashekar rasa vati 56

XV

LIST OF GRAPHS

Sl.

No. Title

Page

No.

1. Distribution of patients according to Age group 64

2. Distribution of patients according to Sex 65

3. Distribution of patients according to Religion 66

4. Distribution of patients according to Education 67

5. Distribution of patients according to Socio-Economic Status 68

6. Distribution of patients according to Marital Status 69

7. Distribution of patients according to nature of work 70

8. Distribution of patients according to Manasika Sthithi 71

9. Distribution of patients according to Vyasana 72

10. Distribution of patients according to Type of Prakruti 73

11. Distribution of patients according to Sara 74

12. Distribution of patients according to Samhanana 75

13. Distribution of patients according to Satva 76

14. Distribution of patients according to Satmya 77

15. Distribution of patients according to Kostha 78

.16 Distribution of patients according to Vyayama Shakti 79

17. Distribution of patients according to occupation 80

23. Comparision of effect of treatment on Aruchi in two groups 90

24 Comparision of effect of treatment on Avipaka in two groups 91

25. Comparision of effect of treatment on Utklesh in two groups 92

26. Comparision of effect of treatment on Amloudgar in two groups 93

27. Comparision of effect of treatment on HridKanthadaha in two

groups 94

28. Graph showing overall assessment of each therapy. 95

Introduction

“A clinical comparative study to evaluate the efficacy of Mrudu Virechana

andShamana chikitsa in the management of Amlapitta” 1

INTRODUCTION

Amlapitta is a Annavaha and Purishavaha srotas disorder. These srotas are the

basis for the very subsistence of life.Amalapitta is a very common dietary disorder in

india. It is increasing now a days due fasting, eating between meals, worry, hurry,

spicy foods , change in life-style, strain, drugs, etc. This can derange the digestive

procedures. Amlapitta is such pathological condition or disease in which the pitta

exteeds in normal level. Due to above said foctors Amlaguna of Pitta increases

which leads to Vidagdhata of ingested food and finally Amlodgara, Urovidaha,

Chhardi etc., signs and symptoms of Amlapitta are evident clinically.It is very

difficult to correlate Amlapitta with a single disease of Modern science But due to the

similarity in causative factors and signs and symptoms one can correlate this disease

to Hyperacidity, Dyspepsia and Gastritis.

1.1 NEED AND SIGNIFICANCE

Amlapitta has high incidence through out the world, which affects almost

45% people in our country .Person fell constant discomfort though out the day. It

predisposes to an overall reduction in the physical activities of the person in its

chronic course. Though Amlapitta is not a life threatening, if left untreated or

neglected, it may invite major life threatening problem.

The ‘Amlapitta’ is composed of word Amla and Pitta. The term Amla has

been used as an epithet to Pitta. Amlapitta is a condition where excessive secretion of

Amla Guna Pitta takes place causing vidahyadi conditions. This causes various

pathophysiological conditions of Anna and Purishavaha Srotasa, such as of Avipaka,

Klama, Utklesha, Amlodgara, Gaurava, Hrit-Kantha-Daha, Aruchi , etc.

In Modern science the Hyperacidity, Dyspepsia and gastritis is managed

by Antacids, Proton pump inhibitor etc .Which are having own adverse

effects of long term such as constipation, diarrhea, skin rash, headache etc. By

virtue of all the above factors, it warrants prompt attention to find out a treatment

which is safer, effective, affordable for long duration use.

Introduction



It is well documented in classics that our contemporary Ayurvedic

practitioner treat Amlapitta confidently and give comfort to individual.In Ayurveda,

the administration of the vamana, virechana, basthi, rathamookshana and shamana is

theline of treatment are told for Amlapitta. The virechana is best therapy, where pitta

is manily vitiatied. The virechana is advised for management of Amalapitta. Here an

attempt is made to analyse the therapeutic efficacy of mrudu virechana and shamana

oushadhi-sootashekara rasa vati

Sootashekara rasa vati is one of the herbominaral combination, explained in the

Yogaranthanakara.

1.2 STATEMENT OF PROBLEM

“A Clinical Comparative study to evaluate the efficacy of

mruduvirechana and shaman chikitsa in the management of Amlapitta”

This clinical study is sincerely effort to analyse the therapeutic efficacy

of Mruduvirechana and shaman oushadhi . With this hope, the present work is

carried out. It is also hoped that this work will give a idea to choice the better therapy

for management task Amlapitta, with this noble intention this work is presented.

1.3 DELIMITATION: the study is limited to

Patients in and around Davangere , who have attended OPD , AMCH

Davagere .

Patients age group is between 15- 60 years .

The duration of study was 37 days . The assessment of result is made

on the base of clinical and functional improvements for the clinical

assessment all sign and symptoms .

Objectives



OBJECTIVES

Literary work on Amlapitta.

To Evaluate the effect of Group A Mruduvirechana.

To Evaluate the effect of Group B Shaman Oushadhi.

To Compare the efficacy of both group in Amlapitta.

Review of Literature



DISEASE REVIEW

Historical Review :-

The Entire Core Of The Universe Is Enlightened, In Its True Form, By The

Lamp Of History, The Destroyer Of The Veil Of Ignorance1

The above statement depicts the need for the historical review of the subject

matter.To have a complete knowledge of subject, it is necessary to trace out

itshistorical background.

Vedic Kala :-

No reference found in the Vedas.

SAMHITA KALA :

Charaka Samhita :In Ch Sam. Amlapitta is not mentioned as a separate entity but

the word is discussed at several places like.

While explaining about qualities of dugdha, it has been mentioned as a pathya

in pandu roga, amlapitta etc., diseases2

Kulattha has been considered as chief nidana of Amlapitta3.

The excessive use of Lavana Rasa causes Amlapitta4

Amlapita has been included in the listed of diseases caused by Viruddhahara5

Rajmashes has the property of relieving the amlapitta6

Mahatikta Ghrita has be indicated in amlapitta7

While describing Grahani Dosha, pathogenesis of amlapitta has bee clearly

mentioned8

The list of Paittika Natmaja Vyadi includes Dhumaka, Amlaka, Vidaha which

are the symptoms of Amlapitta9

Indication of Kansaharitaki also includes Amlapitta10

A clear-cut, Samprapti of this disease is available, "Kulattha", Lavana Rasa

and Viruddhahaa were listed as the causes of Amlapitta where as Mahatikta ghrita and




Kansaharitaki are prescribed for its treatment. Hence, it can be concluded that

duringthe period of Caraka all aspects of Amlapitta disease were considered.

Sushruta Samhita (1000 BC) :Sushruta while describing the disease caused due to

excessive use of Lavana has mentioned a disease Amlika which is similar to

Amlapitta.

Kasyapa Samhita :Kasyapa Samhita is the first available text where Amlapitta has

been mentioned as a separate entity. Not only vivid description of Amlapitta with its

treatment has bee mentioned in it, but suggestion to change them lace for peace of

mind in case where medicine does not work out has also given.

Harita Samhita :Ha. Sa. in has described as a separate disease and given the

treatment.11 He has also given aspecial symptoms Amla Hhikka (Hicough with sour

taste).

Madhav Nidana (7th century AD) :After Kasyapa, Madhava Nidana is the first

available text which gives importance to Amlapitta and described its nidana, roopa

and samprati in details along with two clinical subtypes i.e. Urdhvaga and Adhoga

Amlapitta.

Vrinda Madhava :Vrinda Madhava has described Amlapitta is an independent

disease and also its chithasa explained.

Chakradutta (11th Century AD) :In this classics, Vamana, Virechana, Basti etc

chikitsa are advised for Amlapitta along with its Chikitsa Sutra.

Basavarjiyam : In text in the chapter of Namatmaja yadhi, has included Amlapitta in

the 24 namatmaya vikaras of pitta.

Among the other symptoms svarahinala Jivna and Vak paridaha has been

attributed to Amlapitta which has not been mentioned by any other texts.

Sarangadhar Samhita :Sha.Sa. being a book of pharmacopea has given only

Amlapittahara recipes without describing the aetiopathological concepts of the

disease.




Bhavaprakasha (16th cen. AD) :Two separate chapters on Amlapitta has been

devoted in this text. Upadrava and arista are explained in this text.

Yogaratnakara (17th AD) :This text has added four more Upadravas to the list of

Upadravas of Amlapitta.

Siddhanta Nidana :Here the Upadravas regarding Amlapitta from different classics

can be seen.

Bhaisajya Ratnavalli :Seven new mineral formulations have been added to the

existing formulation starting from Bhaskaramrutabhrakam to Sitamanduram. Two

palatable formulations have been mentioned by the author Govindadas Viz

Amlapittantaka modaka and Saubhagya Shunti Modaka, one of the taila added is

Sribilva Taila.

Previous Work done:

1. The study effect of Eladi choorna in Amlapitta –Mrs Sudhaka P -1995 –

HYDERABAD

2. The study of effect of Lakshadi Guggulu on the treatment of Amlapitta-Mrs Rao

Bhoswanth-1996-HYDERABAD.

3. A Clinical study of Amlaki Kvatha –bhavita shankha bhasma in the patient of

Amlapitta-Mrs Ravikumar T-2001-Lucknow.

4. A clinical study of indigenous composed on Amlapitta –Mrs Shivastava -1999-

Lucknow.

5. Amlapitta Ka Nidana Samprapti – paraka evam Upashyatmaka Adhyayana

Avipattikar choorna evam Kaparda Bhasma Ke pariprekshya mein –Mrs Rawate

R – 1997—Jaipur .




DISEASE REVIEW

NIRUKTI

Etymologically the word “Amlapitta” comprises of two components ‘Amla’

and ‘Pitta’.

Amla is derived as ‘Amyatya amlaha’. From the dhatu ‘Am’ meaning to be ill

or be afflicted or diseased.

The word amla has commonly been used to express one of the six kinds of

taste. In this present context the meaning of amla can be taken as one of the properties

of pitta.12

The second component the word pitta is derived from the dhatu ‘Tap’ i.e. to eat

or to burn or to warm. These terms seems to have three meanings, i.e. tap santapae,

tap dahe and tap aishvarya.

1. Tap santapae: it refers to the generation of heat.

2. Tap dahae: it refers to the act of burning of nutrition, which is consumed.

3. Tape aishvarya: it refers to those factors, which are responsible to make one

achieve the eight kinds of benefits.

These references are obtained from Bhattaji’s “Sidhanta Koumudi” and the

words furnish the vyakarana version of the term pitta. In this present context, if from

the word amla we take its meaning as diseased, then etymologically Amlapitta may be

diseased state of pitta.13

Paribhasha:

Chakrapanidatta in his commentary on Charaka Samhita defines Amlapitta

as

“Amlapittam cheti amlagunoudriktam pittam”14

Here pitta, which is acquiring more amla guna, is called as Amlapitta.




Srikantadatta in his Madhukosha vyakya defines

“ Vidahadhyamla gunoudrikta pittam amlapittam”15

That is, the pitta becomes augmented or vidagdha because of excessive

increase of amla guna of pitta.

“Amlam vidagdam cha tat pittam amlapittam”16

The pitta, which attains amla guna and vidagdhata, is called as Amlapitta.

Apart from the above there are some definition of Amlapitta, they are:

Kashyapa explains in Kashyapa Samhita khila sthana that the vidagdha

anna rasa terns to Shukta, this Shukta anna rasa is retained in amashaya and

produces Amlapitta.

Another by Madhava Nidana, the Amlapitta is that condition where the

pitta which has previously accumulated from the self aggravating causes gets

vidagdha due to virudha, dustha, amla, vidahi and pitta provocating foods

and drinks.17

These two definitions to a certain extent would speak of Nidana and Samprapti

of the disease.

By these definitions we come to know that Amlapitta is an abnormal physiological

condition of pitta. In this condition the amla guna of pitta is augmented and its

functions are altered. Hence there will be a loss of doshic equilibrium and digestion

process is affected. This results in Shukta paka and production of ama. This condition

exhibits typical clinical presentation known as Amlapitta.

Paryaya:

The paryayas of Amlapitta signify different aspect of it. Indu in his

commentary of Astanga Sangraha, has given synonyms of Amlapitta as




1. Prameelaka: The pachyamana vidagdha anna rasa immediately provokes pittadi

dosha, there by producing mukha vairasya, hritshula, sadana, continuous lavana

tiktamla Chardi, burning sensation, excessive sleep, constipation, restlessness,

and watering of the mouth. This state where all these symptoms are stated is

spoken of as prameelaka. In Astanga Sangraha we find this term under kaphaja

vyadhis.18

2. Amlapitta: The implication of the term Amlapitta signifies the abnormal state of

pitta especially in its amla guna. Yoga ratnakara and Kashyapa have used the

terms pittamla and shuktata respectively as synonyms of Amlapitta, though they

are not directly stated so.

3. Pittamla: The term would imply the sense of the term Amlapitta that is

mentioned in Amlapitta chikitsa in Yoga ratnakara.19

4. Shuktata: It is mentioned synonym for Amlapitta 20.

5. Amlaka: It refers to one of the nanatmaja vyadhis of pitta mentioned in the

context of pittaja nanatmaja vyadhis and Indu commenting this says hritsula,

antardaha, Kukshidaha, amloudgara. All these symptoms are totally called as

amlaka.21




NIDANA

Here the term Nidana refers to the causative factors, which play an important

role in the manifestation of a disease. All diseases stem from indulgence in improper

diet and regimen that may promote the morbidity of the Dosa, go contrary to the well

being of the Dhatu and also vitiate the Srotas. It is said, “The character of a man’s

digestive system moulds and shapes his destiny on this planet:.

This statement holds good as the Annavaha srotas and Ahara have a direct

proximity. Thus a thorough knowledge of the Nidana is imperative such that

preventive measures can be adopted. Nidana parivarjana22forms the first and foremost

step in the treatment of any disease in general and specifically in Amlapitta

In classics a large number of Nidana have been explained in the context of

Amlapitta. After a careful screening and analysis of the nidana of Amlapitta, they may

be discussed under four groups.23

Aharaja Hetu

Viharaja Hetu

Manasika Hetu

AagantajaHetu

A brief resume of these factors may be presented as under.

Aharaja Hetu [dietary factors]: -

The first and the foremost group of nidana of Amlapitta may be considered as

the Aharaja hetu. Under this group the intake of food against the code of dietetics i.e.

Ahara vidhi vidhana 24and Ahara vidhi visheshaayatana25 is included. Various type of

incompatible substances, excess of pitta aggravating factors like Katu, Amla, Vidahi,

etc. and irregular time of consumption of food are the factors against the dietetic code

and they are directly responsible for the annoyance of pitta.

Viharaj Hetu [Habit oriented factors]: -




To maintain the sound and good health, one has to follow the code of habits.

He is required to have regular habits of defecation, eating, and sleeping in time. He

has not to suppress the natural calls, maintain the equilibrium of the body

constituents’ and by that, obviously, he would maintain good health and proper

functioning of the body. If this is not followed regularly, the whole functioning of the

body will be disturbed and in long run, they will cause the disturbances of the

equilibrium of pitta and digestion, which ultimately will lead to Amlapitta.

Manasika Hetu [Psychological factors]: -

Psychology also plays a great role in maintaining the health of a person. An

abnormal psychology of a person in terms of anxiety, anger, greediness, etc. would

affect the physiology of the digestion. These factors tend to affect the secretion of the

pitta and by that, they are disturbing the homeostasis, which interns Amlapitta.

Agantuja Hetu [other related factors]:

Under this group constant and excessive consumption of alcohol, tobacco,

beverages, smoking, or other irritant stuffs, etc are taken. These substances cause a

local irritation in the amashaya, which in turn secrets more pitta, which may be

grouped under this category.

TABLE NO 1 COMPARATIVE TABLE SHOWING THE CLASSICAL

ETIOLOGICAL FACTORS OF AMLAPITTA

Sr Etiological Factors K.S.26

M.N27

. B.P.28 B.R.29

G.N.30

S.S.31

1. Adhyasana (To eat before the

previous food is digested) + - - - - -

2. Abhishyandi Bhojana + - - - - -

3. Ajirna (Indigestion) + - - - - -

4. Ama (Undigested) + - - - - -

5. Ama Pakwanna

(Semi-digested food) + - - - - -

6. Akala Bhojana + - - - - -




(Untimely diet)

7. Amla Sevana

(Eating of acidic substances) + + + + + +

8. Ame Ame Ca Puranant

(To eat without appetite) + - - - - -

9. Antarodaka Prana (To drink

much water during food) + - - - - -

10. Ati-ushna Ahara (Very hot

diet) + + + + + +

11. Ati-snigdha Ahara (Fatty diet) + - - - - -

12. Ati-ruksha Ahara (Coarse diet) + - - - - -

13. Ati-drava- Sevana

(Excess liquid) + - - - - -

14. Atisnana (Lengthy bath) + - - - - -

15. Avagahana (Tub-bath) + - - - - -

16. Bhuktwa – Buktwa + - - - - -

17. Bhrista – Dhanya + - - - - -

18. Dustanna - + + + + +

19. Diwaswapa + - - - - -

20. Gorasa (milky product) + - - - - -

21. Guru Bhojana (Heavy diet) + - - - - -

22. Ikshuvikara

(Sugarcane product) + - - - - -

23. Kulattha Sevana + - - - - -

24. Madya (Alcohol) + + + + + +

25. Paryusitanna + - - - - -

26. Pitta Prakopi Annapana - + + + + +

27. Pistanna + - - - - -




28. Pruthuka Sevana + - - - - -

29. Pulaka Sevana + - - - - -

30. Vidhanya - + + + + +

31. Viruddhasana

(Incompatible diet) + + + + + +

These may again be simplified in a more systemic way as below.

According to the type of ahara:

[a] Kulattha [b] Pruthuka [c] Pulaka (husky food)

According to the quality of food:

[a] Abhishyandi [b] Ati snigdha [c] Ati ruksha [d] Gurubhojya [e] Vidahi anna

According Samskara done on the ahara: -

[a] Apakwa anna [b] Bhrishta Dhanya [c] Ikshu vikaras [d] Pishta anna anna

According to dushti of ahara:

[a] Dushta anna [b] Paryushita anna

According to the pitta provocative properties of ahara:

[a] Adhyashana [b] Ajirnashana [c] Ama Purnata [d] Ati ushna [e] Ati Amla

[f] Ati Drava [g] Ati Tikshana [h] Ati panam [i] Katvannapana [j]

Viruddhashana

According to the capacity of weakening the digestive power by the ahara:

[a] Ati snigdha sevana [b] Ati ruksha.

TABLE – 2 A COMPARATIVE TABLE SHOWING THE CLASSICAL

ETIOLOGICAL FACTORS WITH DOSHA INVOLVEMENT OF

AMLAPITTA




Nidana

Doshika

Involve-

ment

K.S. M.N. B.P. S.N. H.S. G.N. Y.R. B.S.

Kulattha Sevana P + - - - - - - -

Pulaka Sevana P + - - - - - - -

Pruthuka Sevana P + - - - - - - -

Guru Ahara K + - - - - - - -

Abhishyandi Ahara PK + - - - - - - -

Atisnigdha Ahara PK + - - - - - - -

Ati Ruksha Ahara V - - + + - - - -

Vidahi Annapana P - + + - - + + +

Pistanna Sevana PK + - - - - - - -

Apakwanna Sevana PV + - - - - - - -

Phanita Sevana K + - - - - - - -

Ikshuvikara Sevana K + - - - - - - -

Paryushitanna Sevana VPK + - - - - - - -

Dushtanna Sevana VPK - + + - - + + +

Ati-ushna Ahara P + - - - - - - -

Viruddhahara VPK + + + + + + + +

Ati-amla Ahara PK + + + + + + + +

Ati-tikshna Ahara VP - - - + - - - -

Adhyashana VPK + - - - - - - -

Amapoornata VPK + - - - - - - -

Ajeernashana PK + - - - - - - -

Akala Bhojana KP - - + - - - - -

Kale Anashana V + - - + - - - -




Visamashana V + - + - - - - -

Vegavidharana VPK + - - - - - - -

Bhuktva Divaswapna K + - - - - - - -

Bhukta Avagahanam VK + - - - - - - -

Bhuktva Snanam VK + - - - - - - -

Ati-madya Sevana VPK + - - - - - - -

Pitta Provocative

factors VPK - - + - - - - +

Pathophysiolagy

Shad Ahara Parinamakara Bhavas are responsible for proper digestion.32

Usma :Usma is a quality of Agnimahabhuta. In this regard two terms are to be

considered viz. Agni and Pitta. Sushruta explains that there is no Agni except Pitta in

body. Pachaka Pitta is situated in Aamashaya and it performs the function of Agni.

Various secretion of G.I.T. can be considered under the light of Pachaka-Pitta. It

should be released in proper time and in proper quantity. Usma of Pachaka Pitta is

essential for proper digestion, disturbance of it will lead to complication of Agni.

Vayu :Samana Vayu is seated in Aamashaya, helps the Pachaka Pitta in digestion.

According to Sushruta, there is a vicious cycle between Prana-Apana-Samana, it

means this two also helps to maintain Agni.

The Apakarshana, Grahana and Munchana Karma of Vayu are essential for

proper digestion.

Any exacerbation or cessation in these function will leads to improper

digestion. As certain time is required for proper digestion, delayed emptying will

cause the Shuktapaka and formation of Amavisha, which are the essential factors of

Grahani Dosha. Now it is clear that all secretary regulations can be termed as function

of Samana Vayu. If Samana Vayu is disturbed it will lead to Ajirna stage like and

start the pathogenesis of G.I.T. diseases. The etiological factors like Krodha, Shoka,




Bhaya, Chinta and other stress factors work through the Vagus chain, which is said to

be mediating through Vayu. Provocation of Vata by any factor will result in hyper-

secretions leading to hyperacidity.

Kleda :This factor is necessary for proper digestion; it loosens and emulsifies the

food. This function is performed mainly by liquid portion of food itself i.e. saliva,

mucosa and liquid portion of various digestive juices. Kledaka and Bodhaka Kapha

may be considered in this regard. Drava has been termed as Kleda in Ahara Parinama

Bhava.

Though Kapha has not been mentioned having Drava quality but Kapha made

up of Apadhatu and so that Kapha must posses Dravata but it depends upon the

temperature. So, the function of Kledaka Kapha can be summarized as Kledana-

Shithilikaran-Mridukarana and Sanghata Bheda. The excessive Klinnata may hamper

the Agni directly as mentioned in the literature, that Dravata ceases the Agni.

Ingestion of any Ati-ushna, Tikshna and Katu Dravya may cause excessive secretion

of mucous, which may interfere with digestion process and cause the Vidagdha

Avastha in excess leading to Ajirna etc. In the same way increase in Kapha causes

Mandagni.

Sneha :Usually Ahara contains Sneha. Kapha is also having the property of Sneha, it

also belongs to Apamahabhuta, Sneha has been described possessing a specific

quality of Apa. Pitta is also having Sneha Guna33. Hence, it can be said that, Sneha is

also the quality of Kledaka Kapha and Pachaka Pitta mainly of saliva and

glycoprotein of stomach as indigenous Sneha and other Sneha coming from Ahara,

Sneha perform the function of Mardava (softness of food stuff). Ultimately it helps in

the proper mastication and churning by stomach musculature, So that the proper

digestion can take place. The decrease in the quality of Sneha may damage the

intestinal mucosa due to roughness of food stuff and also due to Ruksha Guna of

various food materials. Decrease of Sneha in stomach will lead to provocation of

Samana Vayu which imbalances the Agni.

Kala :This is an important factor for every process to carry out. Time required for the

proper secretion of all the digestive factors and for digestion and absorption. Kala




means mainly the time required for the digestion of ingested food stuff. But other time

considerations are also necessary for proper digestion and absorption of food, i.e.

Kshudhakala, Trishakala, Doshakala and also Charvankala. The food is to be taken

after the proper digestion of pervious meal. The meal taken without proper digestion

of previous meals is called as Adhyashana and this is the main cause of Agnidushti.

Emptying of stomach requires certain time. Retention of food material in

intestine is regulated by Vayu. Any disturbance of Vata will disturb the Grahana and

Munchana period leading to improper digestion and absorption which will lead to

further provocation of doshas. Excessive Dharana of acidified Anna may cause

damage to duodenal mucosa. The Adhyashana and Ajirna-Bhojana, may cause the

Prakopa of all the three Doshas simultaneously Agnidushti.

Samyoga :Equilibrium of all above factors is necessary for the proper digestion of

ingested food material. Ashtavidha Ahara Ayatana should be considered to avoid

Agnidushti. Charaka has given a deep thinking on various aspects of qualities of food

materials, which is obvious from the fact that most of the diseases have a long list of

etiological factors from dietary habits and diet articles. Charaka has formulated

guidelines for a healthy diet selection and same time he has also formulated the rules

for healthy eating.34




PURVARUPA

Purvarupa are premonitory symptoms, which herald the forthcoming disease

and appear at the onset of Dosa-Dusya sammurcchana..

Chakrapani has classified the purvarupa into two types,35

Vyakta lakshanas i.e. visible.

Avyakta lakshanas i.e. invisible.

In Amlapitta purvarupa are not evident as they probably belong to the latter

category. Even if they are present it is not possible to recognise them, as minor

fluctuation of doshas are common events. Hence no purvarupa have been mentioned

for Amlapitta in classics.




RUPA

The laksana that indicate the disease are called as Rupa. The sources of

knowledge are many viz. Pratyaksa (direct observation), Anumana (inference),

Aptopadesa (instruction), Yukti (reasoning) etc. All the above can be applied

individually or in combination for impeccable knowledge. So also, the Laksana that

have appeared in a disease can be discerned with the aid of the above Pramana for

prompt diagnosis and treatment. The appearance of Laksana in a vyadhi follows

Dosa-dusya sammurcchana and helps to clinch the diagnosis.

These are produced during the Vyakta stage of Kriya Kala. This has been

classified in to two types. Samanya and Visista Rupa. The Samanya Rupa of

Amlapitta and the Laksanas of Amlapitta have been listed in the table below.

Table – 3 Samanya Laksanas of Amlapitta:

Sl. No. Laksanas K.S. M.N. B.P Y.R. V.S.

1 Amlodgara - + + + +

2 Tiktodgara - + + + +

3 Kantavidaha + + + + +

4 Urovidaha + - - - -

5 Kuksidaha - + + + +

6 Utklesa - + + + +

7 Amla Utklesa + - - - -

8 Avipaka - + + + +

9 Hritdaha - + + + +

10 Guru Kostata + - - -

11 Udaradhmana + - - - -

12 Antrakujana + - - - -

13 Vidbheda + - - - -

14 Aruci - + + + +

15 Klama - + + + +

16 Gourava - + + + +

17 Angasada + - - - -

18 Romaharsa + - - - -




The important factors that are involved in the manifestation of Amlapitta are,

1. Vidagdha Pitta

2. Agnimandya

3. Suktapaka

Vidagdha Pitta is the vitiated state of Pitta. This causes Agnimandya. During

this state if the person consumes food, that doesn’t get digested and gets converted in

to Aama. Continued presence of Aama in the Amasaya attains Suktata. This produces

Amlodgara, Utklesha, Hritdaha, Kukshidaha and Kantadaha. The Laksanas produced

by Sukta Paka can be considered as Pratyatma Laksana. Other symptoms Avipaka,

Aruchi, Hrillasa are due to Agnimandya. The persistence of Agnimandya and Aama

causes the improper formation of Rasa Dhatu. Hence the Rasaksaya Laksanas like

Klama, Bhrama, etc. Along with the above the Sarvadaihika Pitta Prakopa Laksanas

like Karadaha, Charanadaha, Angadaha, Usnata etc are seen.

Classification Of Amlapitta:

(A) According to the movement of the Dosha.36

1. Urdhvaga Amlapitta.

2. Adhoga Amlapitta.

(B) According to the Dosha Samsarga,37 Amlapitta has been classified as

follows -

1. Sanila

2. Sakapha

3. Sanilakapha

4. Slesmapittaja




(C) According to Acarya Kasyapa:38

Amlapitta is of three types.

1. Vataja

2. Pittaja

3. Kaphaja

Urdhvaga Amlapitta:The tendency of the movement of the Doshas towards upward

direction produces Urdhvaga Amlapitta. Hrithkanthadaha, Utklesha and Chardi are

prominent features. The Laksanas of Urdhvaga Amlapitta mentioned by different

Acaryas are listed in the following table.

TABLE – 4 OF URDHVAGA AMLAPITTA LAKSANAS:

Sl.No. Lakshanas M.N Y.R. B.P. V.S.

1 Vantam Haritam + + + +

2 Vantam Pitam + + + +

3 Vantam Nilam + + + +

4 Vantam Krisnam + + + +

5 Vantam Arunam + + + +

6 Vantam Raktam + + + +

7 Vantam Ativamanam + + + +

8 Vantam Mamsodakabham + + + +

9 Vantam Atipichilam + + + +

10 Vantam Sleshmanugatam + + + +

11 Vantam Rasena Vividham + + + +

12 Vantam Bhukta Vidagdha Amlavami + + + +

13 Vantam Bhukta Vidagdha Tiktavami + + + +

14 Vantam Abhukte Tiktavami + + + +




15 Vantam Abhukte Amlavami + + + +

16 Tiktodgara + + + +

17 Amlodgara + + + +

18 Hritsula + + + +

19 Kanthadaha + + + +

20 Kuksidaha + + + +

21 Shirasula + + + +

22 Karadaha + + + +

23 Charanadaha + + + +

24 Usnata + + + +

25 Aruchi + + + +

26 Jwara + + + +

27 Kandu + + + +

28 Mandala + + + +

29 Pidaka + + + +

Adhoga Amlapitta:

The movement of the Dosha to downward direction produces Adhoga

Amlapitta. The features related to the Adhopravritti are predominant. The features

mentioned by different Acaryas are Trishna, Daha, Murcha, Bhrama, Moha,

Adhopravahana of Doshas with different colours, Hrillasa, Kota, Analasada, Harsa

and Sweda.394041




Table.no 5 Showing Lakshana of Adhoga Amalapitta.

Sl.no Lakshana K.S M.N B.R Y.R V.S

1 Trishna + + + + +

2 Daha + + + + +

3 Murcha + + + + +

4 Bhrama + + + + +

5 Moha + + + + +

6 Hrillasa + + _ + _

7 Kota + + + + +

8 Analasada _ + + _ +

9 Harsa + + + + +

10 Sweda + _ _ _ +

Sanila Amlapitta:

The aggravated Pitta and Vata, causes Agnimandya, due to which the ingested

food gets converted in to Aama. This on retention in Amasaya results in Sukta Paka.

Besides the Pratyatma Laksanas some more symptoms are produced and they

represent the Vata Dosha. The symptoms are listed in the following table




Table.no 6 Showing Lakshana of Sanila Amalapitta.

Sakapha Amlapitta:

The aggravated pitta and Kapha, causes Agnimandya, due to which the

ingested food gets converted in to Aama. These with in Amasaya produce Sukta Paka.

Besides the Pratyatma Laksanas some more symptoms are produced which represent

the Kapha Dosha. The symptoms are listed in the following table.

Sl.No. Laksanas K.S. M.N. B.P. Y.R. V.S.

1 Tamodarsana - + + + +

2 Sita + + + + +

3 Gatravasada + + + + +

4 Murcha - + + + +

5 Kampa - + + + +

6 Chimachimatva - + + + +

7 Pralapa - + + + +

8 Vibhrama - + + + +

9 Vimoha - + + + +

10 Harsa - + + + +

11 Jrimbha + - - - -

12 Snigdha upasaya + - - - -




Table.no 7 Showing Lakshana of Sakapha Amalapitta.

Sl.No. Laksanas K.S. M.N. B.P. Y.R. V.S.

1 Kaphastiavan - + + + +

2 Vamana - + + + +

3 Aruchi - + + + +

4 Sleshmaliptasyata - + + + +

5 Gourava + + + + +

6 Jadata - + + + +

7 Shitatva - + + + +

8 Bala Sada - + + + +

9 Anga Sada - + + + +

10 Kandu - + + + +

11 Nidra - + + + +

12 Chardi + + + + +

Sanilakapha Amlapitta:

Vitiated Kapha and Vata Doshas in Aamasaya along with Vaikritha Pitta

produces Agnimandya, which on stasis converts in to suktapaka. The symptoms

pertaining to the vitiated Vata and Kapha Doshas also seen along with the Pratyatma

Laksanas. The mixed features of Sanila and Sakapha Amlapitta are observed.

Slesma Pittaja Amlapitta:

The Laksanas are tabulated, which are mentioned in Madhava Nidana. The

Laksanas represent Pitta and Kapha Dosha and they are similar to Urdhvaga

Amlapitta.




Table no 8 showing laksanas of Shlesma pittaja Amlapitta:

Sl.No. Laksanas K.S M.N B.P Y.R V.S

1 Siroruk - + + + +

2 Praseka - + + + +

3 Chardi - + + + +

4 Tiktodgara - + + + +

5 Amlodgara - + + + +

6 Katukodgara - + + + +

7 Kantadaha - + + + +

8 Kuksidaha - + + + +

9 Alasya - + + + +

10 Murcha - + + + +

11 Bhrama - + + + +

12 Ruksa Upasaya

Usna Upasaya

-

-

+

+

+

+

+

+

+

+

Pittaja Amlapitta:

Pitta gets vitiated without the other Doshas, produce Agnimandya and results

in to Sukta Paka. The Laksanas that are produced are the contribution of the vitiated

Pitta Dosha only.




Table no 9 showing Laksanas of Pittaja Amlapitta:

Sl.No. Laksanas K.S M.N B.P Y.R V.S

1 Bhrama + - - - -

2 Vidaha + - - - -

3 Ruksa Upasaya

Usna Upasaya

+

+

-

-

-

-

-

-

-

-




SAMPRAPTI

Samprapti means description of physiological derangements and pathological

process, which takes place in a person due to nidana sevana. It helps to understand the

manifestation of clinical features and it also has therapeutic importance. The ancient

scholar has stated that samprapti vighatanameva chikitsa, that is, reversal of

pathogenesis is the complete treatment.

Kashyapa, Madhava and Gananatha sena have maintained specific Samprapti

of Amlapitta as follows.

Over indulgence in above mentioned aetiological factors cause vitiation of

Vata-Pitta Dosha. Anyone of the involved Dosha Slackens the Jatharagni (to below

the normal level) i.e. Jatharagnimandya. During this state, whatsoever food is

consumed becomes Vidagdha. Then it becomes Sukta and it lies in the Amashaya

stagnant. Any food which is taken becomes Vidagdha. At this stage Vidagdhajirna

manifests which is the purvarupa of the disease.

Further vitiated Pitta get mixed with Sukta and causes Pitta Amavisa

Sammurchhana. The Amlapitta with its cardinal symptoms is then born.

If not treated properly in this stage, the disease leads to Bhedavasta where the

typical characteristic of types like Urdhwaga, Adhoga etc. are differentiated.

Further complications like Sitapitta, Udara, Annadrava and Parinama shula etc

may occur in the advanced course of the disease.

Gananath Sen in Sidhanta Nidana has mentioned that when food is dominant

with Amlarasa, then in Amashaya also Amlarasa in produced and when it is taken in

more quantity it irritates the Amashaya. If food is not consumed at proper time, then

the secretion of Amlarasa increase and it then irritates the Amasayakala resulting in

various incurable disorders like Shula etc.

Dr. Harinath Jha et al (1986) has described details regarding the Samprapti of

Amlapitta in 2 ways i.e. the Sushruta concept of Samprapti and Charak concept of

Samprapti.

The Samprapti of Amlapitta may be transformed into a schematic diagram as

follows.




NidanaSevana

Aharaj Viharaj Manasika Agantuj

Pitt

sanchaya

Agni

Dushti

Punaha

Sevana

Pitt

Prakopa

Atiamlata

Agnimand

haya

Avipaka

Vidhagata Ama Rasa

Dushti

Shuktamlata

Pitta Ama Visha

Samurchhana

Amlapitta

Urdhavaga

Adhoga

Diagramatic presentation of the Samprapti of Amlapitta

Atidravatva

Urdhavaga




Samprapti of Amlapitta (In terms of Charak)

1. Sankhya Samprapti :

a. Two types according to Gati

i. Urdhwaga ii. Adhoga

b. Three types according to Kashayapa

i. Vatolvana ii. Pittolvana iii. Kapholvana

c. Three types according to Madhavakar

i. Vatika ii. Vatakapha iii. Kapha

iv. Also counted fourth types Shleshma Pitta.

2. Vidhi Samprapti :

a. i. Nija ii. Agantuja

b. i. Svantantra ii. Paratantra

c. According to curability

i. Naveena - Curable by factful persuasion

ii. Chirothita - Krichhasadhya

iii. Chirothita - Krichha Sadhya, Yapya

3. Vikalpa Samprapti :

i. Vata - Chala, Ruksha karmataha

ii. Pitta - Dravyataha, Ushna, Teekshna, Sara, Amla, Katu, Drava

iii. Kapha - Dravyataha, Karmataha, Guru, Mridu

4. Pradhanya Samprapti :

i. Pitta - Vriddhatama

ii. Kapha - Vriddhatara

iii. Vata - Vridha




5. Bala - Kala Vishesha :

a. Seasonal aggravation - i. Sarada ii. Greeshma

b. Day / Night - i. Noon ii. Mid night

c Dietetic time - Bhojanottar

SAMPRAPTI GHATAK OF AMLAPITTA :

1. Dosha - i. Vata - Samana

ii. Pitta - Pachaka

iii. Kapha - Kledaka

2. Dushya - Ahararasa

3. Agni - Jatharagni i. Mandagni

ii. Vishamagni

4. Ama - Jatharagnijanya ama

5. Srotas - i. Rasavaha

ii. Annavaha

iii. Purishavaha

6. Srotodusti - i. Sanga

ii. Vimarga Gamana

7. Adhistana - Amashaya

8. Sancharastana - Mahasrotas

9. Vyaktastana - Amashaya

10. Rogamarga - Abhyantaroga marga

11. Swarupa - Chirakari

12. Prabhav - Danuna

13. Sadhyasadhyata - Sadhyavyadhi




UPASAYA ANUPASAYA

Specific mentioning about Upasaya and Anupasaya is given only by Kashyapa

while describing dosaja types of Amlapitta.

Vataja Amlapitta - Snigdha Upasaya42

Pittaja Amlapitta - Swadu and Sita Upasaya44

Kaphaja Amlapitta - Ruksa and Ushna Upasaya44

UPADRAVA

The occurrence of another disease in the wake of primary disease is called as

Upadrava45. . These are produced during the Bheda Avastha of the disease. These are

dependent on the primary disease. Unless they are life threatening, don’t need special

treatment. Even still, the presence of the Upadravas helps to identify the

Sadhyasadhyata of the disease.

In Kasyapa Samhita46 the Upadrava of Amlapitta are explained as:

1) Jwara

2) Atisara

3) Pandutva

4) Sula

5) Shotha

6) Aruchi

7) Bhrama

Though Madhavkara has not mentioned the complication of Amlapitta but

included Shoola in its Vatika predominant variety. Hence, Parinama and Annadrava

Shoola can be taken as complications of Amlapitta.

According to Acharya Gananath Sen Upadravas of Amlapitta are -




1. Amasayakala shopha

2. Grahani Kala Shopha

3. Kandu

4. Mandala

5. Pidaka

6. Shitapitta

7. Udara

8. Vicharchika

9. Vispota

DHATUGATATVA OF AMLAPITTA

Doshas vitiated due to Same Nidana can produce different diseases as per their

lodging w.s.r. to Ashaya and Dushya.47. Though Amlapitta is simple disease but

treatment given in some condition does not give relief, this shows another view to

think over. Each and every dosha resides by the shelter of any of Dhatu. But vitiated

doshas moves in different places, dhatus and leads to Vikruti of that particular dhatu,

this condition is known as Dhatugatatva. If Doshas are following Dhatugatatva then

there should be difference in its treatment.

Dhatugata Doshas are generally Tiryagagata. Doshas might be SAMA or

NIRAMA, that’s why we must think on the line of SAMADOSHA and

TIRYAGAGATA doshas management. They are chronic in nature. So Pachana-

Shamana should be done by observing the State of Dosha-agnibala etc. otherwise

Doshas should be brought into Kostha and thereafter, they should be eliminated out of

the body.

“Dhatu Vaisamya” is nothing but the discordance of the Dhatu.

Dhatu Vaisamya is not actually a disease but it is the former stage of

pathogenesis i.e. it is precondition for “Dosha-Dushya Sammurchana”.




But according to Dr. S.C. Dhyani (1958), Dhatu Vaisamya is not present

before the Dosha-Dushya Sammurchana but will occur during the sammurchana

Avastha only. If one will go through the mode of pathogenesis mentioned for diseases

he will get that Vaisamya Avastha is present before the Dosha-Dushya Sammurchana.

Though Doshas are present all over the body it’s Gata condition specifically indicates

it’s abnormal localization at a particular Dhatu or Asaya. In this condition the

etiological factors are only of Doshas and not of two fold nature i.e. of both Dosha

and Dushya.

Acharya Vagbhata48 has described the Dhatugatatva of Pitta dosha and Kapha

Dosha. Charaka has explained the Gatatva of Vata. In Dhatugata Avastha Dosha

disturbs to Sthayi Dhatu along with Poshaka Dhatu. Generally, it leads to Kshaya

condition of that Dhatu. At such place treatment should be based on that particular

Dhatu. In Raktagata Jwara, there is symptom of Raktasthivanam in such condition

drug used for treatment should have Rakta-Pittahara property so in this condition one

may should use Vasa and Pravala.

Dr. Sadashiva Sharma (1960) have described that, in the Samhitas, Dhatugata

stage of three diseases have been described namely 1) Jwara, 2) Kustha, 3)

Vatavyadhi. He explained that, these diseases are representative of Dhatugatatva of

Pitta, Kapha and Vata diseases respectively. He further explained that Jwara should be

taken as example for all the Pittolvana diseases, Kustha for Kapholvana and

Vatavyadhi for Vatolvana diseases, Raktasthivana shows the establishment of

diseases in Rakta Dhatu.

By the study of symptomatology of Amlapitta and with the help of Jwara

Dhatugata Avastha and Dhatugatatva of Pitta described by Vagbhata, we can describe

the Dhatugatatva of Amlapitta as below ;

Rasagata Amlapitta :Rasagata Amlapitta produces the symptoms like Gaurava,

Jadata, Aruchi, Chhardi, Avasada, Praseka.

Raktagata Amlapitta :Raktagata Amlapitta shows the symptoms like Daha,

Hastadaha, Padadaha, Hritadaha, Kukshidaha. Along with it produces several




Pittadushtaraktaja Vyadhi as Agnisada, Kandu, Kotha, Mandal, Pidaka, Headache

(severe).

Mansagata Amlapitta :In the stage of Mansagata Manasapaka can be observed

which can be co-related with peptic ulcers, gastritis etc. formation of ulcer after

Amlapitta is the result of progression of pathogenesis into Mamsadhatu. Antardaha

and Trushna also manifest.

Medogata :In this stage, Swedadhikya, Trishna, Pralap, Chhardi, Aruchi, Glani can

be seen.

Asthigata Amlapitta :In this stage, severe Daha all over body, Atisara, Vamana is

observed.

Majjagata Amlapitta :In this stage Tamodarshanam, Murchha, Moha, Bhrama,

Parvashula. Haridravarna in Netra and Nakha is observed, As there is also strong

relation between Majja and Netra.49.

Shukragata Amlapitta :In this stage, Shukra becomes Puyayukta and yellow in

color. Besides this Angasada, Shrama, Sadahalpashukravisarjana, Daurbalya,

Panduta, Mukhasosha etc. symtpms can be observed.

In Dhatugata avastha, diseases shows the symptoms of previously involved

Dhatus also, means Mansagata Amlapitta shows the symptoms of Rasagata and

Raktagata Amlapitta.

In Dhatugata condition of Dosha the Asthi-Majjagata conditions is said to be

untreatable (Asadhya).




SADHYASADHYATA

Sadhyasadhyata is consider as prognosis of a disease, Acarya caraka difined as

“Sadhyasadhyavibhagajno jnanapurvam cikitsakah /

kale ca arabhate karma yattat sadhayati dhruvam //”50

Prognosis of a disease distinguishes between the curable and the incurable and

gives an idea regarding the modality of treatment to be adopted. In addition to the

general guidelines for deciding the Sadhyasadhyata, the following are specifically

mentioned in Amalapitta.

The prognosis of the disease is not uniformly favorable. Madhavakara has

pointed out that in case the patient has been suffering from Amlapitta recently and is

treated properly the prognosis is good. Chronic cases may either improve a little or

may be relieved completely during the course of treatment. As soon as the patient

deviates from the wholesome diet the disease relapses. When disease is of short

duration then it is Sukhasadhya, it is Yapya when chronic Krucchrasadhya, when the

duration of the disease is long and cured with great difficulty and Asadhya when the

patient will have different Upadravas and symptoms of Dhatu Kshaya.51.

Kashyapa has indicated that in case of patients of Amlapitta gets complicated

by Jwara, Pandu, Shula, Shotha, Aruchi and Bhrama with Dhatu Kshina are

incurable52. Age of maximum occurrence is Yuvavastha which is Pittakala, Prakopa

Kala i.e. Sharad Ritu, is also Pitta Prakopaka Kala and the Hetus also are many in the

causation of this disease i.e. Ahara, Vihara, Manasika etc. These are the factors which

contribute to convert this disease in Krichhrasadhy




VYVACCEHDAKA NIDANA (DIFFERENTIAL DIAGNOSIS)

A proper examination of the patient is very necessary before going to the

threatment in all the disease.Our science also mentions that ‘Rogamadau pareeksheta

tatonantharamoushadam” before going to the treatment physian should elaborately

examine the patient and come to conclusion about the diagnosis.

The difference between Amlapitta and other diseases which have similar features are

mentioned below.

Vidagdhajeerna: Bhrama, murcha, sadhumaudgara, amloudgara, sweda, daha, pittaja

vividharuja are the lakshanas of vidagdhajeerna which certain symptoms are similar

to Amlapitta. The diffence between these two are only in its chronocity and its course.

Pittaja shula: Teevra shula, trishna, mutra daha, sweda, murcha, bhrama, chosha are

the symptoms which aggravated by pitta prakopaka ahara, madhya dina, madya ratri

and ahara pachyamana kala. And swadu sheeta ahara, snigdha, sheetopachara factors

which relieves the pain.

Parinama shula: This is shula pradhana vyadhi which associated with adhmana,

vibandha, atopa, trishna, atisweda lakshanas. The shula relieves by intake of food,

after the digestion and by doing vamana.

Annadrava shula: Here shula is continuously and only relieved by vamana.




CHIKITSA

Ayurveda has 3 basics of Chikitsa regarding any type of disease.

Nidana Parivarjana53 : Removal of alleviating factors of Ahara and Vihara which

are responsible for causation of the disease. It is to be advised to patient to avoid such

type etiological factors which are responsible for the manifestation of disease.

Apakarshana : Kashyapa has described Vamana as the first line of treatment

followed by Langhana and Laghu Bhojana. Kashyapa opines that just like a tree with

its trunk and branches is destroyed by striking blow at its root. As per Chakradatta,

Yogaratnakara, the second line of treatment is to carry out Mrudu Virechana. The

next regimen consists of Administration of Anuvasana followed by Asthapan in the

chronically afflicted patients. Vangasen and Yogaratnakara added Raktamokshana as

tool if Amlapitta is not cured by Vamana and Virechana,

Vamana : In amalapitta kelada khapa and pachaka pitta endanger the amashaya in

presence of ama hence vamana is best remedy. Drugs used for Vamana are,

Lavanambu, Sukhosna Dugdha, Ikshurasa, Madhudaka and Tiktadravyas.

Vasa, Nibhutvaka, Madanaphala, Sindhava and Madhu.

Gritha, Patholapatra, Triphala, Tvaka, Trayamana, Rohini, Nibha,

Masura and Yashti.

Virechana : When the morbidity is ascertained to have passed on to the pakayashaya

the Virechana would be the measure of choice. Drugs used for Virechana are,

Amalaki swarasa and Trivrit churana.

Avipatikara churana.

Trivrit leha.

Trivrit, Rohini, Katuki, Triphala54

Samsarjana Krama : After every vamana or virechana measure Samsarjana karma

should be followed be by planned and graded diet such as vilepi-yavagu with lagu

ahara constituting deepana-pachana materials. This gradually rejuvenates the jataragni

and then the person should be provided with pathya.




Basti : In vataja amalapitta and in dathugata avastha basti may be optional. So

Anuvasana followed by astapana basti should be given.

Rathamookshana : when sodhana measures fail to subdue the turbulent mobidity and

the case of amalapitta exhibits shishira-alpatha, kota, udarda, visuchika, etc than

Rathamookshana may de resorted.

Prakritivighata : Prakritivighata refers to the use of drugs which suppress the Dosha;

such treatment is termed as Samana therapy. Kashyapa opines that, after Vamana if

the doshas persist, the physician should resort to Samana Chikitsa with the aid of

Laghu, Bhojana, Samana and Pachana Aushadhi. It is forbidden by Acharyas to give

Drava Aushadhi if the doshas are in condition of Utklesha; because if Vamana is not

done the Drava Aushadhi will not be metabolized. When the Dosha Utklesha has

reduced with the help of Ahara and Vihara, physician can give, Ama Pachana and

Bhedana Aushadhi. Once the doshas have been expelled and Aamashaya is devoid of

vitiated Doshas, the physician should ask the patient to take care of the Agni. The

doshas lodged in the Pakvashaya, should be removed with the help of Sramsana

Aushadhi Aragvadha given at Swapna Kala along with cold water.

Mainly Tikta Rasa, Laghu, Snigdha Guna, Katu or Madhura Vipaka, Sheeta

Virya drugs are advocated by all Acharyas. Use of Shamana drugs that opposite to

that of Pitta is beneficial in Amlapitta.

According to Kashyapa :

1. Since the disease is amashaya oriented and Kapha and Pitta are the dominating

Doshas, Vamana should be administered at first.

2. After the Vamana, Samana drug (anti-Pitta, Kapha drugs) should be used. At

the same time Pachana drugs should be given.

3. When the Samsarga doshas are eliminated and stomach becomes clear,

Deepana drug should be administered.

4. If the Doshas have shifted into Pakwashaya, Virechana or Sransana drugs

should be used to eliminate the dosha




PATHYAPATHYA

“The doctor of the future will give no medicine but will interest their patients in the

care of the human frame, in diet and in the cause and prevention of disease.” 55

Thomas Edison1

The food and the behavior which is compatible to the health is called as

Pathya56. And that which is not conducive to health is called as Apathya. Pathya can

only control the disease. Apathya is similar to Nidana Sevana and it worsens the

disease condition.

Pathya :The following are the Pathyas stated in Amlapitta - Laghu Bhojana,

Shalidhanya, Yava, Godhuma, Mudgayusha, Lajasaktu. The Jangala Mamsa Rasa

Kalayashakha, Karanja Rasa Pushpa, Godugdha, Goghrita, Mudga. The Dravyas that

have Tikta Rasa and Laghu Guna also serve as Pathya. Those Dravyas, which does

not produce Vidaha and the foods or activities which are Sathmya to the body, are

considered as Pathya57.

Apathya:Pitta Prakopaka Ahara and Vihara ie; excess use of Tila, Masha, Kulattha,

Taila, Dhanyamla, Brista Dhanya, Madya and Rasa like Amla, Lavana, Katu are

considered as Apathya

MODERN PERSPECTIVE

It is very much essential to co-relate the diseases which are mentioned in the

classics with the recent disease of Modern medicine for a better comprehension of the

pathogenesis. In modern medical literature, some technical terms have been used to

indicate an abnormal condition resembling to Amlapitta. These terms either explain

the pathological condition of the disease or explain the characteristics of the disease.

It is very difficult to correlate Amlapitta with a single disease of Modern

science. Following is the opinion of scholars till date –




Year Scholar Disease correlated

1968 Fourth national seminar on Ayurveda

(i) Sri Purushottam Vaidya Acute Gastritis

(ii) Vd. Vishwanath Dwivedi Chronic Gastritis

1982 Tripathi Non ulcer dyspepsia

1986 Harinath Jha Hyperacidity

HYPERACIDITY :This is one of the commonest terms also used by the patients to

subject each gastric discomfort as Hyper acidity. Usually patients having following

signs and symptoms are coming with the chief complaint as hyper acidity Heart Burn,

Chest Pain, Gastric discomfort, Abdominal distention, Sour Belching, Refluxes of the

food taken, Nausea and Loss of Appetite. All these complexes together makes the

disease hyper acidity

Defination :This word is composed of two components i.e. hyper and acidus. Hyper

means over or excess and acidus means sour. So a straight meaning may be derived as

excess of acid i.e. any acid not particularly the HCL in stomach and a disease which

contains this abnormal pathology is defined as hyperacidity.

Pathophysiology :Hyperacidity term indicates about the functional

abnormality i.e. hyper activity of the secreting glands.

Four processes normally take place in the stomach. 1) The conversion of

starch into sugar, begun in the mouth, is carried a stage further. 2) Proteins are

changed into peptones; 3) Fat globules are set free from their envelopes. 4) Milk is

curdled. Delay in digestion may be caused by i) Deficient peristalsis of the stomach

walls, ii) Deficient quality or quantity of the gastric juice, iii) Consumption of

indigestible article or iv) The dilution of the gastric juice by drinking too much fluid

at meal time.

The gastric juice contains HCL, water, pepsin, renin, mineral salts, a little

mucus, and castle’s intrinsic factor. Pepsin and rennin exist in the secretory cells only

as zymogens, which, on secretion into the stomach, become active ferment or




enzymes. In the healthy state, as the result of digestion, about 30 ml of fluid should be

obtained from the stomach one hour or so after a test – meal (vide – infra), straw

colored, without much odour, without organic acid and with about 0.2% of free HCL.

As regards HCL much depend on the time of examination. Hyperchlorhydria

has come to be somewhat loosely used for “excessive acidity”, and thus to be

confused with the acidity of fermentation (due to organic acid) on the other hand,

after a meal, a negative result on testing for HCL would indicate the absence of peptic

activity as this acid is required for the normal digestive action of pepsin. Excess of

HCL is diminished in catarrhal conditions of the mucus membrane, in anaemia, the

majority of cases of malignant disease, during pregnancy and in states of nervous

exhaustion.

Three organic acids are met in the presence of fermentation in the stomach,

lactic acid, butyric acid and acetic acid. Lactic acid is easily recognized on testing

with uffelman’s reagent and is the only one of diagnostic importance. It is normally

absent in the gastric juice after the digestion has proceeded for one hour, but traces

may be found, due to the ingestion of lactic acid in certain foods, or to fermentation in

the mouth. Fermentation occurs when HCL is deficient or when there is delayed

emptying of the stomach. Lactic acid is most frequently found in cases of gastric

carcinoma with achlorhydria.

The secretion of pepsin is not interfered with, unless there be destruction of

the glands of the stomach. An acid secretion without peptic activity does not occur.

Etiology :These symptomatology may occur due to many under laying causes they

are as discussed below:

General Factors:Vagal effects, Hormonal effects insufficient circulation, shock,

general ischameia, etcConstitutional and environmental factor:Sex, Age,

Temperament, Family history, Social class, Geographical distributions & Occupation,

etc.




Local factor related to stomach

Aggressive Factors: -Hydrochloric acid, Pepsin, Refluxed bile, NSAIDs,

Alcohol, Pancreatic and Proiolytic enzymes, ingested irritants, bacterialtoxins,

psychological trauma.

Defensive Factors: - Mucus, Bicarbonates, Blood flow, restitution of epithelium.

Thus defensive factors are responsible for the enhancement of mucosal

protection. Although no single element may account for mucosal protection, all

may be potentially contributing factors. Insight into mucosal protective

mechanisms was provided by studies performed by Robert. These studies lead to

the introduction of term “Cytoprotection” generally accepted to mean protection

of the gastric mucosal by prostaglandins (PGs) against damaging agents.

Defense of normal gastric mucosa against aggressive factors:Three basic levels of

defense underlined the remarkable ability of normal gastro duodenal mucosal to resist

injury from the acid and peptic activity ingastric juice.

Surface epithelial cells secret mucus and bicarbonates, creating a pH gradient

in the mucous layer and change the very acidic gastric lumen to the nearly

neutral surface of the mucosa.

Gastric mucosal cells have a specialized apical surface membrane that resists

the diffusion of acid back into the cell.

Mucosal cells may directly resist injury by intrinsic mechanisms; such as

extrusion a back diffused hydrogen ions by means of basolateral carriers (e.g.

Sodium-hydrogen or Sodium bicarbonate exchange).

The rapid repair of injury to the mucosa is essential to maintain the mucosal

integrity. Surface epithelial cells continually slough and adjacent cells that

move to fill them by cell replication in response to still unknown trophic

signals reseal the gaps. Blood flow in normal mucosa removes the acid that

has diffuse across a compromised mucosa. Prostaglandins enhance the

mucosa’s resistance to injuries under certain conditions, perhaps by increasing

mucosal blood flow, stimulating the secretion of mucus and bicarbonate,

strengthening of the gastric mucosal barrier, decreasing the gastric motility,

increasing release of endogenous mediators of gastric Cytoprotection like

Sulfhydryls and epidermal growth factors, etc. scavenging of free radicals,




decreasing release of endogenous mediators of gastric injuries vasoactive

amines and leukotrienes and stimulation of cellular growth and repair.

Role of Infection:Lately some more information has poured in about the prevalence

and changing pattern of the disease, the influence of environmental factors and

speculation on the role of recently characterized bacterial organisms, Helicobacter

pylori, which colonized the gastric mucosa, particularly the antral region.

H. Pylori are a gram-negative spiral bacterium that is found in a patchy

distribution overlaying in gastric epithelium. It was formally named as campylobector

pylori. At present 9 species of Helicobacter genus are available and all excluding

H.plyori, are of animal origin. H. Felis can be introduced into mice to produce intense

colonization and inflammation of stomach.

H.plyori organisms have strong capability of urease production. The bacteria

then split urea and the ammonia thus released may become cause of increased acidity

and hence enabling organism to survive. The released ammonia may also be

cytotoxic.

H.pylori has been implicated in the etiology of belching, indigestion and

chronic peptic ulceration. H.pylori induced gastritis present in about 60% of patient

with gastric ulcer. Until recently pathogenesis of gastric and duodenal ulcers has been

attributed to an imbalance between aggressive factors such as acid and pepsin that

damage the gastric mucosa and protective factors such as prostaglandins that prevent

the damage. Recent evidences relate H.pylori to the pathogenesis of chronic duodenal

ulcer as H.pylori infection and antral gastritis are found together in more than 95% of

patients with duodenal ulcers.

Pathogenesis:

Following factors are important in development of Hyper acidity:

Luminal acid and pepsin are requisite.

Increased mucosal tissue acidosis with subsequent decrease secretion of

bicarbonate (The alkaline ‘tide’).

Reduced mucosal blood flow, whatever its basis (Shock, Drugs, Stress)

causing hypoxic injury & impairing the secretion of bicarbonate.




Disruption of the so-called mucosal barrier (i.e. the intake layer of

surfacemucosal epithelial cells), permitting back diffusion of hydrogen ions

and in turn increased shedding of surface of cell.

Clinical Features: Signs and symptoms are coming with the chief complaint as

hyper acidity Heart Burn, Chest Pain, Gastric discomfort, Abdominal distention, Sour

Belching, Refluxes of the food taken, Nausea and Loss of Appetite.

Treatment:Controlling gastric acidity, hyper motility, and spasm and thus reliving the

associated pain. One or more of the following methods may achieve it.

Uses of antacids, or ion exchange resins.

Stimulating the release of CCK by means of a fatty meal or vegetable oil.

Inhibiting gastric acid secretion by drugs.

Withdrawal of stimulants of, gastric acid secretion such as, alcohol, tobacco

etc.

Surgical removal of the acid producing gastric mucosa by gasterctomy and

vagotomy.

GASTRITIS :Gastritis is inflammation of the gastric mucosa. Gastritis is not a single

disease, rather it is a group of disorders that have inflammatory changes in the gastric

mucosa in common but that have different clinical features, histologic characteristics

and pathogenesis.

Several classifications of gastritis exist. In general, these classifications have

been based on 1) The acuteness or chronicity of the clinical manifestations, 2)

Histologic features, 3) Anatomic distribution or 4) Proposed mechanism of

pathogenesis.

In general on the basis of clinical features, the two principle forms of gastritis

are acute and chronic gastritis.

Acute Gastritis :The onset of H. pylori infection may result in acute gastritis

associated with a transient increase in gastric acid secretion followed by

hypochlorhydria for up to one year. Acute gastritis is characterized by epigastric

pain, nausea, vomiting, anorexia and massive haematemesis.




Chronic gastritis :The inflammatory cell infiltrate in chronic gastritis consists mainly

of lymphocytes and plasma cells. Polymorphonuclear leukocytes and eosinophils may

be present in small numbers. It involves the superficial and glandular areas of the

gastric mucosa initially and progress to glandular destruction.

Chronic gastritis is characterised by the absence of grossly visible mucosal

erosion. But chronic inflammatory changes may lead to mucosal atrophy. Although,

usually it is asymptomatic, but it may be associated with Pernicious Anaemia, Gastric

ulcer, Duodenal ulcer and Gastric carcinoma.

Types of chronic gastrtis

Type A- Body and fundus of stomach is involved

- Less common

- Auto immune in origin

- Asymptomatic

- Gastric cancer chances are high

Type B - Antrum of stomach is involved

- Helicobacter pylori is the causative agen

Chronic non specific gastritis

Chronic gastritis forms (rare)

Common causes of Gastritis :

Acute gastritis (often erosive and haemorrhagic)

Aspirin, NSAIDs

H. Pylori (initial infection)

Alcohol

Drugs e.g. iron preparation

Severe physiological stress, e.g. burns, multi organ failure




Bile reflux e.g. following gastric surgery

Viral infection e.g. cytomegalovirus (CMV), herpes simplex

Chronic non-specific Gastritis :

H. pylori infection

Auto immune (Pernicious Anaemia)

Post gastrectomy

Chronic specific forms (rare) :

Infections, e.g. CMV, tuberculosis

Gastrointestinal disease e.g. Crohn's disease

Systemic disease e.g. sarcoidosis, graft-versus host disease

Idiopathic e.g. granulomatouos gastritis

Diagnosis :The diagnosis is best established by upper gastro intestinal endoscopy,

which reveals mucosal haemorrhage, erosion, congestion, superficial or deep

ulceration usually in the body or fundus of the stomach. Radiographic examination is

less reliable than endoscopy. Fractional test meal (F.T.M.) or gastric juice analysis

may help in diagnosis.

INVESTIGATIONS :

1. Double contrast Barium meal

2. Endoscopy

3. Biopsy of gastric mucosa

4. Stool routine and gastric analysis : for detection of blood in stool or gastric

aspirate in acute gastritis respectively.




Treatment principles :

1. Acute gastritis :

Prevention of erosive gastritis

Treatment of associated disease

Withdrawal of offending agents

General supporting measures as required

2. Chronic gastritis :

No specific treatment required for type A or type B Chronic gastritis with

or without mucosal atrophy

Pernicious anaemia form of manifestation demands the parenteral vitamin-

B12 administration on indefinite and regular basis.

DYSPEPSIA :

Dyspepsia is the term used by the common man in order to reveal the

symptom complexes as mentioned above under the heading of Amlapitta. In modern

science the same is explained under the heading of Functional dyspepsia. This often

includes symptoms like nausea, vomiting, anorexia, postprandial fullness and bloating

in addition to pain or discomfort.61.

French’s Index of differential diagnosis62 explains it as indigestion with an

upper abdominal discomfort amounting even to pain, nausea, vomiting, heartburn and

distention. Further, the severe pain should be excluded from either dyspepsia or

indigestion.

Similar explanations are quoted in Harrison’s medicine where in, it is a

symptom complex equivalent to indigestion appreciated as upper abdominal

discomfort, associated with intake of food.63

The modern technological advancement has helped to understand the disease

in a better way. With the radiological advancement it was found the majority of the

patients didn’t had the ulcer and the term X-ray negative dyspepsia was introduced.




The same was superseded with the introduction of endoscopes and a better description

given was Non – Ulcer Dyspepsia.

Functional dyspepsia 64 and the Non – ulcer dyspepsia65both refer to a similar

condition where a symptomatic individual is not found to have an ulcer or other

structural diseases. The Functional dyspepsia is a condition, characterized by the

presence of chronic intermittent symptoms of epigastric pain often associated with

epigastric fullness, early satiety, bloating and vomiting without mucosal lesions or

other structural abnormalities of the gastrointestinal tract. 66.

Synonyms: Different words have been used for this condition by different authors.

They are Non-ulcer dyspepsia, Nervous dyspepsia, Non-organic dyspepsia, X-ray

negative dyspepsia and Pseudo–ulcer dyspepsia.67.

Prevalence: It is one of the most common disorders. It is estimated that, it effects 20-

30% of the population but amongst only 20-30% of patients with dyspepsia seek

medical care68..

Patients are usually young (< 40 yrs.) and women are affected twice as common as

men69.( D.P.P.M, pg-434).

Etio – pathogenesis:The pathogenesis of Functional dyspepsia is poorly understood;

Most of the patients have normal gastric acid secretion and a relation between

Functional dyspepsia (Non-ulcer dyspepsia) and duodenitis or duodenal ulcer has not

been demonstrated. Similarly a role of Helicobacter pylori and associated chronic

gastritis in causing dyspepsia ulcer is not proved. Disordered gastro duodenal and

small intestinal motility appears to account for some cases of Functional dyspepsia

(Non-ulcer dyspepsia)70.

Clinical features:The symptom complex is described as Functional dyspepsia. It is a

disorder with intermittent symptoms particularly related to the upper abdominal

distress. The patient intermittently develops indigestion. The symptoms are abdominal

pain, which is gnawing or burning type and improve or worsen by intake of food. He

also develops heartburn (retro-sternal pain) due to gastro intestinal regurgitation. The

other symptoms include belching, anorexia, post-prandial fullness, early satiety,




bloating (abdominal distention) flatulence, aero-phagia, nausea and vomiting may be

present. Intermittent dyspepsia is rare and upper abdominal tenderness is usually

present71..

Investigations:The routine blood investigations like hemoglobin percentage, total

count, differential count, erythrocyte sedimentation rate shows normal values and no

mucosal lesions and structural abnormalities are found by radiography and

endoscopes.

Imaging recommended are72

1. Patients over 45 years of age at the onset of symptoms.

2. Patients with symptoms and signs suggesting a more serious disease.

3. Patients who need added reassurance.

4. Younger patients who do not respond rapidly to empiric treatment.

Usual images done are Endoscopes and Barium meal X-ray.

Measurement of gastric acid output may be of value in Zollinger-Ellison

Syndrome un less suspected73.

Food regimen: The diets recommended in functional dyspepsia are

1. Avoid foods known to exacerbate symptoms.

2. Frequent small meals, low in fat.

3. Avoid tea, chocolate, meat extract.

4. Avoid regular and decaffeinated coffee.

5. Avoid heavy alcohol use.

6. Avoid cigarette smoking.

7. Avoid aspirin containing compounds and NSAIDS etc.

Some other activities like stress reduction, physical exercise, relaxation

techniques are beneficial in cases of Functional dyspepsia74.




Differential diagnosis:Amlapitta is a functional disorder, which has to be

differentiated from organic. The following Table distinguish between functional and

organic disease of the gastro intestinal tract75.

Distinguishing between Functional and Organic/Structural disease of

gastrointestinal tract.

Organic

Symptoms Functional Neoplastic Inflammatory Weight loss None Common Sometimes

Diarrhea Day time only Nucturnal Day and Night

Blood loss None Frequent Frequent

Fever None Rate Frequent

Pain Cramping, Minor to severe May be

by defecation localised,

severe

Bowel habit Alternating Constipation Diarrhea or normal

(diarrhea diarrhea/ (rarely diarrhea)

or constipation) constipation change in caliber

Pellet like

stools

Laboratory tests

Hematocrit Normal Often decreased May be decreased

WBC count Normal Usually normal Often elevated

Erythrocyte Normal Usually increased Usually increased

sedimentation rate

The following diseases should be excluded before diagnosing the Functional

dyspepsia.

Gastro esophageal reflux: Heartburn is the major feature that is aggravated by

bending, stooping or lying down positions. The regurgitation of food and acid into the

mouth can occur, only during those positions.

Peptic ulcer disease: Indigestion is a frequent symptom but epigastric pain is the

characteristic feature of ulcer disease along with water brash, heartburn, loss of

appetite and vomiting. The relationship of the pain to food is variable and on the

whole is not helpful in diagnosis. Sometimes the ulcer is completely silent and

express for the first time with anemia due to chronic undetected blood loss, along with

weight loss.




Before treating, the similar diseases should be considered and the tentative

diagnosis, be confirmed by laboratory investigations (if necessary).

All these causes, pathogenesis and symptomatology can be correlated with the

disease named Amlapitta in Ayurvedic Literature. Due to the similarity in causative

factors & sing and symptoms, one can easily correlate these diseases as a same

disease to some extent. It is not always necessary that each sign & symptoms of the

diseases should be met with each other but the maximum possible findings are

suggestive of the similarity between both the diseases. So in the present study

Hyperacidity, Gastritis and Non ulcer dysphiea has been taken as Amlapitta

according to the Ayurvedic point of view.

Drug Review



DRUG REVIEW

Amlapitta is pittaja vikara, virechana is best procedure to eliminate the morbid

pitta dosha from the system. Yashtimadhu churuna has been selected as

Mrudvirechaka draya.

Sootashekara rasa vati is a herbomineral preparation intended to be used in

Amlapitta as Shamana aushadi. This was formulated by Yogarathankara. The chief

ingredients of which are Parada, Gandhaka, Pippile, Maricha, Datoora, Tamar

bhasama, Sunthi, Swarana bhasama, Vathsanaba, Tankana, Shanka bhasama,

Karchoora, Twak, Ela, Patra and Nagakeshara.

The above drugs qualities and compositions are very important, to assess the mode

action in amlapitta.

CONTENTS OF YASTIMADHU CHURNA76

Botanical Name : Glycyrrhiza glycyrrhizaglabra linn

Vernacular Names : Hindi – Mulethi , English – Liquorice

Chemical constituents : Glycyrrhizin , glycyrrhizic acid , liquirtin ,glabrolide..

Properties :

Rasa – Madhura

Guna – Guru , Snigdha

Virya – Sita

Vipaka – Madhura

Karma – Tridoshahara , rasayana , vrshya , cakshusy

Part used : Root

Drug Review



Table No .9 Ingredients of SOOTHSAKHER VATI 78

Name Family / Chemical Name

Chemical composition Properties Pharmacological Action

Thereputic Use

Part Use

Parada Hydrargirum Cinnbar ,Metacinnebar Calomel Brick one of merecury

Rasa- Shadra Guna –Snigdha Virya –Ushna

Vipaka -Madhura

Tridoshahara Agni Vardhak Whole

ShuddhaGandhaka Sulphur Sulphide Sulphate Copper Sulphate Ferrous Sulphate

Rasa –Katu Guna –Tikshna Virya –Ushna Vipaka – Katu

VataKaphahara Agni deepk Amapachaka

Whole

Pippali Piperaceae piper langumlinn

Caryophyllence Piplartine

Piperine

Rasa –Katu Guna –Laghu ,Snigdha

Virya - Ushna Vipaka - Madhura

VataSlemahara Udarroga Aruchi

Raktavikara

Fruit , Root

Maricha Piperaceae piper Langum

Piperene Ascorbic Acid Comphene Piperacide

Rasa –Katu Guna – Laghu , Tikshna Virya – Ushna Vipaka – Katu

KaphaVatahara Kasa Aruchi Agnimanda

Fruit

ShuddhaDhattoora Daturametellinn Scopolamine

Atropine Meteolodine Hysciamine

Rasa – Tikta , Katu

Guna – Laghu ,Ruksha Virya - Ushna Vipaka – katu

Kaphavatashamaka Vatarakta

Udarshoola

Seed,

Fruit

TamraBhasma Cuprum Oxide Carbonate

Rasa – Tikta ,Madhura Guna – Snigdha Virya - Ushna Vipaka – Katu

Kapha Pitta shamaka Amlapitta Raktavikara

Bhasma

Shunthi Zingiberaffecinale rose Protein Fats Vit A,B ,C Iron

Rasa – Katu Guna – Laghu , Snigdha Virya – Ushna Vipaka –Madhura

Kaphavatashamaka Ajirna Amlapitta

Risome

SuddhaVatsnabha Aconitum ferox wall ex seringe

Pseudo Aconitine Aconitine Picroaconitine

Rasa –Madhura Guna – Laghu , Tishna Virya – Ushna Vipaka - Madhura

Kaphavatashamaka Amlapitta Shirashoola

Moola

Drug Review



SwarnaBhasma Aurum [Au ] Gold Metallic ,Silica,Iron ,potas, sulphate ,copper

Rasa - Madhura Guna – Sheeta Virya – sheeta Vipaka - Madhura

Vata Pitta shamaka AAyuvardhaka Bhasm

ShuddhaTankana Sodium Pyroborate Sodium Pyroborate

Rasa – Katu Guna – Ruksha ,Tikshna Virya – Ushna Vipaka - Madhura

Kapha Pitta shamaka Atishar Kasa

Bhasm

ShankhaBhasma Calcium bi carbonate Sulphate Megnsium

Rasa – katu Guna –Sheeta Virya –Ushna

Vipaka –Katu

Grahi –deepanaPachana Amlapitta Gulma

Bhasm

Karchoora Curcuma zedoaria Rosc

Pitabh Starch

Rasa –Katu ,Tikta Guna – Laghu , Tikshna Virya –Ushna Vipaka – Katu

Kapha Pitta hara Aruchi Amlapitta

Kand

Twak Cinnamomnm Zeylanicum

Cinnamic Acid Tanin

Rasa – Katu ,Tikta , Madhura

Guna – Laghu , Tikshna ,Ruksha Virya- Ushna Vipaka –Katu

Pitta shamaka Aruchi Amlapitta

Twak

Ela Eletteria cardomum

Terpinyl acetate Cineale Terpincol

Rasa –Katu , Madhura Guna – Laghu , Ruksha Virya - Sheeta Vipaka - Madhura

Vatahara Swasa Kasa

Beeja

Patra Cinnamomum zeylanicum

Rasa – Madhura Guna –Laghu, Picchia Virya - Ushna Vipaka – Katu

GrahiDeepanaPachana Amlapitta Shoola Gulma

Patra

Nagakeshara Mesuaferrea Hexadeoicacid,octadecatriefoliicacid,mesuaferrol,sisterol are present in seed oil

Rasa – Katu , Tikta Guna - Laghu , Ruksha Virya – Ushna

Vipaka - Katu

Kapha Pitta Nashak Amlapitta Aruchi

Stamens ,leaf

Drug Review



Showing of Yasti madhu churna

Showing of Sootasakher vati

Methodology



METHODOLOGY

This clinical study is based on classical explanation. The Mrudhu virechana is

done with Yasthimadhu churana along with Sootashekara rasa vati as shamana

aushadi is given, which can be presented as follows

Materials And Methods

Materials taken for the study

1) Yastimadhu churana for mrudhu virechana

2) Sootashekara rasa vati as Shamana.

Preperation Yastimadhu churana :The fresh Yashtimadhu roots were collected and

were washed properly to remove mud and other physical impurities. The cleaned

roots were made into small pieces and dried in driyer at 60oC. Completely dried

pieces are made into sookshma choorna.

Sootashekara rasa vati: The detail description of the drugs of this trail yoga is

mentioned in drug review. The ingredient of Sootashekara rasa vati are shown in

Table 10 –Showing ingredients of Sootashekara Vati

Sl.no Name of Ingredient Quantity

1 Parada 1 part

2 Shuddha Gandhaka 1 part

3 Swarna Bhasma 1 part

4 Shuddha Tankana 1 part

5 Shuddha Dhattoora Beej 1 part

6 Shankha Bhasma 1 part

7 Tamra Bhasma 1 part

8 Ela 1 part

9 Tvak 1 part

10 Patra 1 part

11 Sunthi 1 part

12 Pippali 1 part

13 Nagakeshara 1 part

14 Karchoora 1 part

15 Maricha 1 part

16 Bang swarasa 1 part

Methodology



Preperation of Sootashekhar Rasa : The Kajjali is prepared by equal quantity of

Parada and Gandhaka. Than kajjiali should mixed with equal quantity of Bhasama

and churana of other drugs. Than the mixture of drugs given mardana with Bhang

swarasa for one day, then vatis are prepared in rati pramana uniformly

METHODS :

Objective :

Literary work on Amlapitta .

To evaluate the effect of Group A mrudu virechana in Amlapitta .

To evaluate the effect of Group B shaman oushadhi in Amlapitta .

To compare the efficacy of both group in Amlapitta .

Study Design :

The total number of patient are ramendely divided into two groups ,

Group A 20 patient and Group B 20 patient .

Group A: Mrudu virechana by yashti madhu choorna 6 grm with hot water

in empty stomach early morning for 7 days. After mrudu virechana , shaman

oushadhi sootashekhar rasa 2 vati bd with water for 30 days .

Group B : Shaman oushadhi sootashekhar rasa 2 vati bd with water 30 days .

Anupana : Sukoshna jala.

Study duration: Prospective clinical trials for 37 days i.e., the abservation study was

conducted. A further follow up of patients for 30 days was done the effect of yoga

was analysed according to clinical functional response before and after the treatment.

Posology :2 vati two times aday

Source ofdata :

The study were carried out on the patients attending the OPD and

IPD of AMCH and ATMH, Davangere .

Special Free camps conducted by AMCH and ATMH.

Methodology



Method of collection data:

Study will be carried out on the patients of 16-60 years of age, irrepective or

sex, religion, economical status and occupation.

About 40 patients will be selected for the study and will be divided into two

Groups, Group A & Group B , each consisting of 20 patients.

The parameter of evaluation of the study is based on clinical signs and

symptoms of Amalpitta and result will be analysed on and statistical data.

Inclusion Criteria :

Patients presenting symtoms of Amlapitta like Avipaka , Aruchi

Patient of age group between 15 to 60 yearrs were selected .

Exclusion Criteria:

Patients with other systemic diseases were excluded .

Complication which will intervene with the treatment were excluded .

Patients below 15 year and above 60 year were excluded from the study .

Diagonstic Criteria : Diagnosis were made on the cardinal sign and symptoms

of Amlapitta as explained in the classics .

Investigation :

Blood - Hb% ,TLC ,DLC ,ESR

Routne Urine examination – Sugar , Albumine , Microscopic

If needed ECG , Endoscopic , USG

Assessment of response to treatment: The state of the disease change after the

intervention was observed before, during and after the treatment. Standard methods of

scoring the symptoms likeAruchi, Avipaka,,Utklesh,Amloudgar,Hrida-Kanthadaha

was assessed before during and after the administration of shamana aushadi at the

interval of 7 days for 30 days.

Methodology



Assessment Criteria: The state of the disease Amlapitta change after the

interventions improvement was assessed by seeing the reduction in the signs and

symptoms of the disease like Avipaka,Aruchi,Utklesh,Amloudgar,Hrida-Kanthadaha.

Similarly other symptoms were also given scores on the basis of this before and after

treatment score, The statistical analysis was done using paired ‘t’ test and S.D., S.E.

and p Value were calculated.

GRADING OF PARAMETERS

Aruchi :

Patient is taking food normally without hesitation -0

Patient is taking food in moderate quantity twice a day -1

Patient is taking food in less quantity twice a day -2

Patient is taking food in less quantity once a day.-3

Patient is not taking food at all.-4

Avipaka :

No Avipak -0

Avipak occurs occasionally 2-3 times per week. -1

Avipak occurs daily but not distrube the patient -2

Avipak occurs daily with more than 2-3 Ajirna ahara lakshan’s like

Ashuddha, /Udgara / Guruta / Glani / distrube the patient -3

Avipak occurs daily which does not subside with medicine or langhana

and which disturbed the routine of patient. -4

Utklesha :

No Utklesha

Occasional episode of Utklesha -1

Frequent and prolonged Utklesha, No Vomiting -2

Utklesha; Followed by one attack of Vomitting -3

Continous Utklesha; Followed by many time vomiting-4

Methodology



Amloudgara:

No Amloudgar at all -0

Amloudgar some times during the day -1

Amloudgar during day and night but does not disturbe the patient -2

Amloudgar during day and night disturbing the patient -3

Small amount of fluid regurgitating from patient’s mouth -4

Hrid-Kanthadaha

No Daha - o

Daha in any area of udara, uras, kantha but not disturbing the patient-1.

Daha which relived by milk,cold drinks or antacids -2

Daha involving Hrita, Kantha .and relived after digestion of food or

vomiting to some extend only-3.

Daha involving major areas of abdomen or whole body like hand, feets

and does not relive by any measure mentioned above -4

Assessment of overall effect: For assessing the overall effect of the treatment, the

total scores of sign and symptoms of Amalapitta after the treatment was considered

as per the reduction in the total scores ofAvipaka, Aruchi, Utklesh, Amloudgar, Hurd-

Kanthadaha .The overall effect is calculated as under.

Major Improvement :Reduction in more than 75% of the initial score after the

treatment.

Moderate Improvement:Reduction in more than 50 % of the initial score.

Minor Improvement: Reduction more than 25 % of the initial score.

Not responded:Reduction less than 25% of the initial score.

Adopting the scoring method, symptoms of the illnesslike Avipaka, Aruchi,

Utklesh, Amloudgar, Hurd-Kanthadaha parameters are take as assessment criteria in

this study.

Methodology



STATISTICAL ANALYSIS :

Descriptive data that included mean, std. Deviations and percentages were

calculated for all the variables in each group.

Post treatment changes were assessed by paired t-test and difference between groups

by unpaired t-test.

For all tests a p-value of 0.05 or less was considered for statistical significance.

Formulae used for statistical analysis

Mean, X =x:

n i = 1,2,………………. 12.

Standard deviation 𝑺𝒅 = √∑(𝑿: −𝑿)

𝟐

𝒏−𝟏

Standard error, 𝑺𝑬 = 𝑺𝑫

√𝒏

Paired t -test 𝒕 = 𝑴𝒆𝒂𝒏 𝒐𝒇 𝒅𝒊𝒇𝒇𝒆𝒓𝒆𝒏𝒄𝒆𝒔

𝑺𝒕𝒅.𝑬𝒓𝒓𝒐𝒓 𝒐𝒇 𝒅𝒊𝒇𝒇𝒆𝒓𝒆𝒏𝒄𝒆𝒔 =

𝒅

𝒔𝒅/√𝒏

Unpaired t- test, t = Difference in means x1 - x2

Std. Error of difference combined Sd x 1/n1 + 1/n2

Observation



OBSERVATION AND RESULTS

In the present study 40 patients suffering from Amlapitta, fulfilling inclusion

criteria were selected. Patient were randomly categorized in to Group -A yastimadhu

churna with Mrudu Virechana & Sootashekar vati as shaman aushadi and Group B

sootashekara vati as shaman aushadi .

Following pages contain descriptive statistical analysis of the patients studied

along with the observation and result are listed below.

Demographic related data.

Data related to disease.

Statistically analysis of the assessment of the patients before and after the

treatment in individual group’s asses efficacy of treatment by the paired ‘t’ test.

Statistically analysis of the assessment of the patients following the unpaired

‘t’test to compare the effect of treatment in two groups.

Observation



OBSERVATION

1 .Incidence of Age

Table No.11: Distribution of patients according to age

Age group (Yrs)

Group A Group B Total

No. % No. % No. %

16-25 8 40 6 30 14 35.0

26-35 8 40 9 45 17 42.5

36-45 3 15 3 15 6 15.0

46-55 1 5 2 10 3 7.5

Total 20 100 20 100 40 100.0

The Study revealed that maximum number of patients were between the age

group of 26 -35 i.e 42%

Graph No.1 :Shwoing the distribution of age groups

40 40

15

5

30

45

15

10

0

5

10

15

20

25

30

35

40

45

50

16-25 26-35 36-45 46-55

Per

cen

tage

Age in years

Group A

Group B

Observation



2 .Incidence of Sex

Table No. 12: Distribution of patients according to Gender

Gender


No. % No. % No. %

Male 15 75 14 70 29 72.5

Female 5 25 6 30 11 27.5

Total 20 100 20 100 40 100.0

The Sex incidence of patients in the study that majority of patients were

male i.e 72 . 5 %

Graph No.2 : Distribution of patients according to sex

0

10

20

30

40

50

60

70

80

Group A Group B

7570

2530

Per

cen

tage Male

Female

Observation



3 .Incidence of Religion

Table No.13: Distribution of patients according to Religion

Religion


No. % No. % No. %

Hindu 18 90 20 100 38 95.0

Muslim 2 10 0 0 2 5.0

20 100 20 100 40 100.0

In the present study 38 patients were hindu is 95% .

Graph No.3 : Distribution of patients according to religion

0

20

40

60

80

100

Group A Group B

90

100

100

Per

cen

tage Hindu

Muslim

Observation



4 . Incidence of Education

Table No.14: Distribution of patients according to Education

Education


No. % No. % No. %

Graduate 11 55 11 55 22 55.0

Illiterate 5 25 4 20 9 22.5

P Graduate 1 5 2 10 3 7.5

U Graduate 3 15 3 15 6 15.0

Total 20 100 20 100 40 100.0

In the present study majority of the graduate ie, 22 patients out of 40

patients .

Graph No.4 : Distribution of patients according to education

25

15

55

5

20

15

55

10

0

10

20

30

40

50

60

Illiterate U Graduate Graduate P Graduate

Per

cen

tage

Group A

Group B

Observation



5 . Incidence of Socio-Economic status

Table No. 15: Distribution of patients according to S E S

SES


No. % No. % No. %

L M C 3 15 1 5 4 10.0

M C 14 70 14 70 28 70.0

Poor 3 15 5 25 8 20.0

Total 20 100 20 100 40 100.0

Study of socio economic status revealed that majority of patients

belonging to Middle Class i.e 70%

Graph No.5 : Distribution of patients according to SES

0

10

20

30

40

50

60

70

M C L M C Poor

70

15 15

70

5

25

Per

cen

tage

Group A

Group B

Observation



6 .Incidence of marital status

Table No.16: Distribution of patients according to Marital Status

Marital status


No. % No. % No. %

Married 16 80 18 90 34 85.0

Un Married 4 20 2 10 6 15.0

20 100 20 100 40 100.0

Out of 40 patients registered in the study maximum 85 % of the

patients were married ie , 34 patients .

Graph No.6 : Distribution of patients according to marital status

0

10

20

30

40

50

60

70

80

90

Group A Group B

80

90

20

10

Per

cen

tage Married

Un Married

Observation



7 .Incidence of nature of work

Table No. 17: Distribution of patients according to their Nature of work

Nature of Work


No. % No. % No. %

Laborious 12 60 14 70 26 65.0

Sedentary 0 0 3 15 3 7.5

Standing 7 35 2 10 9 22.5

Travelling 1 5 1 5 2 5.0

Total 20 100 20 100 40 100.0

Maximum 65 % of the patients had laborious work in the present study

Graph No.7 : Distribution of patients according to nature of work

0

10

20

30

40

50

60

70

Laborious Sedentary Standing Travelling

60

0

35

5

70

1510

5

Pe

rcen

tage

Group A

Group B

Observation



8 .Incidence of Manasika sthithi

Table No. 18: Distribution of patients according to Manashika Sthithi

Manashika sthithi


No. % No. % No. %

Bhaya 4 20 6 30 10 25.0

Chinta 8 40 9 45 17 42.5

Krodha 3 15 5 25 8 20.0

Shoka 5 25 0 0 5 12.5

Total 20 100 20 100 40 100.0

In the present study , it was observed that most of the patients under

stress of more than one manasika bhava , causing Amlapitta . Maximum

number of patients i.e , 42 % were practicing chinta as manasika bhava.

Graph No.8 : Distribution of patients according to Manasika Sthithi

0

5

10

15

20

25

30

35

40

45

Bhaya Chinta Krodha Shoka

20

40

15

25

30

45

25

0

Pe

rcen

tage

Group A

Group B

Observation



9. Incidence of vyasana

Table No. 19: Distribution of patients according to Vyasana

Vyasana


No. % No. % No. %

Alcohol 2 10 2 10 4 10.0

Bidi/ cigrate 3 15 4 20 7 17.5

Tea /Coffee 10 50 12 60 22 55.0

Tobaco 5 25 2 10 7 17.5

Total 20 100 20 100 40 100.0

Most of the patients in this study were having the history of taking one on

other types of irritants of gastric mucosa . All patients were regularly taking

either tea or coffee . In the present study 55% of the patient having habits of

taking tea or coffee more than 2 times per day .

Graph No.9 : Distribution of patients according to vyasana

0

10

20

30

40

50

60

Alcohol Bidi/ cigrate Tea /Coffee Tobaco

10

15

50

25

10

20

60

10

Per

cen

tage

Group A

Group B

Observation



10 . Incidence of prakruti

Table No. 20: Distribution of patients according to Prakruti

Prakruti Group A Group B Total

No. % No. % No. %

P K 10 50 8 40 18 45.0

V K 6 30 4 20 10 25.0

V P 4 20 8 40 12 30.0

Total 20 100 20 100 40 100.0

Among all patients a predominance of Pitta – Kapha constitution was

observed in the patients with 45 % of evidence .

Graph No.10 : Distribution of patients according to prakruti

0

5

10

15

20

25

30

35

40

45

50

P K V K V P

50

30

20

40

20

40

Per

cen

tage

Group A

Group B

Observation



11.Incidence of sara

Table No. 21: Distribution of patients according to Sara

Sara


No. % No. % No. %

Avara 2 10 3 15 5 12.5

Madhyama 18 90 15 75 33 82.5

Pravara 0 0 2 10 2 5.0

Total 20 100 20 100 40 100.0

In the present study maximum patients were madhyama sara i.e , 82.5%.

.

Graph No.11 : Distribution of patients according to sara

0

20

40

60

80

100

Avara Madhyama Pravara

10

90

0

15

75

10

Per

cen

tage

Group A

Group B

Observation



12 .Incidence of samshamana

Table No. 22: Distribution of patients according to Samhanana

Samhanana


No. % No. % No. %

Avara 3 15 7 35 10 25.0

Madhyama 15 75 10 50 25 62.5

Pravara 2 10 3 15 5 12.5

Total 20 100 20 100 40 100.0

The present study revealed that 62.5 % of patients had madhyama

sahanana .

Graph No.12 : Distribution of patients according to samshamana

0

10

20

30

40

50

60

70

80


15

75

10

35

50

15

Per

cen

tage

Group A

Group B

Observation



13 . Incidence of satva

Table No. 23: Distribution of patients according to Satva

Satva


No. % No. % No. %

Avara 1 5 4 20 5 12.5

Madhyama 18 90 12 60 30 75.0

Pravara 1 5 4 20 5 12.5

Total 20 100 20 100 40 100.0

Analysis of satva revealed 75 % of the patients had madhyama satva .

Graph No.13 : Distribution of patients according to satva

0

10

20

30

40

50

60

70

80

90


5

90

5

20

60

20

Per

cen

tage

Group A

Group B

Observation



14 . Incidence of satmya

Table No.24: Distribution of patients according to Satmya

Satmya Group A Group B Total

No. % No. % No. %s

Madhyama 18 90 12 60 30 75.0

Pravara 2 10 8 40 10 25.0

Avara 0 o 0 0 0 0

Total 20 100 20 100 40 100.0

The study revealed that 75 % patients were showing Madhyama satmya

i.e ., madhyama satmya .

Graph No.14 : Distribution of patients according to satmya

0

10

20

30

40

50

60

70

80

90

Madhyama Pravara

90

10

60

40

Pe

rcen

tage Group A

Group B

Observation



15 .Incidence of kostha

Table No. 25: Distribution of patients according to Kostha

Kostha


No. % No. % No. %

Krura 2 10 3 15 5 12.5

Madhyama 13 65 12 60 25 62.5

Mrudu 5 25 5 25 10 25.0

Total 20 100 20 100 40 100.0

In the present study maximum patients is having madhyama Kostha i.e ,

62 % .

Graph No.15 : Distribution of patients according to kostha

0

10

20

30

40

50

60

70

Krura Madhyama Mrudu

10

65

25

15

60

25

Pe

rcen

tage

Group A

Group B

Observation



16 . Incidence of vyayama shakti

Table No. 26: Distribution of patients according to Vyayama

Vyayama


No. % No. % No. %

Avara 1 5 5 25 6 15.0

Madhyama 15 75 12 60 27 67.5

Pravara 4 20 3 15 7 17.5

Total 20 100 20 100 40 100.0

In the present study maximum patients is having Madhyama i.e 67% .

Graph No.16 : Distribution of patients according to vyayama shakti

0

10

20

30

40

50

60

70

80


5

75

2025

60

15

Pe

rcen

tage

Group A

Group B

Observation



17 . Incidence of Occupation

Table No. 27: Distribution of patients according to Occupation

Occupation


No. % No. % No. %

House work 3 15 5 25 8 20.0

Job 3 15 2 10 5 12.5

Painting 3 15 2 10 5 12.5

Study 2 10 3 15 5 12.5

Worker 9 45 8 40 17 42.5

Total 20 100 20 100 40 100.0

In the Present study maximum patients is having worker i.e 42 % .

Graph No. 17 : Distribution of patients according to occupation

0

5

10

15

20

25

House work Job Painting Study

15 15 15

10

25

10 10

15

Per

cen

tage

Group A

Group B

Observation



DATA RELATED TO DISEASE

1 . Showing incidence of Etiological factor :

Table No .28 Showing the incidence of etiological factors in 40 patients of

Amlapitta .

Sl.

No.

Etiological Factors Total

1 Aharaja

2 Virudhashan 35 %

3 Amlarasatmaka 20 %

4 KatuRasatmaka 10 %

5 Ushna 45 %

6 Fanita 70 %

7 Dadhi 65 %

Vihara

1 Vegadharana 45 %

2 Atisnana 10 %

3 Divaswapna 60 %

4 Santapa 55 %

Manasik Bhava

1 Bhaya 25 %

2 Chinta 42 %

3 Shoka 12.5 %

4 Krodha 20 %

Observation



2 . Showing incidence of predominant of Rasa sevana in 40 patients of

Amlapitta :

In this study maximum patients i.e , 35 % taking katu rasa pradhana

dravya in their daily dite .

Table No . 29 Showing incidence of Rasa sevana

Predominant

ofRasa

sevana


No . Percentage No . Percentage No . Percentage

Madhur 5 25 6 30 11 27.5

Amla 2 10 3 15 5 12.5

Lavana 1 5 02 10 3 7.5

Katu 8 40 6 30 14 35

Tikta 3 15 2 10 5 12.5

Kashya 1 5 01 5 2 5

3 .Incidence of water intake in Amlapitta patients :

In this study maximum patients i.e ,70 % taking 1- 2 liter water in their

daily dite .

Table No . 30 Showing incidence of water intake

IN TAKE

WATER



< 1 2 10 0 0 2 5

1-2 14 70 14 70 28 70

2-3 4 20 6 30 10 25

>3 0 0 0 0 0 0

Observation



4 .Incidence of Duration of Symptoms :

Table No . 31 Distribution of Patients according to duration of symptoms

Duration of

Symptoms



0-1 6 30 8 40 14 35

1 – 2 8 40 8 40 16 40

2 – 3 6 30 4 20 10 25

In this study maximum patients i.e, 40% were having symptom of

amlapitta from 1 – 2 months .

5. Incidence Mode of onset of Amlapitta :

Table No .32 Distribution of patients according to Mode of Onset

Mode of

onset



Sudden 10 50 10 50 20 50

Gradual 10 50 10 50 20 50

In this study both group of sudden and gradual patients i.e, 50% were

having sympom of Amlapitta .

Observation



6 . Incidence of Relieving factor of Amlapitta :

Table No. 33Distribution of patients according to Relieving factor

Relieving

Factor



Food 10 50 11 55 21 52.5

Exercise 6 30 4 20 10 25

Seasonal

Variation 4 20 5 25 9 22.5

Others 0 0 0 0 0 0

In this present study 52 . 5 % patients reliving factor of food of

Amlapitta .

Results



RESULTS

Effect of Mrudhu Virechana with Yasthi Madhu Churna for 7 days

followed by shaman Aushadhi Soothsakher Vati 37 days in A group and

Shaman Aushadhi Soothsakher Vati for 30 days in B group .

Effect of Archi in group A :

Table No. 34 : Effect on Aruchi in Group – A

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T p

Aruchi 3.35 1.30 2.05 61% 0.94 0.21 9.71 <0.001

HS

Effect of treatment with Yasthi Madhu churna and Soothsakher Vati on

Aruchi before and after the treatment in 20 patients of Amlapitta are given below .

In group A statistical analyses revealed that the mean Aruchi score of Amlapitta

Which was 3.35 before the administration of yasthi Madhu Churna and

Soothsakher Vati was reduced to 1.30 after the treatment . The change is statistical

significant . Further details with standard deviation , standard error of mean ‘t’ and

‘p’ values are given below .

Effect of Archi in group B :

Table No. 35 : Effect on Aruchi in Group – B

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T p

Aruchi 3.65 1.65 2.00 56% 1.17 0.26 7.65 <0.001

HS

Results



As assessement of Aruchi in 20 patients of Amlapitta before and after the

treatment with Soothsakher vati showed marked reduction in the mean of Aruchi

from 3.65 to 1.65 . This change is found to be statistically highly significant .

Effect on Avipaka in Group – A :

Table No. 36 : Effect on Avipaka in Group – A

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Avipaka 3.35 1.20 2.15 64% 0.99 0.22 9.73 <0.001

HS

As revealed by the statistical analysis , the reduction in the symptom

Avipak before and after the treatment in yasti Madhu churna and Soothsakher vati

are given below . The mean score observed in Avipak before administration of

treatment was 3.35 which reduced to 1.20 after the treatment . This improvement in

the symptom after the treatment is highly stastically significant , particularis of

statistical analysis are given below .

Effect on Avipaka in Group – B :

Table No. 37 : Effect on Avipaka in Group – B

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Avipaka 3.60 1.50 2.00 56% 1.26 0.28 7.12 <0.001

HS

The severity of the symptom Avipak assessed before and after the

treatment showed very significant improvement with reduction in the mean score

from 3.60 to 1.50 in the patients of Amlapitta after completion of treatment in group

Results



B. This change in group B is statistically highly significant . Detailed data with

statistically analysis are given below .

Effect on Utklesha in Group – A :

Table No. 38: Effect on Utklesha in Group – A

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Utklesha 2.80 0.85 1.95 70% 1.00 0.22 8.73 <0.001

HS

According to statistic the reduction in the symptom Utklesh before and after

the treatment by Yasthi Madhu churna and soothsakher vati in the patients of

Amlapitta . showed reduction in the mean score was 2.80 which was reduced to 0.85

after the completion of treatment . Hence It is statistically highly significant .

further details are given below .

Effect on Utklesha in Group – B :

Table No. 39 : Effect on Utklesha in Group – B

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Utklesha 2.75 0.60 2.15 78% 1.14 0.25 8.46 <0.001

HS

On examination the effect of Soothsakher vati on the symptom Utklesh

before and after the treatment was documented.The statistical analysis of the data

in group B revealed the mean score of the symptom utklesha before the treatment was

2.75 which was reduced to 0.60 after the treatment .This change is statistically highly

significant.

Results



Effect on Amlodgara in Group – A :

Table No. 40: Effect on Amlodgara in Group – A

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Amlodgara 2.75 0.50 2.25 82% 1.07 0.24 9.40 <0.001

HS


Avipak before and after the treatment in yasti Madhu churna and Soothsakher vati

are given below. The mean score observed in Avipak before administration of

treatment was 2.75 which reduced to 0.50after the treatment . This improvement in

the symptom after the treatment is highly stastically significant , particularis of

statistical analysis are given below .

Effect on Amlodgara in Group – B :

Table No. 41 : Effect on Amlodgara in Group – B

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Amlodgara 3.20 0.60 2.60 81% 1.10 0.24 10.61 <0.001

HS

An assessement of Amloudgara in 20 patients of Amlapitta before and after

the treatment with soothsakher vati showed with Soothsakher Vati showed marked

reduction in the mean of Amloudgar score 3.20 to 0.60 . This change is found to be

statistically highly significant are given below .

Results



Effect on Hrikanth Daha in Group – A :

Table No. 42 : Effect on Hrikanth Daha in Group – A

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Hrikanth

Daha 2.90 0.45 2.45 84% 1.05 0.23 10.43 <0.001


Hridkanthadaha before and after the treatment in yasti Madhu churna and

Soothsakher vati are given below . The mean score observed in Avipak before

administration of treatment was 2.90 which reduced to 0.45 after the treatment .

This improvement in the symptom after the treatment is highly stastically significant ,

particularis of statistical analysis are given below

Effect on Hrikanth Daha in Group – B :

Table No. 43 : Effect on Hrikanth Daha in Group – B

Parameter

Mean Reduction

in mean

%

reduction

Paired t-test

BT AT4 SD of

mean

SE of

mean T P

Hrikanth

Daha 3.35 0.50 2.85 85% 0.99 0.22 12.90 <0.001

The severity of the symptom Hridkanthadaha assessed before and after

the treatment showed very significant improvement with reduction in the mean

score from 3.35 to 0.50 in the patients of Amloudgar after completion of treatment in

group B. This change in group B is statistically highly significant . Detailed data

with statistically analysis are gven below

Results



UNPAIRED ‘t’ test :

Comparison of treatment on Archi between group A and group B :

Table No. 44 : Comparison of effect of treatment on Aruchi between two groups

Groups No.of

patient

BT –

AT

mean

Difference

in means SD SEM PSE

Unpaired t-test

t P Remarks

A 20 2.05 0.05

0.94 0.21 0.34 0.15 0.88 NS

B 20 2.00 1.17 0.26

Graph No.18: Comparison of effect of treatment on Aruchi in two groups

In the present study the effect on Aruchi in the patients of Amlapitta was

observed . Marked reduction was observed in both the group . The difference in

mean Aruchi score after administration of Mrudhu Virechana and Shaman Aushadi

in group A was 2.05 and this mean score was more than the difference in mean

Aruchi scores of group B which was 2.00 ,this difference in mean score is stastically

not significant .Here group A is better than group B .

0.0

0.5

1.0

1.5

2.0

2.5

Group A Group B

2.05 2.00

Results



Comparison of effect of treatment on Avipaka between two groups :

Table No. 45 : Comparison of effect of treatment on Avipaka between two

groups

Groups No.of

patient

BT –

AT

mean

Difference

in means SD SEM PSE

Unpaired t-test

T P Remarks

A 20 2.15 0.15

0.99 0.22 0.36 0.42 0.68 NS

B 20 2.00 1.26 0.28

Graph No.19 : Comparison of effect of treatment on Avipaka in two groups

In the present study the effect on Avipak in the patients of Amlapitta was

observed . Marked reduction was observed in both the group . The difference mean

score in group A was 2.15 this mean is comparatively more than group B which

was 2.00 this difference in mean score is stastically not significant

Results



Comparison of effect of treatment on Utklesha between two groups :

Table No. 46 : Comparison of effect of treatment on Utklesha between two

groups

Groups No.of

patient

BT –

AT

mean

Difference

in means SD SEM PSE

Unpaired t-test

t P Remarks

A 20 1.95 0.20

1.00 0.22 0.34 0.59 0.56 NS

B 20 2.15 1.14 0.25

Graph No.20: Comparison of effect of treatment on Utklesha in two group

In the present study the difference in mean Utklesh score in group A was

1.95 .This is compartitively more than the difference in mean utklesh score in group

B which was 2.15 on statistical analysis with un paired ‘t’test it was revealed that

this difference in mean Utklesh score is highly significant .

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Group A Group B

1.952.15

Results



Comparison of effect of treatment on Amalodgara between two groups :

Table No. 47 : Comparison of effect of treatment on Amalodgara between two

groups

Groups No.of

patient

BT –

AT

mean

Difference

in means SD SEM PSE

Unpaired t-test

T P Remarks

A 20 2.25 0.35

1.07 0.24 0.34 1.02 0.31 NS

B 20 2.60 1.10 0.24

Graph No.21: Comparison of effect of treatment on Amalodgara in two groups

In the present study the difference in mean Amalodgara score in group A

was 2.25 .This is compartitively more than the difference in mean Amlodgara score

in group B which was 2.60 on statistical analysis with un paired ‘t’test it was

revealed that this difference in mean Utklesh score is highly significant .

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Group A Group B

2.25

2.60

Results



Comparison of effect of treatment on Hridkanth Daha between two groups :

Table No. 48 : Comparison of effect of treatment on Hridkanth Daha between

two groups

Groups No.of

patient

BT –

AT

mean

Difference

in means SD SEM PSE

Unpaired t-test

t P Remarks

A 20 2.45 0.40

1.05 0.23 0.32 1.24 0.22 NS

B 20 2.85 0.99 0.22

Graph No. 22: Comparison of effect of treatment on Hrikantha Daha in two

groups

In the present study the difference in mean Hridkanthadaha score in group A

was 2.45 .This is compartitively more than the difference in mean Hridkanthadaha

score in group B which was 2.85 on statistical analysis with un paired ‘t’test it

was revealed that this difference in mean Hridkanthadaha score is non significant .

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Group A Group B

2.45

2.85

Results



Overall assessment in Group A and Group B :

Table No 49 - Overall assessment in Group A and Group B

Response in Percentage Group A Group B

No Percentage No Percentage

Major improvement 8 40% 6 30%

Moderate improvement 7 35% 7 35%

Minor improvement 4 20% 5 25%

Not improved 1 5% 2 10%

Graph No. 23 :Overall assessment in Group A and Group B

Analysis of the overall effects in Group A indicate that 40% of patients

showed major improvement of the illness, 35% of patients showed moderate

improvement where as other 20% of patient showed minor improvement. And 5% of

patients Not improved .

Similarly analysis of the overall effect in the Group B indicate that 30% of

patient showed major improvement of the illness, 35% of patient showed moderate

improvement, where as, 25% of patients showed minor improvement, and 10 % of

patients showed Not improved .

0%

5%

10%

15%

20%

25%

30%

35%

40%

Maj Imp Mod Imp Minor Imp Not imp

40%

35%

20%

5%

30%

35%

25%

10%

Group A

Group B

Discussion



DISCUSSION

Discussion is must in each and every aspect of life to add new dimensions and

there by improving its understanding. Here a humble attempt has been made to

discuss the entire work done under following headings.

• Discussion on concept of disease.

• Discussion on materials and method

• Discussion on observation made

• Discussion on the result obtained.

• Mode of action of Yashti Madhu Churna and Soothsakher rasa Vati

DISCUSSION ON CONCEPT OF DISEASE

Today’s life style is completely changed by all means. Our diet pattern, life

style and behavioural pattern is changed and it is not suitable for our normal

physiology of digestion of body. We had developed western culture and it is more

harmful to us. We adopted their diets, behavioral pattern and this is the reason for

most of the diseases. Especially, Amlapitta are mainly caused by dietetic pattern

which is related to our digestion. The food articles which are not according to normal

code and conducts, creates this problem. Western people are mostly suffering from

gastric problem in comparison to Indians. It seems that our old pattern of diet and

behaviour was up to mark for nourishing and carrying physiological processes.

Amlapitta is one of the disorders caused by faulty dietetic and behavioural

pattern. Amlapitta is not a disorder caused only by the habitual, irregular diet schedule

and activities, but also as a result of physiological and psychological aberrations. The

increasing rate of Amlapitta presents a constant challenge to research workers of

Ayurveda.

Charaka Samhita is a first recorded medical literature describing the disease in

systemic pattern. Though the disease Amlapitta is not explained in it as a full-fledged

disease but there are several references regarding Amlapitta. Here discussion was

done on Historical review, Nidana, Porvarupa, Rupa, Samprapti, chikitsa and Pathya.

Discussion



Sushruta and Vagbhata do not follow the Charkas view and even they did not

mentioned the word ‘Amlapitta’ in Samhita. Charaka has given vivid description of

diseases of Annavaha srotas in Grahani chapter. Kashyapa is the first person, who

described the disease Amlapitta, so elaborately and gives the due importance for its

management.

Madhavakara has described the disease separately by giving a full status to

disease Amlapitta. Srikanthadatta describes the disease by giving different quotation.

Later workers of Sangraha Kala followed the same as Madhava, Kashyapa and

Bhavamishra added Sleshma pitta as one more type. Gastritis,Hyperacidity and non-

ulcer dyspepsia have been correlated with Amlapitta by several scholars of Ayurveda.

Kashyapa and Madhvakara have given the long list of Nidanas of Amlapitta.

They have different opinion in giving the etiological factors. Kashyapa has mentioned

the Nidanas which represents the involvement of all three doshas, means he gives the

list of Nidanas which are responsible for provocation of Tridoshas, Where as

Madhavakara has mainly given the Pitta prakopaka factors. In the Nidanas mentioned

for Amlapitta, there is stated the strong role of Manasika factors too. Mental stress

and strain is related with digestion and metabolism and thus it is related with disease.

Amlapitta too, as it produces Ama as mentioned by Charaka.

Factors responsible for manifestation of the disease of Annavaha srotas are

almost similar. Diet which is against Ashtavidha Ahara vidhi vishesayatana, dietetic

code and conduct are mostly responsible for most of the disease.

These factors mostly perform the function of Agnidushti, Dosha Prakopa,

Kha-vaigunya and Dushya daurbalya. The Nidanas mostly disturb the digestion

process and are responsible for such diseases.

Viruddhahara, Diwaswapa, Antarodaka Pana, Vidahi Anna, Sheetajalapana

are the few common factors mentioned by all Acharyas. Mandagni or Agnidushti

caused by any nidana is responsible for such diseases. This first vitiate the doshas and

further dushya and samprapti progresses.

Discussion



Kashyapa has mentioned Rasa as a dushya of disease Amlapitta. The disease

involves mainly Rasavaha and Annavaha srotas. The Purvarupa of disease is not

mentioned in any classics..

Madhavakara has given general symptom of Amlapitta as Avipak, Klama,

Utklesh, Amloudgara, Gourava, Hritkanthadaha, Aruchi etc. It is mostly Chirakari in

nature. This is caused by Jivha-Laulya, as patients are aware of the Nidanas and still

he tries to consume the nidana. When the disease progresses it leads into Dhatugatatva

and creates complications like Parinama Shula etc.

Charaka has given the detailed description of digestion process and described

vividly the samprapti of diseases of Annavaha srotas in Grahani roga. Kashyapa has

described the samprapti of Amlapitta, he says that any one dosha among vatadi after

their provocation causes mandagni and if unwise person consume any food in such

condition it leads into vidagdha state and if it mixes with Pitta produces the disease

Amlapitta. Madhavakara as usual has not given the samprapti of Amlapitta.

Madhavakara has accepted the pitta as arambhaka dosha of disease, which is also

supported by Charaka in Grahani. Kashyapa has mentioned the involvement of three

doshas in this disease.

The Samprapti of Annavaha srotas disorder constitutes the different stages and

each stage has been accepted as a separate disease entity like Ajirna, Amlapitta,

Parinama Shula etc.

There are two types of Amlapitta; Urdhvaga and Adhoga mentioned in

classics. Madhavakara has mentioned three more type as vatika, vata-kapha and

kapha. Kashyapa has mentioned vatolvana, pittolvana and kapholvana types.

The similar treatment of Amlapitta has been mentioned by all the Acharyas.

Vamana and Virechana have been given as a shodhana process followed by Basti.

As Pitta and kapha dosha are a chief dosha involved in the disease; The selection of

shamana drug, it should have madhura and tikta rasa, sheeta virya, laghu and snigdha

property and madhura vipaka..

So for the shaman chikitsa and Mrudu virechana,soothsakher vati is selected

as its maximum drugs are madhura and tikta in rasa, virya is samashitoshna , laghu

Discussion



and snigdha guna and kapha-pitta shamaka karma. And Yashti Madhu Churna is

madhura in Rasa and virya is Sita , guru and snigdha and tridoshahara karma .

Complications of Amlapitta not described by ancient acharyas except

Kashyapa. He included shula along with other symptoms as complication. Jwara,

Atisara, Pandu, Shula, Shotha, Aruchi, Bhrama are the upadravas mentioned by

Kashyapa.

Pathya in this diseases form an important part of treatment and non-

compliance with pathya, may make this disease incurable. A long list of Pathya for

Amlapitta has been mentioned in Kashayapa Samhita and other sangraha granthas.

Discussion on material and methods :

A Clinical comparative study to evaluate the efficacy of Mrudhu virechana

and Shaman chikitsa in the management of Amlapitta.

In Brahatriya direct reference of Amlapitta is not available but in Laghutriya and

others ayurvedic classics virechaha and shaman chikita are mentioned in the

management of Amlapitta disease. In yogratnakar Amlapitta adhikara acharya has

mentioned sootashekara rasa vati which shows its important is Amlapitta disease.

Rationality behind selection of the treatment :

1) Yasthi Madhu Churna: Ingredients of this preparation possess madhura

Rasa, Seetha virya , guru and snigdha guna and tridoshahara karma. And it is

indicated as best mruduvirechaka

2) Soothsakher rasavati : Its maximum drugs are madhura and tikta in rasa,

virya is samashitoshna , laghu and snigdha guna and kapha-pitta shamaka karma

Posology : Yastimadha churana 6gms or according to kosta with water. Sootashekara

rasa vati 2 vati bd with suksshana jala.

Plan of study : In the present study a total of 40 patients suffering from the disease.

Amlapitta were taken and were selected between the age group of 15-60 years

irrespective of sex, religion etc.

Discussion



They were randomly divided into two groups. Twenty patient were treated

with yasthimadhu churna for mrudu virechana for 7 days after sootashekara rasa vati

for 30 days and 20 patients were treated with the sootashekara rasa vati for 30 days as

shaman chikitsa.

Inclusion and exclusions criteria:

Patient of both gender were selected for the study between the age group of

15-60 years. Patients presenting with classical sign and symptoms of amlapitta like

Aruchi, Avipak, Utklesh, Amloudgar, Hrida-Kanthadaha were selected for the study.

Patients with other major systemic disorder are excluded.

Diagnostic criteria and assessment criteria :

Diagnosis was based on cardinal signs and symptoms of Amlapitta explained

in the classics. Assessment of lakshnas eg. Avipaka, Aruchi, Utklesh, Amloudgar

Hrida-Kanthadaha was made by grading them and assessed before during and after

the treatment.

Investigation :

1) Blood – Hb% ,TLC ,DLC, ESR

2) Routine urine examination – Sugar , Albumin ,Microscopic

4) if needed ECG , Endoscopic , USG

Discussion on observation:

The observation made on 40 patients of Amlapitta is being discussed here seperately.

Age : Maximum number of patients 42.5%were belonging to 26 - 35 age group

followed by 35.% in 16- 25 years. This indicates that the middle age populations are

affected by this disease more, which is Pitta predominant period of life. This Pitta

predominance makes disease chronic and Krichha sadhya.

Sex : Out of total 40 patients, 72.5% were male. This may be due to faulty dietary

habit, increased stress and strain among males and also due to habits like smoking,

pan etc.

Discussion



Religion : Maximum 95% patients were Hindu. This may be due to that this region

belongs to more Hindu population and patients from this community were attending

the O.P.D.

Marital Status : Maximum 85% patients were married, because this status is related

to middle age group. Family involved patients were under stress due to various

reasons.

Occupation : Maximum 42% patients were labour (poor). This reflects the general

trend of people attending the hospital. This high incidence may be due to irregular

diet habits among these groups and improper diet.

Educational Status : In this study 55% patients were educated. This incidence is

maximum in educated people due to hurried and worried life, irregular diet habit etc.

Socio-economic Status : 70% patients were from middle class. One reason for this

may be poor peoples are generally attending O.P.D. and secondly due to inadequate

diet pattern, As balanced diet is required for gastric protection. Lower classes people

are generally consuming the more masala diet which provoke the pitta-kapha dosha

predominantly.

Deha Prakruti : 45% patients were having Pitta - Kapha Prakruti and 30 % had vata-

pitta Prakruti.

Sara, Satva, Samhanana : Maximum 82.5% patients were having madhyama sara,

75% patients were madhyama satva and 62.5% patients had madhyama samhanana.

This reflects the general sara, satva, samhanana in the society and this can not be

correlated to disease.

Vyama Shakti : 67.5% were having madhyam vyayama shakti, it does not have any

reaction with disease, which shows that disease has mild progression and not causes

reverse dhatukshaya leading to daurbalya.

Satmyata : Maximum 75% patients were having madhyama satmya.

Kostha : 62.5% patients were having madhyama and 25%patients were having

Mrudu kostha. madhyama kostha is due to kapha. This is responsible for weak

digestion which ensues in diseases.

Discussion



Vyasana : All patients were taking either tea or coffee. 17.5% and 17.5 patients were

using smoking and tobacco and10% were taking alcohol. These factors are mostly

irritant to gastric mucosa and thus cause daurbalya of amashaya along with vitiation

of dosha mainly pitta-kapha.

Ahara : 35% of patients were consuming Virudhashan,, 45% were having ushna, .

Maximum patients were having one of the faults in their eating habits. This is

responsible for vitiation of dosha which leads into agni-dushti and establishment of

disease, its exacerbation and relapses.

Vihara : 60% were having diwaswapa , 55% patients were having santapa and 45%%

patients were having vegadharana. These all things are responsible for improper

digestion and vitiation of doshas, leading to ama stage.

Manas bhavasa : 42% were having chinta, 20% had krodha and 12.5% had shoka.

Most of the patients were suffering from mental tension and this is responsible for

improper digestion which leads to ajirna like condition as mentioned in ayurvedic

classics. For the process of digestion our manasika bhavas should be under control.

Duration : 40% patients were having symptoms of Amlapitta 1- 2 months and 70%

patients had the symptoms sinces 1 month and 5% from 2-3 months. As this is not

routine life disturbing disease, patients initially does not care of mild symptoms and

keep them on self medication once prescribed by physician just as antacid, milk, cold

drink. They are attending hospital lately and this disease is more over chronic in

nature.

Follow up: will be done after 30 days after completion of treatment. Reoccurrence of

symptom were seen in few patients with respect to disease frequency in comparison

with after completion of treatment scores.

Discussion on result:

The assessment of result was made by adopting the standard methods and

scoring was given to the sign and symptoms of the disease and was assessed

statistically to see the significance. The effect of the therapies on the individual signs

and symptoms are being discussed under the separate heading.

Discussion



Effect on Aruchi : It was observed in almost all the patients of both groups.61%

result was observed in group A and 56% result was observed in group B in tsshe

symptom of Aruchi. Group A shows comparatively good results in Aruchi.

Effect on Avipaka : This is the symptom of Agnidushti, but it was mostly observed

in patients of Amlapitta.64% relief was observed in group A and 56% result in group

B in Avipaka symptom. It is highly significant result at the level of P<0.001. Here

group A is good result.

Effect on utklesh : Utklesh either occasionally or daily was observed in maximum

patients and this may be due to nauseatic feeling due to the pathogenesis of the

disease. 70% result was observed in group A and 78% relief in group B. This result is

statistically highly significant at the level of P<0.001in both groups. Again group B

shows good results.

Effect on amlodgara : This is the general and mostly observed symptom of the

disease Amlapitta. 82% relief was observed in group A while 81% improvement was

observed in group B. The analysis of the result was statistically highly significant in

both groups. Group A showed comparatively good result but not very much

difference in both groups.

Effect on Hridkanth daha : Daha is very troublesome symptom of disease

Amlapitta. In this symptom 84% relief was observed in group A and 85% relief was

observed in group B. However, the statistical data suggests statistically highly

significant in relieving the symptoms Hridkanta- daha at the level of P<0.001 in both

the groups. Obviously the result provided by group B was better in comparison to

group A, daha is mainly due to the involvement of pitta and rasa srotasa maximum

drug of group B are tikta and madura rasa pradhana dravya reduces pitta and Katu

rasa dravyas reduces Kapha , which was the reason of difference in effect

observed.

Effect on amlodgara : This is the general and mostly observed symptom of the

disease Amlapitta. 82% relief was observed in group A while 81% improvement was

observed in group B. The analysis of the result was statistically highly significant in

both groups. Group A showed comparatively good result but not very much

difference in both groups.

Discussion



Overall assessment: Analysis of over all effect of the treatment in the patients of

Amlapitta in group A i.e Yashti madhu churna and soothsakher vati revealed that in

group A 40 % cases showed Major improvement , 35% cases Moderate

improvement , 20% cases Minor improvement and 5% cases Not improved .

In group B,30% cases showed Major improvement, 35% cases showed

moderate improvemet ,25% Minor improvement and 10% cases Not improved .

The administration of Yashti Madhu churna and soothsakher rasa vati in A

group for 37 days and soothsakher rasa vati in B group for 30 days shown good

therapeutic effects and the severity of illness therefore had been markedly

reduced . Further the comparison of the therapeutic effect in two groups showed

better improvement in group A .

None of the patients in both the groups developed any complications, or

any untowards symptoms or any side effects during the course of treatment

and therefore these treatment modalities are safe and are of the therapeutic

value .

PROBABLE MODE OF ACTION OF YASTIMADHU CHURNA AS MRUDU

VIRECHAKA

The Aashaya involved in this disease is Aamashaya . The dosha involved is

mainly Pitta, which includes the Pachaka Pitta of Amashaya and Achcha Pitta of

Pittashaya and the Dushya is Rasa. Considering these entire factor it was tried to give

mrudu Virechana to remove the vitiated Dosha, which will be having an ideal

cleansing action on Pitta. The process of Virechana may be able to expel the

excessive Dravata of Pitta and Pitta present in rest of Avayavas can be eliminated out.

Rasa Dushti can be corrected by this process. After the process of Virechana, the

Agni, digestive power is increased so it is beneficial for further digestion. After

mrudu Shodhana patient usually felt lightness. Even just after mrudu Virechana

process there is reduction in severity of symptoms. Aruchi, Avipaka,

Amlodgara,Utklesha, and hrthkantadaha sign and symptoms were lessened just after

Virechana process, which helps in further Shamana therapy, as it is corrected earlier.

Discussion



PROBABLE MODE OF ACTION OF SOOTASHEKARA RASA VATI ON

AMLAPITTA

The contents of sootashekara rasa Vati are Laghu and Ruksha in property.

There is increase of Drava Guna in Amlapitta. Kledaka Kapha and Pachaka Pitta are

Drava in dominancy. So Laghu-Ruksha Guna performs the function of Dravansha -

Shoshana. This formulation is Tikta dominant and it performs the functions of

Pachana rather than Deepana. Tikta Rasa helps in Shoshana of Jala dominant

substances it includes Kleda, Meda, Vasa, Lasika, Pitta and Kapha. Tikta-Kashaya

Rasa help in pacifying the Kapha-pitta both. In these two rasa Tikta is better as it is

Laghu and it does not stagnate the Ama. It performs the function of Pitta-Sleshma

Shoshana as described by Charaka. “Tikta –Vishadyati” can be observed throughout

gastrointestinal tract (G.I.T.).

Conclusion



CONCLUSION

The purpose of this present study was Based on the conceptual analysis and

observation made in the clinical study, the following conclusion were drawn after

logical interpretation of the results obtained in the clinical study which are listed

below

Amlapitta is such pathological condition or disease in which the pitta

exteeds in normal level. Due to etilogical foctors Amlaguna of Pitta

increases which leads to Vidagdhata of ingested food and finally Amlodgara,

Hridkanthadaha utklesha etc., signs and symptoms are produced

In Brihattrayi Amlapitta has not been considered as a separate disease entity.

But Kashyapa has described Amlapitta as a separate disease. After Kashyapa,

Madhavakar has described elaborately with its two clinical subtypes i.e.

Urdhvaga and Adhoga Amlapitta.

Amlapitta is a commonly occuring psychosomatic disease.

Amlapitta cannot be correlate with a single disease of modern medicine. Some

diseases like Gastritis, Hyperacidity. Non-ulcer dyspepsia etc. show some

similarity to causes, some signs and some symptoms of Amlapitta.

It is well observed that in Group A yastimadhu churna and sootashekara rasa

vati provide better relief in the signs and symptoms of the disease amlapitta

when compared to Group B sootashekara rasa vati only. Inter group

comparison of statistical data proved to be statistically nonsignificant.

No complications were observed in any patient during the study period

Recommendation for the further studies :

The short treatment period did not suffice for total subsidence of all laksana.

This study can be carried out in further studies for better objective analysis

Summary



SUMMARY

The thesis entitled“A clinical comparative study to evaluate the efficacy of

Mrudu virechana and shaman chikitsa in the management of Amlapitta” comprises of

four parts i.e. Conceptual study, Clinical study, Discussion, Summary and

Conclusion.

In the first Section a brief introduction is given in the beginning of the

dissertation which deals with the need of the study, reason for the selection of the

disease Amlapitta, aims and objectives.

Part I: Conceptual study

The Conceptual study is divided into 2 parts viz Disease Review and Drug

Profile. In Disease Review, description of Amlapitta in details including its historical

back ground, review of previous works, Nidana, Samprapti and its ghataka,

Purvarupa, Rupa, Varieties, Sapeksha Nidana, Sadhyasadhyata and Chikitsa Sutra.

After the Ayurvedic description, modern interpretation of Amlapitta with Gastritis,

Hyperacidity, Non-ulcer dypepsia have been described.

The drug profile part deals with the review of Yastimadhu and sootashekara

rasa vati contents. In this section the detailed description about Name, Family,

Chemical name, chemical composition, Properties and Pharmacological action of

above drugs have been mentioned.

Part II: Clinical study

The materials and methods including selection of patients for study, plan of

study, assessment criteria for results are all elaborated. The observations regarding the

patients and statistical analysis of results obtained from the treatments are put forth.

Part III: Discussion

The interpretations of the conceptual study, clinical study, and probable mode of

action of the medicines are discussed here.

Summary



Part-IV :The Conclusions drawn from the Observations are presented here.

40 patients of Amlapitta were studied, out of whom, 42% were in the age group

26-35yrs.; 72.5% were male, 85% married and 95% Hindus. 55% of the patients

were Graduates, 65% had laborious of work, 70% middle classes. 65% were

consuming mixed diet, 65% gave a history of visamasana and 55% consumed

tea/coffee excessively. 42.5% of the patients gave a history of mental stress and

50% complained of sleep disturbances. No family history of similar illness was

evident in any patient.

45% of the patients were of pitta and kapha dominance, 82.5% of patients

weremadhyama sara, 62.5% of madhyama samhanana, 75% of madhyama satva,

35% katurasa satmya, 75% of mandagni and 65% of pravara bala. 35% of the

patients gave a history of 6mth-1yr. of illness. Among laksana, 90% had aruchi,

50% had avipaka , amloudgara was seen in 95%, hrid-kanthadaha in 65%

Fourty patients who had completed the clinical trial were considered for

assessment of results.

Group A: In the post treatment period, statistically significant results were obtained

in Laksana like Aruchi – 61%, Avipaka - 64%, Amlodgara – 82%, Utklesh – 70%,and

Hridkantadaha – 84%

Group B: In the post treatment period, statistically significant results were obtained

in Aruchi – 56%, Avipaka - 56%, Amlodgara – 81%, Utklesh – 78%,and

Hridkantadaha – 85%

Over all result,In group A 40% cases showed Major improvement, 35%

showed moderate improvement, while 20% cases showed Minor improvement,5% of

cases showed not improved .In group B, 30% cases showed Major improvement, 35%

cases showed moderate improvement, while 25% cases showed Minor improvement

and in 10% of cases showed Not improved was found .

At the end of the study it was concluded that yastimadhu churna as mrudu

virechaka with sootsshekara rasa vati as shaman oushada provided better and more

effective results when compared to sootashekhar rasa vati as shaman chikitsa.

List of References



LIST OF REFERENCE

1 BHAGAVAD GITA Adiparva 1/ 27

2 Ca .Su – 1/110

3 Ca .Su – 25/40

4 Ca . Su 26/43

5 Ca .Su 26/103

6 Ca. Su-27/25

7 Ch . Chi 12 /52

8 Ca. Chi-15/ 47

9 Ca. Su -20/ 1

10 Ch. Chi-12/52

11 Ha .Sa . in 24th chapter of 3rd sthana

12 Su. Su – 21 / 11

13 Su .Su - 21 /13

14 Ch . Chi – 15 /47

15 M .Ni - 51 / 1 Madhu Kosha

16 M.Ni. – 51 / 1 Madhu kosha

17 M . Ni - 51 / 1

18 A .S . Su 20 / 16 Indu Teeka

19 Y.R. Amlapitta. Chit/24

20 Ka .Sa . Khi .sth . 16 th chapter

21 A .S . Su -20 / 16

22 A .S . Su - 12 / 6

23 Ma . Ni - 51 / 1

List of References



24 Ch. Vim 1/ 24

25 Ch . Vim 1/ 21

26 Ka . Khil – 16/ 3- 6

27 M . N - 51 / 1

28 B . P Part 2 – 10 /1

29 B . R - 56

30 G . H – 38 / 1

31 S .S – Sha . Purvakhand 115/118

32 Ch . Su - 6/ 14

33 Ch . Su 7/ 60

34 Ch . Vi - 1/ 21 - 22

35 C . Ch - 1/ 8

36 M . Ni -51/ 3

37 M . Ni - 51 / 8 - 12

38 K .S . Khi – 16/ 16 - 17

39 M .Ni -57 / 3

40 Y . R .Amlapittachikitsa / 3

41 B . P , Madhy Aamakhanda /

42 Ka . Khil 16 / 15

43 Ka . Khil 16/ 16

44 Ka . Khil 16/ 17

45 C . Chi , 21 / 40

46 K .S . Khi , 16 / 49

47 Chakra. Chi , 28

48 A .S . Su , 19/21

List of References



49 Su . Su , 35

50 C . Ni – 5/15

51 M . Ni – 5/17

52 Ka . Khi – 16/49

53 K .S . Khi – 16/42

54 Ka . Khi - 16

55 Thamas Edison

56 C .Cu . 24 /45

57 K..S .Khi – 16 /33 -40

58 K .S . Khi - 16/ 33 - 40

59 B . R , 56 / 156 - 159

60 K .S . Khi , 16/ 44 - 48

61 C . T .M vol 1 Pg - 641

62 Page No - 307 - 310

63 H .P . I .M Vol 2 Pg - 232

64 C T M Vol 64 1

65 French;s Index of differential diagnosis Pg No 307 - 310

66 5 Minute clinical assessment CIMS Pg 344

67 5 Minute clinical assessment CIMS Pg 345

68 H . P .I . M, Vol 2 Pg - 333

69 D .P . P .M , Pg - 434

70 H . P .I .M Vol 2 Pg - 233

71 5 Minute clinical assessment CIMS Pg - 344

72 5 Minute clinical assessment CIMS Pg - 344

73 H . P .I .M , Vol 2 Pg - 1592

List of References



74 5 Minute clinical assessment CIMS Pg – 344

75 H . P .I .M , Vol 2Pg - 1582 , table no . 288

76 D. G

77 Yograt chp Amla Pitta chi ,Pg No.244 , shlo No .56 . .

Bibliography



BIBLIOGRAPHY

Charaka Samhita - Charaka Chandrika Hindi Commentary By Bramhanand

Tripathi.

Kashyapa Samhita - Hindi Comm. By Satyapal, Chaukhambha Sanskrit

Sansthana Varanasi.

Madhava Nidana - Madhukosha Comm. with Hindi Vidyotini Comm. By S.

Shastri. Vol. I & II, Chaukhambha Sanskrit Sansthana, Varanasi.

Yogaratnakara – Vidyotini Hindi Comm. By Laxmipati Shastri, Chaukhambha

Sanskrit Series, Varanasi.

Sushruta Samhita - Hindi Comm. By Ambikadatta Shastri, Chaukhambha

Sanskrit Series, Varanasi.

Ashtanga Hridaya - Nirmala Hindi Commentary By Bramhanand Tripathi,

Chaukhambha Sanskrit Pratisthana, Delhi.

Harita Samhita - Ed. By. Ravidatta Shastri., Shri Krishnadas Academy,

Mumbai.

Chakrapani - Ayurveda Dipika Commentary on Charaka Samhita,

Chaukhambha Surabharati, Varanasi.

Bhavaprakasha - Ed. By Bramhashankar Mishra with Vidyotini Hindi

Commentary Chaukhambha Sanskrit Pratisthana, Varanasi.

Sharangadhara Samhita – Dipika Hindi Comm. By Bramhanand Tripathi,

Chaukhambha Surabharati Prakashan, Varanasi.

Bhaishajya Ratnavali - Ed. By. Rajeshwara Dutta Shastri, Chaukhambha

Sanskrit Sansthana, Varanasi.

Bhela Samhita - Ed. By Vd. Venkatasubrahmanya Shastri & Sri. Rajeshwar

Shastri, C.C.R.A.S., Delhi.

Dalhana - Nibandha Sangraha Comm. on Sushruta Samhita. Ed. By YT.

Acharya, Chaukhambha Orientalia, Varanasi.

Bibliography



Ashtanga Samgraha - Hindi Commentary By. Pd. Lalchandra Shastri,

Baidhyanath Ayu. Bhavan Ltd., Nagpur.

Chakradatta - Ed. By. Pandit Sadanand Sharma, Meharachand L. Publication,

New Delhi.

Desai Ranjit Rai - Ayurvediya Kriya Sharira, Baidyanath Ayu. Bhavan,

Nagpur.

Desai Ranjit Rai - Nidana Chikitsa Hastamalaka, Baidyanath Ayu, Bhavan,

Nagpur.

Dwarakanath C. - Introduction to Kayachikitsa, 3rd ed., Chaukhambha

Orientalia, Varanasi.

Kasture H. S. - Ayurvediya Panchakarma Vigyana, Baidyanath Bhavan,

Nagpur.

Pathak Ram Raksha - Kayachikitsa, Chaukhambha Bharati Academy,

Varanasi.

Sharma P.V. - Dravya Guna Vigyana, Vol. I & II, Chaukhambha Surabharati

Academy, Varanasi.

Davidson - Principles & Practice of Medicine, 19th edition., Saunders, UK

Harrison - Principles of Internal Medicine, 14th Ed. Mc Gram Hill, New

Delhi.

Kumar & Clark - Clinical Medicine, 5th ed., W.B. Saunders, New York.

Guyton & Hall - Textbook of Medical Physiology, 10th ed., Saunders.

API- Text Book of Medicine – Siddhartha N Saha 7th Edition.

Taber's Cyclopedic Medical Dictionary, 17th Ed., Jaypee Brothers, New

Delhi.

British Medical Journal.

Annexure



a clinical comparative study to evaluate the efficacy …

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