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An open clinical trial to analyze Samyak Snigdha Lakshana of Shodhananga Snehapana with Mahatikthakam Ghritam in Psoriasis

 

 

Rajkala Ramteke1, G. Vinodkumar2, T. Meharjan3

1Lecturer, PG Department of Panchakarma, KVG Ayurveda College, Sullia, Dakshin Kanada, Karnataka,

2Professor and Head, Department of Panchakarma, Nangeli Ayurveda College, Kuthamangalam, 3Associate

Professor, Department of Kaya Chikitsa, Government of Ayurveda College, Thiruvananthapuram, Kerala, India

 

Abstract

An open clinical trial was conducted in Govt. Ayurveda College Hospital, Thiruvananthapuram, Department of Kayachikitsa and Panchakarma. As there is no work done on the Samyak Snigdha Lakshana (SSL), this study was undertaken to work on the different aspects of Samyak Snigdha Lakshana. To minimize variables, subjects suffering with psoriasis and same Ghritam were selected on the basis of strict inclusion and exclusion criteria. Shodhananga Abhyantara Snehapana was advised before Vamana and Virechana. Samyak Snigdha Lakshanas which are described in all texts are different in milieu. Shodhananga Snehapana with Mahatiktakam Ghritam was given according to Koshta and Agni in 30 subjects. Samyak Snigdha Lakshanas were assessed using a special scoring pattern and the biochemical parameters were observed in all subjects. Statistical analysis using paired‘t’ test were done. In all patients Vatanulomana, Diptagni, Snehodvega, Klama and Adhastat Sneha Darshanam were seen; whereas Angalaghava and Twak Snigdhata were noted in less percentage of persons. The onset of various Samyak Snigdha Lakshanas occurs in sequence. There

are changes in some biochemical parameters like serum cholesterol, Serum glutamic‑oxaloacetic transaminase (SGOT) and fat globules in stool after Snehapana. Shodhananga Snehapana with Mahatikthakam Ghritam decrease features of psoriasis up to some extent. More in depth studies are required to evaluate their importance and for their application in modern medical practice.

Key words: Mahatikthakam Ghritam, Psoriasis, Shodhanang Snehapana

 

Introduction

Panchakarma is the main treatment modality which is widely used in all the eight branches of Ayurveda. The Shodhana therapy is more admired by virtue of its capability to completely eliminate the Doshas.[1] On the other hand, it has major disadvantages too. If this therapy is not done with proper indication and Purva‑Karma, it may cause hazardous unwanted effects like shock, hemorrhage and death also. To avoid these unwanted effects, Acharyas have instructed to do a proper Purva-Karma.[2] Before adopting Shodhana, it is necessary to do Snehana and Swedanaproperly.  Snehapana is a major preparatory procedure because of its multifaceted action. Shodhananga Abhyantara Snehapana is advised before Vamana and Virechana. Samyak Snigdha Lakshanas which are described in all texts are different in milieu.  Acharyas have mentioned it in the context of Shodhanartha Snehapana, whereas Acharya like Kashyapa have mentioned it in the context of Shamana Snehapana. So there is no clarification regarding the Samyak Snigdha Lakshana according the type of Snehapana. There are many works available on Snehapana, but there is no work on the Samyak Snigdha Lakshana. Hence this study was planned to work on the different aspects of Samyak Snigdha Lakshana. Psoriasis is a common chronic scaling skin disorder.         The latest survey suggests that as many as two in every hundred of the

total population have it at any time in their life. In Ayurvedic classics, Kushtha is the disease where Shodhana is indicated at specific time intervals of which Snehapana is indicated first.

Considering the need of study and availability of the patients, psoriasis patients were selected as the condition usually is not associated with major complications.

Aims and objectives

  1. To assess the Samyak Snigdha Lakshana subjectively

and objectively with various clinical and biochemical parameters.

  1. To study the effect of the Snehapana with Mahatikthakam Ghritam in Psoriasis.

Materials and Methods

Source of data

Patients of Psoriasis consulting the OPD of Kayachikitsa

and Panchakarma Department, Govt. Ayurveda College,

Thiruvananthapuram.

Method of collection

30 patients willing to participate in the study were selected

based on the clinical features of Psoriasis, considering the

inclusion and exclusion criteria. Necessary investigations

were carried out and their details were recorded in a special

proforma.

Inclusion criteria

  1. Patients with all forms of Psoriasis who are clinically fit to

undergo Shodhananga Shodhana procedure.

  1. Age ‑.15 to 60 years.
  2. Sex ‑.Both sexes.

Exclusion criteria

  1. Clinically unfit for Shodhananga Snehapana.
  2. Chronic debilitating disease.
  3. Malignant Hypertension.
  4. Pregnant ladies.
  5. Patient not willing for admission.

Laboratory investigations

Blood parameters testing and stool examination were done

before Snehapana, after Snehapana and after Virechana to

assess the changes.

  1. Haemogram‑ Hb%, TC, DC, ESR.
  2. Blood chemistry‑ LFT, RFT, BSL, Lipid Profile.
  3. Urine examination‑ Albumin, Sugar, Deposits.
  4. Stool examination‑ Fat globules.[3]

Methodology

Assessment of Agni and Kostha was done in every patient on the

basis of assessment criteria. Deepana and Pachana were done by

administering Panchakolasavam 30 ml twice a day after food

and Vaiswanara Choornam 5 gm twice a day before food with

warm water for 3 to 5 days till the appearance of the Nirama

Lakshanas. In the morning, around 6 a.m. Mahatikthakam

Ghritam was given in Arohana Karma from 30 ml to 300 ml

to the patient when there was Jeerna Ahara Lakshana and

Akshudhita Avastha, with fresh mind, courage and remembering

favorite Devata.[4] Ushna Jala boiled with Sunthi approximately

400‑500 ml was given as Anupana.[5] Snehapana was stopped

after getting Adhastat Sneha Darshanam and Samyak Snigdha

Lakshanas were assessed. An interval of three days was given

between onset of Samyak Snehana and Virechana Karma.

Avipattikar choorna 20‑30 gm according to Koshtha of the

individual was given with honey around 7 a.m. on the day of

Virechana. Samsarjana was advised after Virechana depending

upon the type of Shuddhi.

Criteria of assessment

Detailed history, physical and mental examination was done on

the basis of a specialized proforma designed for this purpose.

Criteria for assessment of Koshtha

Routine Bowel Habit was considered for assessment of Koshtha

as per the following features:

  1. Frequency per day
  2. Less than one ‑ 1
  3. Once/twice ‑ 2

iii. More than two ‑ 3

  1. Consistency
  2. Hard Stool ‑ 1
  3. Soft, well formed ‑ 2

iii. Loose/Watery, not well formed ‑ 3

  1. Urgency
  2. No urgency at all, sits long time

with discomfort ‑ 1

  1. Moderate urgency can be controlled

but no need to sit long ‑ 2

iii. Marked urgency cannot be

controlled ‑ 3

  1. Your experience regarding intake of 200 ml milk/100 gm

grapes/50 gm Jaggery/200 ml Ikshu Rasa/10 gm Avipathikar

Choorna.

  1. No change in bowel habit ‑ 1
  2. Normal well formed stool ‑ 2

iii. Watery stool/not well formed ‑ 3

  1. Whether changes in food habits will affect the bowel habits
  2. Frequently hard ‑ 1
  3. Occasionally ‑ 2

iii. Frequently loose ‑ 3

Score

  1. 1 to 5 implies ‑ Kroora Koshta
  2. 6 to10 implies ‑ Madhyama Koshta
  3. 11 to 15 implies ‑ Mridu Koshta

Assessment of Agni

Effect on hunger, digestion, defecation by occasional, irregular

food habits:

  1. No alteration ‑ Tikshn Agni
  2. Mild/Inequitable alteration ‑ Visham Agni
  3. Gross alteration ‑ Mand Agni

Criteria to assess Samyak Snigdha Lakshana

The following subjective criteria were considered for assessment

of Samyak Snigdha Lakshana[6]

  1. Vatanulomana

1 = Urdwavatapravritti, Udgara Bahulya and

Adhmana.

0 = Improper evacuation of flatus, faeces, urine and

absence of Udgara Bahulya etc.

2 = Proper evacuation of flatus, faeces and urine.

  1. Agnidipti

For easy calculation and understanding of Agnidipti factor,

one standardized formula is accepted based on dose of

Sneha and time taken for digestion.

Agnibala index=

Test dose×Time taken for digestion

Given dose

Lesser the Agnibala index (A.B.I.), more will be the

Agnidipti.

1 = A.B.I.>3

0 = A.B.I.=3

2 = A.B.I.<3

  1. Twak Snigdhata and Gatra Snigdhata

1 = Dry skin

0 = Softness of skin (Mriduta)

2 = Proper oiliness of skin

  1. Purisha Snigdhata

1 = Ruksha Purisha

0 = Soft stool

2 = Loose stool with Sneha

  1. Snehodvega

1 = No aversion

0 = Minimum aversion without nausea

2 = Nausea, vomiting on thought and sight of

Sneha

  1. Klama/Glani

1 = Enthusiastic

0 = Reasonably active as usual

2 = Tiredness without exertion

  1. Angalaghavata

1 = Heaviness in body

0 = Usual lightness in the body

2 = Feeling of lightness in the body

Score pattern

7‑8 = Avara Samyak Snigdha Lakshana

9‑11 = Madhyama Samyak Snigdha Lakshana

12‑14 = Pravara Samyak Snigdha Lakshana

<7 = Asnigdha Lakshana

Observation and Results

Maximum patients were from 45 to 60 years age group. Among

total patients, 67% of subjects were male and 33% were female.

Religion wise distribution showed that maximum number

of patients (74%) were from Hindu community. Most of the

patients (40%) were having occupations which led to mental

stress. Economic status wise distribution of patient shows that

37% patients were belonging to middle class. 53% patients were

of Vatakapha Prakriti and 66.6% patients were of Madhyama

Sara and 56.6% of Madhyama Samhana. Also, maximum

number of patients’ (53.3%), were of Avara Satva category,

which may be due to Manasika involvement in Kushta or due

to social stigma of skin diseases.

 

                      Among all subjects, 49.9% were having Avara Satmya where

as 39.9% patients were having Madhyama Satmya. Maximum

patients 46.6% were having Madhyama Abhyavaharana

Shakti followed by 33.3% and 19.9% of Avara and Pravara

Abhyavaharana Shakti respectively. The Jarana Shakti wise

distribution shows maximum patients were having Madhyama

Jarana Shakti, i.e. 56.7%. In the study, 53.2% patients were

having Vishama Agni and 59.9% of patients were having

Kroora Koshtha. Among psoriasis features, 100% subjects

were having scaling over skin whereas only 26.6% subjects

were having itching over skin lesion. 66.6% subjects reported

pain as a symptom and 73.2% subjects had erythematic on

the lesions. Maximum of 39.9% subjects were administered

Ghrita in the dose of 800‑1000 ml. Maximum of 49.9%

subjects were given 250‑300 ml dose on last day. Maximum

of 56.6% subjects took 6‑7 days for Samyaka Snehana. 36.6%

subjects required 4‑5 days for getting Samyak Snigdha Lakshana.

Observations on Samyak Snigdha Lakshana

In the Arohana Snehapana group, after administration of Sneha,

the symptoms of Sneha Jiryamana were observed. The mean

onset time and duration of those symptoms were noted in

minute [Table 1].

All the Sneha Jiryamana Lakshana reported by the subjects

automatically subsided on Sneha Jeerna.

Observation related with mean score of Samyak Snigdha Lakshana

with S.D. and percentage was on last day of Snehapana all

subjects showed Vatanulomana, Diptagni, Purisha Snigdhata and

Snehodvega with mean score of 1.9, 1.9, 2.0 and 1.8 respectively.

Whereas 93.3% subjects showed Klama Lakshana with S.D. 0.4,

86.5% subjects noticed Twak Snigdhata with mean score of 1.4

(S.D.±0.8) and only 13.3% subjects perceived Angalaghavata

with mean score of 0.6 (S.D.±0.2) [Table 2].

The pattern of Samyak Snigdha Lakshana found in 30 subjects

with respect to Snehapana days. Vatanulomana was seen in 80%

of subjects on 1st day, 87.7, 96.4, 97.6, 98.5, 89.6 and 100% of

subjects showed on subsequent days. Diptagni was seen in 100%

subjects on 1st day followed by 97.5% of subjects on 2nd day,

93.4% on 3rd day, 96.5% on 4th day, 95.9% on 5th day, 98.3% on

6th day and 100% subjects on 7th day [Table 3].

Maximum number subjects (60%) noted Pravara Snigdhata

grade while 30% subjects reported Madhyama Snehana grade

and only 10% subjects put in the picture were of Avara Snehana

grade [Table 4].

The details of Samyak Snigdha Lakshana during the gap

days shows - on the 1st and 2nd gap day, Vatanulomana was

experienced by all subjects while on 3rd day only 96.5% of

subjects recounted it. Diptagni was described by all subjects on

1st Vishrama Dina whereas 93.2% subjects reported it on 2nd day

and 83.5% stated it on 3rd gap day [Table 5].

The role of Snehana according to Prakriti reveals that maximum

subjects, i.e. 11, who took 6‑7 days to get Samyak Snehana were of

Vata-Kaphaja Prakriti and the same no. of subjects attained Pravara

Snigdhata grade. Among Pitta-Kaphaja Prakriti subjects, five subjects

necessitated 4‑5 days for Snehana therapy and two subjects required

6‑7 days and only one patient required 1‑3 days for Snehana therapy.

Among them, five subjects got Pravara Snigdhata grade and two

subjects reported Madhyama Snigdhata grade.

In case of Vata-Pittaja Prakriti, maximum four subjects required

6‑7 days for Samyak Snehana therapy, 1 patient got Samyak

Snehana in 1‑3 days and the same no. in 4‑5 days. Among

them four subjects attained Madhyama Snehana grade and two

subjects reported Pravara Snigdhata grade [Table 6].

In this study, seven subjects of Vishamagni amongst sixteen

took 4-5 days for Samyak Snehana and nine subjects required

6‑7 days for getting Samyak Snigdha Lakshana. Out of them,

eight subjects got Pravara Snigdhata grade, six subjects got

Madhyama Snigdhata grade and only two subjects got Avara

Snigdhata grade. Among Mandagni subjects, six subjects

attained Samyak Snehana in 6‑7 days and three subjects took

4‑5 days. Amongst them, six subjects attained Pravara Samyak

Snehana grade, two subjects reported Madhyama Snigdhata

grade and only one patient showed Avara Snigdhata grade.

Among five subjects having Tikshnagni, two subjects achieved

Samyak Snehana in 6‑7 days and one subject took 4‑5 days.

 

 

 

Amongst them four subjects attained Pravara Samyak Snehana

grade, one subject reported Madhyama Snigdhata grade [Table 7].

In this study sixteen subjects having Kroora Koshta among

eighteen, took 6‑7 days for Samyak Snehana and two subjects

required 4‑5 days for getting Samyak Snigdha Lakshana. Out of

whom eight subjects got Pravara Snigdhata grade, eight subjects

got Madhyama Snigdhata grade and only two subjects got Avara

Snigdhata grade.

Among Madhyama Koshta subjects, only one subject attained

Samyak Snehana in 6‑7 days and the rest seven subjects took

4‑5 days. Amongst them seven subjects achieved Pravara Samyak

Snehana grade and only one patient showed Avara Snigdhata

grade. Among Mridu Koshta subjects, two subjects attained

Samyak Snehana in 1‑3 days and two subjects took 4‑5 days. Out

of them three subjects attained Pravara Samyak Snehana grade,

one subject reported Avara Snigdhata grade [Table 8].

Effect of therapy

Effect of Snehapana on blood parameters

Effect of Snehapana on erythrocyte sedimentation rate was found

decreased with statistically insignificant results [Table 9]. Serum

cholesterol level was decreased significantly (P<0.01) in SSL

and AS in comparison to BS [Table 10]. SGOT and SGPT levels

were decreased in SSL and AS in comparison to BS which was

statistically significant (P<0.01) [Tables 11, 12]. But the changes

found in all the blood parameters were within physiological limits.

Effect of Snehapana on stool parameter

The result of Snepana was assessed on stool fat globules which

was found statistically highly significant (P<0.01) in BS, SSL

and AS as compared to each other [Table 13].

Effect of Snehapana on psoriasis features

Effect of Snepana was assessed on cardinal features of Psoriasis

i.e. on Scaling shows statistically highly significant results

(P<0.01) [Table 14]. Maximum number of subjects who showed

Pravara grade of Snehana, also reported Pravara Shodhana and

vice versa [Table 15]. No significant increase or decrease in vital

data like pulse, respiratory rate and blood pressure were found

before and after Snehapana

 

 

 

 

Discussion

Shodhanartha Abhyantara Snehapana is the foundation for

purification procedures. There are mainly two effects of the

Shodhananga Snehapana;

 

 

 

which may be because of Snigdha Guna of Sneha. Due to intake

of Sneha Anulomana of Apana Vayu occurred, which resulted

in the good functioning of Apana Vayu and Pachaka Pitta and

in turn Agnidipti was observed. Purisha Snigdhata was started

to be observed from 3rd day onwards. It suggests the gradual

Snigdhata of Purishavaha Srotas, which will reach maximum

by 7th day. Twak Snigdhata suggests that Sneha has reached up

to Rasa, Rakta, Mamsa and also Majja Dhatu as explained by

 

 

 

 

Vagbhata, “Sneho Akshi Twagvisham…”

Caraka explains this with illustration that just as water saturates the

cloth to its capacity then drains off, similarly the unctuous dose gets

digested according to the strength of Agni and drains off when it

exceeds the limit of Agni. Cakrapani comments that it is direction

to find when to stop Snehapana.[8] The data suggest that all the

symptoms of Samyak Snehana do not appear on the same day but

as Snehana process goes on, the Lakshana appear one by one. At

first Mahastrotas becomes Snigdha. So, Agnidipti and Vatanulomana

are observed in initial days. Further when Asamhata Varchas appears

the complete Snehana of Annavaha and Purishavaha Srotas can

be understood. Afterwards Twak Snigdhata appears. This reveals

that Snigdhata has reached up to Dhatu level. At last Snehodvega

and Adhastat Sneha Darshanam were noted suggesting that there

is no need of further Snehana. So from the above data it can be

understood that the onset of Snehana Lakshana described by Caraka

and other Acharyas are in the sequence of appearance. However the

symptom like Twak Snigdhata is little difficult to achieve or may not

appear in all the patients.

Probable mode of action of Snehana

  1. Shodhananga Abhyantara Snehapana is the basis to

make a smooth platform for Shodhana, i.e. to attain the

Utkleshavastha of Dosha.

  1. The importance of Snehana as Purva Karma for Shodhana

is well known.

iii. The features produced after Snehana suggest that there

is loosening of morbid Doshas which were adherent to the

walls of transforming channels and which in turn will help in

the Shodhana Karma, performed afterwards. When Snehana

was done by increasing dose schedule where increase of dose

per day was decided according to Agni, Koshta, Bala Avastha,

etc. the Snehana occured in its full fledged form.

  1. Snehodvega suggests the Sanchayavastha by “Chayakarane

Vidvesha” as per Sushruta. The symptoms of Rasa Vridhi like

Hrillasa, Praseka signifies the increase of Apyamsha in the

body which is the action of Snehana i.e., Vriddhi for bringing

the Doshas from Sakha into the Koshtha from where they

can be easily expelled out. Adhastat Sneha Darshanam

suggests that there is no need for further Snehana.

  1. After proper Snehapana three days gap has been given

before Virechana to get Agni in its normal form so that it

can digest Virechana medicine as ‘Pachyamane Virechanam’

is told by Acharya.

  1. Effect of Virechana Karma was also dependent upon

Snehana process.

vii. Mahatikthakam Ghritam was used for Snehana and so it

has provided Shamana effect on Psoriasis features.

Conclusion

Snehapana should be done with well planned method.

Consideration of Agni and Koshtha must be done for deciding

the dose and duration of Snehapana. Onset of various SSL

occurs in sequence which may be helpful in predicting the

duration of Snehapana. There are no significant changes

in the blood parameters due to Snehapana. The significant

changes in stool with respect to presence of fat globules were

seen. Shodhananga Snehapana with Mahatikthakam Ghritam

in Psoriasis decreases the clinical features to some extent.[9] If

Virechana is performed after proper Snehana, better and safer

Suddhi can be achieved.

Acknowledgment

For this study I am very thankful to all my seniors, juniors, classmates

and my patients who tried to understand while I communicated in

Malayalam and taught me a better language for communication.

References

  1. Caraka‑ Caraka Samhita, commentary by Cakrapani, edited by Vaidya

Yadavji Trikamji Acarya, Varanasi: Chowkhamba Krishnadas Academy,

Oriental publishers,1994.

  1. Vagbhata Ashtanga Hridaya, commentary by Arunadatta and Hemadri,

edited by Harishastri Paradkar, Varanasi: Chowkhamba Krishnadas

Academy; 1995.

  1. Praful B. Godkar and Darshan P Godhkar, Text book of Medical

Laboratory technology. 2nd ed, Mumbai: Bhalani Publishing house; 2003.

  1. Sushruta Sushruta Samhita, English translation by P.V. Sharma, Varanasi:

Chaukambha Vishwabharati; 1999.

  1. Vagbhaa Ashtanga Sangraha, English translation by Prof. K.R. Srikanta

Murthy, Varanasi: Chaukambha Orientalia; 2000.

  1. Ramteke Rajkala, M.D. Ayu. thesis, An open clinical trial to analyze Samyak

Snigdha Lakshana of Shodhanang Snehapana with Mahatikthakam Ghritam in

Sushruta ‑ Sushruta Samhita, commentary by Dalhana and Gayadasa,

Varanasi: Chaukambha Orientalia; 1992.

  1. Caraka‑ Caraka Samhita, commentary by Cakrapani and

Gangadhara Kaviratna Kaviraja, Su.13/96 Varanasi: Chaukambha

Orientalia; 1991.

  1. Indira Balachandran, Indian Medicinal Plants, V.P.S.V. Aryavaidyasala Kottakal,

Chennai: Orient Longman Publication, 1994.

 

Address for correspondence: Dr. Rajkala Ramteke,

Lecturer, PG Department of Panchakarma, KVG Ayurveda

College, Sullia, Dakshin Kanada, Karnataka, India.

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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